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Why dental insurance makes good people do bad things

January 10, 2018 By Trish Walraven 28 Comments

When I was a kid, my dad would tell me on the way to the dentist to be prepared to pay out of my own pocket for any cavities I had. $38 per filling was an insane amount of money for an eight year old with a 75 cent allowance per week and 7-Eleven candy habit. I hedged my bets that his threats were empty, that I’d get my dental care and never have to pay up.

And it worked. Since I didn’t have a proper income, my parents went ahead and took care of the bills for me, got me to the dentist, fixed those cavities right up. Instead of making me pay in cash, however, I paid up in guilt, for not taking care of my teeth like I should have.

I carried that guilt for years, right into college and ultimately into dental hygiene school, when I learned something interesting about the type of fillings that were in my teeth: if I’d had sealants as a child, there would have existed the possibility for me to grow up cavity-free. But sealants weren’t widely available to dentists until the mid-1980’s, too late to save me from the drill.

That’s the thing, though. Dental practice is not malpractice if it’s within the current standards of care, so my dentist growing up was in no way neglectful of my dental health. It’s just the way things were then. I have a bunch of pits and fissures in my back teeth full of silver instead of smooth white sealants, like my kids do – all those deep grooves they inherited from me were sealed just as soon as their permanent teeth came in.

Dentists and hygienists have a belief ingrained in us throughout our education: The best dentistry is NO dentistry, because natural healthy teeth will almost always be better than man-made teeth. We are driven to help you keep your teeth in their most natural state as possible, for your entire life. We can’t do this, though, unless you visit us for preventive care. Our experience and training lets us see the earliest signs of things that aren’t quite right in your mouth, so that we can help you take the necessary steps to correct them way before they become disfiguring, painful, or expensive.

This might be a good time then to start talking about dental insurance. Before we do that, though, let’s explore more generally. What is insurance? It’s money you pay to someone else to take care of things if the unexpected happens.

If you’re fortunate enough to never have a house fire, or die, or crash your car, there’s nothing that your insurance policies need to cover, so you’ll never get a reimbursement check. Medical insurance used to be a reimbursement system, too, until insurance companies had to come up with clever ways not to cover people’s health problems so that the insurers wouldn’t run out of money. Hospitals and doctors also became clever with their billing, and this back and forth game of “how can we make the money flow in our direction” has resulted in our current health care situation.

This cleverness has also invaded dentistry. Here are three truths that exist right now:

1. A lot of people have crappy dental plans

2. They go to dentists they don’t trust and

3. Get treatment they don’t need.

Do you want to help me change these three truths? You can, you know. We’ve done it before, you and I. You helped me get the word out that plastic in toothpaste was a bad idea, and we got that banned in the United States shortly afterwards. This is so much bigger: helping each American keep their teeth for life, at a cost they can afford.

To do this, we’re going to have to get everyone working together, but differently. You can’t change the system by just saying it needs to be changed and then doing nothing from your place within it. There’s also no ability to change if you don’t understand how to make a difference with your own actions. Right now, inadequate dental insurance is the standard of care, sort of like silver fillings were in the 70’s. Are you ready to help me move dentistry another big step forward?

Look at yourself in the mirror.

This is where it starts. With you. What do your teeth mean to you? Are their appearance important, or is it good enough that they don’t hurt and you can chew with them? Take a hard look at your teeth, and answer these two questions honestly to yourself.

Believe it or not, dentists spend a lot of time trying to guess people’s values. If you don’t know how you feel about your own teeth, then how does your dentist decide what’s right for you?

Natural teeth are going to be everyone’s first and best option. You get the first two sets of teeth for free – they’re given to you, as part of your body. If you’re fortunate enough to have parents who were able to take you for early dental care, who reminded you to brush your teeth regularly, who did their best to manage your habits and your diet, then you are less likely to need a third set of teeth. Without getting into details, let’s agree that anything dentist-made in your mouth which takes the place of natural teeth is part of the “third set.”

That dentist-made stuff, though, is the set of teeth that ends up costing a lot of money. Fixing teeth is how dentists stay in business, after all. But it’s also where insurance breaks down, on that third set of teeth. Even the best plans only cover, at most, the dollar equivalent of about 2 dentist-made teeth per year. If you have 28 teeth, that means you’ll have to use up all your benefits, every year for 14 years to get your third set of teeth paid for. If your insurance only pays for 2 teeth per year, but you have 10 teeth that are in trouble, what do you do, only treat a few and let the others all rot while you’re waiting on your insurance checks?

Something else you need to admit to yourself is to make the realization that you’re not immune to the lure of the bargain. Too often, that’s all dental insurance is. It’s sold to you as a bargain, or something that you have to have to get in the game, when the reality is that it’s only a game. Take this example:

Yep, that insurance made a $755 dent, which is big. But at what cost? Were the fillings and crowns built to last, or will they need to be replaced in less than five years since you felt you had no other dentist who would take your insurance and the one that you did go to didn’t seem to do that great of a job?

Let’s back up now and talk about your first two sets of teeth. You get the baby set as a toddler, the other set as you grow up. Both of those sets of teeth don’t cost anything; they just sort of show up one day, ready to get to work. And they need a dentist to check in with them every so often, to say hey, howya doin? Everything all right in there?

That’s what most people think of as a check up, and if you’ve had good luck with your teeth so far, it’s safe to say that having at least one dental visit per year will assure that someone’s keeping a professional watch on them.

Checkups are cheap.

Can you afford $50 per year? That’s the current average cost for a routine dental checkup in the US, across all dentists – city dentists, rural dentists, group dentists, solo dentists.

If dental checkups are not crazy expensive, then why isn’t this common knowledge?

Have you assumed that basic checkups cost more than $50? If you have, you’re like most people. It’s probably why you’ve been worried about the cost of going to the dentist, why you’ve been worried about not having insurance, why you make sure that the dentist you choose takes your plan, why you visit low cost clinics. You haven’t known the cost of the alternative.

This knowledge is your power. You can go to any dentist, and $50 is the average price for a periodic examination – this what they will charge to take a look at your mouth during a routine visit. It’s a little more for your first time, say $75-$100. A series of four bitewing xrays? Usually less than $60. Certainly not free, but all together not as much as you may have imagined.

So let’s bring insurance into our discussion once again. Remember, insurance, for everything except your body, pays nothing until there’s an unexpected event. A dental checkup is not unexpected – it’s prevention! And if you’ve ever worked with dental insurance, you know this: Almost every dental insurance policy completely covers the cost of a checkup. But they don’t do so universally. With many of those checkups, your insurance will only cover the cost if you visit certain dentists.

Dental insurance pretends to pay for your teeth.

If it really paid for them, like insurance is designed to do, it would cover the unexpected problems, especially in emergency situations. Instead, dental insurance gives you just enough coverage to make you feel like it’s a value, and scares you into thinking you can’t go to the dentist without it. Most plans offer a fixed dollar amount, around $1000, to use per year, and that’s it. If repairing your teeth costs significantly more than your maximum, it’s not protecting you. Dental insurance shouldn’t even be called insurance, because it works more like a dollar-off coupon. $1000 off of a $6000 treatment plan is at best only a 17% discount. Call yourself a sucker if you tolerated care at your “in network dentist” so that you could get less than 20% off the cost of going to a dentist of your choosing.

Dental insurance changes how dentists care for you.

We have been conditioned to believe that a procedure must be the right thing to do because “insurance will pay for it.” There is a sweet spot, right in the middle of insurance plans that covers so much more of a percentage of the total cost than either end. People with healthy teeth get basically a 20% discount for the cost of their care after taking premiums into consideration. It’s also 20% off of the cost of really expensive needs like crowns and dentures. But look how the dental benefit skews within the middle tier of dental needs:

Whoa! It jumps up to 60%. This can go one of two ways:

1. There are a few things you really need to have done, and insurance will help out a lot!

2. Your insurance will get billed for stuff you don’t need because you won’t have to pay for it yourself.

This doesn’t bother me all that much for preventive care because it’s not permanent and mostly reversible. But when dental offices intentionally “massage the insurance” to abuse this 60% sweet spot, a dentist might take a drill to a tooth that didn’t really need it, and guess what? You’re damaged. You’ve actually been broken by someone you trusted to take care of you. They took out a piece of your tooth, forever, and you can never grow it back.

Destroying healthy tooth enamel for profit makes me angry.

I’ve seen this dressed up at dental practices to make it sound like they have patient’s interests in mind. It might be called “their philosophy of care” but really, you’d be surprised how many people exist whose paychecks are dependent upon exploiting insurance codes to get the most money for their practices. “Maximizing fee schedules” is their philosophy of care. And you are a pawn to them. This is the essence of why dental insurance makes good people do bad things.

 

Exploiting Insurance Codes for Maximum Dollars.

Let’s blow this up a little and list some of the ways that insurance is abused. You may want to be on alert when you see these on your treatment plan or billing statement:

Core Buildups. This article from the American Association of Dental Consultants states, “In the last twenty years there have been a reported increase in the number of core buildups submitted to dental benefit plans out of proportion to the increase in crown submissions….Also growing are the numbers of dentists who admit, with no compunction, that they place core buildups under every crown they seat regardless of need. The financial ramifications from this trend are significant since a core buildup can add twenty to thirty percent to the final cost of a crown.”

Periodontal scaling and root planing. Often called a “deep cleaning,” gum disease treatment is the primary weapon against tooth loss, but it is a time-intensive procedure. If an office charges out periodontal therapy but you weren’t even numbed, or it took less than an hour to have treatment in all four sections of your mouth, that’s a reason for your eyebrows to go up. Also, be cautious of any dental office where your routine cleaning appointments seem super-speedy, according to this article, or if you’ve always been healthy like this person.

The need for many fillings suddenly. You’ve been off and on with regular dental care, and have had few fillings in your life. Then you visit a new dentist and are told that you have a lot of cavities. According to this article from the New York Times, some doctors may wait longer than others and “watch” small cavities, but if you feel suspicious, you should definitely seek a second opinion before the drilling starts. One pediatric dentist’s editorial on the ADA website goes so far as to call this “creative diagnosis.”

Replacement of silver fillings. Sure, they don’t last forever. But silver fillings do typically last longer than tooth-colored fillings, and if there is no pain or an obvious hole or cavity in a tooth with one, most dentists won’t try to scare you into changing them out, especially not all at once. The National Council Against Health Fraud issued this statement defending amalgams. I personally have six silver fillings that are around 40 years old, and they all still feel better than the two that were replaced.

Procedure Upselling. Any time a dental practice uses intimidation to get you to agree to something, that’s wrong, regardless of whether or not the treatment is appropriate or covered by insurance. Don’t ever feel pressured, especially if you’re in a vulnerable position, to agree to whitening, bite guards, cancer screenings, or even orthodontic care. A reputable dentist will let you take your time to make decisions about your mouth.

Suspicious dates or billing. Look over these examples of fraudulent and abusive practices; these may be signs that a practice is illegally obtaining insurance benefits on your behalf.

Preventive care is not immune.

With preventive care, dentistry as a whole tends to over-treat because, after all, “insurance will pay for it.” Big Deal, We took better care of them than they needed, who cares, we all win, blah blah. When someone feels entitled to an insurance benefit because, by George, it needs to be worth SOMETHING for all those dollars, that’s when you’ll agree when your hygienist says “see you in six months.” I guarantee that every hygienist has patients for whom getting their teeth cleaned every six months is complete overkill. Some people simply have nothing on their teeth to clean off. We spend most of your appointment scraping at stuff that’s not even there, despite our best efforts to find it. I’ve done it, lots of times, and it’s frustrating because the patient expects a cleaning every six months and we truly want everyone to feel like we’re helping them stay healthy.

That’s what I mean. There is no motivation to correct the situation. The insurance pays for cleanings every six months, so no one will challenge the perception that having your teeth cleaned twice a year is not necessary. Money is wasted, but to the patient, they “miss out on their free cleaning.”

This gets super abused in dental practices that are dependent upon patients who have insurance to stay in business. The more dependent, the more likely the abuse. That’s not to say that most dental practices are doing their best to stay within the standard of care, while carefully checking everyone’s insurance plans. Cleanings twice per year? Checkups twice per year? X-rays once per year? Everyone is treated the same. The six month visit is a safety net, and both patients and clinicians accept it because of what insurance covers, not because treatment is necessary.

On the other hand, insurance dependence can also can cause a dental practice to neglect your needs. The dentist is less likely to tell a patient to have X-rays every six months if their insurance doesn’t cover it, even if the person is suffering from severe dry mouth that is resulting in a lot of new problems that can be diagnosed with the help of more frequent imaging. If you need your teeth cleaned more often than what your insurance will pay for, an office may simply let that recommendation slide past. You are much less likely to get personalized care when you allow insurance coverage to dictate what gets done, and when. You’ve allowed yourself to be seen as “the person with insurance who is not going to pay for anything that it won’t cover.” Even if you don’t feel this way. It’s like a trap. Not just to patients, but to clinicians as well.

The Five Traps of Dental Insurance.

Trap #1: DMOs that bill for treatment above and beyond their negotiated rates. Dental Maintenance Organizations are lowest tier of dental insurance. Dentists on these plans get capitations, which are small monthly payments for being on the provider list. To be profitable they need to bill out as much treatment as they can. Patients have come for second opinions (note: always get a second opinion if you’re unsure!) after visiting a DMO practice enough times for me to see a consistent trend of overcharging for excessive care; not just hundreds, but for thousands of dollars of treatment, out of pocket. If you have insurance that only lets you go to one or two clinics that have many doctors who cycle in and out of the offices, you probably have a DMO plan.

Trap #2: Missing Tooth Clauses. Sometimes having a tooth removed is the least expensive way to get out of pain. If you’ve ever lost a tooth, unless you had your existing insurance in place, the replacement of that tooth in the future won’t get covered. So much for getting your teeth back to working order. To the insurance company, a missing tooth is considered a pre-existing condition, so it’s your responsibility, not theirs.

Trap #3: Waiting Periods. Now you have insurance, but you’ll have to wait six months to a year to pay into the system before it might give you that money back, plus a little more? Individual dental insurance plans are notorious for waiting periods.

Trap #4: Major treatment. We’ve already established that less expensive the dental service, the more likely your insurance is to cover it. What about the expensive stuff? If it costs more than $300 per tooth or section, then your insurance will most likely only cover half of that. Ever. End of story. Need dentures? A crown? A wisdom tooth removed? You’ll have to pay at least half the bill, if not more, even if you followed the rules and went to the dentist on your plan.

Trap #5: Discount dental plans. There’s one type of discount plan you should run, run, run away from – those are the referral services. They’re not really even discount plans, if the truth must be told. You pay a fee to a third party. That third party gets to keep some of your money, and in return you receive a list of dentists who will “accept” a reduced cost for a few treatments. In the meantime, the third party often encourages the dentists on their list to compensate for their reduced fees by billing for services not bound by the discount plan. I would be cautious of any dentist who uses this method to find new patients.

There would be no game of chess if the pawns refused to play.

So how do we encourage good people to stop doing bad things because of dental insurance? There’s only one way: Stop the flow of money! Have a crappy dental plan? Don’t allow your money to fund it. And if insurance abusers have no patients, they’ll eventually stop the bad behaviors.

You’d be surprised how many dentists out there would be thrilled if even half their patients decided to do everything they could to save money. The reason most dentists got into the profession? They love knowing that they’re helping people. And if the main reason you go to the dentist is to save money in the long run, they will be pleased that you chose them to partner with you to work towards that goal.

You can afford to go to the best dentists in town.

What if you could always visit the absolute best dentists, the ones that you thought only the most wealthy people visit, and you would get better and cheaper care there?

You can, and you should. The best dentist is the best, not because they cost the most, but most of the time, because they cost what you decide they cost. The best dentists have built something very important in the community that brings many people to see them.

This is where the biggest, most powerful word in dentistry comes in.

Trust.

That word goes both ways. Too many dentists don’t trust their patients to make good choices about their teeth, so they often only present one option. This is it, period. This is what your mouth needs, like it or don’t, but this is what you need, and what it costs, and this is just what we do around here and how we do it.

Instead, a good dentist will listen to the people they serve carefully, and trusts that the patient will share enough about their concerns to be able to formulate several options, not just a single option, especially for more complex care. If the financial burden even to get someone out of pain is too much, the “best dentist” is still the best value for an honest opinion. Think of them as the gatekeeper, the one who knows which dentists in your neighborhood to steer clear of, the ones who do not seem to value trust.

But they don’t take my insurance.

Seriously, you came through all of this with me, and you’re still stuck on insurance? Do you want dentists to treat your insurance, or do you want them to treat you? A good dentist’s goal is to put you in charge of your own care, and follow your values as much as possible, which is how you’ll truly end up saving money.

Should I keep using my insurance?

Sure! If you’re lucky enough to have even minimal dental insurance and you trust the practice where you’re already a patient, there’s no compelling reason to make a change just because you’re not happy with your plan. If not, it may be time to find a real dental home, one that will do honest work for honest pay, and not play games with your health, your money, and your insurance company’s money.

What is the best dental insurance?

You are fortunate if your dental insurance policy has just one or more of the following features:

  1. You pay nothing extra per month for your dental plan.
  2.  You can go to any dentist you want.
  3.  You have no maximum dollar limit.
  4.  Major services are paid for at 80%.

If none of these apply, then your insurance probably costs you more than you receive from it. My suggestion would be to opt out of your dental plan and let yourself get paid a little more per month instead. Then if you simply must be on a plan, many dentists offer their own form of in-house insurance, where you pre-pay for your preventive care each year and in return you get a percentage discount for any other services you’ll need. It’s sort of like a twice-yearly gym membership, with reduced pricing for personal training sessions.

I still wish someone else would pay for my teeth.

Me too! Wouldn’t that be great? But there came a point in my life where my parent’s money stopped being my dental insurance. I had to accept that my teeth were my responsibility, and that I would have to find a way to help them stay as natural as possible. Even with a career working daily in a dental practice, I’ve always had to pay out of pocket for the level of dental care that I value. One cleaning, checkup, and set of X-rays per year costs about $150 in my area, which isn’t worth jumping through insurance hoops for.

In the meantime, if you don’t have someone else paying for your teeth (like a rich relative or a great insurance plan), go to the best dentist you can find, explain that you’re done with “what insurance will cover” and ask them to treat you like a human being instead. You might just be surprised at the quality of care you receive for the cost.

And none of us, on either side of the equation, will miss the dental insurance game, not one bit.

 

 

Trish Walraven, RDH BS is a dental hygienist in the Dallas/Fort Worth area who is proud of the quality dental work that was placed in her mouth as a child and is still keeping her teeth strong today. She champions those who will not accept anything less than good dentistry, and hopes that her explanation of dental insurance and its flaws inspires you to share this article’s message with your friends, family, patients and colleagues.

 

References and further reading:

How not to get ripped off at the dentist:  https://askthedentist.com/
Dental insurance: A systematic review: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4278106/
USA 2016 Dental Expenditures: http://www.ada.org
Dental Insurance “Scam” or Not: https://collegetimes.co/dental-insurance/
A screenshot from a referral/payment service:  Cost Comparison screenshot
Sealant review of the literature: http://citeseerx.ist.psu.edu/
How to Know when Tooth Fillings are Unnecessary: https://www.wikihow.com/Tooth-Fillings
The Truth About Dental Insurance: https://www.blodgettdentalcare.com/
Dental Insurance: Facts and Reality Checks: http://www.dentalleaders.com/facts/
Dr. James Pedersen, DDS. Dental Dilemma: My Experiences in the Dental HMO Field
Misrepresentations to Consumers: A Dark Side to Dentistry. http://www.dentistrytoday.com/news/

Thank you also to Concerned Dentists of Texas – https://concerneddentistsoftexas.org – for their help in mobilizing dentists to get this story out to their patients and the public.

Filed Under: Dental Debates, Featured, Money, Practice Management, Preventive Care Tagged With: affording a good dentist, best dental insurance, dental insurance, dental overtreatment, good dental practice, How insurance works

Should dental hygienists give shots?

March 15, 2017 By Trish Walraven 13 Comments

healthyteeth212

When people talk about what they hate most about going to the dentist, they’re usually talking about the needle. I mean, who in their right mind would ever consent to allowing another person to give a shot in a place that has as many nerve endings as our tongues, lips and cheeks? Shots in the mouth are pretty dang scary. And when you’re trying to calm down and prepare yourself for an injection, it’s almost worse than trying to relax for the air-burst thingy they do at the optometrist’s office when you’re getting your eye pressure checked.

cottonrollssyringe

And yet, anyone who has had significant dental treatment performed has allowed someone to inject their mouth with a needle, right? We’ve all accepted the fact that shots are so much better than the actual thing that we hate about going to the dentist.

Pain. Pain is what we really hate.

And shots? They make pain go bye-bye. No shot? You’re all-knowing (in a very bad way) about every little thing that is getting fixed in your mouth.

But you already realize this unpleasant truth. What you might not know is that there’s a stink in Texas right now about who can give shots at the dentist’s office and who can’t. Here’s a little backstory: Dentists go to college for 6-8 years to learn all the things they need to do in order to be dentists. Dental hygienists are in college for 2-4 years to learn everything they need to learn in order to be dental hygienists. In states that allow dental hygienists to give shots, their anesthesia education follows the same curriculum as dentists. These states also test dentists and hygienists to make sure that they are qualified to give shots before granting their licenses.

In Texas and five other states, this is not true. A dental hygienist’s education in regards to anesthetic delivery is considered inferior, and therefore, allowing hygienists to stick a needle in a patient’s mouth allegedly places the public in unnecessary danger.

On this map, you’ll see red states, with years next to their abbreviations. These are the states that allow hygienists to give shots, along with the dates when administration and licensing first became available.

redstates

 

Do I think that Texas should allow dental hygienists to give shots just because “everyone else is doing it?” No. We tried being our own country once, and if we still were our own country we wouldn’t care one tiddly bit what was going on in the US.

The reason that Texas should allow dental hygienists to give shots is simple:

We are tired of hurting people.

The alternative is to ask the dentists we work with to leave a hole in their schedule so they can come give a shot for us. And come anesthetize again if the first time didn’t work. And again if our patient is still in pain.

Here in Texas, hygienists learn to say “I’m Sorry” a lot to our patients, instead of continuing to interrupt our dentists.

Thankfully, most of our patients don’t need shots. Those who come regularly have healthy mouths and their visits with the dental hygienist are preventive in nature, comfortable, maybe even relaxing. But take a person who has been scared to go to the dentist for a while and they’ve noticed that their gums bleed when they brush. There are sores in their gums, and guess what? The treatment it takes to heal up those sores can hurt! Hygienists in all states are highly trained to provide this deeper therapy – it’s what we “really” do. And if there are obstacles to providing this treatment painlessly, well, it’s either not going to be painless, or else the treatment won’t be as thorough as it would have been if it would have been if the patient had gotten completely numb.

Last week’s hearing of the Texas Senate Committee on Health and Human services highlighted the stances of those both in favor and against granting dental hygienists the permission to deliver local anesthesia, in other words “give shots.” The original video was 2 1/2 hours – I’ve shortened it down to a little under 40 minutes of testimony only about this bill, edited out all the procedural or repetitive bits, and left the juiciest parts behind.

Full video of the archived meeting: http://tlcsenate.granicus.com/MediaPlayer.php?view_id=42&clip_id=11813

Here are my bullet points, yes… •Bullet •Points for this committee meeting:

• The map handed out in the chamber is the same one you see in this article (feel free to scroll up and follow along).

• The bill is permissive, not mandatory. If a dentist does not want to allow a hygienist in their office to give shots, they can’t. Furthermore, dentists must be present in the office for hygienists to administer anesthetics.

• No evidence of harm is presented in any testimony. Scroll to 18:45 where you’ll see Dr. Scott Dowell testifying for the Texas Society of Periodontists against this bill. His admission of the relative danger of local anesthesia is…interesting.

• The Texas Dental Association states that they opposed to this bill due to patient safety because they feel that it lowers the education standard and it’s only about expanding dental hygienist’s scope of practice, possibly to open the door to independent practice by hygienists.

• Dr. Matthew Roberts, who represented the Texas Dental Association, seemed surprised to learn that physicians are legally allowed to delegate the duty of administering anesthesia shots to even medical assistants in their practice when this is brought up in the meeting.

• There are 9000 members of the Texas Dental Association, but in a poll, 53% of the members were actually in favor of hygienists giving shots.

• The amount of training dentists receive to legally put patients “to sleep” is less than the training hygienists receive in order to be legal to give shots.

If you’re not convinced by this video, then you didn’t actually watch it (my opinion, sheesh!). But if you did watch it and still feel like hygienists are unqualified to give shots, your voice is very important to us right now. Maybe there are more problems with hygienists using needles, maybe there are negative reports that haven’t been correlated properly. Do you have concerns? Post them here in the comments below. I’m serious – if there is a compelling reason that is being hidden from the public and even from hygienists, we all deserve to know the truth.

At this point, though, if the day ever comes when I’ll be able to give my patients shots, it will be like someone trusted me with the most delicate equipment available in the Compassion Toolbox. It is a precious gift to be able to deliver painless dental care, and for those in the caring business (which most of medicine is, if you think about it) sometimes it’s the best gift we can give to others.

Yuck, ick, too late, the mush landed. Bottom line? Please don’t hate me if I ever get to stick you with a needle.

 

 

Trish Walraven RDH, BSDH is a dental hygienist who lives in the suburbs of Dallas/Fort Worth. She longs for the day when she can drop a couple grand of her own money and leave her family to take a week-long college course, just so she can sit for an anxiety-provoking board exam that will grant her the license to poke a shot in places that no one wants poked. Goals, man. Goals.

UPDATE 4/5/2017:   The April newsletter from the TSBDE states that SB 430, which would authorize dental hygienists to administer local anesthetic was heard in the Senate Health and Human Services Committee on March 8, 2017.  The committee considered testimony both for and against the legislation.  The bill was voted out of the Health and Human Services Committee on April 5, 2017 with some changes.  The change is that only infiltration administration would be permitted.  The bill is now waiting to be scheduled to be heard by the full Senate.

Filed Under: Dental Debates, Featured, News, Operative Dentistry Tagged With: dental anesthesia, TDA, Texas dental hygienists

Battlebots: American Eagle vs Hu-Friedy

July 16, 2015 By Trish Walraven 9 Comments

Do you want to see a secret video of one dental hygiene instrument killing another? Sure you do.

But first, a confession: It’s not really secret. This video has been on YouTube since May of 2013 but as of the time I’m writing this it’s had less than a thousand views. I find it to be pretty scathing.

How can a video about dental curettes be scathing?

Because it challenged my opinion about my beloved Hu-Friedy instruments, that’s how.

As hygienists, we’ve been taught to “click” calculus deposits off of teeth. If you have a traditional stainless steel instrument, it needs to be sharp so that it can dig into the deposit, right? Right.

There’s sharp, and there’s hard. Sharpness is what gets you “clicking” the calculus off.  Hardness is… well, it can shift your whole method of OMG YOU WANT ME TO SHAVE WHAT? instrumentation.

We’ll get back to shaving and being hard in a little bit. (!) What I want you to do now though is to watch the video below so that you can understand the rest of this post (just please ignore the first 40 seconds of suck):

What just happened there? Pretty simply, there’s this thing called the Rockwell C hardness scale that measures the hardness of metal, it’s on a scale of 1-100, and when cryogenically-processed steel with a hardness of 60 meets plasma spray-coated steel with a hardness of 89, the softer metal is going to get damaged. That TOOL done got OWNED.

And why does this matter now? These two curettes, one made by American Eagle Instruments and the other by Hu-Friedy, are apparently in direct competition with one another, and Hu-Friedy is making a big stink about the claim that American Eagle’s instruments are sharper.

“Mine are sharper!”

“No, Mine are!”

It’s like that. You can pretty much ignore both sides, and take the marketing for what it is. LOOK AT MY SHINY NEW STUFF IT’S THE BEST (i love youuuuu).

Whatever. Especially the I Love You part. So, you remember Nevi 4, right? – the Traveling Plushie Scaler?

nevi4trishmolly

here I am hanging with Nevi and my co-hygienist at the ADA meeting in Vegas.

My mini-Nevi watching TV with his buds like he does sometimes.

No, I will NOT be posting the photos from that crazy after-party thing that happened with all Nevi’s friends – you know, the Travelocity roaming gnome, Chester Cheetah, the Noid, Stefon from SNL, yeah, that crowd – because I’m not going to give you blackmail material on me like that. But I did just make you look at a picture of my cutsie wootsie doggies, aren’t they just the most adorable schnauzers ever?

Anyways….

So yes, I understand the loyalty thing we’re supposed to have with a company like Hu-Friedy that respects hygienists and is nice to us and is the market leader and the oldest in the business. But sometimes, a product comes along that is actually different enough to give it a chance.

I’m going to say it. I think harder is better.  (shut up, the person who just muttered “you would.”)

Step to the left, Nevi plushie. You have your soft place in the world, and American Eagle XP has its place as well.

What I’ve noticed with using the XP instruments and their hard coating is that the texture of calculus feels really different. Like, it’s softer. Like, I don’t click it off. I shave it off.

SHAVE.

Shaving teeth instead of scaling? It’s really, really weird, but I like it. Who ever thought that you could slice through calculus like you’re carving a turkey? But it feels like that. Instead of biting off the whole chunk of tartar at once, the XP technology lets you lighten up your touch in an entirely different way than you do with even the sharpest stainless steel instrument.

Now, there is a down side to owning American Eagle XP instruments over traditional stainless steel ones – you have to baby them a little more because they can bang up against each other and shorten their lives. That part irks me, of course, because not only do I not want to have to put my instruments in cassettes, I don’t want to ever have to sharpen them either like you do with the Hu-Friedy EverEdge. I’m stuck somewhere in the middle.

And yeah, there’s that “sharp” thing again.

According to the study that was released yesterday by Hu-Friedy, compared to American Eagle XP instruments the Hu-Friedy EverEdge instruments will always be sharper. Also they launched the claim that XP instruments wear out faster because they aren’t able to be sharpened.

Does this mean Hu-Friedy is fighting back?

Well good then. That means they’re probably feeling threatened by a smaller, newer company, and competition is better for progress. It’s good for us because it means that we get to evaluate free instruments from both Hu-Friedy and American Eagle. And good for dental hygiene as a whole, too, because you’re not going to let a little emotion of loyalty get in the way of some good old-fashioned brawling to win your business. You’re free to explore all your options.

Let the metal shavings fly, and you know what they say about having competition, right? Steel sharpens steel. Iron sharpens iron.

And may we all have better instruments for it.

 

A blogger since 1997, Trish Walraven, RDH, BSDH is a practicing dental hygienist in the suburbs of Dallas, Texas and marketing manager for BlueNote Communicator, software that keeps dentists running on time for their hygiene checks. She’s having to take back the “harder is better” comment now with her new mattress. Oops.

 

 

References:

Hu-Friedy Commissions Independent Study to Evaluate Scaler Sharpness:
http://www.enhancedonlinenews.com/news/eon/20150715006545/en/sharp/scaler/dental 

RDH Magazine: No More Dull Instruments!
http://www.rdhmag.com/articles/print/volume-32/issue-5/features/no-more-dull-instruments.html

The Uncoated Truth:
https://www.hu-friedy.com/TheUncoatedTruth

RDH Magazine: How instruments increase productivity
http://www.rdhmag.com/articles/print/volume-33/issue-4/features/how-instruments-increase-productivity.html

That was cool, right? The shaving thing? Be sure to share this video with everyone that didn’t realize that SHAVING is what XP is all about.

Filed Under: Dental Debates, Featured, Instruments

Is Arestin® a red flag?

September 5, 2014 By Trish Walraven 68 Comments

placementflags
Not long ago, all dental practices were owned by the dentist who took care of you. Sure, they might not have given you any anesthetic before they smashed silver crunchy metal into your cavities, and they may have slapped you around and given you Post Traumatic Stress Disorder any time you thought about opening your mouth wide for anyone, but at least you knew that the dentist shoving their knuckles into your nostrils was the one dictating how things were done around there.

Since then, dentistry has gone all Wal-Mart on the public. There are thousands of dental offices that are part of large chains, where the dentists who take care of you are merely employees, where the quality of dental care provided to patients is secondary and instead the amount of profit generated by each provider becomes the indication of that person’s worth within the company. Can you imagine a leaderboard, like in a sales department, where all the dentists’ production numbers are on display for the entire office, so it’s a race to see who can make the most money?

LeaderboardDental

As a patient, don’t you get giddy at the thought of being ridden like a thoroughbred horse? Me neither. My health is not a commodity.

Dentistry is a little different creature than regular medicine in the sense that TEETH ARE OPTIONAL. You can be a very healthy individual, only with no teeth. It’s kind of like having a hand amputated – your quality of life may be affected, but a hopelessly infected hand should be removed and replaced with a prosthetic. If your body is rejecting your teeth for whatever reason, that’s when there are health concerns as well. Dental professionals make it their life’s work to help you keep your teeth in as close to original condition as possible.

The problem is that when money is involved, you can bet that there are those who will abuse this relationship. There’s scare tactics, there’s bait-and-switch, there’s all the usual sleazy sales pressure used to extract as much income from each patient as possible. New patients often bring us treatment plans that they are unsure of, looking for second opinions, trying to figure out why they don’t trust the previous dental offices’ diagnoses. I just want to say it straight, “They’re taking you for a ride, dear.”

Whip. Whip.

Well crud, I never wanted this article to be an analogy of horse racing with the big hats and Bourbon and milk-drinking and jockeys. So, let’s start over and begin talking instead about Red Flags and Grey Areas.

redflag

Red flags, of course, are the signals you get when you realize something that seems good, isn’t so good. Red flags are big fat warning signs.

 

Greyarea
 

Grey areas, are, well, not really black and not really white.  Grey areas are where black and white kind of blur into each other, and sometimes they end up looking a little suggestive (!) like the image above. Yeah, sorry about how weird that looks when I take it out of context.

When it comes to the health of your mouth we usually look at two things: your teeth, and the stuff that holds your teeth in your mouth. That’s what we’re going to talk about in this discussion, what you think of as your gums. Dental professionals call this part of you your periodontium. If your gums are in excellent condition, you have what is called periodontal health. On the other hand, if your gums are seriously letting go of your teeth you have periodontal disease.

 

 

As you can see, the biggest part of this diagram is the Grey Area. This is where most people land, especially if they haven’t been to the dentist in a while. Even if your front teeth are mostly healthy often you’re automatically categorized into the Very Diseased category because you have too many spots in your mouth that are infected with bacteria to treat you as a Very Healthy person. That’s when you’ll get a treatment plan designed to minimize the effects of your disease.

When your mouth is in the Grey Area, this is where treatment recommendations can vary the most from office to office and even from person to person. Almost every dentist will prescribe the same treatment course if your case is black and white (very diseased or very healthy). If you’re in the Grey Area though, this is when Red Flags will start to stick out.

There’s one Red Flag in particular that keeps showing up. Arestin® is a yellow powder containing minocycline microspheres – an antibiotic designed to help diseased gums heal faster. The powder is puffed deep into an infected spot under the gumline where it hardens upon contact with moisture and time-releases the antibiotic for about three weeks. Here’s what the package of cartridges looks like, with the yellow powder in the tip:

cartridges

 

Arestin is a great product! I’ve seen stubborn gum disease completely disappear when we’ve used it very selectively in our practice. So the Arestin itself isn’t a problem. The problem is how it’s being prescribed.

Say you had your gum disease treated with scaling and root planing (a “Deep Cleaning”), but a few spots are still unhealthy a month or two or three later. If your dentist or hygienist sees that you still have open sores that are higher than a certain parameter (over 4mm is considered the standard) this is when Arestin therapy provides the most benefit.probingexample

So when is Arestin a Red Flag? You’ve visited a new dental office, and not only are they recommending that you have treatment for your periodontal disease, they’re also saying you need a course of Arestin to be placed on the same day that you have your initial treatment. It’s even a bigger red flag if you floss regularly and never see your gums bleed.

The thing is, Arestin isn’t cheap. Just a single cartridge costs your dentist upwards of $15. Then there is the insertion fee; in other words, what the patient is billed for placement, and than can run as much as $60 per site.

Here’s where it gets crazy. An average mouth has 28 teeth. Each of your teeth has as many as six sites where Arestin can be placed. Let’s see, that’s $90 in material costs, $360 in placement costs. That’s potentially going to cost you $450 – per tooth.

You’re seeing the big picture now: treating gum disease can be quite profitable! This is why Arestin is such a big deal in the offices that are part of corporate dental chains designed for maximum shareholder profit. This antibiotic is marketed to dental professionals as a way to help us make money, all in the name of “helping our patients.”

So how do you end up getting prescribed Arestin therapy if your mouth is pretty healthy? If your hygienist or dentist was instructed to “force the probe” to create a deep measurement, that’s how. Stab ’em hard and voila! Fake gum disease! Here’s a story that exposes some of the bad things that have allegedly happened in corporate dentistry, including this example:

http://www.pbs.org/dentalworks-chain-misdiagnosed-for-money-dentists-say/

As you can see, lots of other stuff can be exaggerated as well to make sure that the dentistry performed on you is as profitable as possible. For now, though, we’ll stick to talking about the Red Flag, because this one cue may help you decide whether or not you’re being over treated.

Here are the professionally accepted general guidelines about Arestin usage, then:

Appropriate therapy gridNow please don’t use this to go and bash your well-meaning dentist and hygienist, or the Arestin company, or worst of all, to justify the reasons you tell yourself why you don’t go to the dentist ’cause it’s all one big scam and you can’t trust anyone. Most of us really do want the best for you.

The point is simply this: if more people understand the difference between dental care that is patient-centered and dental care that is profit-centered, then greedy dental corporations are less likely to thrive.

If you think you have ever had this happen to you, I wrote this story for you. For you, so that you don’t feel so dumbfounded the next time you wonder whether or not a dental office is looking out for your health or only for their own. As a hygienist who knows fraud when I see it, I wanted to be sure that patients have a resource to help them defend themselves against predatory practices.

I’d like to end this with a small confession, then: I actually love placing Arestin, because when the dentist and I decide that it’s a good fit for a stubborn case of gum disease, it just feels so right.

So much for being objective.

 

 

References and resources:

Explanation of insurance coding of Arestin therapy after initial SRP: http://www.practicebooster.com

An example of Arestin-based fraud in a DHMO: http://caldentalplans.org/downloads/Henderson.pdf

Arestin drug label and study that shows slight improvement of using Arestin with SRP vs. SRP alone: http://dailymed.nlm.nih.gov/arestin

Criticism of Arestin studies and concerns about Arestin therapy : http://periodontist.org/is-arestin-a-therapeutic-treatment-for-reducing-gum-pockets/

A blogger since 1997, Trish Walraven, RDH, BSDH is a practicing dental hygienist and marketing manager for an indie dental software development company. Her mission with DentalBuzz is to offer a fresh podium of discourse for those involved in dentistry and to expose fun in our professional lives.

Filed Under: Anecdotes, Dental Debates, Featured, Money, Operative Dentistry Tagged With: antibiotic use in dentistry, Arestin, corporate dentistry, dental fraud, minocycline, periodontal disease

Crest toothpaste embeds plastic in our gums

March 4, 2014 By Trish Walraven 347 Comments

This is polyethylene:

bottlesandbags

Did you know that polyethylene is the most common plastic in the world? It is used primarily for containers and packaging, such as these bottles and plastic grocery bags, and has been a concern for the environment because polyethylene lasts practically forever and isn’t biodegradable. It only breaks down into smaller and smaller particles until you can’t see it anymore. That’s why a couple of states are trying to ban it in body scrubs and dental products.

This is also polyethylene:
PeasizedTPaste

Well, not all of it. Most of it is toothpaste. But do you see those blue specks? That’s plastic. This is the suggested pea-sized amount that you should use when you brush your teeth. Yes, there is plastic in this toothpaste.

Want to see how many pieces of plastic are in this exact sample?

PasteSmear

Not that I’m counting the bits but that seriously looks like A LOT of plastic… err…high density polyethylene. That’s what plastic trash cans are made from! If you throw away the box like most people do, the ingredients aren’t actually listed on the tube (sneaky, sneaky, Procter & Gamble!) However, I was able to track down the box here at this link. We’re not talking about polyethylene glycol, which is soluble in water. This stuff won’t dissolve in water, or even acetone or alcohol for that matter. How do I know it won’t dissolve? Because I put on my little scientist hat and tested it.

Like many of you, we often let our daughter pick out her own toothpaste at the store. She liked the tween vibe of this particular product so much that she chose it twice, but eventually the squeezed-out tubes ended up in the back of her toothpaste drawer.

Crestforme

When I first got wind that plastic was in some toothpastes, it was kind of exciting to realize that we had some on hand! And a bit concerning, because, after all, this is in my own home, used by my own child. Able to confirm that, sure enough, there was polyethylene in this toothpaste, I squirted out a pea-sized sample, mixed it up with some water, strained out the undissolved particles and let them dry on a paper towel. Oh, and I used a hair dryer to speed things up because I’m impatient. Then I shook approximately half of the sample into each of two pyrex bowls and added some household solvents:

acetonealcohol

They didn’t dissolve in the acetone, (nail polish remover) or in the alcohol either. I even left the samples in the solutions overnight, then re-hydrated them. No change in the particles.

specks1polyethylenefinger

So it has been established here that polyethylene will not dissolve in the mouth, or even in household products. It is an inert substance, which means that it doesn’t change at all. You know, that’s pretty good in some ways, because at least it’s probably not morphing into big blobs of plastic evil cancer bait.

Here’s where the story gets scary, though.

You see, I’m not just a concerned mom. I’m also a dental hygienist. And I’m seeing these same bits of blue plastic stuck in my patients’ mouths almost every day.

Around our teeth we have these little channels in our gums, sort of like the cuticles around our fingernails. The gum channel is called a sulcus, and it’s where diseases like gingivitis get their start. A healthy sulcus is no deeper than about 3 millimeters, so when you have hundreds of pieces of plastic being scrubbed into your gums each day that are even smaller than a millimeter, many of them are getting trapped:

plasticingums

The thing about a sulcus is that it’s vulnerable. Your dental hygienist spends most of their time cleaning every sulcus in your mouth, because if the band of tissue around your tooth isn’t healthy, then you’re not healthy. You can start to see why having bits of plastic in your sulcus may be a real problem, sort of like when popcorn hulls find their way into these same areas. Ouch, right?

Like I said, I’ve been seeing these blue particles flush out of patients’ gums for several months now. So has the co-hygienist in our office. So have many dental hygienists throughout the United States and Canada who have consulted with each other and realized that we have a major concern on our hands.

This is what an actual polyethylene speck looks like when it’s embedded within the sulcus, under the gumline:

gingival specks

I am not saying that polyethylene is causing gum problems. I’d be jumping too soon to that conclusion without scientific proof.  But what I am saying definitively is that plastic is in your toothpaste, and that some of it is left behind even after you’re finished brushing and rinsing with it.

Do you want plastic in your toothpaste? So far the only mention of polyethylene on the Official Crest website at this link is that it is added to your paste for color, not as an aid in helping to clean your teeth or to disperse important anti-plaque or anti-cavity ingredients. [Note: as of 9/3/14 Crest took down the link about polyethylene, but I saved a copy of it here in case this ever happened.]

In other words, according to Crest:

Polyethylene plastic is in your toothpaste for decorative purposes only.

This is unacceptable not only to me, but to many, many hygienists nationwide. We are informing our patients. We are doing research separately and comparing notes. And until Procter & Gamble gives us a better reason as to why there is plastic in your toothpaste, we would like you to consider discontinuing the use of these products.

Here are some of the brands (click each to see their ingredient list and labeling) that we currently are aware of which contain polyethylene:

• Crest 3D White Radiant Mint
• Crest Pro-Health For Me
• Crest 3D White Arctic Fresh
• Crest 3D White Enamel Renewal
• Crest 3D White Luxe Glamorous White
• Crest Sensitivity Treatment and Protection
• Crest Complete Multi-Benefit Whitening Plus Deep Clean
• Crest 3D White Luxe Lustrous Shine
• Crest Extra White Plus Scope Outlast
• Crest SensiRelief Maximum Strength Whitening Plus Scope
• Crest Pro-Health Sensitive + Enamel Shield
• Crest Pro-Health Clinical Gum Protection
• Crest Pro-Health For Life for ages 50+
• Crest Complete Multi-Benefit Extra White+ Crystal Clean Anti-Bac
• Crest Be Adventurous Mint Chocolate Trek
• Crest Be Dynamic Lime Spearmint Zest
• Crest Be Inspired Vanilla Mint Spark
• Crest Pro-Health Healthy Fresh
• Crest Pro-Health Smooth Mint

What you can do

At this point, it’s probably best if you leave your flaming torches back in the barn. We’re not going after witches or Frankenstein here; you’re using your power as a consumer to send a message that you do NOT want plastic in your toothpaste. Heck, you might even be worrying about what may happen if you or your children swallow some of it.

1. If you’ve already purchased one of these toothpastes you can take it back to the retailer where you bought it, make sure that the manufacturer knows why you’re returning it, and ask for a refund.

2. Lodge a Crest consumer complaint at (800) 959-6586 and report an adverse health effect, namely, that you’re concerned that plastic pieces may be getting trapped in your mouth.

3. Click here to send an email to Procter & Gamble, the makers of Crest.

4. Share this! Let your friends and family know that you are also concerned about the plastic in their toothpaste by clicking on your favorite social media link below and getting the word out.

Response to criticism

Procter & Gamble’s current party line? “We will discontinue our use of PE micro plastic beads in skin exfoliating personal care products and toothpastes as soon as alternatives are qualified.”

And your response then may be, “I will discontinue MY use of Crest toothpaste until there are no more decorative microplastics entering my mouth.”

Trish Walraven RDH, BS is a mom and practicing dental hygienist in the suburbs of Dallas, Texas. She is also the co-creator of BlueNote Communicator, the top selling intra-office computer messaging system for dental and medical offices.

References and acknowledgements

Plastic Trades Industry: http://www.plasticsindustry.org/AboutPlastics
US National Library of Medicine: http://dailymed.nlm.nih.gov/crest
HygieneTown: http://www.hygienetown.com/blue-dots-in-patients-mouths

And a HUGE thank you goes out to my friend and colleague Erika B. Feltham, RDH for bringing this problem to our attention and for her extensive research. Erika is dedicated to providing the best possible care for her patients. She has been active in the dental profession for over 30 years, is a recipient of the 2008 American Dental Hygiene Association/Johnson and Johnson Hygiene Hero Award, the 2010 RDH Sunstar Americas (GUM Dental)Award of Distinction, lectures extensively about the harmful effects of sour candies, energy and sports drinks, and along with her San Diego component, she is responsible for presenting the resolution on sour candy labeling at the 2009 CDHA House of Delegates.

Update on 9/10/14:

As requested, here’s a quick video I made today that demonstrates polyethylene microbeads becoming embedded after brushing. This is for real; I didn’t poke the plastic in my gums (although I may have brushed a little more rough than normal!).

Update on 9/20/14:

This story got picked up nationally over the past week, with these notable entries:

The American Dental Association issued this press release regarding the safety of plastic in toothpaste and whether or not to remove the ADA Seal of Approval on Crest products.

FDA says that plastic is not approved as a food additive: NBC National News – Today Show

Interview in Phoenix, AZ  mentioning the influence of DentalBuzz on Procter & Gamble:

Trish’s interview on Good Morning America:

http://abcnews.go.com/video/embed?id=25560562

Brian Williams on NBC:

http://player.theplatform.com/p/2E2eJC/nbcNewsOffsite?guid=nn_09_bwi_toothpaste_140917

A concise writeup at the Washington Post

And a final word on why we shouldn’t even be so preoccupied with toothpaste in the first place:

https://www.dentalbuzz.com/2014/12/30/toothpaste-can-do-more-harm-than-good/

Filed Under: Dental Debates, Featured, News, Products Tagged With: Crest polyethylene, Crest toothpastes that contain plastic, plastic in toothpaste, Polyethylene in toothpaste

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