Introduction to Dentistry for Healthy Midlifers
I feel privileged to have been asked by the Healthymidlife.com team to contribute to their online catalogue of information. I remember being in dental school (at the ripe age of 26) looking at older visiting alumni thinking, “What’s that old guy doing here?” Eventually being the nice guy that I am, I would approach them and try to make them feel welcome. On numerous occasions the dentist would have been 10-15 years out of dental school and was back to visit. I distinctly remember thinking, 'wow, that guy is old'. Having just turned 40 myself, it seems that all of a sudden I’m THAT old guy. It’s weird being at this stage in my life. I know that I’m not 20 anymore and yet I don’t feel limited much by my body or by my age. In fact, there are many things I do better today than I did a few years ago. So, overall I feel pretty fortunate. I’ve decided that 40 is just a number. But legitimately I MIGHT, just MIGHT be creeping in on midlife. I can tell you that I don’t act like an old man or feel what I thought being 40 would feel like. The obvious advantage of being that “old guy” is there is a LOT more wisdom that comes with age (thankfully).
As a dentist, my profession lends a particular perspective to aging as I have clients that range in age from teens all the way to 90+ years of age. There is a particular challenge for my generation and those that are a little farther along because of the rapid and quite significant changes that have occurred in the last 30 years. So, like most of you in the 40-65+ age range, I was at the dentist as a child and received those “old-school” mercury-based silver fillings (aka “amalgams”). I even got to play with the mercury one time before they mixed it. Wow, a liquid metal!
There are a plethora of patients that still have these amalgams that were done in the 50’s, 60’s, 70’s, 80’s, etc. You might be shocked to hear that there is still a significant percentage of dentists that STILL place mercury-based silver fillings in adults AND children. In the military today, it is still the “go to” restoration of choice. My personal belief is that there are really only two uses for Mercury-based amalgams today. 1) If you are a military dentist on the front lines, and you have to get your soldiers back into the field of battle quickly with a dental material that has very low technique sensitivity, then amalgams are great. They can be placed with blood, saliva, and all kinds of other contaminants in the mouth. They set up quick and require little adjustment. It’s cheap and requires little instrumentation that is expensive. 2) There are certain patients that are “next to impossible” to work on. These are typically the extremely elderly patients that are stricken with Alzheimer’s, dementia, or Parkinson’s. Most modern dental materials require isolation of the tooth being fixed (no contact from the tongue, saliva, blood, and especially no humidity) in order to do the procedure right. So, amalgam, which is easy and not environmentally sensitive, is a great option. One added bonus, elderly are not at risk of additional harm from a low amount of mercury (what is present in amalgams) compared to a younger person.
Another interesting thing about amalgams is that they have been banned in Europe for anyone under the age of 18. I believe this is a bold statement by the Europeans to say that “we can do better.” While I have zero evidence of this, I think that the American Dental Association (ADA) could not be so bold because they might open up the chances for legal action. Considering the sheer number of frivolous lawsuits in the U.S.today, I can only imagine the mass of lawyers that would be ready to run commercials saying, “Did your dentist place mercury fillings in your mouth? Call us! We can help!” I truly believe that the ADA should take more aggressive steps to truly dissuade dentists from using this material. A ban on using amalgam in kids 18 and under would be a great start. The real risk is that a study comes out that shows a direct link from these fillings and serious medical conditions. Even worse, if someone in the ADA knew about it and hid this fact. Separate of all these hypothetical situations, what really matters is that we CAN do better.
So, where are we now? We are 2 or 3 generations stuck in between a technology and dental-material revolution. How so? Most kids that were born in the 80’s or after had sealants placed on their teeth. Preventative, conservative treatment BEFORE decay started was the new modality starting in the 80’s. Our generations started a down an irreversible path that has been documented in study after study. What path? Once an amalgam is placed, on average 5-7 years later it needs to be replaced with another filling. Then another 5-7 years later, you need a crown, an onlay, a root canal, or even an extraction! Even worse, amalgams do NOT bond to teeth, nor do they increase the strength of them. They only serve to keep food from packing in the hole. But in reality, microscopically, amalgams start leaking and letting in bacteria (that cause decay) in a relatively short amount of time. It is a prescription for failure.
Unless you’re a dental professional, it’s really hard to know all the capabilities and options available today. The most highly trained and most progressive dentists these days are being paid by their patients to SAVE tooth structure. This is exactly the opposite philosophy of traditional business and insurance models. I’ll explain more in a second. The material and technology revolution has given us the capability to avoid the traditional crown prep where a tooth looks like it’s been drilled down to a small peg. There are many philosophies out in the world. It’s not my job to tell you which is right or wrong, but they all have pros and cons. If I’m your dentist, would you rather pay me MORE to take my time and see how conservative I can be, or would you rather me just “prep it to a nub” and finish a little quicker? My own personal belief is to vote on being conservative. The challenge is changing the perspective of not only the dental profession and the ADA, but most importantly insurance companies.
The fee scale in dentistry is based on the concept of “the bigger the filling or restoration, the more expensive it is.” There is less value built into the system these days for dentists who are conservative. Example: I typically will be paid more to do a build-up and a crown than I would be to do a porcelain onlay (which saves cusps and LOTS of tooth structure). I can prep a crown in about ten or fifteen minutes easily. Other than the build-up (used to idealize the shape and retention of a crown), it is a relatively simple procedure. However, prepping an onlay typically takes MUCH more time. Why? It’s a prep which requires conservative removal of an old amalgam, time to search out additional decay, cracks or fractures, time to determine which cusps or how much tooth structure can be saved, and more time to idealize a preparation shape that will allow for the onlay to fit precisely.
Why not just start doing ultra conservative dentistry? The problem is the ADA and insurance companies typically agree to higher fees for the “quick-n-easy-n-aggressive” crown prep vs. paying a greater fee to be conservative. So, as a result, most dentists cannot afford to mess with trying to be as conservative because they a) don’t get reimbursed as well, b) don’t get paid for their expertise, and c) the WHOLE SYSTEM does not value conservative dentistry especially when large restorations (what would normally be crown preps historically) can NOW be something that may save 60-70% of the enamel and remaining tooth structure. Keep in mind, if a patient develops decay on that same tooth at a later stage (which is entirely possible) a crown could still be done!
The ultimate challenge for us “healthymidlifers” (and un-healthymidlifers trying to get healthy) in dentistry is really insurance companies. I politely refer to them as evil entities, but they are really far worse. Their CEO’s get paid multi-multi-million dollar bonuses annually because they “saved their policy-holders money,” “earned the share-holders more,” and “found ways to cut cost for the benefit of all.” Read carefully into those statements. The long and short of it….. they hire HUGE legal, marketing, branding teams and corporate gurus, all to find a way to “negotiate” with physicians and dentists to decrease their fees. How does this translate to you, the patient? Insurance companies continually pressure dentists to do the same procedure at a lower fee and they try to deny claims for procedures that should be covered. Are dental materials decreasing in cost? Are employee payrolls going down? Are lab fees decreasing? The answer is a resounding “no” to all of these? Overhead in dentistry (and medicine) is going up every year.
Why is this a problem? I’ll answer this question with another question. Do you know what the average annual dental insurance benefit was for someone in 1960? It was about $1000. Do you know what the average annual insurance benefit is today (over 50 years later)? It is about $1000. You, the patient, are being short-changed. If you don’t use your benefit, the insurance company makes money. If you DO use your benefit (coverage), they limit you in how much they cover! How many of you have been denied coverage on a procedure that should be covered? How many times were you mad at the dentist’s office about the denial? Is it the dentist’s fault? Insurance companies have been sued and found guilty in multi-million dollar class action lawsuits on multiple occasions for having a protocol to deny covered procedures many times. Their hope is that you, the patient, or the dentist’s office tires of re-filing the claim. The longer the insurance company does not have to pay means the more money they keep and make interest on! Given these companies can have millions of clients, that is a LOT of money they are keeping in their big pockets. You have to ask yourself, “What companies occupy most of the big buildings in downtown areas across the country?” Think about it. Now you know who is really making money in this age of skyrocketing health care cost.
As healthymidlifers, whether you are a dentist like me, or John Q. Public, the challenges are out there. I could expand more on this topic, but to a certain extent, it feels like beating a dead horse. I am not a whiner. No one has an easy option this day in dentistry or medicine. Challenges abound. There are rays of hope out there, but don’t expect your benefits to change any time soon. Don’t expect traditional dentistry to change quickly. There are those dentists who are going to be on the cutting edge and those that will stay the course. What I hope to do is help you know the difference. It takes dedication and a belief that things can be better to think outside the box. If you are looking for dentists who believe this way, they are not terribly hard to find. Ask your friends and neighbors who they see and if they like them. But beyond that, don’t choose based on one opinion. Look online at doctor websites. What kind of work do they show? What do they say? A healthymidlifer cannot be afraid to ask questions! A cutting edge dentist is going to be excited to tell you about all the cool stuff that is happening. A “stay-the-course” type is going to get tired of your questions.
I am particularly excited to be a dentist in 2012! We, as a profession, have an amazing opportunity today to truly affect people’s lives on a grand scale. Over the next several months, I will write more about different topics in dentistry: CEREC CAD/CAM technology, implants, i.v. sedation, snoring/sleep apnea, new porcelain materials, smile makeovers, and even air quality! I hope that this little dental intro for healthymidlife.com created some excitement and even awareness so you can ask the right questions (or be better prepared) for your next challenge in midlife.
Health and happiness to you!
W. Scott Wagner, DMD, LVIF
Smiles, Skin, Sports and Wellness
Dr. Wagner is a new guest blogger to our healthy midlife family. Dr. Wagner has been Kathy’s dentist since he came to Jacksonville almost 15 years ago. His office exceeds expectations. He has a wonderful professional staff and I actually enjoy my time there. Dr. Wagner is going to be writing a series of articles at our request. Hope you enjoy them!
Filed under: Middle Age Health
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