News & Politics

An Insider’s Guide to Dental Care

The fact is that dentists don’t mind if you talk while you’re in the chair—except if you talk about money. Here are some other things that may surprise you about dentistry—plus a guide to the area’s top dentists and specialists.

Photograph by Vincent Ricardel.

Dentistry can seem a bit like a secret society—at least that’s how it’s always felt to me. You lean back in the chair, open wide, and then—surprise—learn you’ve got big problems with your teeth.

Only a decade or two ago, dentists practiced reactionary dentistry: If a tooth hurt, they’d fix it—otherwise they’d leave it alone. Most dentists today thumb their nose at this “tooth by tooth” approach. They’ve been trained in comprehensive care: Give a patient’s mouth a full examination and then tell the person what’s wrong and in what order the work should be done.

You can sometimes leave the dentist feeling the way you might when you leave an auto mechanic, wondering if you’ve been taken.

We asked area dentists to talk about common perceptions—and misperceptions. Full disclosure: I’m married to a dentist, so some of this insight comes from engaging in many candid conversations with other dentists.

Here are things you may not know about dentistry.

Dental Work in This Area Does Cost More

According to the American Dental Association, the average cost nationally of a composite filling is $119; the average crown costs $841. In Washington, fees can be as high as $300 for a filling and $1,800 or more per crown.

Why the disparity? Location, location, location.

Dentists we spoke with say the area’s cost of living—including office rent, lab fees, and staff salaries—dictates pricing. That’s why dental work in a far-out suburb may cost less than the same procedure in downtown DC. If an office focuses heavily on the latest intraoral cameras or if it’s spa-oriented, those extras will be reflected in the cost, too.

Not All Patients Are Treated the Same

Time factors into a dentist’s fees. Some HMO dentists see up to 20 patients a day, while a fee-for-service practice—where patients pay out of pocket—might see eight.

One dentist who used to work at an HMO practice says he was forced to see a patient every 15 minutes. “The compensation is so low that you have to make it up in volume,” he says. Many dentists don’t accept HMO insurance because they say the reimbursement rates are too low.

Some who don’t accept HMOs do accept PPO insurance, because those reimbursement rates vary. Still, if a PPO is known to reimburse less, one dentist says, it can feel like a waste of time to do the work. Then again, higher fees may encourage some dentists to do unnecessary work.

“If the reimbursement is too low, then yes, you can be tempted to spend less time,” says a dentist in Maryland. “If the fees are high, you might think, ‘I can make a lot of money if I sell a lot of crowns.’ Then you might overtreat. It goes both ways.”

Some dentists say the quality of care can suffer when patients are rushed through. “You’ll have to cut corners somewhere,” says Danine Fresch Gray, a general dentist who runs a fee-for-service practice in Arlington.

A Dentist Doesn’t Want to Talk About His Car

When my husband was shopping around for practices to join, he was told never to drive a fancy car to work—patients would resent it.

There can be a financial tension between dentist and patient. Some people feel that the high cost of dentistry probably is funding a dentist’s upper-crust lifestyle.

“I often hear, ‘I probably put your kids through college,’ ” says Gray. “I’ll say, ‘Yes, this is how I make my living.’ ”

According to the American Dental Association, the average salary of a dentist who owns his own practice is $202,930 a year, while specialists make $329,980 a year—and most dentists work 35 to 40 hours a week.

“You probably don’t want your dentist to own three Porsches, because you’ll think that they’re ripping people off,” says one dentist. “But you probably don’t want them driving a 20-year-old Honda, either—then they’re not doing so well.”

Most dentists try not to bring up money at all. That’s why you’re often sent to a financial coordinator when it’s time to talk payment.

Your Dentist Can Handle Your Case—but May Not Feel Like It

Every job has parts to love—and not love. Dentists are lucky: Whenever a case comes up that they don’t feel like doing, they can send you to a specialist.

Often there’s a good reason. While most general dentists can do root canals, for example, the dentist may not feel comfortable working on a complicated case without the high-power microscope that a specialist—in this case, an endodontist—uses.

But some dentists simply don’t like doing certain procedures, such as root canals, and they refer all of them out.

“Some doctors like doing crowns and bridges but don’t want to do root canals and gum surgeries, and vice versa,” says Rustin Levy, a periodontist in downtown DC. “I know plenty of dentists who don’t like to see blood, so anything like that is sent to a specialist.”

It can be annoying for a patient to make multiple trips for one dental problem. Still, doing so can work in your favor. One dentist says he refers out tough root canals for the patient’s sake: “I would take two hours to do a root canal that an endodontist can finish in 45 minutes.”

There’s No Such Thing As a Cosmetic Dentist

Ads for cosmetic dentists are common, but it’s mostly marketing.

“Cosmetics is not a specialty,” says Joe Kravitz, a prosthodontist at the Center for Dental Health in DC. There’s no ADA accreditation or advanced degree when it comes to training general dentists to do cosmetic work. All dentists are cosmetic dentists. Your general dentist was trained to do many of the procedures done at a so-called cosmetic practice.

For $425 a year, dentists can join the respected American Academy of Cosmetic Dentistry by taking oral and written exams and sending in cases for evaluation. They’re given a certificate and told they can use the AACD name and logo in their marketing. Some dentists attend the Las Vegas Institute for Advanced Dental Studies, a for-profit company offering continuing-education classes.

Kravitz says it’s great for dentists to go on for additional training, but he’s frustrated when he sees dentists using the initials of some of these programs after their names; he thinks it tricks the patient into thinking the doctor gained an additional degree from an accredited dental school. The ADA discourages dentists from using any extra initials—beyond those for degrees such as DDS (doctor of dental surgery) or DMD (doctor of dental medicine)—after their name, but some do anyway.

The bottom line: You don’t have to go to a practice that markets itself as “cosmetic” to get whitening, veneers, and bonding. General dentists do those procedures—and they may cost less. When evaluating any dentist who’s offering extensive cosmetic services, you might ask to see before and after photos of his work, ask how many of these procedures he’s done before, and ask to speak with a few references.

Expensive Whitening Isn’t Better

Not everyone is a candidate for whitening. According to the ADA, yellowish teeth will bleach well, while whitening for brownish and grayish teeth will be less effective.

There are many ways to bleach teeth. One popular approach is an in-office treatment that requires the dentist to smear gel on your teeth, then shine a light on your mouth to activate the whitening agents. This approach typically costs about $1,000 and takes an hour or so.

But less invasive, take-home bleaching systems work just as well, says David Paino, a general dentist in Vienna: “With some of the light-activated bleaching, the results may be exaggerated for the first 24 hours because the light tends to dry out the teeth, making them appear lighter.” Ultimately, your teeth will probably get the same results with either approach.

Paino recommends in-home kits that take about two weeks to complete. He says these prescription kits are just as effective and cost less; treatment runs about $400 at his office.

While several dentists echoed Paino’s sentiments, some say they offer light-activated bleaching because patients are convinced from TV shows such as Extreme Makeover that it makes the biggest difference.

Some Practices Send Lab Work Overseas

Last year, TV station WJLA reported that several crowns ordered from labs in China and shipped to Washington contained lead. The crowns from China cost about $30 to $50 to make; a local lab might charge five times that.

Only about 4 percent of dentists nationwide send their lab work overseas, but the ADA was concerned enough about the practice that it tested 100 foreign crowns to check for anything that could be harmful.

While many dentists believe overseas lab work is of lower quality, that hasn’t stopped some from using these labs. One dentist cites an old adage: You get what you pay for.

“A lot of the success of our work hinges on the ability of the lab tech to carry out our plan,” says Paino. “You can be the best dentist in the world, but if you work with a bad lab tech, the work is going to be bad.”

If a dentist offers you a cheaper-than-average crown—say, $500 to $700—it may be because he’s using a cheaper lab. “You have to ask yourself if you want something that’s going to last three years or 20 years,” says Danine Fresch Gray. “If you’re getting a crown for $700 and they’re paying a lab $30 for the work versus a few hundred dollars, you can almost guarantee that it won’t last.”

Dentists suggest checking with your doctor about which lab he or she uses. Is it registered with the American Academy of Cosmetic Dentists? Is it local or overseas?

Young Dentists Cringe When You Ask for a Silver Filling

I was at a cocktail party full of younger dentists when they began complaining about silver fillings. Some of the dentists, who worked as associates, complained that their older partners still used the material. Others rolled their eyes at the thought of patients who demanded silver. “Who would even want that?” one dentist said. “I just refuse to do it.”

Many younger dentists have left behind the amalgam material in favor of composite fillings, which are tooth-colored and tend to be more aesthetically pleasing. According to the ADA, about 70 percent of fillings placed today are white composite. Dentists who have been practicing less than ten years were trained in the age of plastic surgery, so there’s a higher allegiance to the way things look. A mouth full of silver is unattractive, these dentists say.

Some older dentists prefer silver fillings—and may push them on a patient—because they’ve been using the material for decades. They believe it’s stronger and lasts longer.

So what’s better for you: silver or white fillings? It’s clinically acceptable for dentists to use either, and both have pros and cons. Silver fillings are about 45 percent mercury, which worries some patients, but the National Institutes of Health and the Centers for Disease Control and Prevention say it’s not harmful when combined with other metals. Silver fillings tend to be about half the price of composite.

Many younger dentists say you get a better seal with a white composite filling. While a composite filling may not last as long as an amalgam one, says Kravitz, you can repair composite without redoing the entire filling: “You can replace the edge without cutting it all out.” That’s easier for you and your dentist.

Yes, You Need X-Rays

Who doesn’t hate biting down on those plastic bite plates so the dentist can snap a picture of your mouth? Do you really need regular x-rays, or do dentists encourage them to pad the bill?

Unless your doctor is pushing for several x-rays a year, that’s unlikely. Without x-rays, dentists say, it’s hard to see what’s going on inside your mouth.

According to the ADA, the need for x-rays varies depending on a patient’s age and symptoms. Children may require them more frequently than adults because their teeth and jaws are developing and they’re more likely to suffer tooth decay. Most dentists recommend “bitewing” x-rays—four x-rays that show cavities or developing cavities between the back teeth—once a year. A full mouth series, which takes pictures of all the teeth and is typically given every three to five years, helps the dentist evaluate the health of the roots and jawbone.

The amount of radiation absorbed through x-rays is minimal. According to the ADA, most people absorb more radiation in their everyday lives than from getting dental x-rays. Some doctors today have digital x-rays—the pictures show up on a computer rather than being developed like film—and these emit even less radiation.

Still, if you’re uncomfortable getting x-rays, speak up. But keep in mind that some cavities are difficult to find without them. And if you have a tumor, an x-ray could save your life.

Pregnant Women Are Dentistry’s Cash Cows

According to a study published in Current Anthropology, women are more likely to get cavities than men, thanks to hormones. The study also says women generally produce less saliva, which disrupts the mouth’s ability to reduce food residue.

John Lukacs, a professor of anthropology at the University of Oregon, says that high levels of estrogen during puberty and pregnancy promote cavities. Dietary changes do, too—and many pregnant women crave sweet foods during their last trimester.

“Pregnant women get more decay, more gum disease,” says Joe Kravitz. He says some women may lose a tooth or two during pregnancy. During times of hormonal change, he suggests, check in with your dentist more often.

Your Dentist Doesn’t Mind If You Open Wide—and Talk

I asked several dentists if they get frustrated when a patient talks a lot in the chair. I assumed they’d get annoyed, because it’s harder to work on a mouth in motion. But they all said the opposite: They like getting to know their patients.

According to a 2006 Gallup Poll, 62 percent of people believe that their dentists are trustworthy; it’s the fifth-most trusted profession. Lots of dentists keep notes about your personal life in their charts so they remember what you’ve talked about and can ask you about those topics on your next visit.

This article first appeared in the August 2009 issue of Washingtonian. For more articles from that issue, click here.