Why is esthetic dentistry grouped with the outlaws?

Dec. 1, 1998
We can`t wait until our leaders take the bull by the horns. We have to do it on an individual basis from within.

We can`t wait until our leaders take the bull by the horns. We have to do it on an individual basis from within.

William G. Dickerson, DDS, FACD

A real devaluing of dentistry has occurred over the last several decades and we have no one but ourselves to blame. Forbes magazine carried a front-cover article a few years back titled "Why everyone is smiling but the dentist." The reason was that dentists` incomes have not kept up with the price of inflation since 1972. How many trade unions do you know that would brag that its members` incomes have not kept pace with the cost of living? The union president would be out of office as fast as you can say "teamsters." But the complacent dentist keeps being led around and made to feel guilty about being successful.

Dentistry is a hard profession. It is cost-prohibitive for most to become a dentist, and the return on the investment for the average dentist is mediocre, to say the least. The best and brightest are not going into our great profession. Seven dental schools have closed in the last eight years, and enrollment has dropped by almost two-thirds. Take out the return on your investment, (loss of income for four years, start-up costs, education, etc.) and, according to the ADA`s figures, the average dentist is making slightly more than $25 an hour.

On the other hand, it can be very rewarding and satisfying if one is able to overcome the doldrums into which we have led ourselves. Some of the happiest people I know are dentists, but so are some of the most miserable people I know. What is the difference between these extremes? Attitude and practice philosophy. The miserable dentists have let insurance companies dictate the delivery and fee structure of their care. They continue to give the amalgam restoration away because that`s what everyone else is charging or what insurance will pay. They let their concerns about what their peers will think, if they dare to be different, influence their professional decisions.

It is true that our practices have grown in complexity, both in the nature of our knowledge and the bureaucratic necessities that accompany them. However, if we step back and look at the resources we now have available and the unlimited possibilities of what we can accomplish with our expanding skills, we will see that this truly is an exciting time to practice the art of dentistry.

In the "better" times, cosmetic dentistry was undervalued as a less-than-ethical profession. The dentist who performed esthetic work was thought to sacrifice function and quality for something inferior. It was believed that a dentist who was concerned with esthetics would create expensive restorations that looked good, but were not as sturdy or reliable as those done through more conventional methods. Cosmetic dentistry was considered to be an unnecessary treatment for the rich or vain and not a valid part of the average practice.

In the last decade, however, dentistry has changed because of numerous esthetic pioneers. Advances in technology, materials, and techniques have created esthetic materials that rival or surpass conventional treatment. These advances also have improved the ability to restore and maintain periodontal health. Because the results have proven predictably superior to more conservative, traditional methods, more patients have begun to demand esthetic dental treatment. Far from being a fad, cosmetic dentistry has moved into the mainstream.

Even more exciting is the rapid growth of communication among colleagues. Today, myriads of clinicians are adept at sharing their knowledge at places like The Las Vegas Institute where dentists can learn the skills required for predictable incorporation into their practices. A sincere commitment and a dedication to excellence are the only qualities one needs to add the skills of modern esthetic dentistry to their practices.

So why are so many dentists unhappy and unable to incorporate esthetics into their practice? What has dentistry done to compound our problems? Nothing. That`s the problem!

As an organized profession, we have failed miserably in educating the public about the value of the mouth and teeth. The fact that 90 percent of our children don`t have sealants is a crime. The fact that 85 percent of Americans have periodontal disease is a crime. The fact that the vast majority of the public has no knowledge of porcelain veneers also is a crime.

Ask them what liposuction is and the vast majority will know. The truth is that most of the public think porcelain veneers have something to do with the toilet. Try it! Ask your waitress in your local restaurant if she knows, and see for yourself.

If the milk industry and the meat industry can convince people of the value of their product, why can`t we? Education is the key to creating a value.

Why do we only clean people`s teeth every six months, if that, when most people can`t go that long? Because that is all insurance will pay for. We neglect this disease because insurance will only pay for its treatment twice a year. Who decided this? We let insurance dictate our treatment rather than treat the disease as professionals. In the meantime, most Americans suffer from periodontal disease because we refuse to question these guidelines.

The real crime is that our profession has allowed dentists to lose money on the amalgam fillings. If you don`t think this is true, figure out your hourly overhead; and see how many of those restorations you would need to do to break even. Then check your schedule and see how many you average an hour. You`ll see that dentistry has been subsidizing health care for years on an individual basis. We have let insurance companies dictate our fees and have done nothing in an organized effort to correct this problem. In fact, we compound this problem by criticizing those who charge more than we do.

What is even more of a crime is that the most common restoration today is the same as it was 100 years ago. Where is the progress in our profession? What other industry has not had a significant advancement in materials used in the last 100 years? I think you would be hard pressed to find one. What has prevented our necessary progress?

I don`t think you have to look much farther than the influence insurance has had on dentistry. The maximum annual benefit for most insurance policies has not changed in the last 30 years, yet the premiums have risen by more than 400 percent. It is time for our leaders to wake up the members and get them to smell the coffee. Although I do not like the amalgam filling, raise your amalgam fees if you`re going to continue to do these restorations. The guy who tries to be the cheapest dentist in town does nothing for himself. More importantly, he hurts the profession. Remember, if you don`t charge what you`re worth, you become worth what you charge.

We are an important profession, providing a valuable service. Therefore, we should be fairly compensated for the time, money, and effort we put into it. We devalue our services by loaning people money for their work. What do I mean by the term "loaning?" Well, that`s exactly what we do when we don`t make people pay for their work at the time of their visit. How many places can this person go and buy something without having to pay for it at the time of purchase? Not many! The real problem is that we create relationship problems with our patients by lending them money. The old adage, "Never loan money to friends and family" should include "and patients." If you want them to be your friend, don`t lend them money. If they owe you money, they will try to find fault with your work and reasons not to pay. People do not like those to whom they owe money. The relationship with my patients improved immensely the day I stopped lending money to them.

I urge you to collect at least the copayment up front and, if required, use a third-party finance company, like Dental Concierge. Banks have a hard enough time being in the banking business. Dentists have little or no financial training and, therefore, have no business being a bank. If they owe this third-party company the money for the work you did, they will still love you. During this explanation in one of my programs, a dentist said: "But the problem with the third-party companies is that they occasionally deny someone credit." My answer was that you have no business lending someone money who an experienced and trained company says is a poor risk. Remember whom your responsibility lies with. It is your family, not the poor-risk patient. Providing your family with a quality life and comfortable surroundings should be your first concern.

I really believe dentistry`s problems have risen from one basic fact: Dentists are not adequately compensated. Dentists` incomes have not kept up with the cost of living in 23 out of the last 25 years, due to the intrusion of insurance. It`s had a profound effect on our profession by keeping fees low and dictating inferior treatment. Its effect also has been on the caliber, quality and quantity of those wanting to be dentists and on all of the adjunct industries in dentistry, as well. You see, the dentist is the beginning of the food chain in our profession. They are the plankton of dentistry. If a dentist isn`t making enough income, whom else suffers? Everyone.

The manufacturers of advanced technology suffer if the dentist can`t afford the products that they produce! Improving dental supplies, materials, and equipment is hampered, since the companies can`t afford the research necessary to create such products. In addition, dentists can`t afford the increased costs of such products.

The dental schools suffer because they can`t get alumni to donate contributions. Seven schools have closed in less than a decade, and much of it has to do with the cost to run the schools as it does to lack of interest from college kids. One third as many college kids want to be a dentist today as when I wanted to be a dentist.

Lab technicians suffer because they can`t charge enough to take the time to do a quality job, since the dentists won`t pay the necessary fee the work would warrant.

But, most importantly, the patients suffer. When the dentist is worried about paying bills and keeping overhead down, service declines. When need of money is the incentive to do anything, ethics is pushed to its breaking point. When the dentist can`t afford the new technology, the patient doesn`t get the advantage that this new technology would provide. But, even more importantly, when dentists do not make enough money, they can`t afford the educational programs that would dramatically improve their capabilities and skills that, in turn, would improve the treatment the public receives.

Unfortunately, many people think that keeping dental fees down is good for the public. It`s their goal to make dentistry cheap and inexpensive. They think this would be good for society.

They are so wrong! We have seen what low fees and the ultimate in managed care (socialized dentistry) has done in England, where the worst dentistry in the western world is done. Why? Because there is no incentive for any dentist to do quality work. We have seen what lowering fees have done to our colleagues in the medical profession and the horrors that have been created by the emergence of HMOs.

The worst thing that can happen to the patient is for dental fees to remain low. The worst thing about today`s dentistry with the intrusion of the insurance industry is that low fees have kept the standard of care so low. Do you need any more evidence than the fact that the most popular restoration is the same one we were doing over 100 years ago? The only way to improve that is to create dentists who value their worth, have the possibility to make a good living, and provide them with an incentive to excel.

Value-added, excellent quality, esthetic-based dentistry is the saving grace that will defeat the evil empire of managed care. The real truth is that dentistry today is a bargain. The reason to incorporate quality esthetics into your practice is to eliminate the control that insurance companies have on you and your profession. Remind yourself that the one specialty in medicine that has escaped the shackles of managed care is the plastic surgeon.

This article was not meant to be a depressing indictment of our profession, but a wake-up call to our members. We can?t wait until our leaders take the bull by the horns. We have to do it on an individual basis from within. Don?t sign up for fee-limiting PPOs. Don?t let insurance companies dictate your quality of care and fees.

Realize dentistry is a valuable service to humanity and be justly compensated for it. Remember Dr. Harold Warths? comment, OPeople have money for what they want, whether they need it or not. It?s our job to make them want what they need.O Next time a patient tells you he/she can?t afford something, look at his/her kid?s feet and notice the $150 sneakers. Listen to them tell someone out in the waiting room about the cruise they are going on this summer. In some extreme cases, listen as she tells your staff that the reason she looks different is because she has had breast implants. You see, it?s all priority. As a profession, we have to make dentistry the top priority it should be.

Do these things in your own practice and watch how your own personal satisfaction changes. I used to hate being a dentist, but because of a simple philosophical change, I now love my job. In fact, I can?t imagine doing anything else. This philosophical change has created a win/win/win environment for me, my staff and, most importantly, my patients. It also has worked for hundreds of other dentists who have taken the plunge.

My friends, the present holds more possibilities than the past ever did. The golden age of dentistry is now, if you take the time to explore what is open to you. The satisfaction you will receive from creating natural form and function with esthetic restorations is the rejuvenation your practice may need. It is an excellent time to be a dentist. In fact ? it?s a golden time!