Photo by brownpau | CC BY 2.0
An excellent article on CounterPunch a few months back (March 1, 2018) by Dr. Ronald Maitland reveals a “broken Medicaid dental care system” offering little coverage to the poor. Medicaid reimbursement rates, he points out, are so low that the cost of care is borne largely by providers. As a result, private dental practices are restricting the number of their Medicaid patients, causing dental care for the poor to be rationed. And for want of timely treatment, the indigent tend to end up in emergency rooms; and their teeth are often extracted—perfectly good, sound teeth that could have been easily repaired.
I’d like to expand on this topic and add a few thoughts. Although, as Maitland writes, “harsh paywalls segregate the poor from those with even modest dental benefits,” millions of working people receive no dental coverage at all through their employer; and many of those fortunate enough to have some form of dental coverage lose it after they are laid off or when they retire. As for those over the age of 65—arguably those in most urgent need of dental care—over 50% aren’t covered by any plan. Many of them haven’t seen a dentist in years. Medicare and Medicaid don’t cover the cost of a dental cleaning—this deprivation can be devastating to human health and poses a major public health issue that the dental community has not even begun to address.
Needless to say, Medicare ought to cover the entire population–not just the elderly–and should include dental care for all (there’s enough individual and corporate wealth to provide the revenue). The field of dentistry, presently organized as an autonomous discipline—somewhere outside the realm of medicine—should be reconceived as an integral part of primary care. (Many’s the time I’ve asked a primary care doctor for a dental referral and received a blank look, as if to say, ‘Why ask me?”) Basic dental surgeries are all too often conflated with cosmetic dentistry (or something akin to plastic surgery), and treated as quasi-elective procedures for the well-to-do.
Yet even those who are able to afford them are confronted with serious issues and problems. Dentistry in its current state is a bit like the Wild West–each practitioner a private entrepreneur–free of meaningful oversight or accountability, dentists organize into county professional societies to defend each other from legal liability—in the spirit of “an injury to one is an injury to all”—a self-serving arrangement necessitating a caveat-emptor attitude on the part of the consumer.
In the present situation, even routine preventive care often incurs unnecessary additional procedures. The cost of receiving a needed dental cleaning might also mean submitting to unneeded X-rays, including panoramic X-rays or a cone-beam CT scan. Dental hygienists have been reciting the same talking points for years: ‘The radiation is minimal or even nonexistent.’ Who said so? The manufacturer? You might ask if their machines have ever been calibrated or inspected. And do I really need to have so many X-rays taken again so soon? Did anything suspicious ever show up on the last ones? But dentists always seem to require new X-rays for their records.
Careful removal of hardened tartar at the gum line is of course the most important part of the hygienist’s job. (They warn against aggressive brushing—it can wear away tooth enamel. But overly aggressive scaling can demolish it even faster.) Efforts are all too often focused on polishing stained teeth, an abrasive polishing of nearly the entire tooth. Even a mildly abrasive polish will wear down tooth surfaces, making them stain more easily, setting up a vicious cycle of ever more frequent and sustained polishing (and the eventual need for veneers).
I discovered the beneficial uses of fluoride varnish through my own Internet researches. When I mentioned this to my dentist, he said the substance is used only prior to surgery—in gel form–on patients too ill to receive dental care. A professor at the local dental school said it’s approved by the FDA only as a desensitizing agent, so they don’t use it on patients. However, it has been shown to prevent caries, and is widely used in Europe, the UK and most other countries to prevent decay, particularly on the teeth of children and the elderly. Medicaid reimbursement isavailable for its application to children’s teeth by pediatric primary care providers (PCPs) in NY State—a safe and simple measure that will help prevent early childhood caries.
Studies have clearly shown that biometric remineralization of initial carious lesions with peptide P 11-4 in combination with fluoride is superior to fluoride alone. . . . It’s “a simple, safe, and effective non-invasive treatment . . . potentially enabling longer tooth life and thereby lowering long-term health costs.” (ClinicalTrials.gov NCT02724592) But try telling this to my dentist.
I told him anyway about silver diamine fluoride—it’s used in Japan to arrest caries—I’d read about it in the New York Times.
All of the commercial products he recommends contain blue dye, saccharin, and many chemicals and questionable ingredients such as sodium laurel sulfate, which badly irritates my gums. He said, “What do you want me to do?”
At the research level, advances are being made in cariology (techniques for reversing as well as preventing decay). True, they are often sponsored by corporations like Colgate. . . .
I’m waiting for the science to reach my dental office and the local dental school.
In rural areas, where people rely on general dentists for root canals, sealers such as EZ fill, which contain formaldehyde, are often used. These offices also provide implants, laser gum surgery, laser dentistry, Cone beam CT scans, and dental implants.
But gold restorations–once considered (literally) the gold standard for restoring carious teeth—are a lost art. I’m told on good authority the “dental labs are biased against it,” and “dentists no longer have the skills.” Instead they invest hundreds of thousands of dollars in Cerec equipment to fabricate one-day crowns in their own offices. Some of the newer porcelain materials look natural but aren’t so great on back molars; they require the destruction of a whole lot more of the tooth structure, and can’t be easily drilled through should a root canal be needed.
On offer in virtually every dental office in the country, dental implants are considered the preferred option for replacing lost teeth–following extraction–the best option hands-down if you can afford it. Also a very lucrative procedure, it forms a major part of the core curriculum in general dentistry. But in all the excitement, too little mention is made of the diligent, conscientious attention to oral hygiene required afterward; the possibility, in spite of everything, of later acquiring an infection (with peri implantitis) somewhere down the road; and the dangerous consequences of so many people needing to take anti-biotics. (The pre- and post-operative use of antibiotics with oral implant surgery is widespread.)
Might it be possible to avoid some of these extract/implant complications were gold crowns more widely available? Will bridges and dentures be the next to go?
Certainly implants are a great stride forward in many cases. But the profession needs to pause for a moment, step back, and evaluate its role in the patient’s long-term health.
Though we’re not quite in that early 20thcentury moment epitomized by Frank Norris’s quack dentist McTeague in his turn-of the century novel bearing the same name as that unforgettable character, the profession does need to put its house in order, to heed the long-term consequences of questionable procedures–and financially motivated overtreatment.