Getting a second opinion


Unsure about Dental Work? Get a Second Opinion

7 tips for getting a second opinion

6 questions to always ask a dentist

Dental care concerns from a top-rated dentist

Both Seldin and Dr. Lucio H. Kim, a highly rated dentist in Glendale, Calif., say the lack of standardization may make navigating dental work confusing, so communication is key. “Your dentist should be able to educate you about your mouth,” Kim says. “It’s important they take the time to explain treatments and give you different options.”

With more than 141,000 dentists practicing in the U.S., Kim says patients should shop around if they don’t understand the diagnosis or treatment plan. “Think of dentistry as you would the airlines,” he says. “You always have options.”

Angie’s List member Nancy Kerr says she decided to seek a second opinion after she took her 11-year-old daughter, Camille, in for a consultation with Dr. William Nguyen, an orthodontist in Laguna Niguel, Calif. She says he didn’t smile much and spoke in very technical terms. “I couldn’t distinctively tell what my options were, so getting another opinion seemed like the sensible thing to do,” Kerr says.

She’s now glad she relied on her instinct, because when she told Nguyen she wanted another opinion, she says he became hostile.

“I think he was offended that I’d question his knowledge,” Kerr says. “I’m very glad I saw him react this way because I ended up finding another knowledgeable orthodontist that’s also funny and warm.”

Nguyen says Camille’s orthodontic issues were complicated, and he tried to explain them in layman’s terms. “It’s really difficult not to use somewhat technical terms to describe some issues,” Nguyen says. He adds he doesn’t think he became hostile at all. “I’ve never had any problems with patients seeking a second opinion,” he says.

Experts say patients can often sense when they should seek a second opinion. “You should always trust your gut,” Levy says. “You either feel comfortable with the dentist or you don’t.”

Besides making sure your dentist is properly licensed, patients shouldn’t be afraid to ask questions to put themselves at ease. “They may ask what school the dentist went to, how long they’ve been practicing and what experience they have with the procedures they recommend,” says Dr. James Carr, a highly rated dentist in Carmel, Ind.

Patients should also make sure they’re happy with all other aspects of the dentist’s practice. “Look around and make sure you feel good in that setting,” Seldin suggests. “Ask yourself if you think the office is neat, or if you like how the front office deals with making appointments.”

Besides an inadequate office environment, Spindel says there are other things that may make people leery. “If a patient goes to a new dentist and is suddenly diagnosed with a large number of cavities, this may represent a good reason to get a second opinion,” Spindel says.

A red flag went up for Allen Atkinson after his 19-year-old daughter, Alyssa, made a first-time appointment with Dr. Charles Bell of highly rated Bell Dental Group in Cincinnati and was diagnosed with 12 cavities.

“It just didn’t pass the smell test,” Allen says, who adds the dentist was defensive when he questioned the findings. “The attitude was: ‘Enough talking, let’s start drilling and filling.'”

Citing patient confidentiality, Bell declined to comment specifically about the Atkinsons, but says differences in diagnoses may be attributable to the tools each dentist uses.

“We use a laser that measures the tooth’s density,” says Bell. “It detects cavities that X-rays and probing with metal tools may miss.”

Allen says he wasn’t convinced by the explanation he received and didn’t want his daughter to have any unnecessary work done, so for the first time he sought the advice of another provider. He says Dr. William R. Wallace, a highly rated dentist in Cincinnati, examined Alyssa and determined she only had one cavity. The experience earned the trust of Allen, who now takes his family to Wallace. “He took the time to explain what he found and why it would need treatment,” Allen says.

Dr. T. Bob Davis, spokesman for the Academy of General Dentistry, says a filling is irreversible, so if a patient is apprehensive, it may be a good reason for them to find another dentist. “You can’t put the tooth material back,” he says. “It becomes an ongoing maintenance issue.”

However, Davis adds there are many reasons people don’t seek a second opinion. “Most patients aren’t as involved in the quality of care as we would like them to be,” he says. “Some may think getting a second opinion is offensive to their dentist and others think it will take too much time or money.”

Davis says you may even be able to save money because it allows people to compare fees, but he warns price shouldn’t be the bottom line. “Quality should always be the main focus,” he says, adding that patients need regular dental care if they want to save money and time in the long run. “Like a car, your teeth need tuneups to avoid a dangerous and expensive wreck.”

The cost of obtaining a second opinion varies, depending on how the dentist charges for the service, whether X-rays are needed, and the dental insurance company’s policy.

Jeff Album, vice president of public and government affairs for Delta Dental, one of the largest dental insurance groups in America, says enrollees are welcome to request a second opinion. “We certainly encourage them – especially when the diagnosis or treatment plan is extensive, likely to involve multiple procedures or there’s a substantial cost involved,” Album says.

Atkinson says his insurance covered Alyssa’s second consultation the same way it did the first exam and it was deducted from his annual allowance, while Kerr says Camille’s consultation didn’t cost a dime. Levy also offers second opinions free of charge. “I feel it’s somewhat a duty of my profession,” he says.

Dr. John Redd II, a highly rated dentist in Tampa, Fla., says once a patient has received two opinions, there aren’t any ethical rules binding either dentist from doing the work – it’s up to the patient.

“They usually end up sticking with the second dentist because they weren’t comfortable with the first,” he says. “They view their mouth as a house they can’t move out of, and want to find the best caretaker.”

While some people may find a new dentist through a second opinion, others see it as an opportunity to gain confidence in their current provider. Chuck Metalitz of Evanston, Ill., had been a patient of highly rated Appell Dental Group in Chicago for 30 years, but when he was told he may need a root canal, he wanted to be sure.

“I thought, ‘Does this guy know what he’s talking about,’ so a friend recommended I get a second opinion from her dentist,” he says.

After a thorough examination, the second dentist told Metalitz he could possibly avoid a root canal, but that the crown work Appell did was of high quality. “That was really important for me to hear,” says the Angie’s List member.

The consultation gave Metalitz the self-assurance he was looking for, and he ultimately decided to stick with his longtime dentist for treatment.

When it comes to getting a major dental procedure, whether it includes an extraction, root canal, or dental implants you may wonder if a second opinion is warranted. For simple dental procedures like a filling, you’ll find the procedure is most likely covered by your insurance plan and a second opinion may not be needed since it tends to fall under preventative dental care. For other dental procedures, however, a second opinion is not only your right but an advisable course of action when deciding on your dental care. Check out these tips for when, where, and how a second opinion for dental treatment is needed.

What the ADA recommends

The American Dental Association (or ADA) is an institution that most respected dentists belong to. It requires all of its doctors to ascribe to the Hippocratic Oath, ensuring your dental health and well-being are always put first. It also requires that its dentist members allow their patients to decide on their own dental treatments. This being the case, if your dentist has recommended a major dental procedure that you’re second guessing the necessity of or simply aren’t comfortable with, it’s best to get a second opinion. Any competent dentist will have no problem with this and may even be able to recommend a fellow dental professional in your area to help make an impartial evaluation.

Where to look for a second opinion

There are a few different perspectives you may want to seek out when looking for a second opinion on a significant dental procedure you may be facing. First, you need to find an office you are comfortable with. If you don’t trust your current provider, it is imperative that you find one who you can trust as any significant procedure adds up to considerable time spent in the dental chair. There are several ways to seek out a provider you trust. You can contact any local dental associations or societies in your area, as many competent dental care professionals will be members or registered with them. Another avenue to check out is the ADA’s “Find-a-Dentist” online tool which can show you qualified dentists in your area and their contact information. Finally, a trusted friend or family member will no doubt know of a dentist they prefer who can provide a reasonably priced evaluation.

What to expect during a second opinion evaluation

During a second opinion dental evaluation, the dentist may require a copy of your dental records to understand your oral health history better. He or she will then schedule a time to thoroughly examine your teeth and gums, perform x-rays, and other diagnostics that will give a better picture of your current dental health. After completing these diagnostics, the dentist will meet with you to discuss the findings, and they should offer an unbiased opinion with different options to meet your needs. While this process may require more than one visit, you’ll find their expertise and insights to be invaluable when forming a decision about an upcoming dental treatment.

Understand your dental and health genetics

Believe it or not, your family’s dental health history may have a significant impact on whether you’re a prime candidate for a dental procedure. For patients whose families suffer from oral cancer, excessive gum bleeding, or other health issues, extra precautions may have to be taken into account before dental work is done. Likewise, if you suffer from heart issues or have had other surgeries such as joint replacement, you may need to premedicate with antibiotics before dental visits. Asking family members about any heart or congenital health problems is advisable, as is scheduling an appointment with your primary care physician to discuss these concerns before moving forward with the procedure.

Evaluate your oral pain and dental health

One question to ask yourself is, do you feel your biting, speaking, and chewing functions are inhibited by the condition for which your dentist has offered a procedure? If you’re feeling ongoing oral discomfort or pain, or a limited ability to enjoy the foods you love or the lifestyle you want, then the prescribed dental procedure may be warranted. Most patients feel not only relieved when a dental procedure is over, but they also find they have more energy and feel absolutely no discomfort. Dental procedures available today use anesthesia during the treatment so you won’t feel any pain and if you’re nervous about getting that procedure done, your dentist has solutions to help with that as well. If you feel anxious about a dental procedure, be sure to communicate this with your dentist. Many dental care providers offer oral sedatives and sedation dentistry that will ensure you feel absolutely no discomfort or anxiety.

Move forward with confidence

If you’re like many dental patients in America, you may feel anxiety or uncertainty about having a dental procedure done, but with an expert second opinion and the confidence the procedure can only improve your quality of life, you should feel more than comfortable in your dentist’s recommendation. Be sure to check out the online resources mentioned above to get a second opinion and communicate with your dentist to ensure he or she understands your concerns. If you’re looking for a second opinion in Colorado, we provide expert impartial dental evaluations and affordable dental care.

Find out more by contacting us today.

In dentistry, the only people “in the know” are you (who presumably is not an expert), the staff who work directly for the dentist, and the dentist him or herself. There’s much more potential for abuse when there’s less chance of being challenged.

The reality of how dental care works is that it’s up to the patient and the insurance company to make sure the right treatment plan is prescribed and implemented. With lower “dental IQ” than dental staff and providers, both you and your insurance company aren’t in a great place to make sure everything is above board.

4 Warning Signs of a Fraudulent Dentist

1. Urgency Without Details

If your dentist tells you that you need to have a procedure done immediately, ask why. A dentist who is vague about this could be pressuring you into a procedure.

2. Heavy Work That Comes Out of the Blue

The number one warning sign is when you sit in a dentist’s chair for the first time and are told you need a bunch of procedures of a type or quantity you’ve never needed before. Trust your gut on this one. If you’ve never had a cavity in your life and at your first appointment with a new dentist, she tells you that you need 12 fillings, that’s a red flag.

3. Deals That Are Too Good to Be True

A common pattern I see is dentists that use a deeply discounted or even free cleaning or checkup to get you in the door, and once you’re in the chair, hit you with thousands of dollars of work that you don’t need.

4. Diagnosing a Lot of Procedures Not Covered By Insurance

A lot of treatment that isn’t covered by insurance is a red flag. Read the section above on how dental insurance pushes some dentists to bill specifically based on how they can make more money.

5. Not Showing You X-Rays

Does your dentist show you what s/he sees on your x-rays and point out the lesions and how they differ from healthy tooth structure? They should!

Looking over x-rays to talk through a treatment plan should be a group effort between the dentist and patient. Avoid working with a dentist who is hesitant to show you their findings on an x-ray.

How Can I Protect Myself Against Dentistry Fraud?

Beware of In-Network

Insurance plans put incentives in place for in-network dentists, like the capitations I described above. When dentists become part of these networks, they agree to extremely low reimbursements for cleanings and exams, in exchange for a steady stream of patients.

To make up for it, some dentists will perform procedures that have a significant patient portion or heavily promote cosmetic work as being necessary.

Choose a Dentist Based on Referrals, Not Who Your Insurance Company Tells You to See

As with any other profession, the way to maximize your chances of having a good experience is by relying on the advice of others who’ve had a good experience.

If you’re new to the area, you can always ask for a recommendation from your local dental society or health professional. Don’t rely on the fact that a dentist is covered by your insurance plan; this is not the same thing as a referral.

The best referrals come from friends, family, and co-workers that have had procedures other than teeth cleanings at the dentist.

Stay Away from Practices That Advertise

Heavy advertising and deep discounts are come-ons. Billboards and TV advertisements should also make you wary. Advertising-driven offices often use deals as a way to get patients in the door and then pressure them to accept an expensive treatment plan.

I call this Wall Street Dentistry. Often, they’re corporate-owned chains, like Aspen Dental. These chains are like dental mills. They give you the free (quick) cleaning, the free cursory exam, and then tell you that you need $4,000 worth of unnecessary dental work.

Many of these franchise-based practices you see in ads rely on a quota-based work model. These sorts of incentives lead dentists to err on the side of extra treatment.

Look for a Name on the Door

Choose a clinic where the dentist has his or her name on the door, which often implies that personal ownership and that, reputation-wise, they have a lot to lose because their name is on the line (or the door). It’s easy to hide behind a sign that says “Big Smiles Dental.”

Ask for a Second Opinion

Even just observing a dentist’s reaction to being told you’d like a second opinion can be telling. If they truly have nothing to hide, they won’t discourage you.

Ask How Long Your Appointment Will Be

New patient appointments should take at least an hour and fifteen minutes to an hour and a half. Offices trying to cram in more patients than they can take might only keep you in the office 45 minutes.

Established patient appointments shouldn’t be as long, but you should still pay attention to how work is done. If you feel rushed, or that your providers aren’t taking enough time on your work, ask questions.

Even established patient cleanings should be 45-60 minutes long. If your cleaning only takes 20 minutes, start asking questions.

Price Check and Do Your Research

Tooth pain is a great motivator. When you’re in pain, you’re often willing to fork over any sum to find relief. But take steps to make sure you’re paying market rate.

First, check the Healthcare Blue Book, a respected online tool that provides a fair price for thousands of medical and dental procedures in your ZIP code. And don’t be shy to call around to other dentists in your area to price shop.

Ask friends and neighbors for recommendations, and check out any potential dentist with your state’s dental board to ensure he or she is licensed and to find out if any disciplinary action has been taken. Most board websites offer an online search tool.

If you’re located in New York City, you might want to try a new tool called Smylen. They offer the option to quote your own price to get matched with a dentist you can afford. (Use coupon code ASKDENTIST for $10 off your first appointment booked through Smylen.)

Be Skeptical of a New Dentist That Prescribes a Ton of Treatment

A common pattern of fraud is a patient visiting a new dentist for a checkup and being told he or she needs a ton of work. Of course, if you’re in lots of pain, or haven’t been to the dentist in years, this might not apply.

Trust Your Gut

If you have a bad feeling, walk away. Dentists are there to help you, they should not be pressuring you. You can always come back if you decide you are overreacting, but with something that can potentially put you out of pocket for a large sum of money, it’s best to trust your instincts.

Ask About Loupes

No dentist should be practicing without loupes, which are little surgical telescopes that magnify. It has nothing to do with ailing eyesight, it’s the magnification factor that lets you see more than you could with 20/20 vision.

If you can’t see it, you can’t treat it! Ask your dentist if she or he uses 2.5x or 4.4x power on her loupes. The higher, the better! An LED spotlight on the forehead is even better.

Be choosy: Pick the Best Dentist for You

Choosing the right dentist isn’t just a matter of not getting ripped off. The right dentist understands the mouth-body connection and enables you to have a healthier, longer life by maximizing your oral health.

Do not underestimate the value of a dentist who is your partner in health—it will extend your and your family’s lifespan, quality of life, and well-being.

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Five things you may not know about second opinions, from the Harvard Health Letter

Published: October, 2011

Most people face at least one major medical decision in their lives. Sometimes the treatment choice is clear-cut — but when it isn’t, getting a second opinion is recommended, notes the October 2011 issue of the Harvard Health Letter.

Second opinions can lead to less expensive tests and treatments, so insurers have an incentive to allow — and may even encourage — second opinions. But the Health Letter editors advise insured patients to check with their health plans to make sure the consultation and any associated services are covered.

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When faced with a life-changing diagnosis such as cancer, many patients may wonder whether to seek a second opinion, especially when facing major surgery, treatments with severe side effects or an uncertain outcome. What if you’re not happy with your doctor’s diagnosis? Is the recommended treatment really your best option? What if your doctor is wrong? Is your doctor not listening to you? What if you just don’t like your doctor?

“If you have a gut feeling that something is wrong, or if you simply don’t click with your doctor, there’s no harm in getting a second opinion,” says Kara Eaton, MA, patient advocate and Executive Director of Patient/Family Experience at Roswell Park Comprehensive Cancer Center. “The right doctor will want you to feel as if you’re getting the best possible treatment, and that includes finding a provider you’re comfortable with.”

Sometimes problems between patients and doctors are due to clashing personalities, and you just need to find a provider who’s a better fit. Other times, the issue is miscommunication. Clear communication is essential, particularly if you’re unhappy with the diagnosis or reluctant to move forward with your recommended treatment plan.

In most cases, it is safe to take the time to get a second (or third) opinion. In fact, doing so may help you learn more about your options and diagnosis, become more confident about your treatment decisions and find the doctor who’s right for you. The right health care provider will want the best available care for every patient. He or she will also take the time to listen to any concerns you may have.

Whether you’re unhappy with your doctor or your diagnosis, check with your insurance company before getting that second opinion. Most insurance plans do cover this option, particularly when surgery or another major medical procedure is recommended.

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How to avoid getting ripped off by the dentist

There are plenty of excellent, trustworthy dentists out there who make their patients’ interests their top priority.

But there are also some unethical dentists who provide unnecessary treatments and products simply for profit.

I’ve discovered this after growing up having dental work done by my father, who is now retired. In the years since, while seeing other dentists, my brother has been told he needed six fillings that turned out to be totally unnecessary (based on my dad’s look at his X-rays) and I’ve been pressured to buy prescription toothpaste and other products I didn’t need.

Back when he still practiced, my father occasionally saw this kind of thing firsthand. His patients would visit other dentists for an emergency while he was away and be told they needed superfluous crowns or other complex work when a simple filling would have sufficed.

dentistry has far less oversight than any other branch of medicine

To be clear, this sort of fraud doesn’t go on in most dental practices. But experts say it still happens all too often. “There are no precise figures about how widespread dental fraud is. The crime is less than a tsunami and more than a trickle,” said James Quiggle of the Coalition Against Insurance Fraud. “The vast majority of dentists are honest and ethical. Even so, more fraud likely is flying under the radar than people realize.”

One of the main reasons is that, in the United States, dentistry has far less oversight than any other branch of medicine. “For a dentist who practices alone, there’s usually no one looking over your shoulder,” my father, Sheldon Stromberg, said. “It’s easy to take advantage of people. You’re basically given a blank check.”

Another reason is that dentistry genuinely involves a degree of subjectivity in each diagnosis. Two honest dentists can disagree about whether a tiny fissure requires a filling or not, and all dentists fall on a continuum of philosophies ranging from conservative to aggressive in their treatments. Some dishonest ones, though, abuse this uncertainty to increase their profits.

With this in mind, I spoke to seven dentists — along with Quiggle and the American Dental Association — to get their advice on how to find an honest practice and avoid unnecessary work. Here are their recommendations.

Beware of practices that advertise and offer deals

(Philippe Huguen/AFP/Getty Images)

Every single dentist I spoke with offered the same advice for finding a trustworthy practice — ask a friend. “The best way to get a good referral is to ask friends or coworkers,” said Robert Rose, a family dentist who practices in Pasadena.

If you don’t have anyone to ask, other options might be getting a recommendation from a local dental society, or even just asking your doctor who he or she sees.

The one thing you shouldn’t do, however, is go to a practice based on an advertisement, especially one that offers a free cleaning, tooth whitening, or other deal. “I would be wary of the big advertisers, who have billboards all over the place and advertise on TV,” said Mindy Weinman, who practices in Buffalo and is a professor at the SUNY Buffalo dental school.

these offices often use deals as a tool to get patients in the door

Her husband, Dave Weinman — who practices with Mindy and also works as a consultant for an insurance company assessing cases of potential dental fraud — agrees. “I barely see any dental offices, in my area at least, that are heavy advertisers and that I’d feel comfortable recommending,” he said.

The reason for this is that advertising-driven offices often use deals as a tool to get patients in the door and then pressure them to accept an expensive treatment plan, whether they need work done or not. Oftentimes, they’re corporate-owned chains, like Aspen Dental. “These big chains are kind of dental mills,” Mindy Weinman said. “They’re the ones that give you the free cleaning, and the free exam, then they tell you that you need $3,000 worth of dental work.”

Relatedly, many of the practices you see in ads rely on a quota-based work model, in which each dentists is required to perform a certain number of procedures per month. These sorts of quotas lead dentists to err on the side of extra treatment, rather than less.

Be skeptical of a new dentist that prescribes a ton of treatment

(Philippe Huguen/AFP/Getty Images)

The most common pattern of fraud is a patient visiting a new dentist for a checkup and being told he or she needs a heavy amount of work.

“If you go to a new dentist, and you’ve barely ever needed any work in your mouth, and all of a sudden he tells you that you need 16 fillings, that’s a big red flag,” said David Silber, a dentist in Dallas.

Of course, if you’re visiting the dentist because of a specific pain, this advice doesn’t necessarily apply. But in some cases, an unethical dentist will seek to maximize treatment on a new patient. “If you go in to a new dentist for a cleaning, and things are feeling good in your mouth, and all of a sudden they say you need a ton of work — that’s probably not a good thing,” Mindy Weinman said.

Related is what James Quiggle calls the pressure trap: “The dentist tries to pressure you to get expensive procedures done right away, citing urgent medical need,” he said. “The dentist is evasive about details involving your medical need but is specific about the urgency for that procedure.”

Watch out for the following products and procedures

(William Warby)

Apart from the general problems outlined above, the dentists I interviewed mentioned several specific products and procedures that are often abused:

1) Replacing old fillings: Although old fillings can sometimes crack or become surrounded by decay, necessitating a replacement, some dentists will try to replace all your fillings simply due to age — a practice that isn’t actually necessary if they’re not causing problems.

“The big red flag is if you go to the dentist and they say, ‘oh, you’ve got old silver fillings, we need to take them out because there’s mercury leeching out,” Mindy Weinman said. “There’s been no evidence to prove that actually happens.”

2) Veneers. Sometimes, a dentist will tell a patient that pricey veneers are necessary to improve the color of a tooth, but if its shape is acceptable to begin with, bleaching — a much cheaper process — is perfectly fine. “A lot of cosmetic dentists tend to push this kind of treatment,” said Sean Tomalty, a family dentist in South Florida. If you’re certain you do want veneers, Dave Weinman recommends going to a prosthodontist rather than a general dentist.

3) Fluoride toothpaste and treatment. I was recently told I needed a $30 fluoride treatment and $25 prescription high-fluoride toothpaste — neither of which was covered by my insurance — even though I’ve only had a couple of cavities in my life.

“Most people get enough fluoride in their drinking water and from regular toothpaste, and by the time you’re an adult, and your teeth have fully formed, the fluoride treatment doesn’t do much,” my dad said. “For someone who doesn’t get lots of cavities, it’s a waste.”

4) Night guards. I was also offered a $700 night guard during my recent visit, due to some signs of wear on my teeth, presumably caused by nighttime grinding.

In truth, some people do need night guards — mainly if they have TMJ pain, or show especially high rates of wear. But all people gradually wear down their teeth over the course of their lifetimes, and not everyone needs a night guard. Some dental practices simply prescribe them to most patients as a matter of course.

5) Sealants. Dental sealants are preventative coatings applied to the surface of your molars to prevent plaque from accumulating in the pits on their surfaces. They can be useful in some cases — especially for cavity-prone kids — but are also overprescribed by some dentists.

“The problem is, a lot of the time, those teeth weren’t going to decay anyway, you’ve weakened the tooth by etching into it to adhere the sealant,” my dad said. “An office that does a lot of sealant for adults is something to watch out for.”

Ask to see X-rays and get a second opinion

(BSIP/UIG Via Getty Images)

Virtually all honest dentists will gladly show you X-rays of your teeth that contain evidence of the work you need. “X-rays, legally, are your property. A dentist can charge for them, but they have to share them with you,” Mindy Weinman said.

You won’t necessarily be able to see evidence of every single type of problem in an X-ray, but many of them should be apparent. A dark spot or blemish, in general, corresponds to a cavity. And in general, the dentist should be willing and able to explain why you need certain procedures, both by using X-rays and other means.

if the first dentist seems reluctant to let you get it, that’s a bad sign

But regardless of what the X-rays show, if you’re skeptical of the treatment a dentist is prescribing — especially if it’s your first visit to the practice, and they’re recommending far more work than you’re ever needed before — the best response is to get a second opinion. This was mentioned to me by every dentist I spoke with, along with the American Dental Association.

“If everything is fine, and all of a sudden I go to a dentist that’s telling me I have a bunch of cavities, I would definitely get a second opinion,” Tomalty said.

Even before you actually get the second opinion, doing this can provide useful information. If the first dentist seems reluctant to allow you to get it, that’s a bad sign. “If they’re legitimate in their diagnosis, they should have no concerns about it at all,” Dave Weinman said. “It’s a red flag if they fight you on that.”

It’s important to remember that no dentist can force you to have work done — and if you’re uncomfortable with how things are proceeding while you’re in the chair, it’s entirely within your rights to get up and leave. In general, they should be willing to listen to you, hear out your concerns, and patiently explain the work they’re prescribing.

Dental insurance can actually cost you more

(Thomas Trutschel/Photothek via Getty Images)

To many people, dental insurance sounds a lot like medical insurance — a prudent way of ensuring you can pay for potentially catastrophic treatment costs.

But for a few different reasons, dental insurance is far less important to have than medical insurance (which is now mandatory in the US) — and might even be a bad deal on the whole.

“Insurance is supposed to be for rare, catastrophic losses that can’t be predicted — like your house burning down, or a heart attack. But dental care isn’t rare, or unexpected, or catastrophic,” my father said. “For the most part, it’s relatively small charges, on the order of hundreds of dollars, and you know you’ll need to visit a dentist every year.”

All types of insurance companies aim to make money, so they make sure that the total money everyone pays in premiums is larger than the amount they pay out in treatment costs. For unpredictable, potentially catastrophic things (like heart attacks), this extra cost borne by the policy holders is worthwhile, because virtually no one has a few hundred thousand dollars lying around to pay for a coronary bypass surgery. But for dentistry, that isn’t the case.

insurance plans put perverse incentives in place for in-network dentists

As a result, people can opt out of dental insurance, then build up treatment needs over the course of several years, then opt in. Dental companies know this, and so to turn a profit, they’re forced to cover relatively little, in terms of treatment. Most dental plans come with a hard cap on the total amount of treatment they’ll pay for in a given year — the exact opposite of the out-of-pocket maximums in medical insurance plans.

Even more problematically, insurance plans put perverse incentives in place for in-network dentists. When dentists become part of these networks, they agree to extremely low reimbursements for cleanings and exams, in exchange for a steady stream of patients. “To make up for it, some dentists will find work to do,” Silber said. “There’s always going to be treatment, because they mathematically need to do something so they don’t lose money on the cleaning.”

Most often, the treatments they recommend are the very ones that insurance doesn’t cover — such as quadrant scaling, an intensive cleaning procedure that requires extra office visits. This is what happened to me when I recently saw a new dentist I found through my insurance network.

Ultimately, your dental plan might give you a free cleaning and exam every six months, but it could also make the dentist more likely to find necessary work that it doesn’t cover. Most of the dentists I spoke with strongly recommended against going to a new dentist solely because he or she is accepted by your insurance plan, and a few warned against dental insurance entirely.

One option: dental school clinics

(Wired Photostream)

If you’re stuck and having trouble finding a dentist you trust, my father recommended one unorthodox option: going for a consultation at the clinics operated by most dental school.

“The work can take a long time, and the hours can be pretty restricted, but they’re inexpensive and the work is generally very good,” he said.

That’s because having work done at a dental school clinic inherently involves a huge amount of oversight: every diagnosis and filling is checked over by several students and professors. Like massage and salon schools, they provide essentially the same product as professionals for a fraction of the cost. And in general — and contrary to many people’s idea of dentists-in-training — dental school students do quality work by the time they’re treating actual patients, after learning on models. In any event, these clinics are a great place to go for a second opinion.

*Why does all this unnecessary work happen?

This article is mainly a guide to avoiding unnecessary work. But it also raises an interesting and important question: why is dentistry more prone to fraud than other branches of medicine? Here are some of the reasons most commonly brought up by the dentists I spoke to:

1) Lack of oversight. “If you go to a doctor, and you have a procedure done in a hospital, the staff and lots of other people know what’s going on,” my father said. “With dental work, no one’s looking at you. You can do and say anything.”

In rare cases, oversight can come in the form of audits by insurance companies suspicious of fishy-looking billing patterns (and in extreme cases, in patient complaints to local dental societies or malpractice suits), but on the whole, few dentists have anybody evaluating their work on a consistent basis. Moreover, for most types of finished work — say, a new set of fillings — it’s pretty much impossible for any other dentist to tell after the fact whether they were necessary or not.

2) Inherent subjectivity. An individual dentist’s treatment philosophies and personal judgement are an inescapable part of dentistry. “You can have five dentists look at your mouth, and sometimes you’ll get five different answers on what treatment you need,” Tomalty said. “Every dentist has their own philosophy.”

Conservative dentists might be content to wait years for a tiny cavity to become bigger before drilling, for instance, while more aggressive ones might want to work on it immediately. Neither is wrong, but in some cases, unethical dentists can take advantage of this grey area to push more treatment.

3) The changing business of dentistry. Several dentists I spoke with singled out a few additional business factors: the increasing amount of debt taken on to pay for dental school and the rising technological costs needed to outfit a new practice.

“The new dentist today is up to their eyeballs with debt and needs to make money, so in some cases, they may be doing too much treatment,” Dave Weinman said. This could mean erring on the side of unnecessary work to sustain a fledgling practice, or it could mean joining a large existing practice that has quotas in place for new dentists.

When Caryn Van Eck moved to Des Moines, she needed to find a new dentist. When the first dentist she saw gave her a care plan for 12 fillings, Van Eck said, “I wanted to fall off the chair. I was pretty shocked.” Van Eck’s former dentist said her teeth were healthy. So, Van Eck got a second opinion.

**note: scroll down for the second half of the video**

Dr. Bob Margeas examined her at Iowa Dental Group. She explained, “(Dr. Margeas) said I was fine.” It turned out that Van Eck had zero cavities. Dr. Margeas said, “She really didn’t (need any fillings). She had a couple of areas that, you know, looked a little bit stained.”

Confused by this seemingly huge disparity, we sent Van Eck to a third clinic. The dentist who examined her at Aspen Dental on Merle Hay Rd. in Des Moines agreed with Dr. Margeas. Van Eck had zero cavities. Dr. Margeas said, “I didn’t feel bad if she wanted to have a third or fourth opinion.”
So we sent Van Eck back to dentist number one. This time, he gave her another treatment plan that was the same as before. It listed 12 fillings at a cost of more than $2,100. This time, Van Eck wondered, “How could this be? (I was) outraged.”

When we confronted the dentist about his apparent difference of opinion, he agreed to an interview… then backed out. He claimed that Van Eck had lied about her visit to his clinic. He threatened Channel 13 with a lawsuit if we aired his name. We tried to obtain a fourth diagnosis from the University of Iowa College of Dentistry, but the staff declined. One of their professors did, however, help us understand why there could be a difference of opinion.

Dr. Steve Armstrong is an expert in “Dental Caries.” He explained that small lesions on the surface of teeth can lead to cavities. He said that dentists have a wide range of opinions about what constitutes a hole worth filling. He admits the range can be troubling. “(The range) has always been there but it hasn’t been recognized as such.” Regarding the difference of opinions about Caryn Van Eck’s teeth, Dr. Armstrong said, “When you’re giving me this scenario, I would hope this “Dentist A” that says (the patient) needs twelve (fillings), he would clean, isolate, open one, learn from that and adjust his treatment plan and probably not finish ‘drilling and filling,’ as you say.”

We sent a Channel 13 producer to all three of the previously mentioned dentists to get three fresh opinions about how many cavities are in a single set of teeth. This time, “Dentist A” told our patient she needed four fillings. The dentist at Aspen Dental agreed with four fillings. So, did Dr. Bob Margeas… sort of. Dr. Margeas found four “areas of concern.” He said two teeth needed fillings. He wanted to monitor two others. Dr. Margeas had previously explained to us, “Some dentists are a little bit more aggressive. Some are more conservative. I just happen to be a little bit more conservative.”

We wondered how that can be the case. A cavity is a cavity… right? It’s either there or it’s not… right? Not so fast. Dr. Armstrong explained that most mouths have bacteria. They eat the sugar that sticks to our teeth. The germs secrete acid. The acid harms the enamel and forms what dentists call a “Caries Lesion.” Depending upon the severity of the lesion, “There’s a broad gray area (where dentists may disagree on) what exactly to do,” said Dr. Armstrong.

The American Dental Association (ADA) suggests dentists should avoid drilling unless it’s absolutely necessary. Instead, they should try to keep healthy tooth structure intact. One option is to clean the tooth and simply monitor it for changes. Another option is to apply a sealant. These are part of Dr. Margeas’s approach. He said, “When you drill it, you’re married to it. Then, it becomes more of a maintenance issue.” Van Eck agrees. That’s why she remains a patient of Dr. Margeas. She wondered, “Why would you want to do all that work (12 fillings) on perfectly good teeth… and put a financial burden on somebody?”

Dr. Armstrong said, “I want to reassure patients and reassure their trust in their dentist. He insisted that dentists have your best interests at heart. Every tooth and every patient is different. That’s why he and Dr. Margeas give other dentists the benefit of the doubt. “And I hope the other dentist would give me the benefit of the doubt,” said Dr. Margeas. Because a cavity is in the eye of the beholder. Dr. Armstrong suggested, “Go ahead and ask (your dentist) questions, understand their philosophy and if something doesn’t seem right, talk about it.”

None of the dentists involved in this story have been disciplined by the Iowa Dental Board for anything relating to patient care. Dr. Armstrong said his best advice would be to form a long-term relationship with your dentist. They should be able to monitor your teeth over a long period of time to see if any problem areas are getting worse.

The people who benefit the most from a second opinion are like Van Eck. They’re new in town, visiting a new dentist, or haven’t visited any dentist in a while. Some dentists use tools that claim to “detect” cavities. However, Dr. Armstrong said that studies show that nothing is more accurate at diagnosing a cavity than the dentist’s eyes and a magnifying glass.

Dec. 2, 2011— — By the time a dentist finds a cavity, that tooth has been through several stages of a chronic infectious disease called dental caries, where acids dissolve tooth enamel, letting bacteria inside. Unchecked, the tooth can die.

Dentistry today focuses on early intervention to prevent bacterial invasion of the dentin, a layer just inside the enamel, and the vital pulp. Laser scanning, fiber optics and fluorescent technologies have allowed dentists to better visualize weakened, decayed enamel before it becomes visible on an X-ray or to the naked eye. Some dentists say high-tech tools enable them to perform minimally invasive dentistry, which preserves more of the tooth, often by treating “incipient carious lesions,” also called microcavities. These abnormalities begin as white spots, which can progress to dark, stained pits and fissures.

Dentistry has evolved from “drill and fill” mechanics to a disease model focused on averting decay, supported by a 2001 National Institutes of Health consensus statement that identified a shift toward improving the diagnosis of early lesions and stopping their progression.

However, this early treatment may — but need not — involve the good old dental drill.

Some dentists want to fill all these little pits and flaws, sometimes warning of cavities to come, perhaps leading to a dreaded root canal, or losing the tooth. “Some dentists may honestly believe they’re doing a patient a favor by treating early,” said Dr. James C. Hamilton, now retired from the University of Michigan dental school. “Some dentists would convince patients caries is like cancer. ‘Do you want me to leave a little cancer in your mouth? No.'”

Hamilton led a five-year study that found early treatment of microcavities using an air drill (less painful than a traditional drill) and a composite filling failed to conserve more of the tooth than watchful waiting until caries were diagnosed.

“We found no benefit at any time for early treatment,” Hamilton said in an interview Thursday. He worries that expensive equipment pushes some dentists toward more aggressive treatment to get a “return on their investment.”

“When you buy this new technology to treat incipient carious lesions, you have increased your overhead. You now have to make this piece of equipment pay for itself,” Hamilton said. With the cost of a filling ranging from about $100 to $250, dentists might be “using this to find and treat those lesions when in fact they ought to be just watching them,” he said.

Patients may balk at what they perceive as overzealous dentists proposing unnecessary and costly filling of microcavities before they’ve eaten into the dentin. That’s why they should ask for a second opinion as they would for a medical issue, said Dr. Irwin Mindell. His mid-town Manhattan dental practice is very conservative and often proposes “watchful waiting” for microcavities.

“We have a very aggressive recall system. It’s not that if you don’t do it now, chances are you aren’t going to come back to the dentist for another three years and at that time, we have another major problem,” Mindell said. “I know I’m going to see the patient six months hence.”

Mindell, who has been in practice since the 1950s, said that if damage hasn’t reached the dentin, “you don’t treat, because it may take years and years and years to become something. A lot of stuff never goes any further.” For patients who aren’t prone to cavities, removing the compromised enamel could lead to “greater loss of tooth than what the decay process will do.”

But there’s also a third way, said Dr. Peter Arsenault, a clinical professor at the Tufts University dental school in Boston. “Does treating mean drilling? Not in my eyes. That’s what carpenters do,” he said.

Another Approach: Neutralize Acid, Kill Bacteria, Remineralize Enamel

For the appropriate patient, Arsenault proposes a treatment plan that requires “a lot of dedication and a lot of education.” It relies on neutralizing acidity in the mouth with frequent use of pH-boosting sprays and drops; killing mouth bacteria with xylitol–a sugar alcohol derived from birch trees, and using re-mineralizing toothpastes that stabilize and shore up weakened enamel.

Arsenault teaches dental students and dental colleagues the Caries Management by Risk Assessment (CAMBRA) approach, which uses a patient’s history of cavities and dental work, oral hygiene habits and consumption of acid-promoting sugary foods, among other factors, to categorize them as low-risk, moderate-risk or high-risk for developing cavities.

“For each level of risk, there’s a bit of an art, and a bit of science to it,” Arsenault said Thursday. He described a low-risk, highly motivated patient who came to him a year ago with four small spots in her dental enamel and conscientiously adhered to the recommended treatments. When he examined her teeth earlier this week, the spots had shrunk. “She’s thrilled I didn’t have to drill this tooth,” he said.

Arsenault first learned about CAMBRA at an NYU conference four years ago, where he said that at first, “it sounded like hogwash.” But he was quickly won over and brought CAMBRA to Tufts. “We’re showing with low-risk patients we can slow down, freeze and reverse” the caries process, he said. With extreme-risk patients, they can fill decayed teeth with materials that release fluoride to safeguard the other teeth.

CAMBRA is now being taught at dental schools. Although the American Dental Association supports a risk assessment approach to dentistry, it hasn’t yet taken a position on treating microcavities.

“Evidence-based things are slow-moving,” Arsenault said. “It’s a momentum thing. It’s on its way. We’re getting closer.”

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