New Age of Dentistry

Joyce Lacovra hid her grin. Because of gum disease and oral infections, she lost one-third of her teeth by the time that she was 52. She had no dental insurance, was bankrupt from oral-surgery bills and needed permanent teeth implants, which, one U.S. dentist told her, would cost $100,000. When she discovered 3 years ago that she could get her teeth fixed in India for just $22,000, she hopped on an 8,000-mile flight to Mumbai, where a U.S.-trained dentist pulled and replaced every one of her remaining teeth.

Today, Lacovra has a full set of gleaming white implants, and she is delighted that she paid about one-fifth of the expected price for her dental surgery. “I thought I would have to spend the rest of my life paying off dental bills, or spend the rest of my career as a singer hoping that my ill-fitting bridges didn’t fly out of my mouth onstage,” says Lacovra, who lives in Washington.

ROOT ISSUES. Lacovra’s experience represents one of the many significant changes in dental care in the past 5 years. At a time when a growing number of Americans are losing dental insurance, consumers have new ways to save on dental care—either by seeking treatment in other countries or by visiting newly available midlevel practitioners who are called dental therapists. At the same time, some U.S. dentists whose profits have been squeezed by the recession are working to polish their own bottom lines by introducing services, such as Botox injections for cosmetic purposes, oral-cancer-screening tests that use light and special rinses, and cutting-edge laser tools, for which they can charge customers more money.

But each of these new developments in dental care presents potential problems for consumers. For instance, there’s little evidence to suggest that the latest cancer-screening tools are more effective than are traditional exams. In addition, the newest cancer-screening techniques and the increased use of Botox injections will increase your out-of-pocket dental expenses, because these types of procedures typically aren’t covered by insurance. And if you’re desperate enough to get dental care in other countries, it can create a financial mess if you have to get a U.S. dentist to fix the botched work of an incompetent dentist who’s outside of the United States.

It isn’t a coincidence that all of these potential problems exist as more Americans struggle to find low-cost dental care than ever before. An estimated 46 million U.S. citizens who are under the age of 65 have no health insurance, and nearly double that number—90 million—have no dental coverage. Arizona, California, Hawaii, Idaho, Kansas, Massachusetts, Minnesota, Ohio and Washington slashed Medicaid dental services for needy adults in 2010 and 2011 by reducing the number of dentists who serve Medicaid patients and eliminating coverage for routine checkups—a short-sighted decision that could result in an increase in more-costly health problems later. Among Americans who are fortunate enough to have private health insurance, 27 percent must pay for their own dental coverage.

What’s more, private insurers for years have capped their dental coverage at around $1,500 to $2,000 per year—less than what you might have to pay for a single crown or a root canal. At the same time, the cost of dental-health premiums is rising faster than inflation is, and it’s forcing many consumers to go without coverage during these lean times, according to The New York State Dental Journal. It’s no wonder that the percentage of people who see a dentist every 6 months as recommended by American Dental Association (ADA) has declined to just 42 percent (127 million patients). And it’s no wonder that Department of Health and Human Services reports that 53 million U.S. children and adults have untreated decay in their permanent teeth.

In short, the new age of dentistry means that now, more than ever, if you’re determined to protect your wallet and your health, you really need to know the drill.

COSTS AND CAUTIONS. Dentists have used their eyes and fingers to look for signs of oral cancer for decades. But ViziLite, which is a tool that some doctors use to screen for oral cancer, can add at least $40 to your bill, because it typically isn’t covered by insurance. However, ViziLite doesn’t necessarily do a better job of finding cancer, independent health experts tell Consumers Digest.

Dentists started to use ViziLite for cancer-screening exams in 2001, but its use has more than doubled in the past 5 years. The 14,000 dentists who offer ViziLite, which combines a special mouth rinse and a hand-held detection device, will tell you that this tool detects oral-cancer cells more readily than other screening techniques do. However, ADA, American Cancer Society and Oral Cancer Foundation (OCF) all say the benefits of ViziLite screening aren’t worth the extra cost. OCF  Executive Director Brian R. Hill says ViziLite doesn’t detect most types of growths that are related to oral cancer. Instead, ViziLite can detect only one of three types of oral-cancer lesions, and the one that it can detect—white lesions—is malignant just 10 percent of the time. Because it detects only white lesions, ViziLite “doesn’t do much,” Hill says. “It’s just smoke and mirrors.”

ViziLite spokesperson Jack Swift defends the cancer-screening approach and says seven clinical trials have shown that ViziLite is an effective cancer-screening tool. However, independent experts whom we interviewed say those studies relied on sample sizes that were too small to be of statistical significance. In other words, independent experts say no definitive independent study proves that ViziLite is more beneficial at detecting oral cancer than are traditional exams.

Just as dentists long have screened patients for oral cancer, they also have spent 2 decades using Botox for medical purposes, such as to treat migraines or to relieve pain in the temporomandibular joint (known as TMJ, the site of lockjaw). But in the past 5 years, dentists increasingly have used Botox for cosmetic purposes in the same way that dermatologists and cosmetic surgeons do.

Dentists are licensed medical professionals who use Botox therapeutically, so all 50 states allow them to give these injections. We don’t necessarily believe that there are any significant reasons for consumers who get Botox injections to avoid getting them from their dentist, given that they typically will pay the same ($300 to $500 per area of treatment) and the results typically will last as long (3 months), regardless of whether they go to a dentist or a cosmetic specialist. But we believe that consumers should be aware of the trend, so they know the cosmetic risks that are involved and they don’t let dentists pressure them into adding Botox treatments to their routine dental checkups.

According to Catherine Maley, who sells Botox marketing kits to dentists, the average dentist can double his/her annual salary to $300,000 by giving Botox injections for cosmetic purposes, such as to smooth the furrows in a patient’s forehead. And companies that train health professionals on how to give Botox injections have cropped up across the country. One such company, Dentox, has a website that urges dentists to implement these lucrative therapies into their comprehensive dental-treatment plans.

An estimated 20 percent of dentists offer Botox injections as part of their practices, says dental surgeon Louis Malcmacher, who is president of Cleveland-based American Academy of Facial Esthetics. In addition to Botox, some dentists also are injecting collagen fillers to plump up their patients’ lips or to fill hollows in sagging or aging skin.

Malcmacher says that in some states, aestheticians or cosmetologists (who offer beauty treatments for skin and hair) are allowed to give Botox injections after just 8 months of schooling, while dentists have a comparative 8 years of schooling, and 4 years of medical training are included in this time frame. According to Malcmacher, dentists are better qualified than other medical practitioners are to get lip lines and smile lines right when it comes to Botox injections, because dentists already have experience in working with the face.

But that doesn’t necessarily mean that dentists are better qualified to give Botox injections than dermatologists or cosmetic surgeons are. It’s no surprise that dermatologists and cosmetic surgeons are crying foul over the cosmetic use of Botox treatments by dentists. They say they’re better trained than dentists are to give Botox injections. “This has nothing to do with the scope of dentistry,” says Malcolm Z. Roth, who is president of American Society of Plastic Surgeons. Dentists who aren’t trained in aesthetics could botch these procedures and leave their patients with unsightly problems that last for months, Roth says. But this sounds as much like a turf war as it does a true challenge of qualifications.

Our take? If you decide to have a dentist treat your wrinkles with Botox injections, don’t do it unless your dentist has professional training in the cosmetic use of Botox, health experts tell Consumers Digest. That training should include at least 2 days of hands-on school experience with live patients, and at least 5 years of using Botox for therapeutic purposes, such as treatment for TMJ disorders. Malcmacher says you should ask to see pictures of the cosmetic Botox work that your dentist  preformed, and you should ask the dentist to provide the names of previous patients. Although it’s likely that the dentist will give you names only of patients who had positive experiences, talking with those people at least will confirm that the dentist is experienced in using Botox.

FOREIGN SERVICE. But reliable references are hardly the only thing that you’ll need if you seek treatment in a foreign country. A growing number of consumers are doing precisely what Lacovra did and are getting dental care in other countries to save money. The trend is known as dental tourism.

But if you seek dental care in other countries, you should know that obstacles abound, regardless of whether you flock south of the border for teeth-whitening or fly across the ocean to get your wisdom teeth pulled. According to consulting company Deloitte Center for Health Solutions, the number of Americans who seek medical care outside of the United States will triple to 1.6 million by 2012, compared with 2008 data. Although researchers have been unable to peg how many medical tourists specifically seek dental services, HealthCare Tourism International, which monitors the medical-tourism industry, says dental procedures are the most popular health-care services that are sought abroad by U.S. citizens. In fact, the Mexican border town of Los Algodones has become so popular for dental tourism that residents have nicknamed it “Molar City.” Patients trek as far as Hungary, India, Korea and Thailand and often go sightseeing in between their drillings and fillings.

Regardless of wherever that you might go and whatever procedure that you might need, dental tourism has the potential to save you plenty of money, even after you add the cost of travel, according to David Boucher, who is president of medical-tourism company Companion Global Healthcare. Lacovra saved more than 75 percent compared with what she would have paid a U.S. dentist, but the amount that the typical consumer will save can vary from 30 percent to 70 percent, dental-tourism experts say. The cost of airfare typically is factored into those savings.

We can’t dismiss the potential benefits and savings of getting dental treatments in other countries, because we found plenty of evidence that many patients received quality care. But getting that kind of treatment requires in-depth individual research, and we believe that it’s best to work with a U.S.-based dental-tourism company that can help you to find the best possible care. At press time, we found 21 U.S. online dental companies. These companies claim to verify the credentials, cleanliness and equipment of dentists who are in other countries.

Experts say the best dental-tourism companies issue written contracts that spell out their fees, services and consumer protections, such as cancellation and refund policies. The best companies also provide you with the contact information of former patients, whom you can call for reference. In addition, you’ll want to use a dental-tourism company that has staff members who speak fluent English, because you’ll want to be able to communicate all of your dental-health concerns clearly. It’s also best if you can find a dentist who was educated in the United States, which has the highest standards of training. Although a good dental-tourism company will perform all of these tasks for you, it never hurts to verify the company’s claims through your own research.

That’s what Lacovra did, and she says the extra vetting helped to put her mind at ease. After investigating IndUShealth online, Lacovra had the medical-tourism company’s representatives put her in direct touch with a U.S.-trained, Mumbai, India-based dentist with whom she exchanged phone calls, emails and dental records. After Lacovra’s dentist answered her volley of questions to her satisfaction, she knew she had found a dentist whom she could trust.

ADA hasn’t taken a position against dental tourism, but the organization warns that few regulations are in place for dental-tourism companies and that, no matter where you go, it’s a roll of the dice as to the quality of care that you’ll receive, because other countries don’t necessarily follow U.S. training, hygiene, sanitation and practice standards. For instance, a brochure that was produced by Arizona-based dental-insurance provider Delta Dental notes that only 21 percent of Mexican dentists are vaccinated against hepatitis B, compared with 90 percent of U.S. practitioners.

Before you leave for any dental treatment in another country, you always should find a U.S. dentist who is willing to tackle any follow-up care that might be necessary, dental-industry experts say. If, say, a gum infection strikes a week after you return from abroad, you’ll want to make sure that you have lined up a dentist who won’t shy away from addressing the problem because of potential liability concerns.

And getting insurance programs to pay for dental-tourism trips can be dicey. Although some work-sponsored insurance providers might pay for such treatments, it’s hardly a given at this point. In addition, there’s no guarantee that insurance companies will cover the cost of any necessary follow-up care on U.S. soil. It’s possible that some dental-tourism companies might follow the lead of South Carolina-based Companion Global Healthcare, which offers a $200 annual policy to cover foreign dental treatments that cost up to $50,000. It does business with 300 companies in 24 states. One of Companion Global’s clients, Blue Lake Casino in Eureka, Calif., even directly reimburses employees for 10 percent of the money that they save on dental treatment abroad by cutting them personal checks that they can then spend however they wish.

CARE OPTION. But a way that consumers might be able to save money on dental care in the United States is tied to the emergence of a new type of practitioner—the dental therapist. Although fewer than 40 dental therapists practice, and in just two states (Alaska, which has had them since 2005, and Minnesota, which has had them since June), dental therapists likely will become commonplace in the future, says Michael Scandrett, who is director of Minnesota Health Care Safety Net Coalition.

Dental therapists are a notch below dentists in terms of what treatments that they can perform. Think of them as the dental equivalent of nurse practitioners in that they are midlevel providers who are overseen by licensed dentists and who perform less complicated—and less costly—services than those of their supervisors. For instance, most dental therapists are qualified to do teeth-cleaning, fillings, sealants, denture repairs and extractions of small teeth in the front, such as incisors, says dental surgeon Mary E. Williard, who is the training director for dental therapists at Alaska Native Tribal Health Consortium in Anchorage. But Willard says dental therapists aren’t qualified to create dentures or perform complicated dental tasks, such as root canals, bridge work or even deep cleaning that’s below the gumline.

Having a dental therapist perform simple tasks can cut the cost of treatment by about one-third when compared with the cost of a dentist, according to W.K. Kellogg Foundation, which is a health-care-advocacy group. And the lower costs will be covered by dental insurance.

Kellogg has poured $16.5 million into a lobbying campaign that’s designed to get other states to allow dental therapists to practice. In addition, the Affordable Care Act of 2010 earmarks a yet-unspecified amount of grant money for states to train more dental therapists. So, we’d be surprised if dental therapists don’t expand to other states in the years ahead.

Yet it’s uncertain just how quickly that expansion might happen. At press time, lawmakers in California, Kansas, Maine, New Hampshire, New Mexico, Ohio and Vermont were considering whether to allow dental therapists. Similar legislation could be introduced in Washington state by 2012.

The major obstacle to getting dental therapists in more states appears to be ADA. In an interview with Consumers Digest, ADA President Raymond F. Gist, who is a dental surgeon, says he opposes dental therapy because of patient-safety concerns. He notes that dental therapists undergo 2 years of dental training, whereas licensed dentists are required to have 4-year college degrees and complete 4 years of specialized dental and medical training. Kellogg and other advocates for dental therapists say 2 years is enough training for the types of limited treatments that they provide. Of course, advocates for dental therapists also say ADA opposes dental therapists because these new practitioners pose a financial threat to established dentists.

But results of an independent study that was published in—of all places—the March 2011 issue of Journal of the American Dental Association found that the work of dental therapists in Alaska boasted “outcomes comparable with those of dentists treating the same populations.” In other words, the quality of their work matched what the patients would have received from dentists but at a fraction of the cost.

That sounds like the kind of treatment that would make anyone smile.

Molly M. Ginty has been a health reporter for 15 years and is a regular contributor to Consumers Digest.