Can you trust your dentist?

Our investigation highlights the diagnostic minefield the average dental patient faces and the pluses of dental tourism.
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01 .Introduction


To investigate the dental industry, CHOICE sent a shadow shopper, X-rays in hand, to 14 dentists across Sydney for a check-up only, no clean. We suspected we might uncover widespread evidence of overservicing.

The main issue that emerged, however, was a disturbing lack of consistency in the verdicts on our shopper's teeth. It highlights just how difficult it is for the typical consumer to know which treatments are imperative, which are optional and which are wait-and-see. And the importance of getting more than one opinion if major dental work is recommended.

Please note: this information was current as of November 2009 but is still a useful guide today.


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Shadow shop preparation

Our shopper's teeth were fairly typical of a woman in her mid-40s, with seven amalgam fillings, some root canal treatment and a crown done some years previously. Some of her teeth could have done with straightening, and she’d never had them whitened, making her a potential candidate for cosmetic procedures.

Our shadow shopper's teeth were first examined by her personal dentist, who agreed to participate in our investigation, and then by a dental specialist and a dental academic, who were our independent experts.

Four potential issues were identified:
• A filled tooth with signs of “ditching” – where the edges of the filling have collapsed. This is common with old amalgam fillings and is sometimes associated with decay.
• A chipped front tooth, while seemingly only a cosmetic issue, was a sign of problems with a single tooth cross bite and bruxism (clenching or grinding teeth). Filling the tooth would have been fairly pointless, as the filling would have fallen out.
• Two impacted wisdom teeth which looked pretty nasty in the X-ray, but were causing no problems.
• Finally, her teeth were due for a clean and scale.

What did the 14 dentists say?

Ditched filling

About half noted the decay around the ditched filling and recommended replacing it. The other half didn’t mention it. The most convincing case we saw of potential overservicing was the dentist who suggested replacing that filling, plus two others, and warned all three teeth might then require crowns. The fillings were estimated at $500 each, and the crowns $2300 a piece.

A few dentists recommended some extra fillings, but there wasn’t consistency as to which ones – and our adjudicators didn’t agree with any of them.

Chipped front tooth

Most dentists told her they could fill it, but correctly pointed out the filling would probably fall out. Four dentists asked if she ground or clenched her teeth, suggesting that may have been responsible, although none offered advice to address the problem – relaxation and other behavioural therapies are good starting points for treating bruxism. None suggested a nightguard to prevent teeth grinding.

Impacted wisdom teeth

All noted them and none recommended touching them. One suggested they could possibly result in cancer - which was alarming and while possible, extremely unlikely.

Clean and scale

One dentist insisted on cleaning our shadow shopper’s teeth, despite her initial protestations. We consider this a contravention of the Australian Dental Association’s Guidelines for Good Practice on Consent for Care in Dentistry, which states a patient should volunteer consent and not be coerced into accepting any treatment.

Subsequent dentists also wanted to clean her teeth, even though it shouldn’t have been necessary so soon after the clean she’d just had. Overservicing? Probably not: a clean and scale is often recommended every six months as a matter of course, and our shadow shopper told them it had been eight months since her last clean. And when our specialist looked at her teeth with a binocular microscope, he found some of the calculus had been missed – something other dentists possibly noticed.

Cosmetic procedures

None pushed any and all correctly noted it was generally better to leave old amalgam fillings than replace them with white composite ones.

The verdict?

There were two dentists whose recommendations could be considered excessive and unnecessary, and the aggressiveness displayed by the dentist who insisted on doing a clean was unsettling.

Dentistry is said to be a notoriously inexact science, or even an art based on scientific knowledge. With most people now assuming they’ll keep their teeth for life, dentists have an unprecedented duty of care. While preventative care is simply good practice, unnecessary work could ultimately destroy a tooth. Most people aren’t in a position to judge whose opinion best serves their long-term interests.

Our shadow shopper was disillusioned by the whole experience. After visiting the first two dentists, she remarked she’d never again agree to any dental work without getting a second opinion. After visiting 14, and getting almost as many different opinions, she realised even a second opinion might not count for much.




Upskilling for the good times

In poor economic times, when discretionary spending is reduced, entrepreneurial dentists take the opportunity to upskill and diversify. If you believe the marketing, courses to get up to speed on orthodontic or prosthodontic skills, such as installing crowns, bridges, implants and braces, can take just a few days.

Meanwhile, referrals to specialist prosthodontists are drying up, with general dentists taking on more of this work, as well as difficult extractions they may have referred on. By and large, general dentists do a good job and many dentists will recognise when a job’s beyond them. But when it goes pear-shaped, specialists – who undertake three years’ further training – are left to fix up any problems that arise.

Other popular courses teach how to improve their profitability – in part by making clients say “yes” more often. In recognising that people resist sales pressure, these courses help dentists phrase their treatment proposals in such a way that patients view their condition as one that must be treated rather than simply could be treated.

One of the initial questionnaires a dentist asked our shadow shopper to fill in had multiple-choice questions such as: “When would you like the treatment to be done? Before problems arise; when it’s worsening; or, after the problem occurs.” And, “How healthy would you like your teeth be? As healthy as they can be; as healthy as they can be; or, as healthy as they can be.”

This line of questioning helps shape expectations, perhaps making you more responsive to suggested treatment plans – which are supposedly in the best interests of your health. The same dentist charged $240 for the consultation with X-rays and recommended more than $1000 of treatment considered unnecessary by our independent experts.


Feeding from the government honey pot

Poor oral health is often a manifestation of deeper health issues, and vice versa. So dentists will usually try to get a complete medical history from patients to determine underlying concerns or conditions.

Under current Medicare arrangements, patients with certain chronic medical conditions, including asthma, cancer, diabetes, cardiovascular disease, mental illness and arthritis, can claim up to $4250 of Medicare-funded dental treatment, including fillings, crowns, bridges and dentures.

However, there have been reports of dentists giving eligible patients substandard work, or treating easily fixed problems instead of more urgent but difficult ones. There are also reports of patients who aren't eligible receiving Medicare-funded treatment. So we became suspicious when one of our shadow shop dentists spent an inordinate amount of time extracting an extremely detailed medical history from her.

The interview asked about family history of heart disease and whether any relatives – parents, aunts and uncles – had missing teeth, and if so which teeth. He asked if she slept well, and when she admitted sometimes waking up tired after having children, he suggested she might have sleep apnoea and he'd recommend a specialist. And so on. Was there an ulterior motive to this intense questioning? We can’t say, but patients should certainly be alert to potential abuse of the system.

The table below contains average prices and price ranges (excluding the top and bottom 5%) for common dental procedures. The figures were obtained by health insurer HCF from its claims database for 2008.

Dental costs table

Average charge based on HCF’s claims data for 2008.
Range of claims covers the middle 90% of claims, excluding the top and bottom 5% of claims.

Universal dental health?

In early 2008 the federal government formed the National Health and Hospitals Reform Commission to find ways of reforming the nation’s health care. One of the commission’s proposals was a universal dental scheme, Denticare, funded by a Medicare-style taxpayer levy.

Expected to cost $3.6 billion annually, the proposed scheme is broadly supported by social welfare groups, who point out that about one-third of Australians currently avoid visiting a dentist due to cost concerns, and more than half a million are awaiting publicly funded dental care.

The Australian Dental Association has slammed the scheme, saying it would only provide basic services and the money would be better directed to people most in need. A final decision on Denticare is expected in 2010.

Dentist-toolsWhen looking for a dentist, there are some simple guidelines to follow.

  • Be wary of accepting extensive and expensive treatment from a general dentist, unless you know their work well. This especially applies to complicated dentistry, such as orthodontics and prosthodontics.
  • Don’t let leading questions sway your judgment, and watch out for the sales pitch that doesn’t sound like a sales pitch. Is your dentist in the business of dentistry or the practice of dentistry?
  • A thorough examination should include an inspection of teeth, gums, inside of the cheek, palate, tongue and lips. A probe should be used to check gum pockets and a mirror for awkward spots. Findings should be charted in detail. An average check-up takes 20-25 minutes.
  • If you’re looking for a new dentist, ring ahead and get prices for a check-up and clean. How does this compare with the average $130-$140? Are X-rays and fluoride treatment included? If you feel you’ve been quoted a high price for dental work, check the table above to see where it lies in the range – you may find it’s a fair price.
  • If you need extensive work, shop around. If you have a written quote with item numbers, ask how much they’d charge for the same work and compare the price with the table we've provided.
  • Don’t be afraid to get a second opinion. Or perhaps a third. 

Carey-SwanCarey Swan was one of many Australians who decided she simply couldn’t afford the cost of the dental work she needed. Root canal therapy, crowns and implants were among the costly procedures dentists had recommended over the years, and unable to put off the inevitable any longer, she started researching and costing overseas options. 

Carey travelled to Bangkok on two occasions to attend a Thai dental practice well regarded among expats and Bangkok’s elite. Major work included eight fillings, an implant and root canal therapy and crowns on six teeth. The cost of having all the work done here would likely have been at least $20,000. 

Dubious friends back in Australia, at first concerned about Carey’s overseas experiment, are now converts, with six making the pilgrimage to Thailand in the past two years to have extensive dental work done.

Carey returned there earlier this year to have a crown fitted to the implant she’d had done in 2007. “I’ve estimated that, even with the price of airfares and accommodation at about $1200 for a 10-day visit to Bangkok, I’ve saved about $10,000 on the price it might have cost me to get the equivalent work done in Australia,” says Carey, who praises the Bangkok dentists as “the best I’ve experienced”.

The Australian Dental Association, however, warns against going overseas for treatment. It points out that overseas dentists may not be as well qualified as Australian dentists and infection control standards may not be as high. Sometimes you need to visit more than once to allow the mouth to settle between visits, such as for implants. And if something goes wrong, you have limited recourse, and may end up having to get further work done here or overseas again.

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