11 ms·

Health Services as Credence Goods: a Field Experiment (2020)

231 points by once_inc 4y ago

once_inc 4y ago
Sci-hub link: https://sci-hub.se/10.2139/ssrn.3036573 https://sci-hub.se/10.2139/ssrn.3036573
once_inc 4y ago
Fifty of the dentists find at least one 'cavity', some of them up to six. 'Cavities' were found in up to 13 different teeth. Socio-economic status of the patient is relevant in how many times 'cavities' are found.
- midasuni 4y ago
  Specifically poor people have more cavities “found” It’s unclear from the abstract what country this applies to.
  - doetoe 4y ago
    This study was conducted in Switzerland
  - deleted 4y ago
    [deleted]
  - SanjayMehta 4y ago
    Switzerland.
- encryptluks2 4y ago
  Punishment should be defacto pull as many teeth from the dentist that they wrongfully pulled from their patients, and do it without anesthesia so that they have some additional remorse.
  - aeries 4y ago
    Please leave this knee-jerk vitriol off of Hacker News. We come here from other sites to avoid this stuff, not to see more of it.
  - cortesoft 4y ago
    Some of them probably genuinely made a mistake.
    - encryptluks2 4y ago
      How do you extract a tooth by mistake?
      - hutzlibu 4y ago
        By making a wrong diagnosis, that it is needed.
        encryptluks2 4y ago
        You mean by making a fraudulent diagnosis that it is needed.
    - mandmandam 4y ago
      Some of them, sure. But 50 out of 180? That's systemic fraud.
      - cortesoft 4y ago
        Right, but my point is that if you go to each one and rip out their teeth without anesthesia, you are going to be torturing at least a few innocent people. Even if only 5% of the 180 aren’t fraudsters, I’d feel bad about torturing 9 innocent people.
        encryptluks2 4y ago
        Weird how the US doesn't feel bad about killing a few innocent children and label them as casualties of war.
- magicalhippo 4y ago
  My previous dentist would show me the x-rays and explain. He'd point out that a cavity was starting to develop, and what measures I should take to avoid it developing further. After some years, if it got worse, he'd show me the old x-rays and the new new so I could see the change, and he'd suggest I'd get it fixed now. Sadly for me he retired recently.
  - dbrgn 4y ago
    My dentist does the same. When I first went there (after not having gone do the dentist for 3-4 years, because I never had any issues with cavities) he told me that there are 4 cavities I need to get fixed. I was very sceptical at first, but agreed to get them done. He fixed all 4 of them in 20 minutes. When he drilled open one of the teeth, he showed me how it looked with one of these small cameras that you could see live on the screen. It was absolutely obvious that there was a considerable cavity. Explaining to your customers what needs to be done, proving it with pictures and/or x-rays, and explaining the different options generates a lot of trust.
    - PeterBarrett 4y ago
      Same with my dentist that I started going to 2 years ago. I live in a differtnt country now and literally book appointments 3 months in advance with them just so I don't have a bad experience with someone else.
- petodo 4y ago
  Also 60% of dentists failed to display prices according regulation. Median price of overtreatment was 450 USD. https://sci-hub.se/10.2139/ssrn.3036573 https://sci-hub.se/10.2139/ssrn.3036573
  - ekianjo 4y ago
    Dentists are charlatans hiding behind a blouse
- sizzle 4y ago
  Also the blatant, don’t worry it’s free insurance covers it “persuasions” as if my only concern is cost rather than necessity that I’ve learned is a shady dentist go-to tactic to open their customer’s wallets via insurance. Half the time I find out the cavity is not in the x-ray but “visual inspection” or “preventative” and the car salesmen tactics and fear of losing teeth are layed on thick while you are at your most vulnerable moment in the chair having a bright light blast your vision. I hate it all, give me the x-rays and I’ll get a second opinion until trust is earned. The mom and pop local family dentists are the best, not the dentists renting chairs in clinics that rotate every time you come in. If they make you sign a disclaimer about exceeding insurance coverage RUN!!
encryptluks2 4y ago
God I hope those dentist lost their medical license forever. I am very untrusting of dentist in general due to issues like this. I remember my brother as a preteen had 6 teeth removed and my mom said she didn't think he needed it but she was trust the doctor always type. Later the doctor was found to be pulling teeth of kids on state insurance that didn't even have cavities.
- bowsamic 4y ago
  > God I hope those dentist lost their medical license forever. I don't think they are going to do anything specific to those dentists based on this study
  - encryptluks2 4y ago
    Maybe the news and media need to get involved here. If they don't face any repercussions then I'll remember to cite that as to why people could be distrustful of doctors when it comes to vaccines and other things.
    - bowsamic 4y ago
      You should always be distrustful of doctors to some degree in my opinion. They are too often seen as unquestionable in our society
    - Spare_account 4y ago
      Every industry has cowboys. This study should just reinforce the notion that we should get a second opinion (or third, if the first two differ) on ANY major work being carried out by ANY profession. To extend that line of thought, and steer it towards the second half of your comment: if you visit two (or three) doctors to seek advice about getting vaccinated, I think we can be sure what the consensus would be.
      - encryptluks2 4y ago
        I didn't say that people shouldn't get vaccinated, just that it is understandable why people would have a general distrust towards doctors because of things like this. Maybe we should try not to ostracize people for having legitimate distrust.
GiorgioG 4y ago
My wife never had a cavity in her life. We moved to a new state/city and the dentist she tried “found” 4 cavities. We went to another dentist, found none. To this day nearly 10 years later the entire family goes to the 2nd dentist and couldn’t be happier. Long after leaving the first practice their office would occasionally send out promo emails offering sale prices for services. Greedy unethical people exist in all professions. Edit: Thinking about it further (it has been almost 10 years) I had also gone to the first disreputable dentist around the same time as my wife's initial visit because I cracked a tooth (furthest back lower mollar on one side). They extracted it and wanted to put in a dental implant to the tune of several thousand dollars. Nothing particularly nefarious so far, except that they kept pressuring me about the implant because without it, the corresponding upper tooth would start coming down due to not having a tooth to match up with below it. I didn't do it, partly for the money and partly because I'd heard implants were painful. It doesn't affect my smile or my ability to chew/eat. 10 years later the upper molar hasn't budged one iota.
- cjmcqueen 4y ago
  Had a very similar experience in San Jose, CA. I've never had a cavity and one dentist made a rush look at my teeth, provided no evidence of a cavity and told me to book time for a filling. I never went back. Five years later I've seen other dentists every 6 months and none of them have suggested I have a cavity.
- nomilk 4y ago
  > the dentist she tried “found” 4 cavities. We went to another dentist, found none. To this day nearly 10 years later the entire family goes to the 2nd dentist and couldn’t be happier. A generalisable experiment anyone can do to find an excellent dentist. I intend to try this. Thanks for sharing.
vasergen 4y ago
Not related to this topic, but I am curious how the situation looks like in IT industry. Say a company without any "real problems" ask for "advice" 180 IT agencies. My guess that situation will be much worse.
- deleted 4y ago
  [deleted]
- crummy 4y ago
  We asked 180 developers if we should rewrite our tech stack in Rust.
  - sgt 4y ago
    We asked 180 developers if the existing solution should be rewritten in Rust from PHP, despite working like a charm.
- draugadrotten 4y ago
  Now do lawyers.
- dainiusse 4y ago
  Oh yes! For bureaucratic reasons we were forced to get external consultancy to evaluate code... Everything was wrong according to them from architecture to tech choices made... yet, the project was most successful within the company... these choices were made due to available talent and starting it with what people know....
runemadsen 4y ago
It's expensive to be poor.
noduerme 4y ago
Bullet point 1: at 35 years old, I hadn't been to a dentist in 12 years; walked into a clinic in Spain for a cleaning, and the lady gasped that I had no cavities and no missing teeth. I only brush once a day, without toothpaste. Bullet point 2: No one on my father's side has ever had a cavity that I know of. We do all get kidney stones. I think it's related. Bullet point 3: I went for a routine cleaning after I moved to Portland, OR (age 38), and was told I had two cavities. I stupidly believed the man. He drilled and filled them. It was the night before Christmas Eve, when they were having their holiday party. I think he was drunk. His nurse was definitely drunk. All fun, and such, until both teeth split in half around the fillings, exposing the nerve (the first on New Years Eve, 9:30 at night; try having emergency dental work done then). I thought about suing him. Who knows; I've never had a cavity since then, and it was 6 years ago, but I'm missing two teeth. And yes, I've decided against firebombing his office. Consciously. Every year on new years.
- dennis_jeeves1 4y ago
  >And yes, I've decided against firebombing his office. Wrong decision.
- deleted 4y ago
  [deleted]
- jaimehrubiks 4y ago
  You should have sued
  - noduerme 4y ago
    I read up on it, but it's pretty difficult to pin a dentist for malpractice. Especially if you don't have the teeth to show it.
- fastball 4y ago
  If you don't brush, do you get more plaque build up? From what I've understood, people generally can have mouths that are more basic/acidic depending. If basic, plaque tends to be a bigger issue but few if any issues with cavities is common. The converse for mouths that trend acidic.
z7 4y ago
I used to go to the dentist every 4-6 months and there was almost always something that seemed to require a drilling procedure. Then after graduation my life became chaotic and I stopped going and frankly haven't been to the dentist in seven years. So far I've felt no toothache or anything like it. I know I'm probably walking around with a host of dental problems. Still seems interesting that I've made it this far.
- dagw 4y ago
  after graduation my life became chaotic and I stopped going I skipped the dentist for over a decade for much the same reason. I had no problems at all, right up until I got lots of problems at once.
- gibolt 4y ago
  So many other problems in life are tied to tooth issues, and most appear hard later in life. A dentist visit without insurance is usually under $100, and is a great investment in your future happiness and health.
- encryptluks2 4y ago
  Some people can not brush their teeth for extended periods of time and not get cavities. It really depends on your diet, mouth flora, etc. Some studies suggest xylitol and other artificial sweeteners may have a positive impact on tooth decay because they cannot be used as food for bacteria and some substantially change the bacteria that live in your mouth over time to those that are not harmful to the teeth.
- floucky 4y ago
  It could also be linked to a change in your diet. I have the same kind of experience, but I eat less sugar and this helped a lot in my case
- deleted 4y ago
  [deleted]
- jwmoz 4y ago
  Exactly what happened to me (UK) last year! Hadn't been to the dentist for something like 10 years. My partner (TW) takes me to her family dentist and I was expecting loads of problems, but he only did one small touch up filling and cleaning. Just one procedure in 10 years!
utdiscant 4y ago
Incredible research! I have had this intuitive feeling for a long time, that the more I go to the dentist, the more issues appear. And when I recently shopped around for different dentists, they all had completely different recommendations for the same situation.
gadders 4y ago
I trust dentists about as much as I trust car mechanics. I'm sure I've had stuff done that was marginal at best and has now caused further issues.
baobabKoodaa 4y ago
Is "cavity" one of those things that develop gradually and it's impossible to draw the line when exactly you have one and when not? Is it possible that some of these dentists just have differing opinions on where the line should be drawn?
- loandbehold 4y ago
  Absolutely. Everyone has "microcavities". Those may be revered by remineralization. Those gradually grow into full blow cavities over time if not remineralized.
- m000 4y ago
  Yes, this is exactly the case. The reason for this is that fillings can't be made super-small, and you always need to grind some healthy tooth tissue for the filling to bind. So, a dentist needs to decide if the decay has gone far enough to make it worth the loss of healthy tooth issue for the filling. Also, dentist treatment recommendations always include a part of expectations management. E.g. if your dentist believes that you wouldn't want to pay extra for a crown, it is more likely they will outright recommend an oversized filling instead. So, it is important to be explicit to your doctor that you want to be listed all the range of treatment options, so you can discuss their tradeoffs and choose what feels right for you.
- deleted 4y ago
  [deleted]
boruto 4y ago
One of the stupidest decisions in life I made after moving to first world country was using my privilege of dental insurance. I did go to a dentist in India(my home) Dentist said nothing wrong just floss. Then I had moved to berlin and hey I have insurance now for dental check ups. The first visit resulted in 4 fillings. One filling was bad resulted in root canal. That root canal went bad and the other molar needed root canal. I took my x rays from first and second dentist to dentist in India, where he told I did not needed those fillings. At this point I have zero trust in any doctor in Berlin, I get my check ups done in India. I also did not save any money from my adventures in Berlin, Because every visit resulted in doctor offering a better choice which is not free under insurance and this ended up way costlier than the whole process in my home country.
- Cthulhu_ 4y ago
  The dental insurance in my country (NL) is limited as well; for one, it's a surcharge on your health insurance (€15 a month or thereabouts), you have to have had it for a year before they start covering things, and then they only cover up to a few hundred € per year depending on how much you pay them, while dental work quickly adds up. I mean I think mine covers €250 a year and the cost is €150 per year, so only if I have recurring dental expenses like that is it financially beneficial for me to have the dental coverage.
  - m000 4y ago
    Yes, dental coverage in NL kind of sucks. The way it is structured now, it often makes more sense to make a "dental savings" account rather than paying the insurance surcharge. There is action to change that though. Doctors of the World currently run a petition for including dental insurance in the basic insurance package (basispakket) [1]. I don't see this happening soon, but it's a start for a future change. [1] https://doktersvandewereld.org/campagnes/mondzorg-in-het-basispakket/ https://doktersvandewereld.org/campagnes/mondzorg-in-het-bas...
- bombolo 4y ago
  There was a scandal in italy a while ago because in a certain hospital they were doing an abnormal number of c-sections, because it counts as surgery and they get paid more from the state.
wtk 4y ago
When I lived in the UK I went to a dentist who recommended to treat 5 or 6 cavities. I only wanted a check-up as I planned to fix anything in Poland which I regularly visited. There I heard that only 2 were actually something worth taking care of. I thought maybe different countries have different standards for what needs attention.
Cthulhu_ 4y ago
I'm really not surprised. My recent dentists have all been really good, but growing up we had one that would want a drilling procedure every time. I'm glad we switched when we did.
weird-eye-issue 4y ago
When I was in the US my dentist said I needed to go every 3 months for some special cleaning that cost more $$ and that I have gum disease. Now in Thailand I go every 6-12 months for a normal cleaning and they say everything looks just fine but that maybe I brush a little hard
jwmoz 4y ago
This is depressing to see and confirms what I thought. We recently went to see a family friend dentist and they just did one small touch-up and a clean-I hadn't been to the dentist in a few years and was expecting a load of issues.
DoingIsLearning 4y ago
I was curious how the High/low Socio-economic status would have played out in Methodology: > To indicate a higher socio-economic status, the test patient wore a high quality suit and high-end accessories such as an expensive watch, a car key and a new and expensive mobile phone. The test patient specified his occupation as a translator at a bank when asked to fill out the patient form. > In the lower socio-economic status role, the test patient wore cheap unbranded clothes, an old backpack and had no accessories. The test patient declared to be a student of translation doing an internship. > Note importantly that in both socio-economic status-roles the patient signals to have studied. Hence, the level of education was kept constant across the two conditions.
deleted 4y ago
[deleted]
revanx_ 4y ago
I used to have a lot of cavities due to poor oral hygiene, after I had a complications with my wisdom tooth, I really decided to step up my game and take care of my teeth. Brush 3 times per day, 15 minutes after every meal. Floss two times per day. Reduce soda intake. Reduce sugar intake. Cavity free for 4 years now. I switched dentist and after several visists she accused me of seeing another dentist because I didn't have any new cavities. Anyway ...
robga 4y ago
Clearly the work of rabid anti-dentites.
recuter 4y ago
If you ever have a long layover in Bangkok be aware that there are plenty of very professional reputable places that offer a proper tooth cleaning for ~$50. They don't view you as a repeat customer, ask for an opinion on your way out. I'm quite sure they never bullshitted me once and I say this as a notorious anti-dentine. Several other places I can recommend trying this: Lima (Peru), Buenos Aires, Israel. I have no idea why that is exactly but I assure you that you would not be compromising on the quality of the care. Quite the opposite.
- MrJagil 4y ago
  Why do you know this?
  - recuter 4y ago
    I travel a lot..
  - roykent 4y ago
    I read a while back that Thailand is huge for dental tourism. There was also some town in Mexico that had a ton of high quality dentists. So people that need a ton of expensive work would sometimes fly to these places and cost of treatment + flights and housing would be significantly less than a place like the USA where it's normalized to drain your savings or go into debt for care.
willyt 4y ago
I’m in the UK and lucky to be registered with an NHS dentist (places are scarce) so they have no incentive to treat problems I don’t have. I have to pay a token amount for dental checks and hygienist visits. Something like £15 a time.
- Robadob 4y ago
  There are still inconsistencies between NHS dentists, visual assessment of cavities and what justifies treatment is inherently subjective. My first dentist retired after I'd had no fillings to date, their replacement on first appointment said I required two fillings and it continued in a similar manner. Later on I had moved city, but was still travelling back for dental appointments. The second dentist said I needed another filling doing, but I ended up moving to a new NHS dentist in my new city. They disagreed about the filling, saying you can't fill teeth if it would go below the gum line. Pulled the tooth instead. Even with NHS appointments, you can go 'private' a-la-carte if you can be convinced to have white fillings or similar extras and pay slightly more.
  - stuaxo 4y ago
    White fillings should be available on the NHS (saying this as someone that can afford the private option).
bearmode 4y ago
This right here is why all healthcare, including dentistry and optometry, should be nationalised.
- Arch-TK 4y ago
  I'm pretty sure the way NHS dental care works in the UK is basically broken and I'm not sure I trust any dental practice which relies solely on NHS income. Let me tell you why: This can be a bit fuzzy and I may make a mistake here or there but I think the gist is still very correct. A few years ago I used to work for a company which wrote dental practice management software, so I got a good idea of how NHS dentistry works. The way you get paid doing NHS dental care is you sign a contract with the dental board on which you tell them the estimated number of Units of Dental Activity (UDAs) which you expect to carry out during the year. You get penalized upon contract renewal if you miss this target by too much. All work done on an NHS patient is broken up into Courses of Treatment (COTs) and each COT has a band given to it. The band is based on the treatments which were performed as part of a COT[1], most importantly, if you perform two fillings instead of one, the band does not go up. Each band gives a different number of UDAs[2]. You can't start a COT too early after a previous one (2 month rule)[3] unless it's a higher band. Due to these factors, two things appear to happen: 1. Very obvious, NHS dental practices will refuse new patients even if they have the capacity to accept them because they expect they will already match their UDA count for the year. I don't think any of them will explicitly tell you this reason but it happens all the time in the UK, the key word is they will tell you to call around April (which is when contract renewals happen). 2. Less than trustworthy dentists will, upon spotting e.g. a cavity starting to develop and a bigger cavity in another place, fill the bigger cavity and then address the smaller one at your 6 months checkup to avoid stacking the COTs and losing out on additional band 2 UDAs. Very much not saying that all nationalised dental health care is shit, but in the UK I have generally had better experience with dental practices which do mixed care than dental practices which solely focus on NHS dental care. Don't be like the UK. [1]: https://www.nhs.uk/nhs-services/dentists/dental-costs/what-is-included-in-each-nhs-dental-band-charge/ https://www.nhs.uk/nhs-services/dentists/dental-costs/what-i... [2]: https://faq.nhsbsa.nhs.uk/knowledgebase/article/KA-01976/en-us https://faq.nhsbsa.nhs.uk/knowledgebase/article/KA-01976/en-... [3]: https://faq.nhsbsa.nhs.uk/knowledgebase/article/KA-01998/en-us https://faq.nhsbsa.nhs.uk/knowledgebase/article/KA-01998/en-...
joaodlf 4y ago
Oh boy. Years ago I visited my home country with my partner. She used to prefer going to dentist there, old habits I guess. On this particular trip I agreed to a check up as well - It had been a while since I had my teeth checked, why not? Really fancy dentists. Big offices, flashy machines, everything looked pristine. X-rays are taken, teeth are checked. Result: You need root canal! You should have it done soon, it's going to get much worse and hurt a lot more! We can do book you in ASAP. Hollllld on. I was on holiday, I'm not about to have a root canal procedure done and ruin my time off. I'll take the xrays and check back with a dentist back home. I pay dearly for the check and xrays and proceed to not enjoy my time off as much as I could have - I was worried. Fly back home, book a session with my usual dentist. "I can't see anything wrong with this tooth. But let me do an xray as well... Nope. Can't see anything wrong." It has been around 5 years now. That dentist would have performed root canal on me for no apparent reason... One really interesting conversation I had with my usual dentist: Me: So really, nothing wrong? Why would they say otherwise? Dentist: Nothing wrong. I'm not sure why they told you otherwise. Me: That's just... Dentist: Tell you what, they say it's this tooth points, right? Do any other of your teeth look different in the xray? Check the root as well, pay close attention. Me: I don't see any difference, but I'm not a dentist... Dentist: Well, I am a dentist, but I also see no difference.
tluyben2 4y ago
My first memory of going to a dentist was the school dentist (in the Netherlands); they said I had a cavity. I was small so I started shouting (when a needle came out) that I wanted my mother; she came and told them to keep their hands off of me. Our family dentist (an uncle) said I have no cavities and don't go to other dentists if I value my teeth. 43 years later I have 0 cavities while dentists in several countries and locations told me I have. I always get at least 2 opinions since that first experience. Luckily I had a total of 3 dentists in my family but they are retired now. Think a good one (multiple people said it) is getting a cleaning; they will see if there are cavities but have no financial incentive to make them up and start drilling.
esskay 4y ago
This happens in the UK as NHS dentists get paid based on work done. My old one before I moved was great, regular checkups and no issues. Moved house and my new dentist 'found' 4 caveties that all needed fixing, one of which was 'critial'. Me being stupid agreed to have the main one done, which they botched and it turned into a root canal. Swapped dentists after that and went private and magically I have no cavities and they couldn't understand why I'd had a root canal. Fuck dentists.
- scarygliders 4y ago
  My local NHS dentist told me four of my bottom front row teeth were "dead" and needed lots of treatment involving needles and drills and such, otherwise they'd start rotting away and get painful and so on... Oh and that I need a root canal in one molar... Which I thought was strange at the time because I could still feel sensation in them, feel blood supply pumping into them, felt no pain. At the time though I had great trust in dentists so I agreed to the treatment, and an appointment was set for the procedure. On the day I was sat in the dentist chair and whilst they were setting up, I had this instinctual feeling that this whole thing was "wrong!" and before they could even administer the first numbing jab I called the whole thing off. A few years later and I've had no problems with those teeth, or any others for that matter.
ChrisMarshallNY 4y ago
But did they see this guy? https://m.youtube.com/watch?v=YoWom0CCRKM https://m.youtube.com/watch?v=YoWom0CCRKM
sammalloy 4y ago
In the US, there were several recent scandals of dentists purposefully cracking molars to get business.
throw03172019 4y ago
Dentists have a trick where they show your old fillings on the intra-oral camera and say the “yellowing” means it’s gone bad and recommend refilling it. If your dentist pulls this trick, leave immediately.
stormdennis 4y ago
Firstly I'd say that although there are 180 dental practices, there is only one patient, I think a study would need a lot more than that. I cannot read the article but at how many practices did this person have x-rays taken? I doubt it was many if any. How did they get out of that, by bringing their own x-rays with them and saying that they were a recent set from their last dentist who'd retired? If they didn't have x-rays taken and didn't bring any with them then the dentist would be diagnosing blind to a large extent. In any case diagnosing cavities is not a binary true/false affair and x-rays can mislead also. There is a lot of human judgement involved. Some cavities never need filling, others can increase massively in size over a short period. Two questions that a dentist will typically ask a new patient are, how long since your last attendence at dentist and are you a regular attender or do you just go when you have problems? If a new patient is a regular attender, a dentist will be happier to keep a cavity they are unsure of, under observation. Sometimes they may schedule shorter recall periods for review until such time as they are comfortable that the patient does not have active decay. Generally a cavity does not need to be filled unless it extends into dentine. Determing if this is the case is not always straightforward. Generally a filling does not need to be replaced unless it is leaky. Again this is not always easy to determine and like programmers, dentists tend to be more critical of other dentists' output than their own. Recent experience also colours judgement. If a dentist has had a run of cavities that turned out to be deeper than expected then they are more likely to diagnose a cavity when unsure and vice versa. Different sub-populations in the aggregate, depending on wealth, diet, dental hygiene and typical frequency of attendence have different dental decay characteristics which can colour a dentist's judgement. There are crooked and incompetent dentists just like there are in every job. Dentists in general get a bad rap. One reason I've heard is the fear of dental treatment breeds an instinctive, subconscious dislike and mistrust of dentists as persons. Certainly doctors, despite being equally good at extracting money from their patients don't suffer from the same degree of antipathy and suspicion.
- shellfishgene 4y ago
  In the paper is says: "Each diagnosis was based on the same x-ray and the same oral condition of the test patient."
mandmandam 4y ago
If anyone is wondering why poor people were targeted more, I'd hazard an educated guess on some of the "complex" factors: 1. The poor are less likely to seek a second opinion. 2. And, less likely to be able to sue. The near complete lack of accountability might even be the main reason. 3. Some people associate how much money you make with how 'worthy' a person you are. There are likely quite a few dentists who quietly 'justify' unnecessary treatment based on that line. People don't seem surprised that 50 out of 180 dentists would fuck up your teeth for money - because we know what dentists are like, and many of us share similar experience. I certainly do. I have some kind of nerve damage from a shitty dentist, was recommended unnecessary fillings and root canals, etc. 50 out of 180 isn't a normal error rate - it's the mark of a broken industry, crying out for overhaul and accountability. Where are the "good" dentists speaking out on this? In my experience even the good ones make excuses for the shysters.
- lupire 4y ago
  Related, there are a few CVS pharmacists desperately trying to convince the vast majority of CVS Pharmacy pharmacists to protest corporate to stop selling homeopathic junk.
alkyon 4y ago
The best option is to opt for a prepaid package with all things included. Then it's not in their best interest in seeking cavities were there are none. Still they couldn't ignore any real one one if it needs attention - leaving it as it is would lead to much more expenses in the future, so they would nip it in the bud.
moonchild 4y ago
> Dentists with shorter waiting times are more likely to propose unnecessary treatment. Does this mean that dentists who are better at dentistry (and as a result have more patients) are less likely to propose unnecessary treatment because they know better? Does it mean that dentists who have fewer patients (and are therefore more desperate for money) are more likely to propose expensive treatment?
- lupire 4y ago
  Can't say for sure without experimentation, but it's seems naturalll for dentists to respond to incentives. If you are sitting on a money printer, bored, while money is burning in your pocket...
Helmut10001 4y ago
Everyone talks about the dentist topic. To me, what this points to is much bigger: Expert knowledge is greatly overrated and researcher-subject effects (biases) are greatly underrated. Heterogeneity of results in many fields that deal with humans suggests that triangulation (a concept known in the social sciences - e.g. to use many data source, many approaches and many opinions) is perhaps the only solution to offset human subjectivity.
- seer 4y ago
  I’ve found rating systems a big help. What I usually do for any doctor is visit a famous online forum in bulgaria that’s filled with people’s opinions regarding doctors. Started as just a place where young mothers hang out and talk about various topics, and is practically an institution here already. Since it’s not affiliated with any business / media it has remained surprisingly honest place and most opinions I’ve read ended up being spot on - both positive and negative. Its pretty great for finding out doctor specialists.
- pas 4y ago
  Is this true for "all fields"? Is there some pattern? Eg. fields that deal with hard data (let's say nephrology) is "better" than fields that stare at blurry Xrays? Or fields where the consequences are relatively light are worse than, let's say fields that revolve around brain surgery? Average years of experience required to practice in that field? Monetary incentives?
  - Helmut10001 4y ago
    I would say that anything beyond pure math is affected to a large degree by subjectivity. I have worked across three research fields (architecture, geography, informatics) and all researchers I met from these fields (apart from 1-2 exceptions) are hugely affected by their subjective intra-group beliefs. Not only that, they extrapolate their world view beyond their respective fields, which I find wrong and concerning.
    - pas 4y ago
mickelsen 4y ago
But I don't understand, don't they do imaging work during diagnosis? Here in Chile, this is usually free with the first diagnosis in private clinics, as a way of getting your business. Plus it's pretty popular to license this software called Dentalink here, which has a patient log complete with graphics on which part of what tooth was treated or if it was just an estimate given and it's pending treatment. One caveat is that the clinics that do free diagnosis + x-rays don't hand them to you as part of the deal, but you can ask to get them e-mailed. Smaller practices without their own machines just give you an order to an imaging center, those are always yours to keep. I've had pretty consistent results (and estimates) between the big retail practices for standard dental work like cavities. Some tried to upsell on the cleaning and whitening, but it's not a big difference.
- once_inc 4y ago
  They are basically using the credentials and reputation that the health industry has afforded medical specialists to claim health issues that aren't there. People of lower socio-economic status rarely have the wherewith-all to ask for evidence or second opinions. They just have the treatment and have it covered by health insurance (if European or somehow well insured).
danielsokil 4y ago
Here is the full text and pdf https://www.researchgate.net/publication/320070183_Health_Services_as_Credence_Goods_A_Field_Experiment https://www.researchgate.net/publication/320070183_Health_Se...
colonwqbang 4y ago
Very readable/accessible article. This finding caught my eye: > Regarding the treatment—the test patient has a superficial interproximal caries lesion that should not be treated by an invasive treatment such as a filling—the suggested number of fillings at dentist ranges from one to six. Moreover, we observe that 13 different teeth to be treated with a filling appear across all cost estimates. Thus, besides our finding of a considerable overtreatment recommendation rate, we also observe a striking heterogeneity in the treatment recommendations.
TheRoad 4y ago
Talking about dental care: Almost a year ago, I had a wisdom tooth removed. I still feel some pain. So I went back to my oral surgeon. He did a 3D-Scan and said the bone has not regenerated. So there is a hole, where the tooth was. His suggestion is to: A) Do the operation again. And remove all the tissue that is where the tooth was. B) Fill the hole with a blood clot generated from some of my own blood, taken from my arm. C) Hope the bone will then regenerate. I have put a lot of time trying to find something about the situation on the web. But to no avail. Any ideas how to find something about the situation that a bone does not regenerate after a wisdom tooth removal? The surgeon said it happens to one or two of his patients per year. So worldwide, there should be tens of thousands of people having this issue every year. Yet I cannot find anything. Is my Google-Fu lacking?
- ibejoeb 4y ago
  You might investigate orthopedic stem cell therapy as a less invasive treatment for bone repair. You'll need a proper assessment, of course, but if you're a good candidate, it is essentially injections rather than surgery. Or, it might be minimally invasive surgery in order to prepare the area, which is still far better than getting full-blown maxillofacial surgery again. Also, a year is not all that long. Many surgeons advise waiting 18 months in these kind of bone tissue generation/delayed union situations.
  - TheRoad 4y ago
    Thanks for the infos! Do you have any links to this type of information? Google seems to not find anything for orthopedic stem cell therapy in regards to wisdom teeth. I also cannot find anything regarding the 18 months you mention in regards to bone regeneration after wisdom tooth extraction. Where did you get this information?
- hanspeterrr 4y ago
  [dead]
wefarrell 4y ago
I wonder if capitation and managed dental care would help mitigate over utilization of dental services. It seems to be working in the medical field.
thret 4y ago
At one time I was living in a very nice apartment, and the building next door had a private dentist. Absurdly expensive, but convenient. So I got a toothache and booked an appointment for the next morning, but the next day my toothache was gone. After taking the x-ray and examining it with me the dentist asked me which side the toothache was on. For some reason I said the left. He pointed at the left side of the x-ray and explained why I needed a filling. Then I remembered it was the right, and corrected myself - he looked at the x-ray again and started to explain why I needed a filling on the right side. I left in disgust and haven't had a toothache in the ten years since.
orzig 4y ago
About to hit the 5 year anniversary of being told I need an urgent root canal. Fortunately, buying a softer toothbrush fixed the issue - I would have paid them $1,000 to get that recommendation a few weeks earlier!
agumonkey 4y ago
It's really a shame on many axis: - what about the hippocratic oath ? - how come there are so many errors ? where are quality checks in this field ? - how come this is not regulated business wise ? dental care costs a lot, it puts people in dire situations are we waiting from a uber teeth to force these people to work properly ?
- pas 4y ago
  The current dentist I went to in the recent years is a self-professed believer in preventative dental care. Meaning she will fill anything that moves, or looks like a cavity, or might become one later. And she is a very caring person. I fully believe she does this to minimize harm. Similarly she recommended tooth cleaning, to get the plaque off, because under it bad things can happen. Sure, let's do it. And during these visits I formed the impression that she's friendly, eager, and frustratingly incompetent. (When I had a problem with the topical anesthetic she had no solution, just to look sad. When drilling she seemed unsure of how deep to go, etc.) All in all, I'm not going to go back to her, because I can scrape off shit from my teeth with a steel tool if I really want that, and the brown spots that might become cavities are 10-20 year old anyway, so maybe I'll just wait. So the errors are because there are just no real trivial standards. There's no simple and easy way to say which dentist is bad, because the whole dentistry is meh - because medicine as a whole is very meh, and that has many causes, but some of those are because biology is very complex, diagnostics is hard, service providing at scale is its own hell, there's politics on top, etc.
  - lupire 4y ago
    Huh? Cavities aren't "brown spots".
    - agumonkey 4y ago
      I think he means that these are signs of future cavities.
    - pas 4y ago
      Yes, but she said that those are the spots where it can develop without getting noticed. (On molars, which already have depressions, "canyons".)
utdiscant 4y ago
I find the re-naming of this post quite weird. The original title "A patient without cavities visits 180 dentists" was informative, and made me click. The paper is about that exact thing, and I enjoyed it. On the other hand, I have no idea what "Health Services as Credence Goods: a Field Experiment" means. With this title, I would definitely not have clicked the link. I know it is the title of the paper, but given that HN is not an academic journal, it should be allowed to give more informative titles to posts than the original content.
- pas 4y ago
  it was a bit clickbaity though :) Unfortunately scientific paper titles are extremely uninformative, so HN's policy on using the original title (unless it's clickbait) is counter-productive. :|
coffeeblack 4y ago
This is something that should be done regularly by health insurers. And maybe even by some sort of government agency that supervises the health industry.
ozim 4y ago
I would say 28% is not that bad. Of course ideally it should be 0%. But thinking about normal distribution of skills I can imagine 20 to 30% dentists not being that competent should be well normal.
- lupire 4y ago
  That's not how statistics works. You and I are in the 80% of people who are incompetent at dentistry, and that's fine. Every practicing dentist passed the filter of school and licensing. Incompetent practicing dentists are criminal frauds.
  - ozim 4y ago
    I assume that if you take only dentists that passed the bar - there are those who just slipped over and ones that passed with ease. So they don't have to be "fully incompetent" just less competent than most dentists.
omginternets 4y ago
Question: what is a credence good? Also: > Dentists with shorter waiting times are more likely to propose unnecessary treatment. I’m admittedly focusing on the narrow end, here, but this is intriguing. How large is the effect? I couldn’t access the full paper. Intuitively, this would suggest that certain dentists are optimizing for low-effort, high-margin procedures. If that’s the case, I’d expect the distribution of wait times to be multimodal, which might offer a path to detecting such practices cheaply.
encryptluks2 4y ago
One thing they should check is of the dentists that were committing fraud had anything in particular in common, like religion or heritage? Some religions teach that other people are subhuman and made to serve them in particular and see no issue commiting fraud against certain groups of people.
beej71 4y ago
In the US, anyway, you should always get a second opinion.
rentonl 4y ago
I've been following a method where every year I see a different dentist and I only get something fixed if two subsequent dentists diagnose the same issue.

231 points by once_inc 4y ago

Sci-hub link: https://sci-hub.se/10.2139/ssrn.3036573 https://sci-hub.se/10.2139/ssrn.3036573

Fifty of the dentists find at least one 'cavity', some of them up to six. 'Cavities' were found in up to 13 different teeth. Socio-economic status of the patient is relevant in how many times 'cavities' are found.

midasuni 4y ago
Specifically poor people have more cavities “found” It’s unclear from the abstract what country this applies to.
- doetoe 4y ago
  This study was conducted in Switzerland
- deleted 4y ago
  [deleted]
- SanjayMehta 4y ago
  Switzerland.
encryptluks2 4y ago
Punishment should be defacto pull as many teeth from the dentist that they wrongfully pulled from their patients, and do it without anesthesia so that they have some additional remorse.
- aeries 4y ago
  Please leave this knee-jerk vitriol off of Hacker News. We come here from other sites to avoid this stuff, not to see more of it.
- cortesoft 4y ago
  Some of them probably genuinely made a mistake.
  - encryptluks2 4y ago
    How do you extract a tooth by mistake?
    - hutzlibu 4y ago
      By making a wrong diagnosis, that it is needed.
      - encryptluks2 4y ago
        You mean by making a fraudulent diagnosis that it is needed.
  - mandmandam 4y ago
    Some of them, sure. But 50 out of 180? That's systemic fraud.
    - cortesoft 4y ago
      Right, but my point is that if you go to each one and rip out their teeth without anesthesia, you are going to be torturing at least a few innocent people. Even if only 5% of the 180 aren’t fraudsters, I’d feel bad about torturing 9 innocent people.
      - encryptluks2 4y ago
        Weird how the US doesn't feel bad about killing a few innocent children and label them as casualties of war.
magicalhippo 4y ago
My previous dentist would show me the x-rays and explain. He'd point out that a cavity was starting to develop, and what measures I should take to avoid it developing further. After some years, if it got worse, he'd show me the old x-rays and the new new so I could see the change, and he'd suggest I'd get it fixed now. Sadly for me he retired recently.
- dbrgn 4y ago
  My dentist does the same. When I first went there (after not having gone do the dentist for 3-4 years, because I never had any issues with cavities) he told me that there are 4 cavities I need to get fixed. I was very sceptical at first, but agreed to get them done. He fixed all 4 of them in 20 minutes. When he drilled open one of the teeth, he showed me how it looked with one of these small cameras that you could see live on the screen. It was absolutely obvious that there was a considerable cavity. Explaining to your customers what needs to be done, proving it with pictures and/or x-rays, and explaining the different options generates a lot of trust.
  - PeterBarrett 4y ago
    Same with my dentist that I started going to 2 years ago. I live in a differtnt country now and literally book appointments 3 months in advance with them just so I don't have a bad experience with someone else.
petodo 4y ago
Also 60% of dentists failed to display prices according regulation. Median price of overtreatment was 450 USD. https://sci-hub.se/10.2139/ssrn.3036573 https://sci-hub.se/10.2139/ssrn.3036573
- ekianjo 4y ago
  Dentists are charlatans hiding behind a blouse
sizzle 4y ago
Also the blatant, don’t worry it’s free insurance covers it “persuasions” as if my only concern is cost rather than necessity that I’ve learned is a shady dentist go-to tactic to open their customer’s wallets via insurance. Half the time I find out the cavity is not in the x-ray but “visual inspection” or “preventative” and the car salesmen tactics and fear of losing teeth are layed on thick while you are at your most vulnerable moment in the chair having a bright light blast your vision. I hate it all, give me the x-rays and I’ll get a second opinion until trust is earned. The mom and pop local family dentists are the best, not the dentists renting chairs in clinics that rotate every time you come in. If they make you sign a disclaimer about exceeding insurance coverage RUN!!

encryptluks2 4y ago

God I hope those dentist lost their medical license forever. I am very untrusting of dentist in general due to issues like this. I remember my brother as a preteen had 6 teeth removed and my mom said she didn't think he needed it but she was trust the doctor always type. Later the doctor was found to be pulling teeth of kids on state insurance that didn't even have cavities.

bowsamic 4y ago
> God I hope those dentist lost their medical license forever. I don't think they are going to do anything specific to those dentists based on this study
- encryptluks2 4y ago
  Maybe the news and media need to get involved here. If they don't face any repercussions then I'll remember to cite that as to why people could be distrustful of doctors when it comes to vaccines and other things.
  - bowsamic 4y ago
    You should always be distrustful of doctors to some degree in my opinion. They are too often seen as unquestionable in our society
  - Spare_account 4y ago
    Every industry has cowboys. This study should just reinforce the notion that we should get a second opinion (or third, if the first two differ) on ANY major work being carried out by ANY profession. To extend that line of thought, and steer it towards the second half of your comment: if you visit two (or three) doctors to seek advice about getting vaccinated, I think we can be sure what the consensus would be.
    - encryptluks2 4y ago
      I didn't say that people shouldn't get vaccinated, just that it is understandable why people would have a general distrust towards doctors because of things like this. Maybe we should try not to ostracize people for having legitimate distrust.

GiorgioG 4y ago

My wife never had a cavity in her life. We moved to a new state/city and the dentist she tried “found” 4 cavities. We went to another dentist, found none. To this day nearly 10 years later the entire family goes to the 2nd dentist and couldn’t be happier. Long after leaving the first practice their office would occasionally send out promo emails offering sale prices for services. Greedy unethical people exist in all professions. Edit: Thinking about it further (it has been almost 10 years) I had also gone to the first disreputable dentist around the same time as my wife's initial visit because I cracked a tooth (furthest back lower mollar on one side). They extracted it and wanted to put in a dental implant to the tune of several thousand dollars. Nothing particularly nefarious so far, except that they kept pressuring me about the implant because without it, the corresponding upper tooth would start coming down due to not having a tooth to match up with below it. I didn't do it, partly for the money and partly because I'd heard implants were painful. It doesn't affect my smile or my ability to chew/eat. 10 years later the upper molar hasn't budged one iota.

cjmcqueen 4y ago
Had a very similar experience in San Jose, CA. I've never had a cavity and one dentist made a rush look at my teeth, provided no evidence of a cavity and told me to book time for a filling. I never went back. Five years later I've seen other dentists every 6 months and none of them have suggested I have a cavity.
nomilk 4y ago
> the dentist she tried “found” 4 cavities. We went to another dentist, found none. To this day nearly 10 years later the entire family goes to the 2nd dentist and couldn’t be happier. A generalisable experiment anyone can do to find an excellent dentist. I intend to try this. Thanks for sharing.

vasergen 4y ago

Not related to this topic, but I am curious how the situation looks like in IT industry. Say a company without any "real problems" ask for "advice" 180 IT agencies. My guess that situation will be much worse.

deleted 4y ago
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crummy 4y ago
We asked 180 developers if we should rewrite our tech stack in Rust.
- sgt 4y ago
  We asked 180 developers if the existing solution should be rewritten in Rust from PHP, despite working like a charm.
draugadrotten 4y ago
Now do lawyers.
dainiusse 4y ago
Oh yes! For bureaucratic reasons we were forced to get external consultancy to evaluate code... Everything was wrong according to them from architecture to tech choices made... yet, the project was most successful within the company... these choices were made due to available talent and starting it with what people know....

runemadsen 4y ago

It's expensive to be poor.

noduerme 4y ago

Bullet point 1: at 35 years old, I hadn't been to a dentist in 12 years; walked into a clinic in Spain for a cleaning, and the lady gasped that I had no cavities and no missing teeth. I only brush once a day, without toothpaste. Bullet point 2: No one on my father's side has ever had a cavity that I know of. We do all get kidney stones. I think it's related. Bullet point 3: I went for a routine cleaning after I moved to Portland, OR (age 38), and was told I had two cavities. I stupidly believed the man. He drilled and filled them. It was the night before Christmas Eve, when they were having their holiday party. I think he was drunk. His nurse was definitely drunk. All fun, and such, until both teeth split in half around the fillings, exposing the nerve (the first on New Years Eve, 9:30 at night; try having emergency dental work done then). I thought about suing him. Who knows; I've never had a cavity since then, and it was 6 years ago, but I'm missing two teeth. And yes, I've decided against firebombing his office. Consciously. Every year on new years.

dennis_jeeves1 4y ago
>And yes, I've decided against firebombing his office. Wrong decision.
deleted 4y ago
[deleted]
jaimehrubiks 4y ago
You should have sued
- noduerme 4y ago
  I read up on it, but it's pretty difficult to pin a dentist for malpractice. Especially if you don't have the teeth to show it.
fastball 4y ago
If you don't brush, do you get more plaque build up? From what I've understood, people generally can have mouths that are more basic/acidic depending. If basic, plaque tends to be a bigger issue but few if any issues with cavities is common. The converse for mouths that trend acidic.

z7 4y ago

I used to go to the dentist every 4-6 months and there was almost always something that seemed to require a drilling procedure. Then after graduation my life became chaotic and I stopped going and frankly haven't been to the dentist in seven years. So far I've felt no toothache or anything like it. I know I'm probably walking around with a host of dental problems. Still seems interesting that I've made it this far.

dagw 4y ago
after graduation my life became chaotic and I stopped going I skipped the dentist for over a decade for much the same reason. I had no problems at all, right up until I got lots of problems at once.
gibolt 4y ago
So many other problems in life are tied to tooth issues, and most appear hard later in life. A dentist visit without insurance is usually under $100, and is a great investment in your future happiness and health.
encryptluks2 4y ago
Some people can not brush their teeth for extended periods of time and not get cavities. It really depends on your diet, mouth flora, etc. Some studies suggest xylitol and other artificial sweeteners may have a positive impact on tooth decay because they cannot be used as food for bacteria and some substantially change the bacteria that live in your mouth over time to those that are not harmful to the teeth.
floucky 4y ago
It could also be linked to a change in your diet. I have the same kind of experience, but I eat less sugar and this helped a lot in my case
deleted 4y ago
[deleted]
jwmoz 4y ago
Exactly what happened to me (UK) last year! Hadn't been to the dentist for something like 10 years. My partner (TW) takes me to her family dentist and I was expecting loads of problems, but he only did one small touch up filling and cleaning. Just one procedure in 10 years!

utdiscant 4y ago

Incredible research! I have had this intuitive feeling for a long time, that the more I go to the dentist, the more issues appear. And when I recently shopped around for different dentists, they all had completely different recommendations for the same situation.

gadders 4y ago

I trust dentists about as much as I trust car mechanics. I'm sure I've had stuff done that was marginal at best and has now caused further issues.

baobabKoodaa 4y ago

Is "cavity" one of those things that develop gradually and it's impossible to draw the line when exactly you have one and when not? Is it possible that some of these dentists just have differing opinions on where the line should be drawn?

loandbehold 4y ago
Absolutely. Everyone has "microcavities". Those may be revered by remineralization. Those gradually grow into full blow cavities over time if not remineralized.
m000 4y ago
Yes, this is exactly the case. The reason for this is that fillings can't be made super-small, and you always need to grind some healthy tooth tissue for the filling to bind. So, a dentist needs to decide if the decay has gone far enough to make it worth the loss of healthy tooth issue for the filling. Also, dentist treatment recommendations always include a part of expectations management. E.g. if your dentist believes that you wouldn't want to pay extra for a crown, it is more likely they will outright recommend an oversized filling instead. So, it is important to be explicit to your doctor that you want to be listed all the range of treatment options, so you can discuss their tradeoffs and choose what feels right for you.
deleted 4y ago
[deleted]

boruto 4y ago

One of the stupidest decisions in life I made after moving to first world country was using my privilege of dental insurance. I did go to a dentist in India(my home) Dentist said nothing wrong just floss. Then I had moved to berlin and hey I have insurance now for dental check ups. The first visit resulted in 4 fillings. One filling was bad resulted in root canal. That root canal went bad and the other molar needed root canal. I took my x rays from first and second dentist to dentist in India, where he told I did not needed those fillings. At this point I have zero trust in any doctor in Berlin, I get my check ups done in India. I also did not save any money from my adventures in Berlin, Because every visit resulted in doctor offering a better choice which is not free under insurance and this ended up way costlier than the whole process in my home country.

Cthulhu_ 4y ago
The dental insurance in my country (NL) is limited as well; for one, it's a surcharge on your health insurance (€15 a month or thereabouts), you have to have had it for a year before they start covering things, and then they only cover up to a few hundred € per year depending on how much you pay them, while dental work quickly adds up. I mean I think mine covers €250 a year and the cost is €150 per year, so only if I have recurring dental expenses like that is it financially beneficial for me to have the dental coverage.
- m000 4y ago
  Yes, dental coverage in NL kind of sucks. The way it is structured now, it often makes more sense to make a "dental savings" account rather than paying the insurance surcharge. There is action to change that though. Doctors of the World currently run a petition for including dental insurance in the basic insurance package (basispakket) [1]. I don't see this happening soon, but it's a start for a future change. [1] https://doktersvandewereld.org/campagnes/mondzorg-in-het-basispakket/ https://doktersvandewereld.org/campagnes/mondzorg-in-het-bas...
bombolo 4y ago
There was a scandal in italy a while ago because in a certain hospital they were doing an abnormal number of c-sections, because it counts as surgery and they get paid more from the state.

wtk 4y ago

When I lived in the UK I went to a dentist who recommended to treat 5 or 6 cavities. I only wanted a check-up as I planned to fix anything in Poland which I regularly visited. There I heard that only 2 were actually something worth taking care of. I thought maybe different countries have different standards for what needs attention.

Cthulhu_ 4y ago

I'm really not surprised. My recent dentists have all been really good, but growing up we had one that would want a drilling procedure every time. I'm glad we switched when we did.

weird-eye-issue 4y ago

When I was in the US my dentist said I needed to go every 3 months for some special cleaning that cost more $$ and that I have gum disease. Now in Thailand I go every 6-12 months for a normal cleaning and they say everything looks just fine but that maybe I brush a little hard

jwmoz 4y ago

This is depressing to see and confirms what I thought. We recently went to see a family friend dentist and they just did one small touch-up and a clean-I hadn't been to the dentist in a few years and was expecting a load of issues.

DoingIsLearning 4y ago

I was curious how the High/low Socio-economic status would have played out in Methodology: > To indicate a higher socio-economic status, the test patient wore a high quality suit and high-end accessories such as an expensive watch, a car key and a new and expensive mobile phone. The test patient specified his occupation as a translator at a bank when asked to fill out the patient form. > In the lower socio-economic status role, the test patient wore cheap unbranded clothes, an old backpack and had no accessories. The test patient declared to be a student of translation doing an internship. > Note importantly that in both socio-economic status-roles the patient signals to have studied. Hence, the level of education was kept constant across the two conditions.

deleted 4y ago

[deleted]

revanx_ 4y ago

I used to have a lot of cavities due to poor oral hygiene, after I had a complications with my wisdom tooth, I really decided to step up my game and take care of my teeth. Brush 3 times per day, 15 minutes after every meal. Floss two times per day. Reduce soda intake. Reduce sugar intake. Cavity free for 4 years now. I switched dentist and after several visists she accused me of seeing another dentist because I didn't have any new cavities. Anyway ...

robga 4y ago

Clearly the work of rabid anti-dentites.

recuter 4y ago

If you ever have a long layover in Bangkok be aware that there are plenty of very professional reputable places that offer a proper tooth cleaning for ~$50. They don't view you as a repeat customer, ask for an opinion on your way out. I'm quite sure they never bullshitted me once and I say this as a notorious anti-dentine. Several other places I can recommend trying this: Lima (Peru), Buenos Aires, Israel. I have no idea why that is exactly but I assure you that you would not be compromising on the quality of the care. Quite the opposite.

MrJagil 4y ago
Why do you know this?
- recuter 4y ago
  I travel a lot..
- roykent 4y ago
  I read a while back that Thailand is huge for dental tourism. There was also some town in Mexico that had a ton of high quality dentists. So people that need a ton of expensive work would sometimes fly to these places and cost of treatment + flights and housing would be significantly less than a place like the USA where it's normalized to drain your savings or go into debt for care.

willyt 4y ago

I’m in the UK and lucky to be registered with an NHS dentist (places are scarce) so they have no incentive to treat problems I don’t have. I have to pay a token amount for dental checks and hygienist visits. Something like £15 a time.

Robadob 4y ago
There are still inconsistencies between NHS dentists, visual assessment of cavities and what justifies treatment is inherently subjective. My first dentist retired after I'd had no fillings to date, their replacement on first appointment said I required two fillings and it continued in a similar manner. Later on I had moved city, but was still travelling back for dental appointments. The second dentist said I needed another filling doing, but I ended up moving to a new NHS dentist in my new city. They disagreed about the filling, saying you can't fill teeth if it would go below the gum line. Pulled the tooth instead. Even with NHS appointments, you can go 'private' a-la-carte if you can be convinced to have white fillings or similar extras and pay slightly more.
- stuaxo 4y ago
  White fillings should be available on the NHS (saying this as someone that can afford the private option).

bearmode 4y ago

This right here is why all healthcare, including dentistry and optometry, should be nationalised.

Arch-TK 4y ago
I'm pretty sure the way NHS dental care works in the UK is basically broken and I'm not sure I trust any dental practice which relies solely on NHS income. Let me tell you why: This can be a bit fuzzy and I may make a mistake here or there but I think the gist is still very correct. A few years ago I used to work for a company which wrote dental practice management software, so I got a good idea of how NHS dentistry works. The way you get paid doing NHS dental care is you sign a contract with the dental board on which you tell them the estimated number of Units of Dental Activity (UDAs) which you expect to carry out during the year. You get penalized upon contract renewal if you miss this target by too much. All work done on an NHS patient is broken up into Courses of Treatment (COTs) and each COT has a band given to it. The band is based on the treatments which were performed as part of a COT[1], most importantly, if you perform two fillings instead of one, the band does not go up. Each band gives a different number of UDAs[2]. You can't start a COT too early after a previous one (2 month rule)[3] unless it's a higher band. Due to these factors, two things appear to happen: 1. Very obvious, NHS dental practices will refuse new patients even if they have the capacity to accept them because they expect they will already match their UDA count for the year. I don't think any of them will explicitly tell you this reason but it happens all the time in the UK, the key word is they will tell you to call around April (which is when contract renewals happen). 2. Less than trustworthy dentists will, upon spotting e.g. a cavity starting to develop and a bigger cavity in another place, fill the bigger cavity and then address the smaller one at your 6 months checkup to avoid stacking the COTs and losing out on additional band 2 UDAs. Very much not saying that all nationalised dental health care is shit, but in the UK I have generally had better experience with dental practices which do mixed care than dental practices which solely focus on NHS dental care. Don't be like the UK. [1]: https://www.nhs.uk/nhs-services/dentists/dental-costs/what-is-included-in-each-nhs-dental-band-charge/ https://www.nhs.uk/nhs-services/dentists/dental-costs/what-i... [2]: https://faq.nhsbsa.nhs.uk/knowledgebase/article/KA-01976/en-us https://faq.nhsbsa.nhs.uk/knowledgebase/article/KA-01976/en-... [3]: https://faq.nhsbsa.nhs.uk/knowledgebase/article/KA-01998/en-us https://faq.nhsbsa.nhs.uk/knowledgebase/article/KA-01998/en-...

joaodlf 4y ago

Oh boy. Years ago I visited my home country with my partner. She used to prefer going to dentist there, old habits I guess. On this particular trip I agreed to a check up as well - It had been a while since I had my teeth checked, why not? Really fancy dentists. Big offices, flashy machines, everything looked pristine. X-rays are taken, teeth are checked. Result: You need root canal! You should have it done soon, it's going to get much worse and hurt a lot more! We can do book you in ASAP. Hollllld on. I was on holiday, I'm not about to have a root canal procedure done and ruin my time off. I'll take the xrays and check back with a dentist back home. I pay dearly for the check and xrays and proceed to not enjoy my time off as much as I could have - I was worried. Fly back home, book a session with my usual dentist. "I can't see anything wrong with this tooth. But let me do an xray as well... Nope. Can't see anything wrong." It has been around 5 years now. That dentist would have performed root canal on me for no apparent reason... One really interesting conversation I had with my usual dentist: Me: So really, nothing wrong? Why would they say otherwise? Dentist: Nothing wrong. I'm not sure why they told you otherwise. Me: That's just... Dentist: Tell you what, they say it's this tooth points, right? Do any other of your teeth look different in the xray? Check the root as well, pay close attention. Me: I don't see any difference, but I'm not a dentist... Dentist: Well, I am a dentist, but I also see no difference.

tluyben2 4y ago

My first memory of going to a dentist was the school dentist (in the Netherlands); they said I had a cavity. I was small so I started shouting (when a needle came out) that I wanted my mother; she came and told them to keep their hands off of me. Our family dentist (an uncle) said I have no cavities and don't go to other dentists if I value my teeth. 43 years later I have 0 cavities while dentists in several countries and locations told me I have. I always get at least 2 opinions since that first experience. Luckily I had a total of 3 dentists in my family but they are retired now. Think a good one (multiple people said it) is getting a cleaning; they will see if there are cavities but have no financial incentive to make them up and start drilling.

esskay 4y ago

This happens in the UK as NHS dentists get paid based on work done. My old one before I moved was great, regular checkups and no issues. Moved house and my new dentist 'found' 4 caveties that all needed fixing, one of which was 'critial'. Me being stupid agreed to have the main one done, which they botched and it turned into a root canal. Swapped dentists after that and went private and magically I have no cavities and they couldn't understand why I'd had a root canal. Fuck dentists.

scarygliders 4y ago
My local NHS dentist told me four of my bottom front row teeth were "dead" and needed lots of treatment involving needles and drills and such, otherwise they'd start rotting away and get painful and so on... Oh and that I need a root canal in one molar... Which I thought was strange at the time because I could still feel sensation in them, feel blood supply pumping into them, felt no pain. At the time though I had great trust in dentists so I agreed to the treatment, and an appointment was set for the procedure. On the day I was sat in the dentist chair and whilst they were setting up, I had this instinctual feeling that this whole thing was "wrong!" and before they could even administer the first numbing jab I called the whole thing off. A few years later and I've had no problems with those teeth, or any others for that matter.

ChrisMarshallNY 4y ago

But did they see this guy? https://m.youtube.com/watch?v=YoWom0CCRKM https://m.youtube.com/watch?v=YoWom0CCRKM

sammalloy 4y ago

In the US, there were several recent scandals of dentists purposefully cracking molars to get business.

throw03172019 4y ago

Dentists have a trick where they show your old fillings on the intra-oral camera and say the “yellowing” means it’s gone bad and recommend refilling it. If your dentist pulls this trick, leave immediately.

stormdennis 4y ago

Firstly I'd say that although there are 180 dental practices, there is only one patient, I think a study would need a lot more than that. I cannot read the article but at how many practices did this person have x-rays taken? I doubt it was many if any. How did they get out of that, by bringing their own x-rays with them and saying that they were a recent set from their last dentist who'd retired? If they didn't have x-rays taken and didn't bring any with them then the dentist would be diagnosing blind to a large extent. In any case diagnosing cavities is not a binary true/false affair and x-rays can mislead also. There is a lot of human judgement involved. Some cavities never need filling, others can increase massively in size over a short period. Two questions that a dentist will typically ask a new patient are, how long since your last attendence at dentist and are you a regular attender or do you just go when you have problems? If a new patient is a regular attender, a dentist will be happier to keep a cavity they are unsure of, under observation. Sometimes they may schedule shorter recall periods for review until such time as they are comfortable that the patient does not have active decay. Generally a cavity does not need to be filled unless it extends into dentine. Determing if this is the case is not always straightforward. Generally a filling does not need to be replaced unless it is leaky. Again this is not always easy to determine and like programmers, dentists tend to be more critical of other dentists' output than their own. Recent experience also colours judgement. If a dentist has had a run of cavities that turned out to be deeper than expected then they are more likely to diagnose a cavity when unsure and vice versa. Different sub-populations in the aggregate, depending on wealth, diet, dental hygiene and typical frequency of attendence have different dental decay characteristics which can colour a dentist's judgement. There are crooked and incompetent dentists just like there are in every job. Dentists in general get a bad rap. One reason I've heard is the fear of dental treatment breeds an instinctive, subconscious dislike and mistrust of dentists as persons. Certainly doctors, despite being equally good at extracting money from their patients don't suffer from the same degree of antipathy and suspicion.

shellfishgene 4y ago
In the paper is says: "Each diagnosis was based on the same x-ray and the same oral condition of the test patient."

mandmandam 4y ago

If anyone is wondering why poor people were targeted more, I'd hazard an educated guess on some of the "complex" factors: 1. The poor are less likely to seek a second opinion. 2. And, less likely to be able to sue. The near complete lack of accountability might even be the main reason. 3. Some people associate how much money you make with how 'worthy' a person you are. There are likely quite a few dentists who quietly 'justify' unnecessary treatment based on that line. People don't seem surprised that 50 out of 180 dentists would fuck up your teeth for money - because we know what dentists are like, and many of us share similar experience. I certainly do. I have some kind of nerve damage from a shitty dentist, was recommended unnecessary fillings and root canals, etc. 50 out of 180 isn't a normal error rate - it's the mark of a broken industry, crying out for overhaul and accountability. Where are the "good" dentists speaking out on this? In my experience even the good ones make excuses for the shysters.

lupire 4y ago
Related, there are a few CVS pharmacists desperately trying to convince the vast majority of CVS Pharmacy pharmacists to protest corporate to stop selling homeopathic junk.

alkyon 4y ago

The best option is to opt for a prepaid package with all things included. Then it's not in their best interest in seeking cavities were there are none. Still they couldn't ignore any real one one if it needs attention - leaving it as it is would lead to much more expenses in the future, so they would nip it in the bud.

moonchild 4y ago

> Dentists with shorter waiting times are more likely to propose unnecessary treatment. Does this mean that dentists who are better at dentistry (and as a result have more patients) are less likely to propose unnecessary treatment because they know better? Does it mean that dentists who have fewer patients (and are therefore more desperate for money) are more likely to propose expensive treatment?

lupire 4y ago
Can't say for sure without experimentation, but it's seems naturalll for dentists to respond to incentives. If you are sitting on a money printer, bored, while money is burning in your pocket...

Helmut10001 4y ago

Everyone talks about the dentist topic. To me, what this points to is much bigger: Expert knowledge is greatly overrated and researcher-subject effects (biases) are greatly underrated. Heterogeneity of results in many fields that deal with humans suggests that triangulation (a concept known in the social sciences - e.g. to use many data source, many approaches and many opinions) is perhaps the only solution to offset human subjectivity.

seer 4y ago
I’ve found rating systems a big help. What I usually do for any doctor is visit a famous online forum in bulgaria that’s filled with people’s opinions regarding doctors. Started as just a place where young mothers hang out and talk about various topics, and is practically an institution here already. Since it’s not affiliated with any business / media it has remained surprisingly honest place and most opinions I’ve read ended up being spot on - both positive and negative. Its pretty great for finding out doctor specialists.
pas 4y ago
Is this true for "all fields"? Is there some pattern? Eg. fields that deal with hard data (let's say nephrology) is "better" than fields that stare at blurry Xrays? Or fields where the consequences are relatively light are worse than, let's say fields that revolve around brain surgery? Average years of experience required to practice in that field? Monetary incentives?
- Helmut10001 4y ago
  I would say that anything beyond pure math is affected to a large degree by subjectivity. I have worked across three research fields (architecture, geography, informatics) and all researchers I met from these fields (apart from 1-2 exceptions) are hugely affected by their subjective intra-group beliefs. Not only that, they extrapolate their world view beyond their respective fields, which I find wrong and concerning.
  - pas 4y ago

mickelsen 4y ago

But I don't understand, don't they do imaging work during diagnosis? Here in Chile, this is usually free with the first diagnosis in private clinics, as a way of getting your business. Plus it's pretty popular to license this software called Dentalink here, which has a patient log complete with graphics on which part of what tooth was treated or if it was just an estimate given and it's pending treatment. One caveat is that the clinics that do free diagnosis + x-rays don't hand them to you as part of the deal, but you can ask to get them e-mailed. Smaller practices without their own machines just give you an order to an imaging center, those are always yours to keep. I've had pretty consistent results (and estimates) between the big retail practices for standard dental work like cavities. Some tried to upsell on the cleaning and whitening, but it's not a big difference.

once_inc 4y ago
They are basically using the credentials and reputation that the health industry has afforded medical specialists to claim health issues that aren't there. People of lower socio-economic status rarely have the wherewith-all to ask for evidence or second opinions. They just have the treatment and have it covered by health insurance (if European or somehow well insured).

danielsokil 4y ago

Here is the full text and pdf https://www.researchgate.net/publication/320070183_Health_Services_as_Credence_Goods_A_Field_Experiment https://www.researchgate.net/publication/320070183_Health_Se...

colonwqbang 4y ago

Very readable/accessible article. This finding caught my eye: > Regarding the treatment—the test patient has a superficial interproximal caries lesion that should not be treated by an invasive treatment such as a filling—the suggested number of fillings at dentist ranges from one to six. Moreover, we observe that 13 different teeth to be treated with a filling appear across all cost estimates. Thus, besides our finding of a considerable overtreatment recommendation rate, we also observe a striking heterogeneity in the treatment recommendations.

TheRoad 4y ago

Talking about dental care: Almost a year ago, I had a wisdom tooth removed. I still feel some pain. So I went back to my oral surgeon. He did a 3D-Scan and said the bone has not regenerated. So there is a hole, where the tooth was. His suggestion is to: A) Do the operation again. And remove all the tissue that is where the tooth was. B) Fill the hole with a blood clot generated from some of my own blood, taken from my arm. C) Hope the bone will then regenerate. I have put a lot of time trying to find something about the situation on the web. But to no avail. Any ideas how to find something about the situation that a bone does not regenerate after a wisdom tooth removal? The surgeon said it happens to one or two of his patients per year. So worldwide, there should be tens of thousands of people having this issue every year. Yet I cannot find anything. Is my Google-Fu lacking?

ibejoeb 4y ago
You might investigate orthopedic stem cell therapy as a less invasive treatment for bone repair. You'll need a proper assessment, of course, but if you're a good candidate, it is essentially injections rather than surgery. Or, it might be minimally invasive surgery in order to prepare the area, which is still far better than getting full-blown maxillofacial surgery again. Also, a year is not all that long. Many surgeons advise waiting 18 months in these kind of bone tissue generation/delayed union situations.
- TheRoad 4y ago
  Thanks for the infos! Do you have any links to this type of information? Google seems to not find anything for orthopedic stem cell therapy in regards to wisdom teeth. I also cannot find anything regarding the 18 months you mention in regards to bone regeneration after wisdom tooth extraction. Where did you get this information?
hanspeterrr 4y ago
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wefarrell 4y ago

I wonder if capitation and managed dental care would help mitigate over utilization of dental services. It seems to be working in the medical field.

thret 4y ago

At one time I was living in a very nice apartment, and the building next door had a private dentist. Absurdly expensive, but convenient. So I got a toothache and booked an appointment for the next morning, but the next day my toothache was gone. After taking the x-ray and examining it with me the dentist asked me which side the toothache was on. For some reason I said the left. He pointed at the left side of the x-ray and explained why I needed a filling. Then I remembered it was the right, and corrected myself - he looked at the x-ray again and started to explain why I needed a filling on the right side. I left in disgust and haven't had a toothache in the ten years since.

orzig 4y ago

About to hit the 5 year anniversary of being told I need an urgent root canal. Fortunately, buying a softer toothbrush fixed the issue - I would have paid them $1,000 to get that recommendation a few weeks earlier!

agumonkey 4y ago

It's really a shame on many axis: - what about the hippocratic oath ? - how come there are so many errors ? where are quality checks in this field ? - how come this is not regulated business wise ? dental care costs a lot, it puts people in dire situations are we waiting from a uber teeth to force these people to work properly ?

pas 4y ago
The current dentist I went to in the recent years is a self-professed believer in preventative dental care. Meaning she will fill anything that moves, or looks like a cavity, or might become one later. And she is a very caring person. I fully believe she does this to minimize harm. Similarly she recommended tooth cleaning, to get the plaque off, because under it bad things can happen. Sure, let's do it. And during these visits I formed the impression that she's friendly, eager, and frustratingly incompetent. (When I had a problem with the topical anesthetic she had no solution, just to look sad. When drilling she seemed unsure of how deep to go, etc.) All in all, I'm not going to go back to her, because I can scrape off shit from my teeth with a steel tool if I really want that, and the brown spots that might become cavities are 10-20 year old anyway, so maybe I'll just wait. So the errors are because there are just no real trivial standards. There's no simple and easy way to say which dentist is bad, because the whole dentistry is meh - because medicine as a whole is very meh, and that has many causes, but some of those are because biology is very complex, diagnostics is hard, service providing at scale is its own hell, there's politics on top, etc.
- lupire 4y ago
  Huh? Cavities aren't "brown spots".
  - agumonkey 4y ago
    I think he means that these are signs of future cavities.
  - pas 4y ago
    Yes, but she said that those are the spots where it can develop without getting noticed. (On molars, which already have depressions, "canyons".)

utdiscant 4y ago

I find the re-naming of this post quite weird. The original title "A patient without cavities visits 180 dentists" was informative, and made me click. The paper is about that exact thing, and I enjoyed it. On the other hand, I have no idea what "Health Services as Credence Goods: a Field Experiment" means. With this title, I would definitely not have clicked the link. I know it is the title of the paper, but given that HN is not an academic journal, it should be allowed to give more informative titles to posts than the original content.

pas 4y ago
it was a bit clickbaity though :) Unfortunately scientific paper titles are extremely uninformative, so HN's policy on using the original title (unless it's clickbait) is counter-productive. :|

coffeeblack 4y ago

This is something that should be done regularly by health insurers. And maybe even by some sort of government agency that supervises the health industry.

ozim 4y ago

I would say 28% is not that bad. Of course ideally it should be 0%. But thinking about normal distribution of skills I can imagine 20 to 30% dentists not being that competent should be well normal.

lupire 4y ago
That's not how statistics works. You and I are in the 80% of people who are incompetent at dentistry, and that's fine. Every practicing dentist passed the filter of school and licensing. Incompetent practicing dentists are criminal frauds.
- ozim 4y ago
  I assume that if you take only dentists that passed the bar - there are those who just slipped over and ones that passed with ease. So they don't have to be "fully incompetent" just less competent than most dentists.

omginternets 4y ago

Question: what is a credence good? Also: > Dentists with shorter waiting times are more likely to propose unnecessary treatment. I’m admittedly focusing on the narrow end, here, but this is intriguing. How large is the effect? I couldn’t access the full paper. Intuitively, this would suggest that certain dentists are optimizing for low-effort, high-margin procedures. If that’s the case, I’d expect the distribution of wait times to be multimodal, which might offer a path to detecting such practices cheaply.

encryptluks2 4y ago

One thing they should check is of the dentists that were committing fraud had anything in particular in common, like religion or heritage? Some religions teach that other people are subhuman and made to serve them in particular and see no issue commiting fraud against certain groups of people.

beej71 4y ago

In the US, anyway, you should always get a second opinion.

rentonl 4y ago

I've been following a method where every year I see a different dentist and I only get something fixed if two subsequent dentists diagnose the same issue.