General Questions – go back

  1. Why is dentistry so expensive?
  2. Are all dentists trained the same way?
  3. Are some dentists better than others?
  4. How can you find a dentist that does a good job?
  5. How does a dentist determine what treatments are really necessary?
  6. Are some dentists unethical?
  7. Are new graduates from dental school experienced enough to do a good job for me?
  8. How do graduate dentists gain enough experience to practice with confidence?
  9. Is dentistry a difficult profession?
  10. What does it cost to get a good dental school education?
  11. What has to be done in order to make a dental practice a successful business?
  12. Do dentists hire people in their practice to help sell the patient on expensive procedures?
  13. When a dentist develops a treatment plan, should he be expected to present alternatives?
  14. Is it worth going to another dentist for a second opinion?
  15. If I go to another dentist for a second opinion, will he/she try to underbid the first dentist so I will have the work done there?
  16. Is an older dentist better than a younger one?
  17. Is a friendly dentist better than an unfriendly one?
  18. Should I get one of the credit cards that the dentist offers me?
  19. Can a dentist generally do a filling or procedure that is less expensive than the one recommended?
  20. How do dental insurance companies work?
  21. There is a large dental clinic near me – is it a good idea to go to one of these offices?
  22. Would it be better to have my work done at a dental school?
  23. How do dentists decide how much to charge for particular procedures?
  24. Are dentists really devoted to helping me avoid decay and the expense associated with restorations?

Answers to General Questions:

  1. Why is dentistry so expensive? First, like all other service professions, one component that goes into the net fee is the training of the practitioner, and how much that translates into hourly rate. If a dentist charges $200 per hour for his time, that is consistent with the time and expense of the education it took for him/her to get to that level of knowledge and ability. These days many recent graduates are paying around $4000 per month on their school loans! Second, the dentist needs to hire trained professionals to work in the office. Third, the dental office is very expensive to put together – not only is the rent generally high for the locations needed, but the patient chairs, X-ray units, air compressors and even plumbing cost a lot – which may translate into a large loan which has to be paid on every month. Fourth, there are specific pieces of equipment that he might lease for doing the work. Fifth, some procedures require the work of a dental laboratory technician, and they need to be paid for what they do. Also – just imagine if your case is complicated – the dentist may take hours of his time just trying to figure out the best approach for you and then present it to you, get approvals from insurance companies, etc………………… BACK to answers ….. BACK to questions
  2. Are all dentists trained the same way? Simple answer is no. Dental schools are all accredited by the American Dental Association, the ADA. If order for them to offer the DDS or DMD degree, they have to meet certain standards. There is proscribed coursework that must be offered, but the most important part is how much experience they have on actual patients. This has changed tremendously over the years. The requirements for graduation are now such that the great majority will seek further training in a general practice residency for example. They might seek specialization as endodontists or prosthodontists, and other areas, but to practice general dentistry, where they must do everything requires great experience. Thirty years ago dental students graduated with all the experience they needed to start a practice with confidence. Also, some dentists did their initial training overseas and then got licensure in this country. How this might be done depends on the individual states, they are in charge of licensure, but many international dentists are quite experienced in some practice areas and not as much in others – depending on where they did their original training. Oral surgery, for example, is generally a strong area for the international dentist, whereas crown and bridge may not be. These days the international dentist coming to the U.S. must complete the last two years of the four-year dental school program, to have a DDS degree in this country. Still – the amount of clinical experience in dental schools these days is far more limited than it was 30 years ago………………… BACK to answers ….. BACK to questions
  3. Are some dentists better than others? This is certainly a loaded question! The short answer is YES! I’d say in any service profession there are some people that offer better service than others. For one thing, you can expect that some dentists will have more skill than others – there is an innate level of hand skill, and there is that which can be learned over time through effort. The good news is that while some dentists are more skillful than others, the great majority have ENOUGH skill to do work which will last the expected lifetime – in other words a great preparation in your mouth will not be more successful than a merely adequately done job. On the other hand, there are dentists who are more concerned with their income than the care of their patients! Sad but true. And sometimes there are dentists who are gracious and kind and caring, but honestly don’t have the sense of technical precision that will allow them to do optimal work – they are just a little over their head, regardless of their level of caring………………… BACK to answers ….. BACK to questions
  4. How can I find a dentist that does a good job? There are ways. In a later section I will go over in more detail this selection process. But Yelp and referral from friends is probably not likely to lead you in the right direction. I’ve seen many instances where patients love their dentist, but I know that his work is substandard. The best dentist I ever knew was actually rather unfriendly. If you are about to embark on an expensive set of procedures with a particular dentist, I’ll mention here one thing that you might do … ASK THEM if you could talk with their laboratory technician. First, if they send their work to a huge lab where the work is more mass produced and there is no set technician that works for them, it’s probably because the price is lower. If they have a dedicated technician in a small office, there is more of a connection, at the level which determines the success of the work. Most dentists will think you are crazy for wanting to talk to their technician if they have a dedicated one, BUT if they are enthusiastic about it, that certainly means they have a good relationship with them, and that means they do good work!………………… BACK to answers ….. BACK to questions
  5. How does a dentist determine what treatments are really necessary? There are many things to take into account here. One should be the financial burden that the patient otherwise faces. If the patient has maxed out their credit cards and has no savings, what business does the dentist have to recommend a $5000 treatment plan? If the patient is in their last 10 years of life, what business do we have recommending a treatment that will last 30 years? Let’s get practical! The average person in the U.S. will have to ask a friend to loan them $400 for an emergency need. They cannot afford a $1500 crown. What are the choices? If the patient has advanced periodontal disease, this needs to be taken care of so the mouth is stable before anything else is done, other than to get the patient out of pain………………… BACK to answers ….. BACK to questions
  6. Are some dentists unethical?  In short – yes!  Sorry for you and for our profession that I have to tell you that.  When I finished dental school for the next nine months, while I was getting my practice set up, I worked for another dentist who had just bought a practice in Riverside CA.  For a few months the front office person was still there from the previous owner, and she used to tell me a lot about how he was running things.  Also, unbelievably, he actually showed me how certain fillings could be done SO THAT they would FALL OUT, and he could do a  more expensive restoration later.  AND – he knew that at the time I was on the faculty of the school from which he had been graduated!  Once he even had a patient come in on my day running his practice for me to do two crowns on teeth that absolutely did NOT need crowns – in fact it would have been a total abuse of the patient to do so.  I got from the patient the “story” that the dentist had told as to why they were necessary – and it was completely fraudulent!  I was staggered – and, of course, did what the patient really needed rather than what the dentist wanted me to do.  But, I did get an irate phone call that evening.  Over the years I have had thousands of student/dentists in my courses that were working temporarily as dental assistants until they got their licenses to practice – from those I almost uniformly heard tales of abuse – sad to say.  Your only defense is knowledge it seems – which is why I am typing this into my computer in the moment………………… BACK to answers ….. BACK to questions
  7. Are new graduates from dental school experienced enough to do a good job for me?  Well – again, the short answer is NO!  I’ll put this in historical perspective.  I was graduated from dental school in 1992.  There are minimum requirements for how many restorations we do on patients in order to graduate.  The most challenging is how many crowns and bridges you do on patients, and in 1992 the minimum requirement was 30.  The highest that some students did in my class was around 80.  There were no students graduating with me that didn’t feel comfortable starting directly into dental practice – and most would be pretty good.  Local dentists looking for associate dentists would not hesitate to hire a new graduate back then.  This was the case for most of the dental schools in the U.S. then, although some schools were famously strong in providing clinical experience to their students.  For most dental schools the minimum graduating requirement NOW in crown and bridge is around FIVE!  This is particularly distressing news to my current students who are dentists from overseas that come to the U.S. to attend the last two, clinical, years of dental school here, so they can be ready to practice.  When I tell them about how the minimum requirements have slipped over 30 years, they are stunned.  The GOOD NEWS that I have for them and you is that as long as the school provided lots of hours per week of access to the clinics, students CAN do a lot more dentistry than the minimum, they just have to be proactive and get patients from the outside themselves.  There are SOME students every year that are really ready to practice general dentistry upon graduation, but not many!………………… BACK to answers ….. BACK to questions
  8. How do graduate dentists gain enough experience to practice with confidence?  This ONLY comes from doing dentistry on patients.  Basic skills can be learned well in simulation laboratories, but for real, living, breathing patients there is no substitute.  If the graduate doesn’t have enough experience on patients, maybe only doing 5 or 10 crowns, for example, they need to go to additional schooling, a residency in General Dentistry, or another educational experience in this area.  An additional year in a hospital or school setting may take them to the point of confidence.  Unfortunately, many of these programs, which have become VERY popular in recent years, do not provide as much mentoring by experienced dentists and teachers as would be hoped.  The bottom line is that every student dentist must take charge of their own education – dental school and residencies provide an opportunity to learn, but each person is responsible for their own education as it turns out.  Dentists learn from every patient they have, if they are paying attention, and have the fundamental knowledge and perspective………………… BACK to answers ….. BACK to questions
  9. Is dentistry a difficult profession?  Yes!  Now, that does not reflect what I heard as a young adult, that dentists have the highest suicide rate of any other profession.  Whether that is true, or even was true, I don’t know.  Having personally never heard of a dentist that committed suicide, I cannot comment.  But this is one profession that combines more aspects of life and business than most others………………… BACK to answers ….. BACK to questions
  10. What does it cost to get a good dental school education?  It is the second largest debt that most people will ever incur in their life – second only to the home mortgage.  For the international dentists that I work with to attend just the last two  years of the four year dental school program, they typically expect to owe $300,000 at the end of it.  So you can imagine how much the four-year students would owe!  The tuition in dental schools were not always so high, of course, but they have been accelerating in recent years.  One of the problems is that the dental school clinics are expensive to run, and they are not run profitably.  Of course, it is a teaching institution, not a profit center – but more efficient management could make a big difference in many instances.  The only other income a dental school has is the tuition, so it is being raised to cover the losses of the clinics.  Even experienced faculty are not having their contracts renewed so that schools can hire less costly faculty.  If the schools were to work with the community dental providers to get more patients referred to the school for care, the students would have a better chance of being confident of their skills, and more hirable at graduation.  This would make the community providers more willing to hire them at a salary that is beneficial to all.  Whether anyone has the foresight to make this happen remains to be seen………………… BACK to answers ….. BACK to questions
  11. What has to be done in order to make a dental practice a successful business?  Since the dental practice is very complex, with many moving parts, the strategies for business success are many.  It’s ultimately all about cash flow.  There is the rent to pay, and the lease on equipment, and the loan servicing on the practice buildout, and the employee compensation – all of this is money going out.  And the income is only from procedures.  Fewer procedures means the outgoing expenses may not be covered.  AND – of course, it is only when there is money left over from paying all the bills that the owner of the practice gets personal income.  And, from his personal income must come the payment on his student loan!  But as long as the practice has enough patients and those patients need and can afford significant dentistry, then the skills and efficiency of the dentist determines the amount of income.  Now – if the practice has several associates, or many in the case of a larger clinic – each associate is under the gun to produce, and their production is closely monitored.  If an associate falls short of how much dentistry he can do in a day, an admonition may be made.  In fact, many times associates are paid a base salary plus a percentage of the production over a certain amount per day.  This goes a long way toward encouraging an associate to work faster.  But – can they do this and keep the quality of the work at an acceptable standard?  Open question ………………… BACK to answers ….. BACK to questions
  12. Do dentists hire people in their practice to help sell the patient on expensive procedures?  Sometimes. These days the “sales associate” is less common except in the high-end, upscale practices where very expensive cases tend to be done.  But back in the early 90s some practices might have hired someone like this to convince patients that they should have their amalgam restorations replaced, presumably because of “health considerations”.  On the other hand, one of the jobs of such a person will be to “upsell” a patient – which means getting them to pay extra beyond what their insurance plan will cover by getting something done that is not on the plan.  The patient needs to be convinced that it is better for them to pay some extra money, when it may well not be better.  The motivations of these sales associates is revealed in their salary structure, as many of them are paid according to a percentage of what they were able to sell.  No different from a car salesman in this regard.  Most people would be well advised not to listen to excessively friendly or even charismatic people………………… BACK to answers ….. BACK to questions
  13. When a dentist develops a treatment plan, should they be expected to present alternativesCertainly.  A complex plan that is designed to restore the patient’s mouth to the most optimum condition is rarely ever accepted – mostly because the cost may be prohibitive.  Not too many people can afford a plan that costs the same as a new car, or even a used one.  There are always alternatives – they may not have the same esthetic benefits, or may not last as long in the mouth – but for now they are perfectly acceptable.  Even if just one crown is needed, there needs to be some imagination on the part of the dentist to find what is the best fit for the patient.  I had a teenage girl in my office one year that needed a crown on a lower molar, and she was showing clear signs of grinding her teeth.  I did not want to put porcelain in her mouth, because it would grind away the opposing teeth much faster.  While gold would be a much better choice in this case as it is very kind to the opposing teeth, I knew she would not want that, with the social pressures that a typical teenage girl is under.  So I designed a crown that was mostly porcelain, but had metal in places where the opposing teeth touched.  This she was quite pleased with, as it looked like a natural tooth with a few shiny silver fillings in it.  There are often compromises that need to be made in cost, appearance or longevity – but these need to be discussed with the patient clearly before a detailed plan is formulated………………… BACK to answers ….. BACK to questions
  14. Is it worth going to another dentist for a second opinion?  Yes and no.  It is a good idea, for sure – but the practical aspects are challenging.  The most common situation is that the second dentist will tell you that not everything on your dentist’s plan needs to be done, and he will undercut the price of what is done.  Now, he gets to do the work – effectively stealing you away from the other dentist.  Maybe the second dentist is a better dentist and told you the honest truth, but maybe he is just telling you what he must to get you to switch to him.  You probably won’t know.  It IS vital that you get informed – get educated – about what your needs are and what the options are.  And, this is what you are doing as you read this site!………………… BACK to answers ….. BACK to questions
  15. If I go to another dentist for a second opinion will they try to underbid the first dentist so I will have the work done there?  Most likely.  Can you tell if they are being truthful?  Now, you could make it a condition of the visit that under no circumstances will you have them do the work!  That would more likely produce a truthful analysis.  Also, of course, take records from the first dentist, and you will be charged for the second opinion – but that may well be worth the money.  When you get a better sense of what your needs are and what the compromises may be, then you may go back to the first dentist or not as you see fit.  One of the reasons I started a business of giving second opinions is simply because I do not have a practice, and don’t desire to DO dentistry in patients these days.  So, I can offer a trustworthy opinion and education to the patient.  I don’t often know exactly what is being expressed to the original dentist when they go back to them, but their choices will be informed!………………… BACK to answers ….. BACK to questions
  16. Is an older dentist better than a younger one?  Not necessarily.  In the later 90s I used to teach a class for practicing dentists in California that wanted to start practices in Nevada – and needed to pass the Nevada Board exam, which was quite challenging.  I had scores of these practicing dentists of all ages come to me to improve their skills and knowledge enough to perform well on an exam.  Believe me, they needed the improvement.  But, nonetheless, it was interesting to see what they knew coming in.  One dentist had been practicing dentistry successfully for 25 years, but he wanted to start over in Vegas, of all places, because he wasn’t happy in his practice.  Soon we discovered why.  As he progressed in the course, he started doing better work, and KNOWING that it was better!  I don’t think that when he was graduated from dental school he actually GOT it – where the fundamental principles and underlying principles of dentistry really made SENSE to him – and the situation did not improve over the years.  He had not really learned from each patient that he saw – he just got the work done in a way that seemed to work for the patient.  In reality, his work was sub-optimal and certainly failed prematurely in many instances.  After the class things really made sense to him, and he started enjoying his practice more, knowing that he was doing good work.  Young dentists these days don’t have much experience to fall back on, but, young or old, without knowing the fundamental reasoning behind what we do, they are lost either way.  ……………….. BACK to answers ….. BACK to questions
  17. Is a friendly dentist better than an unfriendly one?  Not necessarily!  One of the other faculty members in my dental school that I liked a lot, because he was such a genuine and friendly guy, was not a very skilled clinician.  I kind of had the idea of that, but we also used the same laboratory technician for making our crowns, and I was told by this technician that he wouldn’t accept cases from the friendly dentist anymore because he never got a good impression.  Now, I had heard how much his patients loved him, and I can see why.  But – if the skills aren’t there, and maybe there is not even the awareness on their part that their work is substandard – whether they know the names of your pets and kids doesn’t seem particularly important………………… BACK to answers ….. BACK to questions
  18. Should I get one of the credit cards that the dentist offers me?  NO.  It will not help you PAY for a dental procedure – it will only allow you to defer payment.  And, we all know how that works.  If you need another card because your current cards are maxed out, you have no business incurring that expense.  Your dentist should understand this and do what is best for you financially, if he cannot do what is best for your dental condition.  He can make compromises – there are less expensive procedures that might not have the esthetic results you would ideally want, but will serve you well in the long term even.  I think all consumers these days get the reality of “introductory APRs”, and that they’ll be paying 29% on the card soon.  The trouble comes when the dentist is not set up in their office, or has lost the skill or will, to do less expensive procedures.  Then you need to look for someone else………………… BACK to answers ….. BACK to questions
  19. Can a dentist generally do a filling or procedure that is less expensive than the one recommended?  Yes!  There might be compromises, but it is generally possible.  A large silver amalgam restoration can be done instead of a crown.  Partial dentures can be done instead of bridges.  Composite can be done on the front teeth rather than porcelain veneers.  Sometimes these things require more skill on the part of the dentist, and their profit may not be as much, but they should have the pleasure of doing something for you that is taking care of you financially.  I once had a patient that had two premolars missing, except the roots were still present at the gum level, healthy, but no crown of the teeth connected anymore.  She had saved $500 to have them replaced, not knowing that a typical dentist would be required to do root canals and crowns on each tooth, at a cost of at least $3000 at that time.  It took me a couple hours, but I ended up rebuilding both teeth with composite (plastic filling material), and connecting them together and to the adjacent teeth for support.  I told her to save her money because she would have to have that all redone at some point – but to my knowledge it was successful for some years afterward………………… BACK to answers ….. BACK to questions
  20. How do dental insurance companies work?  Great for them, OK for the dentist, and maybe not so well for you.  Later I’ll get into a more detailed discussion about this, but they have a business, and what all insurance companies hate is to pay out money.  They will do anything to avoid it.  If they don’t pay the dentist because they think he did a poor job, that is not your problem (except if he really DID).  But in general they will cover little of what you really need.  Especially as you get older, you may need a more comprehensive treatment that simply is not covered at all.  One needs to study plans such as this carefully to see what the BENEFITS and conditions really are.  Certainly, you don’t let the dentist start any work until you know that the insurance company will cover it.  That SHOULD be up to the dentist to make sure THEY don’t start the work until they have prior approval if necessary. ……………….. BACK to answers ….. BACK to questions
  21. There is a large dental clinic near me – is it a good idea to go to one of these offices?  Perhaps ….  If you have some kind of insurance coverage that requires that you go to a participating office, and they are participating, there is little choice.  If there is another acceptable clinic in the area that is smaller, that may be a better choice.  I would visit the office first and get the feel of the place – if you are open to it you can often tell if the office is “healthy” – how do the assistants look, rushed, comfortable and smiling, how do the dentists look?  Is there a sense of impatience or that someone is pushing them all for production, or is there the sense that they enjoy serving the patients in a very efficient and effective manner?  Some large clinics are extremely profit-driven and the dentists constantly “under the gun” to produce.  Others that are better organized and maybe not signed up with plans that don’t pay them much, can do good, caring dentistry.  Whether you are driven to check them out by a particular plan, or by price, or because they are close by your home – get a sense of what the office is like………………… BACK to answers ….. BACK to questions
  22. Would it be better to have my work done at a dental school?  YES!  Even though the students are often less experienced, you can count on an adequate job being done, at a reasonable price.  Sometimes you can get work that is far above the quality of what is done in the dental practice community!  The best thing is that whatever work is planned and done, it is done in collaboration with several experienced faculty members, and they might even chip in at some point to help optimize the work.  For ONE thing, you know that you will get what you pay for.  It will take longer and more visits, but that is the way it must be.  And, you will have the honor of helping a dental student learn his profession………………… BACK to answers ….. BACK to questions
  23. How do dentists decide how much to charge for a particular procedure?  Mostly this is based on how much of their time is required to plan and do the work.  It may require several visits with follow-ups to make sure everything is serving you well.  Or it may be something that is done in a half-hour.  Sometimes the lab fees are high, and sometimes the materials used are expensive – for example with dental implants.   And, of course, the overhead in the office must be covered – basically the dentist has a calculated price that he has to pay just to have a dental chair you can sit in with an assistant to the side.   It’s really about covering their costs.  Some procedures DO cost a lot more than others, and it is pretty clear that some dentists charge more than necessary.  When one dentist charges $1500 for an implant and another charges $2500, you have to ask why?  On the other hand, if you are living in Beverley Hills and go to a dentist there you’ll have to pay three times the price for a crown as you would anyplace else.  This is not just because of the really expensive office that they must maintain so the patients feel they are in their mansions, but really rich people tend to be quite discriminating about their appearance, and you can assume that a crown will have to be redone a couple of times to get it “right” – and this has to be priced in………………… BACK to answers ….. BACK to questions
  24. Are dentists really devoted to helping me avoid decay and the expense associated with restorations?  YES, and no!  Can’t speak for all dentists.  I CAN say that dentists are not uniformly devoted to preventive dentistry – some see your decay as their profit (BOY, do I hate to say this).  But in general dental offices are set up to help you learn to keep your teeth and gums in good condition, and the decrease in decay is a consequence.  As you get older and different surfaces of the teeth become exposed to the decay bacteria, things become a little more challenging, and I hope that your dentist will familiarize you with the different methods of cleaning that may be appropriate at different ages………………… BACK to answers ….. BACK to questions