A radical approach to improving the quality of dentistry in the United States

The controversy.

Before I begin this post, please understand that I know this will be met with strong controversy from dental professionals. Please read with an open mind before jumping to conclusions.

The problem.

What is the focus of this “hot” topic? The 6-month hygiene recall and examination in the general dentist office.

So, why do people choose their dentist?

1.     They are friendly and “painless”

2.     They accept their insurance

3.     They like their dental hygienist

4.     They like the location and cleanliness of the office

5.     They were well-referred to the practice*

6.     They have trust and confidence in the dentists abilities to meet their goals and expectations*

*indicates less likely reasons, but more important

I believe that many people choose their dentist because of the factors above, but are unsure if their dentist can adequately screen for complex dental problems. I have always maintained that a patient will spend less dollars, have more predictable dentistry, and a better dental outlook in a quality dental office. The real cost of dentistry is redoing bad dentistry and/or waiting until a crisis that was never identified before (tooth-by-tooth dentistry).

I want to approach this topic by first addressing the standards in the dental community. If a general dentist decides he or she wants to perform root canal treatment in his or her office, then they are held to the standard of the specialist: the endodontist (three additional years of training). If a general dentist decides he or she wants to perform restorative dental procedures (esthetic dentistry, implant restorative, crown and bridge, etc.) then they are held to the standard of the specialist: the prosthodontist (three additional years of training).

So let’s take a look at the majority of prosthodontic practices in the United States. Most people don’t even know what the heck a prosthodontist is, so if they end up in their office they likely know they have a complex problem that needs to be solved.

Prosthodontists diagnose and treat complex dental problems typically utilizing a team of other specialists. They need lots of time to be meticulous with laboratory work, procedures, treatment planning, and interdisciplinary team communication.

What do prosthodontists not generally do? Check two (some three) hygienists on the top of every hour for their “recall exam.”

So, what is my issue with the dreaded “recall exam?”

It is multifactorial in nature. First, the dentist has to check 168 surfaces of teeth (192 with third molars), periodontal health, occlusal issues, head and neck musculature, temporomandibular joints, and surrounding tissues. And review radiographs. And review medical history. And get to know the patient. And…

This simply cannot be done in five minutes. This also takes away time from procedures scheduled in their restorative schedule.

It begs the question: if the experts (prosthodontists) can’t check two patients on the hour while doing their cases, how can the average general dentist who is “technically” less qualified?

I believe this is causing the decline and devaluing of dentistry in the United States of America.

The perception.

Patients think they are having a real comprehensive examination when the dentist checks their teeth for five minutes and chats about the kids and weather. It is clear that things must be missed in this exam, unless the patient has been fully restored to optimal dental health in the past. This is even worse if the first visit to the dentist is with the hygienist. Talk about a scenario that is guaranteed to lead to disaster (I do not care if you are 19 and home from college on spring break and just need your teeth cleaned… we do not know each other yet!)

This model leads to problems. It is an insurance-driven model. It makes no sense in contemporary dentistry. This leads patients into a path of complex, overwhelming problems while going to the dentist every six months thinking they are receiving “comprehensive care.”

The solution.

I think the guidelines set forth by governing agencies can solve this problem. First, I think it should be mandated that the first visit to a dental practice must be a comprehensive examination and hygiene services cannot be performed on the first appointment. Therefore, it will force dentists to take a thorough look at the problems and take time to study them before their patient returns.

I also believe that hygienists should be allowed to operate without the direct oversight of a dentist. Let’s face it: some patients will never choose health. I know there are numerous ways to show people they have a problem, but some patients just want their teeth cleaned. Well, let them have their teeth cleaned. Trust me, they will know when problems arise. Why put the responsibility on the dentist to try and psychologically make the patient aware there are problems and watch them self-destruct under our care (this leads to discussions such as "you never told me about...")? Sometimes, even the best patient communicator cannot educate someone enough to accept treatment for their problems.

What must the patient do to be a patient in my practice? Trust, appreciate, and own their own problems.

So, after the comprehensive examination, the patient now understands their risk factors (functional tooth, muscle/TMJ, periodontal, and esthetic). Knowledge is power. If they choose to neglect their health, let them. Who are we to tell you what to do with your health? Why do I need to come in and do a cursory exam for five minutes when we both have a detailed understanding of what our game plan is for the future? Why do I need to leave my restorative patient who has accepted treatment and wants optimal care for a hygeine check on someone who has been properly educated but chosen they do not want any treatment (but it is legally required)?

My job is to educate and guide, not to mandate. If someone wants their teeth cleaned, that is fine with me, but don’t put the responsibility on me to come in every six months for a “check” when we have laid out the framework for optimal health and you have chosen to decline it. Quite frankly, I would rather you have your teeth cleaned elsewhere and come to me if you have a complex problem that needs solving.

The paradigm shift.

It is time to move away from this model. I don't care what your insurance company says (trust me, I really don't). I strive my best to model a prosthodontic practice, but I am stuck with the dreaded hygiene exam. Of course, I invite patients back for a comprehensive examination when changes arise, but some simply will never cross the abyss. For that, they do not need my services. For that, I do not need to interrupt my goal of providing exceptional restorative dental care for my patients.

If the experts don’t do it, why should the less qualified be required to do so? All this does is decrease the quality of care in the office.

I finally said it: the six-month hygiene exam decreases the quality of restorative care in the average general dental office.

Can we (please) re-think dentistry of the past and strive to be better and more thoughtful?

Dentists and patients, I believe, would benefit greatly.

Matthew Kogan, DMD

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So what should truly be covered in that five minute exam? Tooth position, tooth arrangement, tooth color, tooth wear, gingival displays, gingival levels, papilla position, contact length, decay, cracks/craze lines, fractures, erosion, failing restorations, missing teeth, missing teeth which need replacement, teeth that will need future attention, gingival inflammation, gingival recession, bone loss, gingival hyperplasia, bone hyperplasia, pathology around roots, pulpal inflammation, abnormal radiographic (x-ray) findings, temporomandibular joint sounds, temporomandibular joint pain, muscle pain, tooth wear, tooth fracture, tooth mobility, malalignment of teeth and... what did I miss (at least the weather)?

To that I say: "Good luck."

[More to come on this topic soon...]