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Walking the Fine Line

Oct. 1, 1999
A man with little income can`t pay for a procedure. Turn him away? Or should the dentist do the work for little or no money? That`s the ethical battle raging today.

A man with little income can`t pay for a procedure. Turn him away? Or should the dentist do the work for little or no money? That`s the ethical battle raging today.

Bill Dickerson, DDS

Many who have heard me lecture know that I advocate providing the highest quality of dentistry while charging enough so that the highest quality of service is always provided. Simply put, you can`t provide excellence unless you charge for it. You can`t use the best labs, best supplies, superior high-tech equipment, and afford the education that will allow you to create superior dentistry if you don`t charge enough.

But that raises the inevitable questions: What are the poor people going to do for treatment if everyone practiced in this manner? What about our moral obligation to treat the poor? It is my opinion, and always will be, that it is our moral obligation to provide for our families with the highest standard of living possible.

The prevailing attitude in our profession is that we must keep fees down and do less quality work because those in need can`t afford high-end dentistry. Continuing to provide the low-cost amalgam restoration so the less-fortunate can afford to receive dental care has had a direct effect on the quality of dentistry in this country. Ignoring the superior restorations simply because the masses can`t afford such treatment (and insurance won`t cover the procedure) is creating an ethical dilemma. The result: People who can afford dentistry are able to receive such care for the same cost that is affordable for the poor. In fact, we, as a profession, have worked to keep our fees down and even criticize those who charge more. I believe that dentists subsidize dental care by offering the amalgam at basically our costs. Therefore, the average dentist`s income has not kept up with the cost of inflation since 1972. The prevailing attitude is that it benefits the public to keep dental fees low so everyone can afford treatment.

But is it ethical to provide inferior care to the less fortunate simply because they can`t afford the best? What if every dentist was making a fair and justified income, so superior care could be provided to the less fortunate for an affordable fee.

It is my contention that it is our professional obligation to only do the very best for our patients, including those with limited income. I am not advocating reduced-cost or free treatment to anyone who tells you they can`t afford treatment. The truth is that we have not created the value or demand that will make the average patient desire the treatment enough to pay for quality. This is a glaring mistake, and it is our fault.

Americans spent more money last year on big screen televisions (each costing more than $2,000) than was spent on all dental procedures combined. If patients tell you they can`t afford dental care simply because they don`t value it enough to pay for it, then it`s a priority issue with them and it becomes their choice to have the inferior procedure.

It is our obligation to inform the public about the value of dentistry so that it becomes a higher priority. Necessary dental procedures are certainly more important than big screen TVs. It is a crime that one-third of the dentists in the ADA threatened to leave if a $300 per member marketing campaign was instituted to create a higher value for dentistry in the minds of the public. By not agreeing to spend $300 per member per year, we prevented ourselves from having the opportunity to provide quality care in our practices.

Unfortunately there isn`t much business training in dental school, and we don`t realize that we have to spend money to make money. The average dentist is underpaid and so cost-conscious that we "nickel and dime" our practices to death. The $300 would have been an incredibly valuable investment, in my opinion. Even if it didn`t work, it was only $300 or roughly $10 a day to attempt to educate the public about the value of good dentistry and a great smile. If the meat industry, milk industry and egg industry can market their products and create high returns on their investments, we surely can educate the public about the great value of dentistry.

Two months ago I received a letter from a very caring mother (left). The letter really tugged at my heartstrings, but I was curious about how she obtained my name and address. I called her and asked how she got my name. She informed me that she sent out 15 letters to dentists she found on the Internet. We discussed her son`s case, and I told her that I was sure her dentist was very capable. But I felt that her son`s case was extremely difficult and challenging since his vertical dimension would need to be increased. I wasn`t sure that, at the price that he charged, it could be done in the manner that I felt was needed. She informed me that her dentist admitted the procedure was beyond his capability.

I told her that, in good conscious, I couldn`t send her any money to have even one tooth done. But, if she could get her son to Las Vegas, I would do the entire mouth for free. It was my decision to provide work for someone who valued quality and was desperately in need of some quality dentistry.

The next day I received a fax from this wonderful mother (below).

Photographs were taken by Dr. Steve Poss in Smyrna, Tenn., my co-clinical director of the Advanced Anterior Program at the Las Vegas Institute. Steve called me to warn me about the extreme nature of this young man`s mouth. As you can see by the before pictures, every tooth was decaying and some had been eroded or worn to gingival height.

Six post and core build-ups were needed on teeth that had already been treated endodontically. Six teeth needed adhesive dentistry type of pulp cap techniques. Many of the molars were almost reduced to nothing when the caries was completely removed.

Using Empress for all of the restorations, the teeth were restored and the vertical dimension was increased under the principles taught by Dr. Jim Carlson, LVI`s director of the Practical Occlusion Program. Scott tolerated the procedure well and had minimal post-operative complications. The restorations were seated in one sitting using the rubber dam and the rapid cementation technique taught at LVI. As you can see from the pictures, there is a dramatic difference in his appearance at an age where a young person`s self esteem can be made or broken.

Again let me reiterate my belief that if all dentists were making a fair fee for such a procedure on those who can truly afford such treatment, it would allow us to provide the same quality care to those who truly can`t afford it. Would it have been ethical for me to place a series of 4-pin amalgam build ups in Scott`s mouth simply because his family couldn`t afford this type of treatment? No. When the average dentist in this country begins to be paid for what he or she is really worth, then the profession can better provide for the truly needy. The emphasis should be on "truly needy," as I believe that the average person can afford good dentistry. Unfortunately, most do not value it enough to want to pay for it. Over the years, we have devalued dentistry and trained the public that it is their right to have dental treatment for a cheap fee. Unfortunately, this attitude has had a profound impact on the lack of improvement in dentistry over the last three decades. When our argument to do amalgams is, "We have been doing them for 150 years," it`s a pretty embarrassing admission that dentistry has not evolved like most other industries or professions.

Dentistry is a great profession. In fact, it is probably the greatest. What we in the dental and medical fields can do for the public is virtually unparalleled. It`s time we began letting the public know what we have to offer. Once we educate the public to the great value of dentistry, we can all provide the best care to everyone who wants such care, regardless of his or her financial position. But, most importantly, we can all love what we do for a living and enjoy our profession more because our financial and emotional needs will be satisfied.

Dear Dr. Dickerson,

We`re writing to you because you know first-hand the difference a SMILE makes!

Our son, Scott, a handsome, popular, and talented 16-year-old, doesn`t smile anymore ... in fact, he now tucks his head and mumbles most of the time.

Scott has an inherited condition that has steadily led to the softening and erosion of his natural teeth. His permanent teeth are now the size of a 2-year-old`s baby teeth. In spite of our best efforts at drilling, filing, canaling, extracting, cleaning, and even bracing his teeth - we lost the battle. Scott`s father, to his everlasting regret, opted for dentures when he was 17. He`s adamant that Scott doesn`t go through that misery at such a young age.

Scott has abscesses in his two upper and lower teeth, and is constantly in pain as one tooth after another erodes. Without a doubt, this is affecting his physical health, but we`re also worried about his mental and emotional well-being, as we see the serious effect this condition is having on him and his daily outlook on life.

We are facing an overwhelming and heartbreaking obstacle - 28 crowns at $465 each -- $13,000! Our family dentist has given us the best price he can, but we do not have enough money to pay it. The only way we can mentally cope with this enormity is to break it into small chunks, or "one tooth at a time."

Scott`s orthodontist donated the price of one tooth, his grandmother is able to pay for two, and Scott can pay for one with his summer-job income tax refund. The most that we (parents) can come up with will pay for six - so now we have 10 teeth covered!

We`re appealing to your office for one tooth, or any amount you can furnish to our "one tooth at a time" plea.

At your request, we will send you "before and after" photos that demonstrate the dramatic and compelling difference cosmetic dentistry made in a young person`s appearance. If your advertising budget is strained, perhaps these photos will warrant your continuing education, case history, or seminar materials budget. We will be glad to supply details for case history study (low saliva output, and oddities like color absorption on his teeth from beverages, etc.).

If you can help, please send your check directly to our family dentist. His office will handle the funds. Please write "for Scott Bryan" on your check. They will know of your generosity, so we can personally say thanks and send you further details if requested.

We realize you have no obligation to help a young person, and we`ll understand if this appeal gets tossed. But if the day comes when we run out of time and Scott has to settle for dentures, at least we`ll know in our heart we did all we could to prevent it.


Johnny and Debby Bryan

P.S. Your favorite patients know the awesome value of the smile you created for them! Perhaps you know of one or two whom would like to share the blessing they received. At your discretion, will you give them a chance to extend their blessing and help create this pivotal difference in our son`s life?

Dear Dr. Dickerson,

Your phone call yesterday was so sudden and unexpected that I fear I did not properly thank you. In fact, the immensity of your generous offer for our family has barely sunk in now.

You deserve a fuller answer to your questions. I found your Web page by typing "Cosmetic Dentistry" into a search engine, which gave me hundreds of hits across the country. I checked my memory of "about 12" and, actually, I sent out 15 letters; yours was number five. How did I carefully choose 15 from hundreds? Well, I don`t suppose my criterion will impress your associates, but I looked at photos...specifically, I looked for dentists with kind eyes. And, you`d be surprised at the number of persons in your profession who, indeed, have kind eyes.

Why did I make the appeal? My normal "we can do it by ourselves" attitude had hit a reality barrier - I was forced to acknowledge we were losing the battle. While we were trying to scrape up money, Scott was losing weight, and going to bed every night with a new toothache. We haven`t seen him smile for five years, and his personality was changing before our eyes. So, for once in my life, I was desperate. But who would understand? Who would care about a kid in the mountains of Tennessee? I thought perhaps someone whose business is creating smiles and happiness would be willing to help with one tooth. Please accept our heartfelt gratitude that you have, not only kind eyes, but an enormous kind heart as well.

God bless you, Dr. Dickerson

Debby Bryan

Click here to enlarge image

Above and top center: Views of Scott Bryan prior to the procedure.

Click here to enlarge image

Above and left: Views of Scott Bryan following the procedure.

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