"That's different"

Richard J. Reinitz, DDS, MBA, FAGD

I have been in practice for more than 20 years and I have heard that refrain from many a patient as have, I am sure, so many of us in the dental community. This statement is usually in response to a treatment recommendation. Take the case of "Ms. Jones" —

"Ms. Jones, there are obvious changes on your X-ray. The decay is into the pulp tissue and will require a root canal."

"But doctor, it doesn't hurt."

"Well, Ms. Jones, there are many medical conditions that do not cause pain but must be treated nonetheless — high blood pressure, for example."

"But that's different," replies Ms. Jones.

In the simplest terms, what we all have experienced in this situation is the disassociation between medicine and dentistry. Patients firmly believe the oral cavity is somehow not subject to the conditions that befall the rest of the human body and therefore is immune to disease, neglect, and normal or abnormal wear. Nevertheless, I believe this statement reveals much more, and refers to the limited amount of respect our patients have for us. More importantly, it speaks to a future that is forever and inextricably linked to economics and convenience rather than medical necessity and adequate prioritization in patients' health.

This is not to say that patients do not trust us; they do, yet they are more than willing to hold to outdated theories, "old wives' tales," or myths when it comes to their teeth, especially in less-than-stellar economic times. In addition, because many patients view us as "tooth doctors," the standards to which we are held are not those of our physician colleagues. Instead, we are held to the standards of a repairman. Thus, we should always be exactly on time, guarantee our work, and not charge more than our initial estimate. The question is, how did we get here, and more importantly, what does this mean for our profession?

For some time, dentists have been deluded into thinking we are immune from the crises that impacted our medical brethren. We have weathered the storm of DMOs, so we should be able to resume our normal activities, charge our normal fees, and practice in the absence of constant interference from insurance companies. Yet, in the place of DMOs, PPOs have sprouted like weeds and demonstrate no weakness. Indeed, they continue to proliferate and dominate the industry, resulting in diminished fees. Our incomes are reduced and therefore our control is diminished as well. We become the PPO's surrogates in that patients expect us to handle the myriad of insurance complexities and coverages, and make us responsible for changes in benefits over which we have no control. Worst of all, it is the dentist who absorbs the patient's frustration over lack of coverage, poor coverage, or nonpayment. It should be noted, however, that even in "good times" (whatever that is or was), a substantial portion of the population does not seek dental care for reasons of money, fear, and most importantly, a lower level of priority. Sure, they will look, feel, and eat better — not to mention have better breath — if their teeth are repaired and maintained, but again, the old wives' tale comes forth and asserts, "If it ain't broke, don't fix it. If it doesn't hurt, nothing is wrong. Besides, Mom, Dad, and Grandpa all do fine with dentures anyway." Sound familiar? "But Ms. Jones, do you really think a prosthetic would function better than what you were born with? Would you really sacrifice your arm or your leg if the arm or leg could be saved? Do you really think you would be better off with an artificial arm or leg?" She answers, "That's different."

When people discuss access to medical care, they use words such as "rights" and "necessity." In the context of medical care, no one even mentions — even cursorily — dental care. Recently, there was a major medical conference in Washington, D.C. There were representatives from virtually every major insurance company in the United States. There were representatives from federal and state governments, as well as assorted physicians and economists. The conference lasted four days and had a lengthy agenda each day, yet not one second was spent on dentistry nor was anyone present at the conference representing dentistry in any capacity. That is the level of importance we have in medicine today. We cannot even get a seat at the table, let alone a voice.

So how did we get here? Once upon a time, dentistry was a subspecialty of medicine, but over time, we evolved into tooth doctors. I am amazed at this evolution because in my educational experience — which I believe is typical — my first two years of dental school were spent essentially in medical school taking the same courses as my medical-student colleagues. After graduation, I spent three years in additional training, all which was hospital-based. Even though not all of us obtained residencies, there was still a substantial portion of medical training we all received in dental school. The sad fact is that most patients are completely unaware of our training and most of us seldom use that training. Every time I encounter a patient with medical conditions or one who is taking medication and I engage the patient about the condition or medications, he or she is actually surprised that 1) I, a lowly tooth doctor, would know anything about medicine, and 2) I would care about it. Some even view medical history and medications as a privacy issue that is, frankly, none of my business!

In too many cases, we are taught in our many CE courses to concentrate on aesthetics or orthodontics, i.e., to concentrate on the fringes of dentistry rather than what is truly needed by the population at large — improving home care and providing restorative dentistry. Perhaps my practice is unique, but I still see a large amount of periodontal disease as well as decay. Most of the problem stems from a combination of poor oral hygiene and an unwillingness to change the poor habits. I believe there is probably more decay and periodontal disease out there right now than can possibly be treated by all of the dental professionals available, yet many of us are faced with the "busyness" problem. Why? Because there has been an acute failure of education as to the importance of teeth and treating dental disease. This has resulted in a less-than-flattering opinion of our abilities by the populace. And what has been our response as a profession? To date, we have had no response. We face nothing less than a crisis in both the short and long term, and we have no organized answer, no plan to market or educate, and no plan to find a means by which we can "get a seat at the table." In my view, it does not require informing the public of the value of oral cancer screenings, although that is important. It also does not require connecting oral disease with overall medical disease, although that is true and vital. It is simply this — from a quality-of-life perspective, what better benefit can we offer our patients than the ability to eat and smile? Certainly, we can speak of implants and bonded porcelain and bleaching, but the issue at hand is convincing the vast majority to seek and receive dental care on a regular basis. Perhaps I am too simplistic or naïve, but I believe that unless we create a situation where dentistry not only becomes a want or a need but a true necessity, our future becomes more uncertain and does not serve our profession or our patients. And despite assertions to the contrary, I do not believe we can effect the desired changes in isolation. We cannot do this on a practice-by-practice, dentist-by-dentist basis. It must be done on a large scale; a national scale.

Until we, as a profession, achieve some equanimity with our medical colleagues, patients will never appreciate what we do, who we are, and the importance of adequate dental care in their overall health. Failure in this area means most people will never seek dental care except on an emergent basis. Failure in this area means our profession will be forever relegated to the medical basement of needs. Failure in this area means a diminished future for us all.