Ok, let's talk about this controversial dental x-ray study...

Since I appear to be on a roll with a number of issues these days, including dental xrays, I might as well add the latest (and very controversial) study to come out about the "links" between dental xrays and some form of brain tumor. It simply must be addressed, as I've been asked my opinion on this a lot recently. As usual, I conduct my own research on the research reportings, plus the fine print (of course!), before presenting the facts. THEN, and only THEN, do I give my opinion. So, here goes...here's what I found....and hold on to your hats, 'cuz this is going to be one heck of a bumpy ride...just sayin'..(shaking my head)...

First thing to state here is that there is a significant difference in the way this study was reported by three sources. Significant is an understatement. I have to wonder if I'm looking at the same study results here. I've looked at four articles "reporting" the study results. I have not viewed the actual study itself as it is not yet accessible to me through the journal Cancer, that published it. I can assure you, though, that I WILL read that study and report back on it, as soon as I can access it. So, consider this Round One (ding! ding!) of this controversial study.

Here are the links to those articles:
1. The Washington Post
 http://www.washingtonpost.com/blogs/the-checkup/post/study-links-dental-x-rays-to-brain-tumor-risk/2012/04/09/gIQALz8k6S_blog.html
2. WebMd
 http://www.webmd.com/brain/news/20120410/dental-x-rays-linked-brain-tumors
3. Yahoo Health
http://health.yahoo.net/news/s/nm/dental-x-rays-linked-to-common-brain-tumor
4. Reuters
http://www.reuters.com/article/2012/04/10/us-dental-x-rays-idUSBRE8390GM20120410

After reading all four articles, all I can say is Holy Biased Study Reporting, Batman! Facts, assumptions, and correlations swing wildly between the four articles. Limitations and potential issues with the study, also swing wildly. This is such a classic case of playing "telephone" with a study. However, we, as the readers and consumers of dental services, have a right to know exactly what the deal is here. Having and knowing the facts can GREATLY impact decisions regarding dental care here. Yowza...while the facts from this study are fascinating; how they are written, in what tone, and with what "spin" they include, will fuel consumers and feed their preconceived notions.  Time to put our "pseudo surgeon's gloves" on and dissect this mystery...

Facts stated:
1. Two groups of subjects were studied; one group with meningioma brain tumors (benign, as in not cancerous), and one group without meningioma brain tumors. Good. A comparison group is good to use. I like it so far.

2. Ages of study participants ranged from 20 to 79. That is a significant variation in age and could be considered a study limitation right off the bat. It would be very difficult to "control" or rule out, other potentially influential factors here with this wide span of "adults".

3. The sample size (# of study participants) was similar for both groups and was fairly large: 1,433 people with tumors, and 1,350 people without the tumors. Apparently, the study participants in both groups were of similar age (?) and from similar states/cities (Conn., Ma., NC., Houston and San Francisco areas). I'm not sure why they chose broad states and two cities as study sites, but my guess is that there were numerous researchers involved in the study and they lived in these areas listed above. However, the 3 states and 2 cities are a strange choice overall. Again, it would be hard to rule out other impacting geographical factors arising from these locations alone, and I'm not sure if locations were even taken into consideration, but this is what I have to work with until I can read the actual study itself.

4. The study participants were asked to remember their xray usage, type, and frequency, dating back to the 1960's. (RED FLAG HERE!!!) Huh? How many of us remember what we had for breakfast in 1968 let alone how many xrays we had taken at the dentist 50 years ago??? This is a SELF REPORTED study. It is not based on gathering actual FACTS from physical DATA, from, say, DENTAL OFFICES. They are relying on people's MEMORIES here. They are basing a HUGE conclusion linking xrays to BRAIN TUMORS on people's recollections!?! That's a huge step and conclusion to make with unreliable data, from decades ago.

Ok, as a researcher myself, I have to step back and gain my breath. (Breathe, Annelise, breathe...inhale, exhale, inhale, exhale..). I am now officially skeptical (understatement of the century). Remember here, that many study participants were in their 60's and 70's when this study was conducted. The age ranges of participants were up to 79. 79, for pete's sake!!!!! You mean, these researchers interviewed senior citizens about when, type and number of xrays they had dating back to the 1960's??? Is that what they are basing these IMPORTANT conclusions & results on????? If so, I might as well stop here and tell you in my most humble and professional opinion, that this study is flawed, if this is the methodology used. I don't mean slightly flawed, I mean, "are you people seriously KIDDING ME?" kind of flawed. I believe the british term here is "bullocks", but I'm not positive. There was NO conclusive, confirmed, credible DATA to back those "guestimates" up. None. Ok, granted back in the 60's, 70's and even into the 80's dental offices used paper, not digital charts and computers, but dental charts were not studied at all here. They relied on people's memories alone. It would be near IMPOSSIBLE to verify ANY of these "guestimates" since most of those dental practices are GONE by now. Not to mention, how mentally and cognitively healthy were those senior citizens interviewed for this study??

 But this is too important to simply state the early limitations of this study that I have found. There is more so let's keep going here...

5. The study looked at 3 different types of xrays that people "recalled" having taken on them. Bitewing xrays (4 films of your back/posterior teeth; 2 of the upper back, and 2 of the lower back), a full mouth series of xrays (FMX) which total 18 xrays of all teeth and INCLUDES a set of 4 bitewings in this series of xrays (remember that), and a pano xray that is taken from further away from the face, circles the face, and gets a wider image of all teeth, bone, sinus cavities, etc. Ok, that said, here is what they found. Ready? This is going to blow you away. Honest. You need to sit down for this level of contradictory reporting. The study found that those study participants who had bitewings and a pano were much more likely to develop this benign brain tumor; 40%-90% more likely, is what they are saying. HOWEVER, (here it comes), those that had an FMX series of xrays (which INCLUDES bitewings, you will recall) are NOT more likely to develop meningioma brain tumors. Huh?? What?? Back up a sec. How is it possible that bitewings by themselves are linked to higher likelihood of developing brain tumors but FMX which INCLUDES bitewings, are NOT linked to developing brain tumors? I'm raising a hale and hearty RED FLAG here. Umm. Pardon me, but that makes NO sense whatsoever. None. Zero. Zip. Nada. No Way, Jose. A flat out Oh HELL NO....you just did NOT say that, did you? Ugh...wow. Ok, well, in the best interest of everyone getting all the "facts" straight, let's continue...I did warn you...this is about to get even bumpier...strap yourself in.

6. The study reported, based on the highly scientific "findings" (oye vey..were the surveys filled out with red crayon too, or burnt sienna, by chance?) that those study participants who were more likely to develop these brain tumors  received a more frequent number of xrays back in the 1960's, because the ionizing radiation from the OLD xray systems was HIGHER then, so THOSE people who REMEMBER that they had lots of bitewings every year at the dentist back in the 1960's were 40-90% more likely to develop brain tumors! Yes, you heard me right!! This HIGHLY "scientific study" linking dental xrays with BRAIN TUMOR development, is basing its conclusions on self-reporting, and on xrays that have not been used in 50 years! Guys, this is like saying that not washing your hands back in 1912 led to a kabillion percent increase in risk of infection! Really? No WAY! I'm FLOORED!....I kid you not. I am beyond floored. The more I read, the more doubtful I became.....but THIS??? Dear Lord, save us all.....from this level of skewed, flawed, and flat out DANGEROUSLY overstated reporting...please...I beg of you...because, Lord, if you don't....people will HONESTLY think that getting xrays at the dentist TODAY will give them brain tumors TOMORROW!

Yes, I am continuing...against my better judgement here...but nonetheless...

7. Direct quote from the lead researcher, Dr. Elizabeth Claus "It's likely that the exposure association we're seeing here is past exposure, and past exposure levels were much higher", end quote. I'm very tempted to quote my adorable grandson, Gage, here when I say something silly and he looks at me and says "Double Duh, Grammalise"! But I won't. What I will say is this: you will receive higher levels of radiation walking out your front door than you will from getting a dental xray taken today. In fact, and I will back this up with REAL facts, dental clinical staff do not even have to WEAR xray badges, like hospital staff or medical staff who take xrays do. Why, you ask? Well, because the miniscule levels of radiation from today's wonderful digital xrays are not even a concern to the health department that REGULATES xray radiation exposure levels!! That's right! Anyone else in ANY medical facility that takes xrays MUST wear a radiation badge around their neck and have it tested for exposure levels throughout the year to avoid staff overexposure to radiation, EXCEPT dental staff. This can be found in Florida's Administrative Code 64E-5.314, and here it is:

64E-5.313 Compliance with Dose Limits for Individual Members of the Public.
(1) The licensee or registrant shall make or cause to be made surveys of radiation
levels in unrestricted areas and radioactive materials in effluents released to
unrestricted areas to demonstrate compliance with the dose limits for individual
members of the public in 64E-5.312.
(2) A licensee or registrant shall show compliance with the annual dose limit in
64E-5.312 by:
(a) Demonstrating by measurement or calculation that the total effective dose
equivalent to the individual who is likely to receive the highest dose from
the licensed or registered operation does not exceed the annual dose
limit; or
(b) Demonstrating that:
1. The annual average concentrations of radioactive material released
in gaseous and liquid effluents at the boundary of the unrestricted
area do not exceed the values specified in State of Florida Bureau
of Radiation Control ALIs, DACs and Effluent Concentrations, July
1993, Table II; and
2. The dose from external sources would not exceed 0.002 rem
(0.02 millisievert) in an hour and 0.05 rem (0.5 millisievert) in a year
if an individual were continually present in an unrestricted area.
64E-5 Florida Administrative Code 64E-5.314
III - 12
(3) Upon approval from the department, the licensee can adjust the effluent
concentration values in State of Florida Bureau of Radiation Control ALIs, DACs,
and Effluent Concentrations, July 1993, for members of the public to take into
account the actual physical and chemical characteristics of the effluents, such as
aerosol size distribution, solubility, density, radioactive decay equilibrium, and
chemical form.
(4) Dental and podiatry registrants are exempt from (1), (2), and (3), above.(Here it is)
(5) Each licensee or registrant shall maintain records sufficient to demonstrate
compliance with the dose limit for individual members of the public until the
department terminates each pertinent license or registration requiring the record.

See? I told you so. AND, if you still need further proof that the radiation exposure in dental offices TODAY is SO LOW that dental personnel who take dozens of xrays EVERY DAY, don't even have to wear an exposure capture badge, you should call my buddies at the Department of Health; they are awesome peeps!
Bureau of Radiation Control
Radiation Machine Section
Suite 300
705 Wells Road,
Orange Park, FL 32073
Telephone: (904) 278-5730 Fax: (904) 278-5737

So, getting back to this study. First, if researchers wish to study whether xray exposure is really linked to brain tumors, they should seriously study dental personnel. They're in the xray trenches everyday for years on end. To date, I have known no one in dental clinic settings, to have developed any form of cancer, let alone, brain tumors. That's not to say they haven't; I just have not heard of any, and believe me, I get around (in a professional way only).

The four articles were extremely selective in what they reported on this study. One article, from WebMd, no less, omitted the most important limitations of this study. By doing so, they have, unfortunately, and in my HUMBLE opinion, done an injustice and disservice to themselves. Based on this important, and omitted, information, I now have my serious doubts as to the credibility of information presented by WebMd. In fact, it states that "Neurosurgeon Michael Schulder, MD agrees that the published findings make a good case for limiting the frequency of dental xrays whenever possible". Wow. Michael...did you even READ this study? Did you READ the methodology? Did you READ the self-reported instrument used? Did you READ the time frame the "link"s were referring to? And, lastly, Michael, did you READ the age groups that self-reported???? Wow... Wow.... And Wow....How incredible to make such broad statements on such flawed and skewed presentation of information. Wow. Unless I am 100% wrong, and the actual study itself states something very different than the articles reporting on them, I'm floored still.

Here's my last word...and it's strong. The only other studies conducted on ionizing radiation and its effects were conducted on atomic bomb survivors or radiation treatment patients. Studies were inconclusive. This study does NOT show cause and effect. The findings CANNOT prove that radiation from imaging caused tumors. This is clearly stated in the articles. I have been reviewing study manuscripts for many peer-reviewed journals and had I received a manuscript of this study to review, with these limitations & biases, I would have rejected it from being published. It is misleading the public dangerously, into believing that dental xrays CAUSE brain tumors, and they don't, according to the current body of knowledge.

With 66% of our population overweight or obese, one can safely say, that those extra pounds didn't come from overeating on salads. The 50% of children who have their first cavity by age 5 did not get them from eating lettuce. Diabetes, heart disease, high blood pressure, certain cancers, and many other current chronic conditions that the majority of Americans suffer from, can be traced back to poor eating habits. Those poor eating habits include the MOUTH as the receptacle for the poor food choices and the MOUTH as the ENTRANCE to the rest of the body. What do you think the oral health status is of this vast majority of Americans? Is it healthy? Not likely. Is it cavity free? Again, not likely. If you ask any of the 88 million Floridians who went to the Emergency Room in 2009 with severe tooth abscesses (NY Times, 4/9/2012), I'm fairly sure they will agree here. Should we wait to take xrays until someone has a symptom, like INTENSE PAIN? Or do we take a more proactive approach in those people who are at a higher risk of tooth decay by taking needed xrays to avoid  waiting 2 years (thanks for that suggestion, Dr. Neurosurgeon) until that little cavity turns into a full blown abscess with more than $2000.00 in needed treatment to save a tooth that a $20 xray and a $100 filling could have taken care of??? Well, I suppose so, bit it certainly is not optimal, now is it.

Instead of worrying about a questionable study, stating that taking those xrays (taken in 1960) could give you a benign brain tumor in 50 years, why don't we address the xray needed to ensure that the abscess doesn't travel to the brain and kill someone THIS YEAR. Just a thought. That's all I'm saying...

Whew! That was a workout. Hopefully, I burned calories over this one. It certainly was draining, wasn't it? Well, that's it for me today. Thanks for stopping by. And, remember, you only have to brush and floss the teeth that you ABSOLUTELY, POSITIVELY, want to keep. That's it. Nothing more.

Dr. Driscoll

The truth, the whole truth, and nothing BUT the truth: Humana, Round Two (ding! ding!)

So, in my last blog, I dissected Humana's new individual dental insurance plan that "rewards" its enrolled members on year two and three. Well, I didn't dissect the WHOLE plan because I couldn't get past that the colossal fees for enrolling and using preventive services. In all fairness to Humana, and having presented the point of view of the patient and dentist, I will shed light on Humana's point of view. I can only speculate here, but providing all sides is what this blog is about, and since there are usually three sides to every story, I will illuminate the third side as best I can.

Here goes:
Humana: There is no shared risk for individual dental plans. "What the heck does that mean, Annelise??", you ask? Well, it basically means that unlike group dental policies, with many enrolled members, like the plans that employers purchase for their employees, individual plans have no shared risk pool. In a group plan, there is an assumption that while many people will use their benefits to the max because they have them (called Moral Hazard), many will only use some of the benefits, and some will use NONE of the benefits of the plan. If a dental insurance plan is paying out up to $1000.00 in annual benefits, but only charging  $467.00 per year in premiums ($35 enrollment fee + approximately $36 per month premium), they will not be making money off of that policy (called a loss ratio). If EVERYONE in the group plan uses all $1000.00 in benefits and only pays $467 per year for premiums each, then the insurance company has lost a crap-ton of money on that group. Obviously, an insurance company can not survive by losing money on insurance plans, therefore, the risk of no profitability is shared in a group policy, and offset by those who will use only some of their benefits and those who will use none of their benefits. That's what a shared risk pool means.

On individual dental plans, it is highly likely that the insured will be using ALL of their benefits for the first year, since most people purchase individual plans when they are in desperate need of dental work all of a sudden. People are famous for doing this. They don't have any dental work, exams, or even cleanings for years on end, then wake up one day in pain and realize, "Oh Crap! I need dental work! I have no insurance! It's going to be expensive (because I waited so long and didn't have even routine cleanings done)! Let's see if I can find a "cheap" individual dental insurance plan so I can get this work done!" Yes, that's how it happens. Nothing like last minute emergency planning on compromised oral health....but I digress.

So, because dental insurance companies KNOW this, they usually do not pay out very much in the first year, which makes people upset since they are paying premiums for little benefits. USUALLY, however, the difference is that almost ALL preventive services are covered at 100% with zero deductible. THAT I understand AND support fully. That's not what Humana's dental plan is doing, though, as you know. And, while I DO see where collecting $467 in premiums from an enrolled member and paying out $1000 in benefits does NOT make good business sense, nor is it a viable/sustainable business model for insurance companies, I STILL believe that putting a $150 deductible on xrays is flirting with disaster on all ends. It just makes everyone cranky: the patient for having to pay out a whopping amount at the first visit, the dentist who gets an aggravated patient upset at having to pay for expensive/needed/required xrays on the first visit, and the insurance company who will have to deal with that upset patient when they call and complain. Three strikes on this one all the way around.

Humana really, really, really, should have put that deductible on basic and major work and NOT on preventive services that are critical to proper diagnosis. In fact, based on the statutes that relate to the actual duties of a dentist, it is not even possible for a dentist to diagnose what type of cleaning a patient needs, without first viewing the xrays to see if there is bone loss (from periodontal disease), debris under the gums (subgingival calculus/tartar), or infection brewing (like an abscess). Soooooooooooo, technically, and according to the statutes, the dentist must conduct a thorough exam and diagnose the cleaning type needed by using a diagnostic tool (called xrays!) along with other visual and manual methods, BEFORE a patient can get their teeth cleaned.

And, JUST so that you know, that INDEED I speak the truth, here is the actual statute on dental records (along with the link for you seriously Doubting Thomas types). Get ready to be impressed by my massive dental geekiness (I'm just a veritable LANDFILL of useless dental legal knowledge)!

CHAPTER 64B5-17
DENTAL PRACTICE AND PRINCIPLES
64B5-17.002 Written Dental Records; Minimum Content; Retention.
(1) For the purpose of implementing the provisions of subsection 466.028(1)(m), F.S., a dentist shall maintain written records
on each patient which written records shall contain, at a minimum, the following information about the patient:
(a) Appropriate medical history;
(b) Results of clinical examination and tests conducted, including the identification, or lack thereof, of any oral pathology or
diseases;
(c) Any radiographs used for the diagnosis or treatment of the patient;
(d) Treatment plan proposed by the dentist; and
(e) Treatment rendered to the patient.
Link: http://www.doh.state.fl.us/mqa/dentistry/rule_64B5-17Dental_Prac-Princ.pdf

I highlighted the brilliant, supporting parts--you don't have to thank me, I'm happy to help.

Anywhoooo, as you can see, those stinking xrays are a thorn in the side of this dental insurance policy that Humana created. While I have presented all three sides now, and you now fully understand the financial loss potential Humana faces with individual dental insurance plans, that does NOT change the fact that, no matter what "loyalty" rewards this policy provides for enrolled members over the first 3 years, it STILL gets a hearty, finger-wagging "tisk, tisk" for subjecting a basic required diagnostic tool to a whopping $150 deductible. Not cool, Humana. It's a disservice to patients and dentists alike, and opens up the door for conflict between the two, which is 100% avoidable and preventable had you placed that deductible on basic and major services only.

Go ahead, Humana. Redo the plan and shift the deductible to basic (fillings) and major (root canals/crowns) services, so there is no fuel for further debate. I can wait. I'm right here. It needs to be done. It's the right thing. Just let me know when it's done so I can reassess this plan and hopefully, recommend it to everyone I know who does not have dental insurance. No pressure or anything, but I'm waiting here. :)

Wow, I'm exhausted! Did I burn calories on this one, or what? Am I thin yet? That was a workout.

That's it for me for today. Thanks for stopping by and remember; you only have to brush and floss the teeth that you ABSOLUTELY, POSITIVELY want to keep.

Dr. Driscoll

Oh Humana....I had such high hopes for you...tisk, tisk.

So, recently I came upon an article in an Orlando business paper announcing that the insurance company Humana was getting ready to offer a dental insurance plan for those who don't have dental insurance, that would "reward its members" for their "loyalty" to the plan. What this means, bottom line, is that they will increase benefit levels in the second and third year of (having) the plan. At first, I thought, hmmm...well that sounds pretty good, especially since there are few, if any, "good" individual dental plans out there. Most cost more then what they provide in limited benefits. In other words, its "slim pickin's" out there for dental insurance if your employer does not provide you with a decent plan. A decent individual plan with little or no co-pays,and increasing coverage after the second and third years? Rewarding my loyalty? Well, alrighty then! Sounds good to me (finally)! I was almost excited! Almost........

Upon further review of this HumanaOne Loyalty Plus Plan, I will let you know what I have found. Before I tell you about their reasonable premiums, let me just say that there is an enrollment fee, and administration fee, and a PBA member monthly association fee ON TOP OF the monthly premium. What is this PBA group that enrollees must subscribe to? Is it something fantastically beneficial to help mankind improve on their dental status? Um. No. It is not. The small writing at the bottom of the page states it is a (and I quote the Humana ad here) "a not-for-profit membership organization that provides health, travel, consumer and business-related discounts to its members". Hmmmm...you mean, I HAVE to join this group to purchase the dental insurance and then I have to PAY money every month to get "travel discounts"? Huh?? Why is this sending off a red flag in my head? Ok, well, as it turns out it is a small fee, which when combined with the other small fees, for other "stuff", you get a monthly premium of $35.74, after an enrollment fee of $35.00. Really. Hmmm...Ok.

Driving on, I realize that they pay 100% for preventive services (exam and healthy mouth cleanings) in all three years, so that's good. That should be a savings right there, no? Oh wait a minute! They don't pay for x-rays at the first appointment or anytime after that until I've met my deductible of $150.00? Holy moly. So, after paying the premiums, and enrollment fees, I have to pay for the x-rays out of pocket, which cost more than $100 for the first visit to a dentist's office. I'm not feeling the "loyalty" being "rewarded here. In fact, if I'm not mistaken, this now will likely become a bigger issue....possibly....

And, here is where we get to the BIG red flag:
Every new patient visit at a dental office requires a full series of xrays to be taken in order for the dentist to view your whole mouth, teeth, roots, bones, etc. Without that full series of xrays, the dentist is not able to see your whole mouth and its total oral health status, nor is he/she able to properly and thoroughly diagnose any conditions that are evident on the xrays, but maybe not by the naked eye's visual exam only. That is a significant issue. But, in all fairness, let's look at this from both sides, shall we?

The Consumer: Having to pay out over $100 for xrays on the first visit, after paying the premiums and other "fees", may seem like a lot. In fact, that consumer may very well say to the dental practice, "Hey, I don't have that kind of money, so can I just get the exam and cleaning at least?" I certainly understand where the consumer is coming from. I really do. I would be annoyed to have to find out that the xrays were subject to a $150 deductible. In most other group dental insurance plans, that is part of the preventive services that are USUALLY covered at 100% by the insurance company. I can see where the consumer might want to just get what is covered. I get it. It feels like the consumer is getting "nickled and dimed to death", as they say, and they will likely be annoyed and request no xrays be taken.

The Dentist: Knowing what their protocols are for a new patient exam, which includes taking a full series of xrays, to "see" everything and assess the true condition of the patient's mouth, this presents a liability issue. The difference between conducting a new patient exam with only the naked eye, and one which includes a full series of xrays, is the difference between looking through a keyhole into a room to see what is in it, and opening the door to get the whole view of what is in that room. They don't compare. It would be a disservice to a patient to not fully view and diagnose the condition of that patient's mouth. In fact, it could very easily lead to a lawsuit if something is "brewing" that was not visible with the naked eye and then did not get addressed. Major Liability Risk: "Danger, Will Robinson, Danger Will Robinson"! Plus, the dentist may very well get cited by the Board of Dentistry for negligence for NOT taking the appropriate and needed/required xrays on a new patient. That dentist's license may now be at risk.

And all because Humana 'rewarded' its enrollees by putting a $150 deductible on xrays.....Oh boy. Hot mess. Not good. Both sides of this equation have merit and can be clearly seen and understood. Both sides have issues that are real and valid. Unfortunately, what I REALLY fear happening here, in this very troubled time, and in this tough economy, is PERHAPS a dentist accepting that patient anyway, because they threatened to see someone else, and waiving the xrays until "next time". Meanwhile, under the gums, 'something wicked this way comes'....like a looming infection, bone loss, resorption, an abscess, a cyst, you name it...I was almost excited about this plan...I really, really was...

But really, Humana, all you have done here, is create a difficult situation for everyone involved; except you. Having a customer pay 3 extra fees plus a premium is enough. It could be overlooked if indeed you rewarded your customers. I see where your benefits for basic and major services increase at year 2 and 3 and I think that's ok; not great, but ok. But do I feel you did the right thing by penalizing both the patient and the dentist by creating the conflict associated with attaching a high deductible to needed/required xrays on the VERY FIRST VISIT??? Nope. I do not. Not only do I NOT think it was the right thing, I fear it will place both parties involved at great risk; both clinically, and ethically/legally.

Sure, there may be many patients who can pay the $70 plus for the enrollment fees and first month's premium, but then another $150 to get an exam, xrays and cleaning after that? Over $200 for the first visit? Unless I'm mistaken, that's pretty comparable to what the patient would have paid without any insurance at all, isn't it? Oh Humana, you were SO CLOSE to being a good policy...SO CLOSE...but not close enough.  Based on all of that (and I couldn't even really get to the rest of the plan "benefits"), I would have to give this policy a big "tisk, tisk"....Buyer beware...and dentists beware too!

That's it for me today. Thanks for stopping by. And, remember, you only have to brush and floss the teeth that you ABSOLUTELY, POSITIVELY want to keep. That's it. Nothing more.

Dr. Driscoll

One Chipped Tooth....4 Different Treatment Plans?

     I am frequently asked by random folks, who know that my field is Dentistry, to comment on their dental problem and proposed treatment solutions. I'm not sure why, but can only guess that it's because I'm honest and direct (?). Lord knows, I have presented enough treatment plans, and spoken to enough patients over decades, about their oral health, and treatment options. While I don't diagnose their oral health conditions or issues, and I don't create the treatment plans or options, I facilitate, explain, empathize, and work on solutions. Because, ultimately, if you walked into a dental office with an issue, you likely walked out with a diagnosis and proposed treatment plan. Somehow, though, in many cases, the blame for the treatment option or treatment recommendations, and their costs, gets placed on the dentist. Honest to God, I have heard this so many times I can barely keep count of them all.

     While the dentist gave you options and discussed alternatives, risks, and benefits of proposed treatment for the chipped tooth (that's Informed Consent), you may have gone to get a second opinion and gotten a whole different treatment option and set of fees. As a result, you are confused and somewhat angry. How could one dentist's opinion and recommendation be so different from another? Why are they so far apart in fees, too?? How do I decide what dentist was "right" and what dentist was "wrong" with what they were recommending I do to get the tooth fixed?? Here is where I usually say, "well, if you went to four different dentists, you may end up with four different treatment plans....and they may all be based on the dentist's sound philosophies and experiences". This is usually followed by a shocked look and a "What??? WHY?????? How do I know which treatment plan to go with????" So, let's talk this out for a minute so you can see this from a three dimensional point of view: not just the one.....

      First, you need to know, that dentists did not cause the issue with your tooth. They are not to blame here. If you chipped a tooth (let's say, a molar in the back of your mouth), and went to four different dentists, you may very well get four different treatment options and four different sets of fees. Dentists have faults, but being the cause of your dental issue is not fair, and its not accurate. Please don't get angry with them for the condition your teeth are in before you walked into their offices. Now that this has been established, let's look at why you might (realistically and appropriately) get four different treatment plans handed to you to fix one chipped tooth.

     It all depends on the professional philosophy and experience level of the dentist. It's that simple. One dentist might take a very conservative approach in believing that smoothing off the chip is sufficient to buy you some time before proceeding on with, say, a filling. One might take a slightly less conservative approach and recommend a filling be placed; maybe even a silver amalgam filling, in that molar, since that dentist might have total faith in silver fillings still. The third dentist may believe in a proactive approach and say that a filling is a temporary measure, like patching a flat tire, and why patch something that could choose to break again, when you can crown the tooth and get 40 more years out of it. The fourth dentist might take a more proactive and prophylactic approach and state that since the nerve is now close to being exposed, that having a root canal done prior to having a crown made, may help to ensure that the nerve of the tooth may not "come alive" after it is crowned, necessitating a root canal through the crown. There you have it: four different recommendations for one chipped tooth and they may all be quite feasible in their own ways. It depends on the philosophy and experience of the dentist.

     Yes, it is subjective and No, there is not one set of standardized, required guidelines, per say, for that tooth. And, No, the dentists are not to blame for these philosophical differences. Somehow, though, dentists DO get blamed. They get blamed if the tooth is smoothed off because your funds were tight, and two weeks later the tooth decides to break off again, and now you are in pain. They do get blamed if they fill the tooth, because the crown was not financially feasible at that time, and the tooth is sensitive for days. They also get blamed if they crown that tooth, and the tooth hurts and the nerve decides to "come alive" 3 weeks later. They do, also, get blamed, when they perform that root canal and crowning of the tooth, and it ate into your paid sick leave and savings account balance. So, when folks ask me about their treatment plans, this is what I tell them. At that time, they get a better understanding of how different treatment plans does not mean automatic negative opinions should be formed. They shouldn't. It means there are options based on a number of different factors, that will carry with them different prognoses for your tooth. Choose carefully and find out all you can and for heaven's sakes, don't blame your dentist because you're upset.

     Philosophical differences might also be the reason why one child may be found to have 4 cavities in one practice, but told they have 10 in another. Before you go thinking that one dentist has no clue while the other is honest, you need to find out more information. It may very well be the case where the child does indeed have 10 teeth that possess caries(decay) in very small amounts in 6 teeth but more noticeably present in 4. The dentist may not want to fill all 10 of them until they are bigger. The dentist may even recommend home fluoride treatments daily to possibly help those teeth get stronger. Meanwhile, the philosophy of the second dentist might be: decay is decay is decay, and if its present, we need to remove it. However, the immediate thought is...4 cavities versus 10?? How could one dentist be so different than the other? Ask questions, my friends. Become more knowledgeable about the how, why and what aspects of dentistry. Know all the facts first, and take accountability for the condition the teeth were in before walking through the door to the office. Don't place blame without knowing all the facts, and understand that different doctors (cardiologists, endocrinologists, ob/gyn's, etc. ) have different philosophies regarding a patient's treatment options. That doesn't immediately make them wrong or otherwise. It means they have had experiences that have shaped those philosophies, and you need to choose with a FULL set of information and an OPEN mind first and foremost. Fair is fair, here.

     So, that's today's soliloquy. Just keep these things in mind, is all I'm asking. For now.


Thanks for stopping by, and remember...you only have to brush and floss the teeth that you ABSOLUTELY, POSITIVELY want to keep. Nothing more. That's it.
Dr. Driscoll

Doctors (and Dentists) Going Broke? Part 2

The article posted a few days ago, and ensuing discussion brought about awareness of an issue crossing over both medical and dental lines; the financial stress and potential viability of independent doctors and dentists to continue practicing. Remembering that among the many reasons they are having financial difficulty are increased costs, decreased reimbursements, patients' inability to meet their financial obligations, and lack of business acumen on the part of the doctors and dentists. So, today's article that I want to share is fascinating (as a Part 2) on a number of different levels, and gives yet another perspective of where some of the issues stem from. Hold on, because you are going to love this! The articles are twofold and are located on the July 5, 2011 and Nov. 21, 2011 postings on the DrBicuspid.com website.

At the end of 2011, the NC Board of Dentistry charged a dentist with violating the Dental Practice Act by selling his dental practice to a large corporate dental management firm. The reasons they became involved revolve around the concept of Dentist controlled ownership and management. You see, Dentists must legally own and have control over the management, financial, administrative, and clinical aspects of the dental practice, along with having control over how care is delivered to patients. The issue here, is that many of these large corporate dental management firms buy the practice but then leave the Dentist on staff as an employee, who does not have final say on the above aspects of the management of the practice or how care is delivered to patients. This is the crux of this problem, and yes, the NC Board of Dentistry issued some severe sanctions on this Dentist, and on the dental management corporation. THIS has raised several red flags....read on...we are about to peel the layers off of this "onion" of a situation...

Issues:

1. Dental management companies must be owned by dentists. Management companies can come in, work FOR the Dentist, and make suggestions on managing the Practice. However, the (a) licensed Dentist must have final say and control of both clinical and many administrative decisions. In fact, the Board is now entertaining the idea of having the final approval on all dental practice sales contracts. A bill for such, has been proposed. This, of course, is controversial.

2. Dentists, as stated in a prior blog, have little or no business knowledge, skills or acumen to successfully and efficiently run their Practices. Opponents of this proposed bill, are stating the Board's decision to approve or disapprove of all dental practice sales contracts as a total intrusion into their practice management and ownership. DENTISTS are opposing this. Yup. I know...bizarre right? They are recognizing their limitations and asking for assistance here because many are not making it financially, on their own (because they have NO business skills).

3. Dental PROponents say that the bill and the Board's decision to intervene is needed because dental management firms are only out for corporate profits and won't put patient needs first. (Did anyone tell them that Dentists need profit just as badly because they have NO business skills to properly manage their OWN overhead expenses and therefore, think the only way to raise revenue is through increasing their fees in their  Practices?)

4. Ironic aspect here: these dental management corporations, have officially purchased hundreds/thousands of dental practices over the last 10 YEARS, all over the USA. They are everywhere......with no one blinking an eye over it!?! Why now, is my question? Did no one notice these "illegalities" before this?? But...I digress.....

So, in my humble estimation, and with all due respect, I will attempt to say this. Dentists are set up to fail. They just are. I know that is direct and blunt, but stay with me here (I'm known for my candor here). This is a continual, vicious cycle of how the SYSTEM of dentistry is set up to fail. The common theme here is that they are LACKING business knowledge/skills/acumen to successfully manage their business, pay off their debt, control their overhead, market themselves, and translate that efficiency into lower fees for patients to pay. If we continue to legally limit Dentists into becoming business owners while providing them with NO knowledge or skills on owning a business, it is no WONDER they want to sell out to anyone who wants to buy the Practice. Because, in all honesty, "Dentists don't know...what Dentists don't know". And, believe me, they don't know A LOT about being business owners. We have an OBLIGATION, in Dentistry, to create a system that is not an automatic set up to fail for Dentists, with a trickle-down failure towards patients, who can't access the care because the fees are high as a result of Dentists not being given the necessary business training to efficiently manage their businesses. We need to address these issues head-on from a systems perspective, not a "blinders on" perspective. Those blinders need to come off with a 60,000 foot panoramic view taken instead.

Surveys of Dentists state that they WISH they learned about dental practice ownership on a much larger scale while in school. Some Dentists state that if they had it to do all over again, they would not go into Dentistry as a result of how much they did NOT learn in school, and the problems it caused when they graduated. I know this, because I have seen it for decades. Dentists will be very honest about this when spoken to one-on-one, and it is a researched and published topic. The solution, as I see it, is to restructure dental education, and provide solid, sound business curriculum into the DMD or DDS degree, so that Dentists have a CHANCE for successful, efficient, effective, financially-sound managing capabilities of their Practices. THEN and ONLY THEN, should we propose a bill that reinforces full control and autonomy of dental practices to Dentists. HOWEVER, until then, Dentists are simply going to remain "gerbils on a wheel", working frantically,and going in circles, with no end in sight. Setting up Dentists to fail, by mandating they are the sole business owners without any business training, in my humble estimation, is a failure of the dental system. It's a colossal breakdown, from a systems perspective. This bill, proposed in NC, is like putting a band-aid on an artery wound, in my opinion. We need to treat the systemic problem, not the symptom.

Let's get back to the drawing board and redesign the dental educational standards to include not just the CLINICAL competencies that Dentists need, but the ADMINISTRATIVE/FINANCIAL/LEGAL/OPERATIONAL competencies that they will need JUST as much (if not more) than their clinical core. After all, without the ability to successfully manage their Practices, they cannot provide clinical services. It's that simple. Honest to God.

Thanks for stopping by and remember, you only have to brush and floss the teeth that you ABSOLUTELY, POSITIVELY want to keep. Nothing more. That's it.
Dr. Driscoll

Reality vs. Perception: Doctors (and Dentists) Going Broke?

This article could not appear at a better time...it's perfect. It's the perfect segway into my next blog; the realities vs. the the perception. CNNMoney published a wonderful, controversial, and utterly thought-provoking article a week ago (well, Jan. 6, 2012, to be exact). The title is "Doctors going broke", and the reason it hit me like a sledgehammer is because this is what has been happening to Dentists for about 5 years now, and is coming to a head. In fact, I STILL hear from Dentists how close they are to not being able to pay their bills, or are actually in the hole, financially. I heard it this week, actually. This is one of those embarrassing secrets (like dirty family secrets) that are becoming more common place than we even think. Here is the link, for those that want to read more: http://money.cnn.com/2012/01/05/smallbusiness/doctors_broke/index.htm. Basically, the short version is that the perception of doctors and dentists is that they are all living high on the hog, on our hard earned money (if we can actually pay our copays),  while the rest of America can't afford their over-priced services. Reality Check #1: in many, many cases, this is false. In fact, the dirty secret here is that its the exact opposite. They are going broke (just like us). I know....you're floored. Keep reading, my friends, because this is where I earn my title as The Scary One. All I ask here, is that you keep an open mind and consider all sides, because there are sides here that you are not aware of. Don't formulate a final opinion until all sides are taken into consideration.

Let's broaden your horizons on some things, and give you a real foundation for the numbers before you make a final judgment. Let's start by giving you the facts: when a dentist (for instance), graduates dental school, their debt load is anywhere from $155,000 (for a public university dental program), to $250,000+ (for a private school dental program). That's a mountain-load of debt...but we're not done yet. In fact, we have barely begun. If they want to buy an existing (older) dental practice from a retiring dentist, they take on another (approximately) $250,000 to $500,000 of debt for that purchase. If the practice has been renovated and updated, it could cost more. If that dentist wants to build a practice instead of buying an outdated one (for instance), the cost of building a 6 operatory dental practice runs approximately $600,000 (without the land and inside an existing building). If they need to construct the actual building itself AND purchase the land, it could easily run another few hundreds of thousands of dollars. If you have your calculator handy, that equates to EASILY a half million dollars and up. Any idea how much that monthly payment is?? It's a staggering amount. In fact, before that dentist has filled their first cavity, their monthly debt load is monumentally huge. And, that's without payroll, supplies, utilities, malpractice and insurances, etc., etc., etc..

Now ponder this: the average dentist receives approximately 3 weeks of GENERALIZED business curriculum. That means a cursory amount, at best. So, with little business knowledge, and a mountain of debt, they open their doors. They have very knowledge on running their business, managing debt, estimating the cost of their overhead, staffing their practices with market-value salaries, or forecasting what revenue they need to pay their bills each month. Nothing. They are unaware of marketing, sales, promotion, advertising, negotiating expenses, setting fees; nothing. It's generally not part of their 3 weeks of "practice management" (that's dental talk for business ownership or business management for dentists). They are unaware of how to track reports, track expenses, estimate their overhead, manage and pay off their debt load, or estimate future capital needs and expenditures, retirement planning, employment law compliance; nothing. I know. Its staggering. In fact, its mind boggling, but there it is. That's why, when this article came up in CNNMoney, I jumped on it to illustrate that its not just an issue with medical doctors but has been an issue for dentists (who suffer in silence out of sheer embarrassment alone) for a dog's age. No kidding. THAT's the reality you just don't know about.

The first thing I hear when I ask someone when the last time they went to the dentist was, is the common phrase "I can't afford it". "Dentists charge too much", is the second comment I hear. And, as much as I try, in vain, to explain to people how important their oral health is, and how highly linked poor oral health is to almost EVERY chronic disease is, people still state the obvious: "I can't afford their fees". Ok, I get it. I hear you. By the time the decay in your tooth has hit the nerve, it requires both a root canal AND a crown (and possibly a build up under that crown since there is little natural tooth left to "anchor" that crown on to), which can total up to $2000 for ONE tooth. I get it; I really do. I'm not out of touch with the realities of that amount of money. In short, it's what we call a "CRAP ton of money". It's huge. Really, it is. ALMOST as huge as the mountain of debt that dentist has taken on (see above) to SAVE that tooth. Between the cost of the dental degree, the cost of the practice, and the monthly cost to run that practice, and the diminishing amount of insurance payments, LACK of payment from Medicare (they don't pay for dental services, although the elderly SURE do need it, I'm just saying...), and PALTRY amount of reimbursement from Medicaid (which most dentists cannot afford to take because it does not come CLOSE to paying their bills), the out of pocket cost of dentistry falls on the patient. In this economy, where people can't pay their mortgages, don't have jobs, and zero savings, we have hit the nail on the head as to why doctors and dentists are going broke. Like you, they cannot pay their bills. They just cannot. If they were kind enough to let you pay off your services (and God bless those who do), and you simply cannot pay and declare bankruptcy on those dental (or medical) bills after the services have been rendered (as 65% of bankruptcies now consist of), they lose that income and cannot pay their bills either. It's a vicious cycle here. The only difference between you and them is the degree of knowledge and the debt load of that knowledge. Otherwise, we are all the same people.

So, the reality is that with little business knowledge and significant clinical knowledge, they can fix your clinical issue. However, like you, they are struggling with how to pay their bills as they (like you) face diminishing income and expanding expenses. They are not very different from you at all. Like you, they simply don't mention how financially strapped they are. They are struggling with where does that income come from to pay the bills. There was an article in the Academy of General Dentistry journal from 2006 that stated that the majority of dentists were overwhelmed as dental business owners because they lacked the business knowledge and it was a major stressor. Many of them stated if they had it to do all over again, they would not have gone into medicine/dental. Too late. Doctors, as evidenced by the above article, are facing the same thing. Corporations are buying up (failing) dental practices at a high rate. From what I hear, its no wonder; they were not taught the business skills they so desperately needed to move into their careers as practice owners. Shame on us for not teaching them that. $150,000-$250,000+ in education and they are not prepared to become dental practice owners? Wow. How tragic. So, as a result, yes, the prices are high. Yup, they are unrealistic. Yup, its not affordable by the average American. No, they cannot afford to take Medicaid and no, Medicare does not pay for dental services either. SUCH a travesty, isn't it? It is truly a vicious cycle. And, on top of it all, most doctors and dentists are embarrassed by this and don't want us to know since the PERCEPTION is that they should ALL be living high on the hog. After all, isn't that why they spent the ADDITIONAL 4-10 years on an education that the rest of society didn't???

So, the point here, today, is that the article I posted opens up the REALITY of the situation right now with health care. It's a hot mess. It really is. Doctors and dentists (and hospitals) can barely afford to practice and society can barely afford to see them for services. So, what's the solution? MY answer is to redesign the system from the inside out. TEACH them how to be business owners, for heaven's sakes! Start with the education process! Why are we NOT? They should not need the "Secret Squirrel Handshake" to successfully run their businesses with affordable rates that patients can afford to pay.

The only secret here is the embarrassment of the inability to practice medicine or dental medicine as business owners first, and clinicians second. And, if I have my way about it, action will be taken and courses will be created. Saving one tooth should not cost more than, say, a whole living room set. It should not. There are better ways to estimate, and negotiate that cost. There are better ways to control overhead. There are better ways.....BUT patients also need to pull their end of it. Specialized knowledge and skills don't come from volunteers. Dentists and doctors are not volunteers. If you have their services, please remember they did not come free. If you don't plan on working for your employers for FREE for a week, please don't expect them to either. There are TWO sides to every story...well, actually three if you count the objective facts (minus the emotions). Just remember that. Be fair and be open.

Well, that's it for me today. I just wanted to share this and begin your TRUE education on the realities versus the perceptions. This IS, after all, "a thought-provoking dialogue on the legal, ethical, and research aspects of dentistry and oral health", as my description states. Consider this my contribution to continued (realistic) life-education.

You don't have to thank me....I'm happy to help.

Thanks for stopping by, and remember, you only have to brush and floss the teeth that you ABSOLUTELY, POSITIVELY want to keep. Nothing more. That's it. Carry on.
Dr. Driscoll

"What's so scary about you, Dr. Driscoll? Why this title?"...

~ "Today is the first day of the rest of your (blogging) life" ~

...And so it begins. This blog arose out of sheer necessity. There just isn't a place to discuss some of the scariest topics affecting dentistry and oral health today. There just isn't. And there certainly needs to be, from what I encounter almost daily by talking to clients, patients, dentists, academics, students, practice managers; you name it. So here I am taking the steps that need to be taken to open up dialogue about some scary topics, and share information, disseminate knowledge, inspire passion, generate a call to action, and hopefully, collaborate on solutions. We have a lot of issues in dentistry, but we also have significant issues with oral health in our communities as well. My desire is to bring specific, researched information and apply it to both the dental industry and the community as a whole. Both sides of a situation must be viewed though, to really view it fairly. This is not a rant blog, but a "things that make you go Hmmmmm" blog. I have a passion for finding the latest research, problem, issue, or need and putting it out there where most people, and most dentists, are just not aware of its scope, but cannot ignore it. Warning: the information in these blogs is controversial and thought-provoking. At times, it may be upsetting, and I don't sugarcoat things. I should tell you that right up front. "I call 'em as I see 'em", as they say. But that's ok because becoming aware is a first step to opening up dialogue. And that, my friends and colleagues, is the first step to generating solutions. You don't have to thank me....I'm happy to help.

So, is it that I'm a scary woman or is it that I scare people with my words and research? Hopefully, the second. I decided to be provocative and choose this title for my blog because that's how I was introduced to a group of dentists at an 8 hour lecture I was giving back in 2010 at the University of Florida, College of Dentistry. My 8 hour lecture was on Employment Law and Avoiding Lawsuits and the Assistant Dean, who had heard me speak before, advised the group of dentists that I was the scariest woman in dentistry with what I had to speak to them about. He literally told them that their jaws would drop open, they would get upset, but that ultimately, my lecture and information HAD to be learned by dentists. He also indicated that they would, indeed, thank me at the end of their exhausting, emotionally draining day.

At the time I thought....did you just say that about me because I'm a truly lovely person!?! Honest to God! I smiled politely but thought...well...since they don't know what's about to hit them, I guess the title fits. Anytime we find out new information that could potentially get us in trouble, and we realize we haven't exactly been doing things correctly; its a bit frightening. When you have to sit and listen to me for 8 glorious hours (I know, it's horrendous but oh so good for you-like sitting down to a HUGE bowl of brussel sprouts; you'll be healthier for it when its done, but its miserable while you're going through it) and you realize just how incorrectly you HAVE been doing things, you get a bit nauseous. Luckily, I hand out Tums. Then I move on to my next topic. Then I provide them with solutions and corrective measures to implement into their practices immediately.

After all, and in all fairness, there's virtually no employment law taught to dentists in dental school so it's not that they are purposely doing things incorrectly; they literally don't know what it is they are legally REQUIRED to know, as business owners. It's not their fault; honest to God. They can't be blamed here. It's lacking in most medical fields, to be honest. So, I tell them, and teach them, and then they sigh a huge sigh of relief. They leave my courses inspired and grateful, ready to implement legally compliant change into their practices. THAT'S the rewarding part. FIXING what is broken. PROVIDING sustainable solutions. BUILDING skills and knowledge from lessons learned. It's not enough to discuss wrongs if you don't have the courage to provide the rights.

My work is not about negativity; its about raw knowledge and data and evidence-based solutions. So, here I am. And there is still a TON of work to do to solve our problems with dentistry and oral health. Consider this one of my major contributions to improving my field. I love dentistry; I really do. And I refuse to wait for others to solve our issues. So, I'm a bit fearless and "on the cutting edge", as my Dissertation Chair told me yesterday. Come along for the ride~you'll be better for it; I promise. It might be tough at times and hard to stomach, but I promise this is worth it. I know you can do it, I have faith in you. Just keep an open mind (and a bottle of Tums close by). Words are powerful, knowledge should be shared, and communication should be safe. We can do this.

Thanks for stopping by and remember; you only have to brush and floss the teeth that you ABSOLUTELY, POSITIVELY want to keep. That's all. Nothing more.
Dr. Driscoll