I have been in practice for more than twenty years, and I have heard the same refrain from many patients. Usually, the statement is in response to a recommendation for treatment:
“Ms. Jones, there are obvious changes on the x-ray we took. The decay is into the pulp tissue and will require a root canal.”
“But doctor, it doesn’t hurt.”
“Well, Ms. Jones, many medical conditions that do not cause pain must be treated nonetheless, high blood pressure for example.”
“But that’s different,” replies Ms. Jones.
In the simplest terms, what we’ve all experienced (in situations like the one above) is the disassociation between medicine and dentistry. Patients seem to believe that the oral cavity is not subject to the conditions that befall the rest of the human body—immune to disease, neglect, and normal or abnormal wear. However, I believe the statement refers to the limited amount of respect our patients have for us. And more importantly, it speaks to a future in dentistry that is forever and inextricably linked to economics and convenience, rather than medical necessity and adequate prioritization in patient health.
This is not to say that our patients don’t trust us (they do), but they hold onto outdated theories, old wives tales, and myths when it comes to their teeth, especially in less than stellar economic times. In addition, because many patients view us as “tooth doctors,” we are not held to the standards of our physician colleagues. Instead, we are held to the standards of a repairman: we should always be exactly on time, guarantee our work, and not charge more than our initial estimate. The question is how we got here and, perhaps more importantly, what does this mean for our profession?
As dentists we have been deluded into thinking that we are immune to the crises that have impacted our medical brethren. We have weathered the storm of DMOs, so we should be able to resume our normal activities, charge our normal fees, and practice in the absence of constant interference from insurance companies. Yet in the place of the DMOs, PPOs have sprouted like weeds, and show no weakness. Indeed, they continue to proliferate and dominate the industry, resulting in diminished fees. Our incomes and control are reduced as well. We’ve become surrogates for the PPOs, in that patients expect us to handle the myriad of insurance complexities and coverage. Worst of all, it’s the dentist who absorbs the patient’s frustration over lack of coverage, poor coverage and nonpayment.
It should be noted that even in “good times” (whatever that is or was), a substantial portion of the population does not seek dental care because of money, fear, and most importantly, its lower level of priority. Sure they will look, feel and eat better (not to mention have better breath) if their teeth are repaired and maintained, but once again the old wives tale comes forth and asserts, “If it ain’t broke, don’t fix it.” “Besides, mom, dad and grandpa all do fine with dentures anyway.” Sound familiar? “But Ms. Jones, do you really think that a prosthetic would function better than what you were born with? Would you really sacrifice your arm or your leg if the arm or leg could be saved? Do you really think you would be better off with an artificial arm or leg?” Answer: “That’s different.”
When people discuss access to medical care they use words such as “rights” and “necessity.” In the context of medical care, no one mentions, even cursorily, dental care. A recent major medical conference in Washington, D.C. was attended by representatives from virtually every major insurance company in the U.S. and the Federal and State governments, as well as assorted physicians and economists. In four days, not one second was spent on dentistry, nor was anyone present representing dentistry in any capacity. That is the level of importance we have in medicine today—we cannot even get a seat at the table, let alone a voice.
So how did we get here? Once upon a time, dentistry was a subspecialty of medicine; over time, we’ve evolved into tooth doctors. I am amazed at this evolution, considering my educational experience; my first two years of dental school were spent essentially in medical school taking the same courses as my medical student colleagues. After graduation, I completed an additional three years of hospital-based training. I am sure that many of my dental colleagues have had similar educational experiences. Even though not all of us obtained residencies, we all received a substantial amount of medical training in dental school. The sad facts are that most patients are completely unaware of our training and most of us seldom utilize that training! Every time I encounter a patient with a medical condition (or taking a medication), and I engage the patient about his or her condition or medication, they are actually surprised: that I, a lowly tooth doctor, would know anything about medicine, and that I would care! Some even view medical history to be a privacy issue and “frankly none of my business”!
In too many cases we are taught in our continuing education courses to concentrate on esthetics or orthodontics—i.e., to concentrate on the fringes of dentistry rather than what is truly needed by the population at large, improving home care and providing restorative dentistry. Perhaps my practice is unique, but I still see a lot of periodontal disease as well as decay. Most of the problem is a combination of poor oral hygiene and an unwillingness to change poor habits. There is probably more decay and periodontal disease out there right now than can possibly be treated by all of the dental professionals available, yet many of us are faced with the “busyness” problem. Why? Because there has been an acute failure of education in the importance of teeth and treating dental disease, which has resulted in a less than flattering opinion of our abilities by the populace. And what has been our response as a profession? To date we have offered no response.
We face no less than a crisis in both the short and long term, and we have no organized answer. No plan to market or educate. No plan to find a means by which we can “get a seat at the table.” In my view, it does not require informing the public of the value of oral cancer screenings, or connecting oral disease with overall medical disease, although both are true. I am simply saying from a quality of life perspective, what better benefit can we offer our patients than the ability to eat and smile? Certainly we can speak of implants and bonded porcelain and bleaching, but the issue at hand is convincing the vast majority of perspective patients to seek and receive dental care on a regular basis. Perhaps I am too naïve, but I believe that unless we create a feeling that dentistry is a necessity, our future will become uncertain—and this end does not serve either the profession or our patients. And despite assertions to the contrary, I do not believe we can effect the desired changes in isolation. We cannot do this on a practice by practice, dentist by dentist basis. It must be done on a large scale, a national scale.
The implications of this situation are that until we achieve, as a profession, some equanimity with our medical colleagues, patients will never appreciate what we do, who we are, and the importance of adequate dental care in their overall health. Failure in this means that most people will never seek dental care, except, perhaps, on an emergent basis. Failure means our profession will be forever be relegated to the medical basement of needs. Failure means a diminished future for us all.