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Throwaway because I run a large dental software company. Dentistry is practiced as a business focused on maximizing revenue. Dentists are routinely coached to

Throwaway because I run a large dental software company. Dentistry is practiced as a business focused on maximizing revenue. Dentists are routinely coached to deploy sales tactics to increase their treatment acceptance beyond what is needed. If you walk into a dental office, you need to protect yourself from being abused. A second opinion unfortunately puts you in the same position, but now with a new dentist who will play into the narrative of only needing to monitor your condition for a while. The business of dentistry is unfortunately antithetical to conservative treatment, which is almost always in the interest of the patient, because it results in significantly lower patient lifetime value.

usrn 4y ago
I've gone to my current dentist for years and he's always extremely reluctant to even do fillings (last time he gave me a speech about how you can't replace what "God gave you" so you should just monitor it or so.) I think there are some dentists that legitimately care. EDIT: Mine is actually in a very wealthy neighborhood and the lady who runs the practice (I think that's how it works?) has a reputation for buying state-of-the art tech.
- lostcolony 4y ago
  Yeah; the ones who treat conservatively are gold. I'm still looking for one in my current location over ones who are aggressive in pushing additional treatments and things.
  - bombcar 4y ago
    I've found that if you can get conversational with the hygienists outside of the office they usually know who is who. But that can be a chicken-and-egg problem if you don't know any hygienists.
- juskrey 4y ago
  Basically you go to several dentists and chose the conservative one - it is not that hard. Yeah, most of them are in so so neighbouhoods and have outdated equipment, but you wanted to have less intervention in any case, right?
- rgersten 4y ago
  This. I come from a family of dentists and they are very hesitant to drill unless absolutely necessary. Their rationale as I understand it is that all fillings, crowns, bridges, etc fail eventually. That anytime you attach something to a tooth you add a failure point and potential for infection. The problem is their businesses can’t compete with the ones that play the insurance game. Insurance reimbursement rates haven’t kept up with overhead and so conservative dentistry is losing marketshare to ones willing to push treatment. We know multiple dentists that have filed bankruptcy in the last couple years. Keep in mind that many people are very reluctant to pay out of pocket for dentistry. Until insurance reimbursement rates favor conservative dentistry, nothing will change. More responsible dentists will lose their practices or turn to over treatment. Maybe the HN crowd wisdom has some ideas on how we can improve this situation.
  - thatfrenchguy 4y ago
    > Maybe the HN crowd wisdom has some ideas on how we can improve this situation. HMO / Capitation dentistry is the obvious answer here, where your dentist gets paid X per patient per year, to focus on preventive instead of pushing unnecessary care. It’s really hard to implement in the US though because people push for a lot of unnecessary stuff.
    - ghaff 4y ago
      >It’s really hard to implement in the US though because people push for a lot of unnecessary stuff. "Unnecessary" is in the eye of the beholder to a certain degree. Extracting a molar is pretty cheap. Root canals, implants, and crowns much less so. But, depending upon the circumstances, more expensive procedures may make sense.
    - Gunax 4y ago
      Well sure, but in the universe where capitation rules the world, we have people clamoring for services that they say they need, but professionals refuse to provide. And there are probably HN threads there explaining why we need to go to a fee-for-service model.
  - matwood 4y ago
- waynesonfire 4y ago
  Same, we have had the same dentist for over 15 years and I now drive across town to visit him. Trustworthy and reluctant to do any care unless required. Still tells me I need to floss.
- teeray 4y ago
  Ugh, yeah… it’s so frustrating that as a consumer you can’t tell for certain whether your teeth need to be drilled or not. I’d so much rather pay some bullshit dentist-needs-an-audi fee, rather than pay to needlessly destroy the structural integrity of my teeth so they can make a buck.
m_ke 4y ago
A few years ago I went for an initial screening to 3 different dentists and was shocked by the gap in suggested treatments. One wanted to do major work on like 11-12 teeth, another just fillings on 2. It made me lose all trust in American dentistry and I ended up going to get work done at a dental school instead because I knew it would be supervised by professors who are not optimizing for their bottom line.
- IvanaSays 4y ago
  I have a very expensive surgery coming up on Wednesday next week. My original dentist didn't even see anything wrong with the tooth. New dentist saw a deep canal but did a deep cleaning (f-ing painful!), and told me to wait a few months to see if it heals. I insisted on seeing a periodontist sooner. Tooth must come out. Sought 2nd opinion - she is convicned two teeth must come out. Then changed her mind. Now telling me bone graft material in the US is superior and I'd better get it done here than originally planned in a few months in Europe (thus saving a few thousand dollars and postponing some suffering so I can go on a vacation). Getting a third opinion the night before the surgery and literally don't know what I am going to do with it. What even the F.
- kalleboo 4y ago
  I remember a Swedish consumer advocacy show on public TV (Plus with Sverker Olofsson for all the Swedes out there) did this test some time in the early 00's, sending the same person to like 10 different dentists, including also public health care ones that don't have a profit motive, and they all had different results.
- ocWavean 4y ago
  Similar story. When I moved to the States (Oregon) for a few years, I had to hunt for a number of services, with dentistry being one of them. I worked for a pretty large SaaS private (at the time) company, so the perks were plentiful, but most importantly, private insurance was up there in terms of quality. Now, I'm originally from Canada, and without getting into the differences in healthcare between the two countries, but the amount of discrepancies I also received, let alone front-desk saying "oh my goodness, your insurance is incredibly good!", usually always resulted in the dentist informing me that I have 12 cavities. The sad thing was in shopping around, and going to a number of different places to try them out, all ranged between 12 and 6 cavities, some even suggesting major dental work (2 crowns) required. I even went to 'work colleagues' recommended ones. All gave shocking details about my teeth. Depressed, and annoyed, I went back to Canada, saw my dentist (and got a second opinion from a 3rd-party as an A/B test), and had 0 cavities to report. The second opinion stated I also had 0 (with maybe 1 on the way, and if I wanted, could opt to have it addressed now, but not the end of the world). In the end it was cheaper (in almost every way, sadly) to see the Dentist on trips back to Canada, instead of opting for what would effectively have been the decimation of my teeth in the States.
adolph 4y ago
> Dentistry is practiced as a business focused on maximizing revenue. All medicine is practiced as a revenue maximizing business (or it would cease as an ongoing concern). It's easier to see this in dentistry since at some early point in the US the field/cartel opted out of many of the omnibus health payment plans that otherwise obfuscate value chains. Aside from the notable exception of tobacco cessation, disease prevention gets short shrift compared to intervention. This is slowly changing but has started from a tremendous deficit.
pc86 4y ago
I've told this story here before, but I grew up with very health-illiterate parents, who were very "old school" in the sense that if anyone in a white coat said something, it was gospel. Doctor, dentist, nurse, whatever (curiously they had and still have extremely negative opinions of medical paraprofessionals like PAs and NPs). Anyway, I was around 15 or 16 and had always had perfect dental checkups. One day I had another routine checkup, but now suddenly I had to get nine fillings. I asked my parents to get a second opinion, but they refused and I got the fillings. In a move that would surprise absolutely nobody, that dentist sold the practice a few months later. I'm 100% confident that he was just goosing his revenue to increase the sales price, or make it a more attractive acquisition based on the revenue trend. That was around 20 years ago and I haven't had a single other dental issue beyond getting my wisdom teeth removed a few years later. I think dental care is super important, but dentists are concerned primarily with maximizing their revenue in a way that would get most physicians' licenses revoked.
- burntalmonds 4y ago
  Interesting. A similar thing happened to me. After a lifetime of zero cavities, the dentist I'd seen a few times for cleanings announces that my luck has run out -- I've got several cavities. I declined any work, but I was concerned. Shortly after that I ended up moving to a different state and it was about year before I got back in to a new dentist. I was dreading it since I figured he'd tell me I've got cavities. Nope -- said everything looks great, see you in 6 months!
  - noduerme 4y ago
    Worse happened to me. I had no cavities until the age of 36. Then I apparently got two. New dentist. I went for a second opinion and a second new dentist confirmed it, but who knows. I got the fillings. Within six weeks, one of the teeth broke in half around the filling and the guy was trying to give me an emergency root canal. I ended up having to have it pulled. The other one broke in half a few months later, another emergency surgery. That time, I went in and I'm pretty sure he worked on me drunk. I haven't tried to sue the guy, but I think seriously about firebombing his office every time I drive by it.
jgurewitz 4y ago
Incentives guide everything in medicine and it's really unfortunate. Even the best meaning doctors get pushed in that direction. See x patients a day for y minutes. X goes up 10% and y goes down 10% every year. My brother is in his residency and in one rotation was asked to see 35 patients a day at a clinic. Impossible to do anything but the most cursory work. Health advocacy is becoming a bigger thing in the United States and it will only continue. People need to remember that medicine is now a consumer good, with all of the pitfalls that entails.
escape_goat 4y ago
What if I ask for a diagnosis and recommend course of treatment in writing, then?
ravenstine 4y ago
Is it just me or do dentists rarely if ever suggest that their adult patients change their diet to avoid dental caries? They probably still tell children "don't eat candy", but since I reached adulthood I don't think a dentist ever told me suggested that the reason I needed so many cavities drilled was because I was feeding bacteria in my mouth. If my experience is as ubiquitous as I suspect, there seems to be a perverse incentive among dentists to allow adults to ruin their own teeth. It's convenient because most people know extremely little about dental health beyond brushing and flossing. A minor carie on the enamel doesn't necessarily progress further than surface damage, and in some cases can even be reversed. Instead of saving the patient time and money by waiting for further progression of a carie, many dentists see the tiniest surface divot as an opportunity to drill n' fill. A more appropriate response would be to suggest the patient eat an appropriate diet that doesn't feed carie-causing bacteria and to come back in 6 months to a year for a follow-up; if the carie is visibly worse, then now it's time to consider drilling. In defense of dentists, I imagine so few adult patients are compliant with suggestions of lifestyle changes that they figure it's hopeless and they might as well be the ones to cash in on cavities rather than some other dentist. Everyone hates going to them and they know they can't win.
- quickthrowman 4y ago
  > If my experience is as ubiquitous as I suspect, there seems to be a perverse incentive among dentists to allow adults to ruin their own teeth. If you read the thread, some dentists will perform needless work on healthy teeth to make money, so I doubt there’s an incentive to let adults ruin their teeth when you can just lie and say they need the work anyways.
- cauliflower2718 4y ago
  A dentist once told me that it's worse for my teeth to sip a soda or a coffee slowly over several hours than to chug it all at once. I wonder if it was suggested because patients might actually do that, compared to not drinking soda or coffee at all. (I might drink coffee slightly faster than I used to. I do not drink soda. I'm fine with stains but not unnecessary tooth decay.)
aleksandrh 4y ago
> The business of dentistry is unfortunately antithetical to conservative treatment, which is almost always in the interest of the patient, because it results in significantly lower patient lifetime value. Isn't this the case with other healthcare providers too, and not necessarily just dentists? For example, physicians will regularly make you wait at least 15 minutes—even in an empty office—so they can bill insurance for that extra time. They'll bill patients for "emotional/grief counseling" and lots of other unrelated charge codes as well. I've seen from firsthand experience how doctors will exploit patients and try to milk as much money as they can from them, rather than prioritizing their wellbeing and health.
- dentalthrowaway 4y ago
  Yes, principal-agent problems in healthcare are pervasive. But while medical upcoding fleeces patients, providers often feel it victimless because the procedures are almost always diagnostic and confused providers believe them to be paid by some third party (insurance, the state, but surely not the patient). Dentists, in contrast, don't just upcode diagnostics, they systematically over treat their patients.
RyanShook 4y ago
If this is really how you feel shouldn’t you get out of dentistry saas and find something you believe isn’t hurting society?
- formerkrogemp 4y ago
  What's that unicorn that doesn't hurt society but still allows me to support my family?
  - deleted 4y ago
    [deleted]

usrn 4y ago

I've gone to my current dentist for years and he's always extremely reluctant to even do fillings (last time he gave me a speech about how you can't replace what "God gave you" so you should just monitor it or so.) I think there are some dentists that legitimately care. EDIT: Mine is actually in a very wealthy neighborhood and the lady who runs the practice (I think that's how it works?) has a reputation for buying state-of-the art tech.

lostcolony 4y ago
Yeah; the ones who treat conservatively are gold. I'm still looking for one in my current location over ones who are aggressive in pushing additional treatments and things.
- bombcar 4y ago
  I've found that if you can get conversational with the hygienists outside of the office they usually know who is who. But that can be a chicken-and-egg problem if you don't know any hygienists.
juskrey 4y ago
Basically you go to several dentists and chose the conservative one - it is not that hard. Yeah, most of them are in so so neighbouhoods and have outdated equipment, but you wanted to have less intervention in any case, right?
rgersten 4y ago
This. I come from a family of dentists and they are very hesitant to drill unless absolutely necessary. Their rationale as I understand it is that all fillings, crowns, bridges, etc fail eventually. That anytime you attach something to a tooth you add a failure point and potential for infection. The problem is their businesses can’t compete with the ones that play the insurance game. Insurance reimbursement rates haven’t kept up with overhead and so conservative dentistry is losing marketshare to ones willing to push treatment. We know multiple dentists that have filed bankruptcy in the last couple years. Keep in mind that many people are very reluctant to pay out of pocket for dentistry. Until insurance reimbursement rates favor conservative dentistry, nothing will change. More responsible dentists will lose their practices or turn to over treatment. Maybe the HN crowd wisdom has some ideas on how we can improve this situation.
- thatfrenchguy 4y ago
  > Maybe the HN crowd wisdom has some ideas on how we can improve this situation. HMO / Capitation dentistry is the obvious answer here, where your dentist gets paid X per patient per year, to focus on preventive instead of pushing unnecessary care. It’s really hard to implement in the US though because people push for a lot of unnecessary stuff.
  - ghaff 4y ago
    >It’s really hard to implement in the US though because people push for a lot of unnecessary stuff. "Unnecessary" is in the eye of the beholder to a certain degree. Extracting a molar is pretty cheap. Root canals, implants, and crowns much less so. But, depending upon the circumstances, more expensive procedures may make sense.
  - Gunax 4y ago
    Well sure, but in the universe where capitation rules the world, we have people clamoring for services that they say they need, but professionals refuse to provide. And there are probably HN threads there explaining why we need to go to a fee-for-service model.
- matwood 4y ago
waynesonfire 4y ago
Same, we have had the same dentist for over 15 years and I now drive across town to visit him. Trustworthy and reluctant to do any care unless required. Still tells me I need to floss.
teeray 4y ago
Ugh, yeah… it’s so frustrating that as a consumer you can’t tell for certain whether your teeth need to be drilled or not. I’d so much rather pay some bullshit dentist-needs-an-audi fee, rather than pay to needlessly destroy the structural integrity of my teeth so they can make a buck.

m_ke 4y ago

A few years ago I went for an initial screening to 3 different dentists and was shocked by the gap in suggested treatments. One wanted to do major work on like 11-12 teeth, another just fillings on 2. It made me lose all trust in American dentistry and I ended up going to get work done at a dental school instead because I knew it would be supervised by professors who are not optimizing for their bottom line.

IvanaSays 4y ago
I have a very expensive surgery coming up on Wednesday next week. My original dentist didn't even see anything wrong with the tooth. New dentist saw a deep canal but did a deep cleaning (f-ing painful!), and told me to wait a few months to see if it heals. I insisted on seeing a periodontist sooner. Tooth must come out. Sought 2nd opinion - she is convicned two teeth must come out. Then changed her mind. Now telling me bone graft material in the US is superior and I'd better get it done here than originally planned in a few months in Europe (thus saving a few thousand dollars and postponing some suffering so I can go on a vacation). Getting a third opinion the night before the surgery and literally don't know what I am going to do with it. What even the F.
kalleboo 4y ago
I remember a Swedish consumer advocacy show on public TV (Plus with Sverker Olofsson for all the Swedes out there) did this test some time in the early 00's, sending the same person to like 10 different dentists, including also public health care ones that don't have a profit motive, and they all had different results.
ocWavean 4y ago
Similar story. When I moved to the States (Oregon) for a few years, I had to hunt for a number of services, with dentistry being one of them. I worked for a pretty large SaaS private (at the time) company, so the perks were plentiful, but most importantly, private insurance was up there in terms of quality. Now, I'm originally from Canada, and without getting into the differences in healthcare between the two countries, but the amount of discrepancies I also received, let alone front-desk saying "oh my goodness, your insurance is incredibly good!", usually always resulted in the dentist informing me that I have 12 cavities. The sad thing was in shopping around, and going to a number of different places to try them out, all ranged between 12 and 6 cavities, some even suggesting major dental work (2 crowns) required. I even went to 'work colleagues' recommended ones. All gave shocking details about my teeth. Depressed, and annoyed, I went back to Canada, saw my dentist (and got a second opinion from a 3rd-party as an A/B test), and had 0 cavities to report. The second opinion stated I also had 0 (with maybe 1 on the way, and if I wanted, could opt to have it addressed now, but not the end of the world). In the end it was cheaper (in almost every way, sadly) to see the Dentist on trips back to Canada, instead of opting for what would effectively have been the decimation of my teeth in the States.

adolph 4y ago

> Dentistry is practiced as a business focused on maximizing revenue. All medicine is practiced as a revenue maximizing business (or it would cease as an ongoing concern). It's easier to see this in dentistry since at some early point in the US the field/cartel opted out of many of the omnibus health payment plans that otherwise obfuscate value chains. Aside from the notable exception of tobacco cessation, disease prevention gets short shrift compared to intervention. This is slowly changing but has started from a tremendous deficit.

pc86 4y ago

I've told this story here before, but I grew up with very health-illiterate parents, who were very "old school" in the sense that if anyone in a white coat said something, it was gospel. Doctor, dentist, nurse, whatever (curiously they had and still have extremely negative opinions of medical paraprofessionals like PAs and NPs). Anyway, I was around 15 or 16 and had always had perfect dental checkups. One day I had another routine checkup, but now suddenly I had to get nine fillings. I asked my parents to get a second opinion, but they refused and I got the fillings. In a move that would surprise absolutely nobody, that dentist sold the practice a few months later. I'm 100% confident that he was just goosing his revenue to increase the sales price, or make it a more attractive acquisition based on the revenue trend. That was around 20 years ago and I haven't had a single other dental issue beyond getting my wisdom teeth removed a few years later. I think dental care is super important, but dentists are concerned primarily with maximizing their revenue in a way that would get most physicians' licenses revoked.

burntalmonds 4y ago
Interesting. A similar thing happened to me. After a lifetime of zero cavities, the dentist I'd seen a few times for cleanings announces that my luck has run out -- I've got several cavities. I declined any work, but I was concerned. Shortly after that I ended up moving to a different state and it was about year before I got back in to a new dentist. I was dreading it since I figured he'd tell me I've got cavities. Nope -- said everything looks great, see you in 6 months!
- noduerme 4y ago
  Worse happened to me. I had no cavities until the age of 36. Then I apparently got two. New dentist. I went for a second opinion and a second new dentist confirmed it, but who knows. I got the fillings. Within six weeks, one of the teeth broke in half around the filling and the guy was trying to give me an emergency root canal. I ended up having to have it pulled. The other one broke in half a few months later, another emergency surgery. That time, I went in and I'm pretty sure he worked on me drunk. I haven't tried to sue the guy, but I think seriously about firebombing his office every time I drive by it.

jgurewitz 4y ago

Incentives guide everything in medicine and it's really unfortunate. Even the best meaning doctors get pushed in that direction. See x patients a day for y minutes. X goes up 10% and y goes down 10% every year. My brother is in his residency and in one rotation was asked to see 35 patients a day at a clinic. Impossible to do anything but the most cursory work. Health advocacy is becoming a bigger thing in the United States and it will only continue. People need to remember that medicine is now a consumer good, with all of the pitfalls that entails.

escape_goat 4y ago

What if I ask for a diagnosis and recommend course of treatment in writing, then?

ravenstine 4y ago

Is it just me or do dentists rarely if ever suggest that their adult patients change their diet to avoid dental caries? They probably still tell children "don't eat candy", but since I reached adulthood I don't think a dentist ever told me suggested that the reason I needed so many cavities drilled was because I was feeding bacteria in my mouth. If my experience is as ubiquitous as I suspect, there seems to be a perverse incentive among dentists to allow adults to ruin their own teeth. It's convenient because most people know extremely little about dental health beyond brushing and flossing. A minor carie on the enamel doesn't necessarily progress further than surface damage, and in some cases can even be reversed. Instead of saving the patient time and money by waiting for further progression of a carie, many dentists see the tiniest surface divot as an opportunity to drill n' fill. A more appropriate response would be to suggest the patient eat an appropriate diet that doesn't feed carie-causing bacteria and to come back in 6 months to a year for a follow-up; if the carie is visibly worse, then now it's time to consider drilling. In defense of dentists, I imagine so few adult patients are compliant with suggestions of lifestyle changes that they figure it's hopeless and they might as well be the ones to cash in on cavities rather than some other dentist. Everyone hates going to them and they know they can't win.

quickthrowman 4y ago
> If my experience is as ubiquitous as I suspect, there seems to be a perverse incentive among dentists to allow adults to ruin their own teeth. If you read the thread, some dentists will perform needless work on healthy teeth to make money, so I doubt there’s an incentive to let adults ruin their teeth when you can just lie and say they need the work anyways.
cauliflower2718 4y ago
A dentist once told me that it's worse for my teeth to sip a soda or a coffee slowly over several hours than to chug it all at once. I wonder if it was suggested because patients might actually do that, compared to not drinking soda or coffee at all. (I might drink coffee slightly faster than I used to. I do not drink soda. I'm fine with stains but not unnecessary tooth decay.)

aleksandrh 4y ago

> The business of dentistry is unfortunately antithetical to conservative treatment, which is almost always in the interest of the patient, because it results in significantly lower patient lifetime value. Isn't this the case with other healthcare providers too, and not necessarily just dentists? For example, physicians will regularly make you wait at least 15 minutes—even in an empty office—so they can bill insurance for that extra time. They'll bill patients for "emotional/grief counseling" and lots of other unrelated charge codes as well. I've seen from firsthand experience how doctors will exploit patients and try to milk as much money as they can from them, rather than prioritizing their wellbeing and health.

dentalthrowaway 4y ago
Yes, principal-agent problems in healthcare are pervasive. But while medical upcoding fleeces patients, providers often feel it victimless because the procedures are almost always diagnostic and confused providers believe them to be paid by some third party (insurance, the state, but surely not the patient). Dentists, in contrast, don't just upcode diagnostics, they systematically over treat their patients.

RyanShook 4y ago

If this is really how you feel shouldn’t you get out of dentistry saas and find something you believe isn’t hurting society?

formerkrogemp 4y ago
What's that unicorn that doesn't hurt society but still allows me to support my family?
- deleted 4y ago
  [deleted]