The 'Irrational' Way Humans Interact With Dentists

There seems to be a massive disparity in techniques and tools, too, though I am reporting only anecdotally. I recently got dental insurance again after a long time, and for better or worse started going to a dentist again. I picked him via "since I have no other metric to use I might as well pick the closest that takes my insurance". Somehow I stumbled onto an older guy with a lot of experience but who has also kept up with the latest technology.<p>He doesn't use X-Rays to find cavities, he's got this laser thing that directly measures the tooth density and makes little werping noises when it is low. He found a couple of things (which I had no reason to suspect weren't problems as they were highlighted as problem areas by another guy ten years ago, and one of the other problem areas he said still isn't enough of a problem to be worth doing). It seems a much more objective system than poking at things or looking at X-Rays. I got a couple of filling done via laser drill, which I didn't need anesthetic of any kind for. (Those with low pain tolerances might, it wasn't pain free, but it was OK and I preferred it to a droopy drooly mouth for most of the rest of the day.)<p>I figured I'd just been out of the game for a decade and a lot has changed but I've mentioned this to my coworkers and few of them recognized any of that stuff. Your anecdotes solicited.

I have about 5 dentists in my immediate family (grandfather, dad, dad's wife, aunt and uncle). My dad is the head of the Perio department in the Hadassah Dental School in Jerusalem. Naturally, I had my teeth checked twice a year like clockwork all my life. I have some gum issues, but never needed a filling.<p>6 month after moving to the bay area, I went to a local dentist for general checkup. He used the "laser thingy" to find cavities and found no less than eight cavities that required filling. He also took XRays that showed no issues at all. I asked him for copies of the records and XRays so I can send to my father for second opinion. He immediately agreed, but despite weekly reminders, he never sent me the films.<p>On my first visit back home, I got my teeth checked by my aunt again. I need one filling.<p>Lessons learned: * US diet accounts for one cavity. * Dentist greed accounts for seven more. * Always ask your dentist for copies of XRay and files and don't return if he will not supply them. It is your right to have those copies of your dental history. * If the XRays don't show the cavities, there are not at a level where you need to treat them yet. You can safely wait until they show up. If you maintain high level of dental hygiene they may never get to the point where they need filling.

I have no problem shopping around dentists, and have even checked my new dentist's professional opinion with my old dentist who I trust completely (I moved overseas). I studied how dentists work with their computers for my PhD using participatory design so learnt the basics of dentist practice, and from my studies at a dental school, got to learn what good and bad dentistry are, so I'm definitely not the norm.<p>It is interesting how devoted most people are to their dentists. I was referred to a dentist who was TERRIBLE. Really really bad. And the person who referred me had referred a whole bunch of people who all went there (which is why I trusted the referral). I never went back, and started asking other people what they thought - everyone had doubts about his skills, but still went. This article is an interesting way of explaining why they kept going regardless of the terrible experience and lack of competence.

This article got me thinking about a trip to the dentist I had a few years ago. From when I was 5-18 years old I had the same dentist and between ages 13-18 I had a really impeccable record when it came to not having cavities.<p>Then, when I came back from my first semester of college I had to switch from my old dentist (who specialized in children/teenagers) to a new one.<p>On my first visit, he identified something like 3 cavities, which was pretty shocking to me. Before I just assumed that the x-rays were easy to interpret so the dentist is 'always right' ... but after hearing about this 50% figure it makes me wonder.

Misaligned incentives.<p>You shouldn't pay your programmers to fix bugs or lay down lines of code, but to produce working software. You shouldn't pay your doctor to treat you, but to make and keep you well. You shouldn't pay your mechanic to fix things, but to make your car run. And you shouldn't pay your dentist to fill cavities, but to keep your teeth healthy.<p>The DoD calls it performance based logistics. We build a system and promise to fix it whenever it breaks. If it's working X well for Y days of the year, we get paid $$$. Otherwise, we get paid $$ or even $.<p>It just makes so much sense. It weirds me out that maintainence is handled any other way. It's just begging for vendors to take advantage of consumers who don't know any better by selling things that are useless or even harmful.

Areas like this (essentially, a complex combination of psychology combined with differing motivations along with a little information disparity for good measure) could be an interesting opening for a startup.<p>If you could get over the admittedly uncomfortable social dynamic of implying a lack of competence in your dentist, you could ask them to send your Xrays over to "2ndopinion.com" where trained and certified dentists would give a second opinion. You might pay $80 for the privilege, and for that price maybe 2 dentists would review it.<p>Anyways, you get the idea. I love disruption around information disparities.

I think this happens with surgeons as well. About two years ago my doctor found nodules on my thyroid... blood tests revealed Hashimoto's Thyroiditis. After a series of ultrasounds, radioactive iodine uptake tests, and needle biopsies, I was referred to an ENT who specialized in thyroid surgeries.<p>The pathology report revealed that there was about a 20% chance I had papillary thyroid cancer, which has the highest cure rate of any type of cancer (&#62;95% are completely cured after a thyroidectomy). So he recommended we take it out.<p>And that's what I did... a partial thyroidectomy where one half was removed. Turned out there was no cancer.<p>It was weird, though. After all of the painful tests, the long weeks waiting for appointments, the waiting in doctor's offices, the uncertainty, I didn't really think to say "Well, this is pretty low-risk... why don't we just wait on it?"<p>Surgeons will operate if you let them. It's what they do.

Reading this while sitting in a chair waiting for four cavities to be filled might not have been the smartest move.

Now that I'm contracting and have to pay for dental care out of pocket, I've been thinking that the next time I go to a dentist, I'm going to tell them up front that I am only there to see them for cleaning and x-rays, and that I will be taking their results to another dentist for drilling and filling.<p>This interview just reaffirms my total lack of trust. It's like going to an auto mechanic. Setting aside notions of customer loyalty and karma, and what would happen if word ever got out, the auto mechanic maximizes their revenue by screwing over their customer.<p>"Well, of course they're trying to screw you. What do you think? That's what they do. They can make up anything. Nobody knows. 'By the way, you need a new Johnson rod in there.' 'Oh, a Johnson rod. Yeah, well, you better put one of those on.'"<p><a href="http://www.seinfeldscripts.com/TheFusilliJerry.htm" rel="nofollow">http://www.seinfeldscripts.com/TheFusilliJerry.htm</a>

I've tried 6 dentists recently, 2 were local; 2 were referred by people I knew; 2 were referred by health-care professionals who were trustworthy and gave me truly excellent results in their own field. I'm in Melbourne, Australia, and I have no reason to believe that our dentists are particularly bad.<p>All 6 were either dishonest or incompetent. Including: preventing my front teeth from meeting; modifying opposing teeth for a fit; key equipment not working; charging me for work not done (I was informed that they'd checked the invoice too); going back on an agreement (to give me the xrays); going ahead with work without asking me (I found it impossible to get out of the chair to stop him); and of course being overcharged (my accountant remarked on it.)<p>However, all 6 were excellent at minimizing pain, and that seems to be what most people notice. I'm more concerned about getting my teeth fixed.<p>The 2 previous to these 6 were not very good. I would have thought 6 more would be enough to find a good one. I have given up on the dental profession as institutionally corrupt. I do not believe there is even any facility to complain about them, as that would also be run by dentists.<p>Because it's difficult for a layman to check a professional's work, especially when that work is also difficult to inspect, I used secondary signals in the above. However, I also bought a small mirror, and a direct inspection also revealed a misplaced shallow drill hole (with no filling). I remember years ago one of the previous dentists had slipped, but I didn't think it had actually resulted in any drilling. <i>None of the dentists mentioned this very obvious rogue drill hole.</i><p>I think most people are happy to get out of there, and if any pain stops. I just wish I could DIY my own dental work.<p>Can anyone suggest how I can find a competent dentist?

My dentist used to be located in a dentist ghetto (i.e. a strip mall full of more than a dozen dentists' offices). At one point, when I had no dental insurance I was told I needed two fillings, come back in a couple weeks, etc. So instead of just walking to my car I went down the side walk and got price quotes from about 6 more dentists for the two specific fillings I needed. Prices varied greatly!

A dentist is the closest thing most of us get to a cosmetic surgeon. They can have a large effect on our appearance and have procedures that will probably cause us the most pain out of anything the normal person has done to them. Plus, they hold up an x-ray and say "This is..." not "This might be...". You really owe it to yourself to get a good look at who is doing the work.<p>As an example, as a child I was under government health care (Indian Health Service in the US) and "had to have" a root canal done. The dentist did the work (come to find out it is generally someone else who does this). I think nothing of it other than the extreme pain. This is when I was in 6th grade.<p>1st year of college and I get this incredible pain in my mouth. I go to a dentist (not IHS) and get my mouth checked. Come to find out the original dentist left some infected material in there and I am in a world of hurt. Antibiotics and Percodan for two weeks and then oral surgery. The oral surgeon had some not-so-kind remarks about the person who originally did the root canal.

I've worked IT for a few dental offices. It's know as "drilling at shadows". (the dark spots on the xray are likely candidates for decay) Some dentists are more aggressive than others who take a "wait and see" approach. (You do go every 6 months right?)<p>Dentists will often drill and fill these dark spots "just to be sure". This is the first time I've ever really considered the financial angle and the perverse incentive that may also be at work.<p>The proliferation of digital xrays with instant networkable images creates a fascinating opportunity here. There's probably a startup in instant second opinions...

This article further confirms the ridiculousness of asking friends and co-workers to recommend a dentist. I do trust friends and co-workers to recommend movies or restaurants because most people have seen hundreds of movies and eaten at hundreds of restaurants. Both most people have had only 1 or 2 dentists in their entire lives. They have no basis of comparison to say whether their dentist is any good.<p>You might as well choose randomly from a phone book. That's what I did when I moved to a new city. Actually I looked for dentists that were close to me, that spoke English natively (I live in a very cosmopolitan city), whose dental degrees were more than 5 years ago (gained experience) but less than 20 years (not outdated), and whose staff were pleasant and prompt on the phone (on the theory that the behavior of the staff will reflect the character of the boss).<p>Thus I picked my dentist without a recommendation and without meeting or speaking with him, but I think my method is less arbitrary than asking your friends and co-workers. (And yes, I do wish there was a better way.)

This stockholm syndrome is annoyingly hard to avoid. I've known about it, but I can recall many similar occasions after reading this article.

I just recently got dental insurance again and now I'm kind of wondering how I should choose my dentist.<p>I was going to a dental school for treatment which meant that I was being treated by students under the supervision of dentists. They don't have a financial incentive to find cavities and everything is checked by two dentists.<p>It's possible that they have an academic incentive to find cavities (more practice for example) but at least two dentists have to agree with their assessment before they continue.<p>Unfortunately they don't accept insurance and my insurance company is kind of a pain when it comes to out-of-network dentists.

While I was in college, I admittedly went ~5 years without seeing a dentist.<p>When I graduated and got dental insurance, I immediately googled for "laser dentistry" in my area (having heard about it from my girlfriend). I chose the dentist with the highest ratings (well, one of the only dentists with any ratings at all).<p>Interesting fact: in 5 years, I apparently accumulated 5 cavities, none of them very serious. I got all 5 filled in under an hour, with no anesthetic whatsoever. Then, when I went for my checkup 6 months later, I had 2 new cavities. (Btw, if anyone is wondering, there is a low-power laser that reflects off your tooth enamel based on tooth density to determine which teeth need attention, and then there is a different high-power laser that actually gets rid of the decay).<p>Being my usual skeptic self, I started wondering if dentists didn't embellish reality a bit (or even create cavities while they're in there... ok, even I'm not that cynical, but I'd be lying if I said the thought didn't occur). Then again, my dietary and health habits probably did change considerably that first year after graduation.<p>In the end, I trust this particular dentist for a couple reasons.<p>1. He readily explains every step of every procedure he's doing, including how the tools work and why they work, even edge cases in which they wouldn't work. And he does so with enjoyment, like it's pleasant for him to have a patient interested in what he does. This appeals to the engineer in me.<p>2. He has said things to me like, "Well let's wait and see on that tooth. There's no reason we need to do anything to it just yet, it doesn't seem to be getting any worse." Also, when doing the laser fillings, he's asked, "Do you want anesthetic?" I responded, "do you think I need it?" And his answer: "Well, we can start without it, and then do it if things get too painful. No reason to numb you up and mess up your day if not necessary." Realizing that he'd get more money from me and my insurance if he used anesthetic, this alignment of interests was refreshing.<p>3. Given that every procedure I've had with him has been without anesthetic, I can say with certainty that he is extremely attentive to any pain I may have. He notices immediately if I wince at all, and makes adjustments accordingly, like turning down the power of the laser.<p>At the end of the day, I pay him for peace of mind, and he delivers.

There is a little bit of over-simplifying going on in this article, but it was an interesting read, especially for an anti-dentite like myself. The problem is that people don't go to the dentist just to have cavities filled. My first trip to my current dentist happened due to a severely painful toothache (to call it in ache is like calling a broken leg a paper cut). I had my bride do some research of local dentists (whatever she could cram into 5 minutes on google) and went with the guy that I perceived as having the best technology (but really the main criteria was the most open schedule).<p>What followed was a great experience: after 2 hours of patching things up, my pain was almost completely gone. After a few days of antibiotics, it was gone. The shot required to numb the area didn't hurt (it may have under normal circumstances, but ... "broken leg"). That single correction brought me back on schedule. I had a filling that was sensitive. He replaced it with a "new material", it was more sensitive, so he replaced it again with a different bonding (Neither I nor my insurance were charged) and that sensitivity went away. No cavity filled since then has been sensitive.<p>I've had a handful of cavities, and I return, reluctantly, but my loyalty lies more in the fact that I had a tangible, identifiable problem (excruciating pain, and later sensitivity) and he troubleshot it until it was fixed to my satisfaction. I wouldn't see another dentist simply because I believe this particular dentist to be predictable. I'll have a problem, he'll fix it. I, like other commentators, have a dentist who uses more than just X-Rays to diagnose cavities. At the moment, I have three spots on the X-Ray and DIAGNOdent that he has said he'd like to "wait on" because he wasn't sure. I had thought -- due to my past experience with tooth pain -- that "waiting on" something like that was asking for trouble, but now I'm wondering if I have a Dentist who understands the limitations of the technology he uses.

I would be short of two teeth, if my mom hadn't had the resolve to get me a new dentist, just as the newly hired one began getting all sorts of weird ideas.<p>I was only there one time, and no harm was done, and no teeth were removed, but you can recognize many kids my from my city by them missing one or two teeth. I don't really know what to think of that, but it sounds like something straight out of a wicked story. I guess it <i>is</i> a wicked story.<p>Teeth are the most difficult part of your body to maintain, which makes it all the more awful considering how proportionally dependant you are on dentists compared to other experts you need regularly.<p>I was never afraid of dentists, because I was there to keep my teeth healthy (and as they always were, I didn't try nor fear a cavity and subsequent drill), but if I didn't have a dentist I loved dearly, I would probably shudder at the thought of <i>them</i> doing a sloppy job.

The conflict of interest problem could be significantly reduced by having a third party read the x-rays (i.e. make the interpretation of dental radiographs a radiology subspecialty or create a subspecialty within dentistry for doing this). This wouldn't have been very practical in the old days of film-based radiography, but with digital technology you could easily transmit all the images to a third party for reading. Having a dedicated specialist reading the x-rays would both address the conflict of interest problem (the specialist has no incentive to be biased; they'd get paid a flat fee to read the images and generate a report) and would very likely also improve the accuracy of cavity detection because the images would be read by someone who reads way more dental x-rays per day than any individual dentist ever would.

"Cognitive dissonance is the idea that when people do something painful they become more committed to the goal."<p>No. Cognitive dissonance is the pain caused by having two contradictory ideas at once.<p><a href="http://en.wikipedia.org/wiki/Cognitive_dissonance" rel="nofollow">http://en.wikipedia.org/wiki/Cognitive_dissonance</a>

My dentists keep changing because they keep leaving the practice I go to. That might be a sign to look elsewhere. Although my first dentist told me that at some time I would need a crown put on a tooth, and as soon as he left and the new dentist looked at my tooth, he said we should get this done now even though nothing had changed. One could have been complacent, while the other was proactive - who knows. There probably should be more of a standard than a gut feeling when it comes to medical procedures.

A dentist in Michigan (Robert Nara) came up with a way for his patients to avoid all cavities. The state dental association had his license revoked or imprisoned or something. A threat to their summer homes and boats I guess.<p>I've tried his approach for a few years and so far no cavities. It comprises a hygiene regime designed to minimize the oral bacteria load by brushing immediate after eating and using salt water rinses.

Why fill a cavity so early?<p>Why not wait till it's a bit more obvious? I don't mean wait till it's so bad you need a root canal, just till it's not a "maybe".

I'd alternate going to my dentist and my girlfriend's dentist. My dentist always wanted to replace some of my fillings. My girlfriend's dentist never mentioned it. Once I even asked before the exam if my fillings needed to be replaced, telling her that another dentist said a few were bad. The final verdict: I was fine. I never went back to my dentist.

I would have thought the main reason for changing dentist is when moving to another area.<p>Cognitive dissonance? Cognitive cacophony.

Peripherally related, but too awesome to pass up on. <i>This Is Going To Hurt Just A Little Bit</i>, by Ogden Nash: <a href="http://wordysketches.blogspot.com/2010/07/this-is-going-to-hurt-just-little-bit.html" rel="nofollow">http://wordysketches.blogspot.com/2010/07/this-is-going-to-h...</a>

I think this is more "the rational way dentists interact with insurance companies". Insurance companies pay well under the usual market rate for treatment, so it makes sense for a dentist that accepts insurance to find a lot of problems that can be fixed in a short amount of time. "Yeah, that's probably a cavity" for 3 teeth on the same side of the mouth requires about as much time-in-chair as 1 cavity, but he gets to bill 3x. And since the insurance company is paying for it, there is no risk of not being paid. (It's bad for the patient, of course, because the fillings have to be redone in 10 years. But that ticking time bomb keeps the insurance payments coming in, and so it's good for everyone. Except the patient.)<p>My dentist doesn't take insurance and so he probably doesn't do this.

DIY fillings <a href="http://www.ivoclarvivadent.com/en/all/products/restorative-materials/amalgams/" rel="nofollow">http://www.ivoclarvivadent.com/en/all/products/restorative-m...</a>

Dentists can be complete crooks though.<p>All my life I went to two dentists. Both were pretty good, and I had cavities pretty rarely.<p>Later, my parents had to switch insurance, so we went to another dentist with a much nicer office. He takes a quick look at my teeth and says, "Oh yeah, looks like about eight cavities. We should drill them etc etc"<p>My parents are shocked and take me back to our most used old dentist for a second opinion. He examines me closely with a pick and tells us the other guy is full of shit, and that behavior is really common in dentistry.