Avoiding the Four Major Scams in Dental Hygiene
Avoiding the Four Major Patient Scams in Dental Hygiene 10-5-2024
By: Michael W. Davis, DDS
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The landscape within the dental industry is in major flux. The dental insurance industry has kept payouts to dental providers nearly static for well over the past decade. Over that same time, costs for labor and supplies have witnessed substantial increases. The COVID-19 pandemic forced large numbers of dental hygienists out of the workforce, with many never to return.1??? ?These disruptions altered delivery of dental hygiene services, as well as all dental care.
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How did the dental healthcare industry adjust to stagnant and inflation-reduced payouts by the insurance industry, including the labor shortage of dental hygienists?
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Initially, many providers attempted to absorb the lost revenue (termed a “loss leader”) from dental hygiene services and basically “eat their losses.” Very quickly, this approach proved to be fiscally untenable. Providers would either need to be transparent and charge appropriately or discover and embrace deceptive work-arounds.
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Many patients observed their dental care providers increasingly informed them that they would continue to receive the trusted therapies they always enjoyed. However, many dental providers embracing integrity were now classified as “out-of-network.”
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Out-of-pocket expenses to patients frequently went up. Ethical providers refused to short-cut clinical measures such as infection control, oral cancer screenings, or a thorough and complete dental cleaning. Since employers purchasing dental plans and the insurance companies themselves refused to make appropriate payouts, the public was on the hook.
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The dental insurance industry countered this move towards dental providers going out-of-network by marketing to patients and employers the great financial savings they realized by utilization of an in-network provider. Out-of-network dental providers were portrayed as greedy, and as the super-wealthy. In reality, the opposite is true.
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In fact, it’s common for a respected dentist to be handed a list of in-network dentist providers by a patient. These lists are the names of dentists and their affiliated corporations which accept a specific preferred provider plan (PPO). The patient asks, “Can you recommend anyone on this list?”
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Although a diminishing number of ethical providers hold out and work themselves to the bone, an unfortunate number of the listings are frequently a rogues’ gallery within the dental profession. Some are active within the addictions of drugs and alcohol. Others are known for delivery of highly suspect quality of care. Others are outright crooks. The venerated term “hands of stone”? was applied to the boxing legend, Roberto Duran. By contrast, “hands of stone” holds a highly negative connotation in reference to a clinical dentist. Generally, the public is fully unaware.
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In essence, elements of the dental insurance industry have made a tacit deal with the devil. They keep ?profits exorbitant and sell discount plans of dental service delivered by questionable providers. The dubious providers are ensured a continual flow of patients by the insurance industry. The employer offers an illusion of offering a valuable employee benefit. All the while, the dental consumer perceives themselves as realizing a great deal in healthcare.
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Options for Dental Consumers
If you already enjoy a trusted and caring relationship with a dental provider, talk with them, and take their advice. They have insider information on the community of other dentists, the world of corporate dentistry, and the games and manipulations of the insurance industry. Do not be surprised if they decline to provide all the gory details, but you should be pointed in the right direction.
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If you lack such an open relationship with a dental professional, it is well past time to establish one. Talk to your trusted family members, valued co-workers, and close friends for a recommended dental professional.
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Never rely or depend on dental healthcare advice from TV or radio ads. It is well-known within the dental industry, that the dental corporate chain with the most abysmal dental care also enjoys the most warm-hearted advertising. Advertising of happy smiling patients and wonderful payment plans often contrasts with the reality the company’s multiple litigations from abused patients, harassed employees, and various state attorneys general offices.
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Once a dental patient states, “I only want what my insurance covers,” options can get very grim and very quickly. If the insurance payout is below the costs involved to provide services to standards of care, patients can be vulnerable to a variety of scams. In reality, few will protect such compromised patients.
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Difficult Landscape for Dental Patients
Since the insurance fee schedule payout to providers for hygiene services is commonly inadequate, certain providers opt to employ questionable practices. Assuming this is always at the doctor’s discretion can be a fallacy.
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Whether the name on the dental office door is that of a corporate chain or an individual dentist/owner may be inconsequential. Numbers of corporate dental chains utilize stealth branding, such that ownership is highly cryptic. What you may assume to be a clinic owned and operated by a dentist is often in fact a tiny cog in a larger corporate affiliation.
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Beneficial ownership and control, inclusive of clinic policies, are frequently managed by unlicensed and unseen “suits.” These managers place return on shareholder investments (ROI) to the fore. Patient care is often a secondary concern, if considered at all.
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Like every dental service rendered, dental hygiene therapies MUST generate corporate profits. Debt service on subprime bonds must be paid and shareholders expect significant returns on their riskier private equity investments.
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Since corporate management lacks dentistry licensure and ownership is often masked by nominee dentist owners, many state dental regulatory boards are reticent to step up and protect the public interest. In fact, through regulatory capture numbers of dental boards highly influenced if not outright controlled by factors within the dental support organization (DSO) industry. *
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*(Author’s note: dental support organization (DSO) is an intentional industry misnomer. It is designed to misrepresent these companies as limited to support of non-dental services, when in reality they profit from control of ownership and are affiliated (or outright) owners.)
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One unfortunate resulting scheme is to run patients though dental hygiene services quicker than green grass through a goose. Dental cleanings are habitually incomplete, unnecessary lacerations (cutting) of patients’ gingiva (gums) are generated in a rush to move patients in-and-out, and dental hygienists frequently suffer from workplace burnout with ensuing staff turnover.
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Regardless, corporate management turned a profit and patients who only wanted what their insurance paid for, got what they came for.
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Four Common Dental Hygiene Upselling Scams
Dental clinics have realized they must serve their local demographic, or a niche demographic to remain in business. In more educated and affluent communities, dental facilities have often decided to be upfront with their patients. The greed and manipulation within the dental insurance industry have been made noticeably clear by groups such as the Alliance of Independent Dentists,2? ??????????American Alliance of Dental Insurance Quality,3??? ?as well as the surrounding debate and education with passage of Massachusetts Question 2 on insurance dental loss ratios (DLRs).4,5,6??? ??Numbers of patients accept that their dentists have been forced to go out-of-network with many dental plans, in order to maintain a reasonable standard of dental care and not take clinical short-cuts.
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Others in our population are less fortunate. Their financial position may force them to select between poor compromised care, or no dental care. It has been an open secret for many years that unlicensed dental assistants have been unlawfully providing dental prophylaxis (cleanings)7,8? ??which only dentists or dental hygienists are legally certified to provide. Uncertified dental assistants also too commonly take dental x-rays increasing risks to patients.9,10
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A deceitful so-called middle ground has developed in which patients are provided with proscribed artificially discounted dental hygiene services under their insurance plan. The bait-and-switch is to ?upsell ancillary dental therapies to make up for the economic shortfall. In most cases, especially with certain corporate dental chains, these add-on therapies cost patients more than seeking care with out-of-network providers. Further, these additional out-of-pocket expenses often have minimal to no clinical efficacy.
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In essence, patients pay to makeup for the insurance shortfall with treatments which cause minimal to no harm, but usually lack appreciable clinical benefit. And they generally pay more overall, than if they sought care from an out-of-network dentist, who declined to participate in dubious practices.
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The art of this bait-and-switch scheme has been brought to its zenith by certain large and small corporate dental chains. Many will retain an overall dental hygiene manager, who is tasked with establishment of dollar production quotas for dental hygienists within their companies. Competitions are levied between individual dental hygienists as well as different clinics within the chain, challenging who generates the most dollar production.
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These dental hygiene managers, often formerly practicing dental hygienists, create a workplace atmosphere somewhere between a gameshow and a grim factory sweatshop. Those dental hygienists selling patient services at the highest levels are rewarded with bonuses and company gifts. Those dental hygienists falling short of their assigned sales quota may face company exposure with resulting humiliation and ridicule. Others overtly fear termination with failure to meet company sales goals.
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These dental hygiene managers share production numbers throughout their companies to keep the pedal the metal, for optimal corporate revenue generation. Individual dental hygienists are viewed less as a valuable trusted professional, and more as a savvy salesperson.
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1.????? Chlorhexidine Irrigation
Chlorhexidine gluconate has long been utilized in the dental field as an effective therapeutic agent. It reduces redness and swelling in patients’ gingiva (gums). It is also a valuable germicidal chemical.
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Chlorhexidine has been utilized as a liquid chemical adjunct in services such as periodontal surgery, oral surgery, with scaling and root planing (deep dental cleaning)11?? and for patient home use after surgery or root planing.
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Chlorhexidine gluconate 0.12 % ?dental mouthrinse in 16 ounce bottles may be purchased online, with or without a prescription. The price should be well under $10.00/ bottle, especially if buying a bulk case order.
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The deceptive practice is to add an out-of-pocket fee to patients for chlorhexidine irrigation of $40-60 per quadrant treated (The mouth has four quadrants.). Yet, this only uses maximally 2-3 ounces of chlorhexidine solution per quadrant. Many dental practices will also add on this fee to standard dental cleanings.
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In an ethical dental practice, chlorhexidine irrigation might be provided by the dental provider, if seen as beneficial to the patient. However, there would be no additional service charge to patients.
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In sketchy dental practices, it is common to see this cost charged to patients. As has been earlier illustrated, dental provider companies may force their dental hygiene staff into sales promotions of this added service which ethically should be inclusive.
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Mendacious methods are achieved to make up for the shortfall of revenue from the insurance industry, and catapult even higher production dollars often for private equity firms.
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?2.????? Adult Fluoride Treatment
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Fluoride treatment in-office can help reduce the rate of tooth decay. This preventive service may be especially beneficial for children with high caloric intake, poor homecare oral hygiene, and a diet high in sugar.12
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It can also be beneficial for senior patients who may lack the physical ability or cognitive skills to maintain effective oral homecare hygiene. Patients with exposed tooth root surfaces, which lack a dense protective coating of enamel, may also be more at-risk for dental cavities. This group of patients may significantly benefit from in-office dental fluoride treatment.13??
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Adults suffering from a variety of conditions associated with xerostomia (commonly called “dry-mouth”) may also be more prone to dental cavities. These patients may also benefit from in-office fluoride dental therapy.14
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However, an across-the-board, all sizes fit one, use of topical fluoride is a waste of dental consumers’ money. Some selected groups of adult patients may see benefit, while most adults with a lowered rate for dental tooth decay see no reward with topical fluoride treatment.
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Again, providing and universally charging adult dental patients for topical fluoride therapy is unwarranted. This service must be examined on a case-by-case basis. Yet, this treatment is too frequently abused as a moneymaker.
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3.????? Universally Diagnosing All New Adult Patients as Needing Scaling and Root Planing (Deep Cleaning)
Patients who require initial periodontal therapy of scaling and root planing may not have seen a dentist for many years. They have calculus (tartar) buildup under their gums generating infection locally, which may impact entire body systems systemically (cardiovascular disease, diabetes, complications in pregnancy, etc.). Sometimes the regions requiring deep cleaning are localized to a single isolated area. Other times, the entire mouth (all tooth root surfaces) needs addressing.
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Unethical practices arise when an adult patient has been getting regular dental visits and exhibits an exceptionally clean and healthy oral condition. They are told they are not eligible for an advertised discounted fee dental cleaning of $14.95 (or some other ridiculously low price). They are told they are not eligible to receive the dental cleaning which their dental insurance purportedly pays. Their only option is a deep cleaning which includes a sizable? personal payment.
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In such situations it is imperative patients seek a second opinion. Get names of providers outside that list which the insurance company offers. Avoid a corporate dental chain, which is not always that easy to ascertain. Seek counsel from trusted friends, family, and coworkers.
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The dental industry is not like it was years ago. Charlatans and hustlers are more rampant. That once trusted and venerated professional may be just another spoke in a corporate wheel. In fairness, the squeeze of the insurance industry has not been favorable to dentistry.
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4.????? Rampant Insertion of Tetracycline Antibiotics into Periodontal Pockets
Periodontal pockets are spaces surrounding tooth roots under the visible gum line. This space can and should regularly be examined by your dentist and dental hygienist. A measurement of 1-3 mm is usually considered normal. A measurement of 4-5 mm may be considered early periodontitis, if associated with bone loss and active disease (active bleeding on gentle probing). Increased measurements are generally associated with moderate to advanced periodontal disease and loss of the bony architecture. Pathological bacterial may enter this space and cause disease, which results in swollen and bleeding gums, loss of tooth supporting bone with tooth loosening, and eventual tooth loss.15
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Initial therapy of periodontal scaling and root planing is delivered first, for moderate to severe periodontitis. Clinicians must assess if any unresolved sites are best referred to a specialist in periodontics, surgery and the type of surgery, a follow and treat on an “as needed” basis, or the option of localized antibiotic therapy on a site-by-site consideration.
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Unfortunate realities have come to the fore, in order to make the corporate numbers work. When periodontal probing numbers fail to meet or exceed ?5 mm, dental hygienists are often told by management “lean harder into your probing.” (Author’s note: Yes, that sounds ludicrous and painfully abusive to patients, but I have been told the exact same quote from multiple dental hygienists.)
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Frequently, patients are upsold the treatment for deep cleaning and placement of tetracycline antibiotics at the same exact visit. In ethical practice, only after the deep cleaning of scaling and root planing is reevaluated should antibiotics come into clinical consideration. The cart is placed before the horse, in order to make the quick sale and maximal dollar production.
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One early study seriously discounted any long-term efficacy of locally applied minocycline for adult patients.16?? ??Minimal pocket reduction was generated with this therapy. “The present patient group responded favourably to scaling and root planing but did not benefit from an effect of local of minocycline (type of tetracycline). Subgingival debridement in combination with oral hygiene instruction by itself has been shown to be effective.”?
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To highlight the skepticism over the periodontal benefits towards antibiotic locally applied, one only need review the literature and pharmaceutical manufacturer monies poured into potentially alter and influence research. A 2023 journal article advocating the efficacy of localized minocycline to treat chronic periodontitis was retracted by the publisher.17 ????
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?“… following an investigation undertaken by the publisher. This investigation has uncovered evidence of systematic manipulation of the publication and peer-review process. We cannot, therefore, vouch for the reliability or integrity of this article. Please note that this notice is intended solely to alert readers that the peer-review process of this article has been compromised.”
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Dental offices typically currently charge approximately $50-120 per placement of a localized antibiotic. Since a tooth has four different root surfaces (front, back, outside, and inside) the cost theoretically could range close to $500 per tooth.
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Obviously, placement of these antibiotics can be hugely profitable, especially when delivered by clinical personnel less expensive than a doctor.
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Conclusion
The public has come to be at a huge disadvantage as dental consumers. The dental insurance industry has forced dentists into an economic vice and turns the lever handle ever tighter. The public has no way to determine if their doctor and their clinical decisions are made exclusively in the patients’ best interest, or to tacitly serve corporate management, or to compensate for inadequate insurance coverage.
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As corporate dentistry has expanded, dental professionals like dental hygienists and doctors, may have few employment options working outside a corporate scheme, which often places profits above patient welfare. A sign on the dental office door is no true indicator of the clinic’s beneficial ownership.
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This article has elucidated the four most common scams in dental hygiene. These include charging for chlorhexidine irrigation, rampant all-inclusive adult fluoride treatment, universally diagnosing all new patients as needing deep cleaning of scaling and root planing, and finally upselling needless localized antibiotics on an excessive scale.
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No one is coming to your rescue. State dental regulatory boards have often been coopted by corporate dentistry concerns.18? ????The dental insurance industry, like most of corporate chain dentistry, serves the interests of shareholders in generation of maximal ROI.
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Organized dentistry is so strapped for cash, and hopeful that the DSO industry (corporate dentistry) will assist finance their operations, that the ADA misrepresents DSOs to the public and profession.19????????? ?DSOs are in reality the true beneficial owners of dental practices.20? ???
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The ADA half-truthfully alleges, “Dental support organizations — commonly known as DSOs — are entities that offer administrative, marketing, and nonclinical support to dental practices. Practice owners contract with DSOs to manage the business side of their practice while they focus on providing care to patients.”
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Patients are on their own, to provide their personal due diligence in support of their family’s dental healthcare. A formerly universally proud profession still retains pockets of honesty and integrity.
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When you find those often hidden gems of ethical dental healthcare, please support them. Without your patronage these dental practices may not survive to see our next generation.
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References (accessed 10-5-2024)
1.????? https://www.ada.org/about/press-releases/research-reveals-impact-of-covid-19-on-dental-hygienists
2.????? https://aid-ma.org/
7.????? https://www.rdhmag.com/career-profession/article/16406591/illegal-dental-assistant-activities
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Michael W. Davis, DDS graduated from the Ohio State University College of Dentistry in 1981. He has participated a range of clinical care including public health, private practice, school-based programs, correctional facility dental care, and locum tenens. His private general practice in Santa Fe, NM was retired in July 2024. Dr. Davis continues to write and lecture on a variety of dental legal and ethical topics. He also serves as consultant and dental expert to a number of law firms. Dr. Davis may be contacted at [email protected] . ?
dentist
1 个月This recently came out from JAMA Internal Medicine: https://medicalxpress.com/news/2024-10-dental-states.html?fbclid=IwY2xjawGA9WBleHRuA2FlbQIxMQABHeLHs6ZjHa5Dcmt9J9HQD_vC0cRzeJjPMruVS5sjK8QPROT_9uPaXcAdxA_aem_rKE9jJ6O72NXpKbWIfBvHA I don't agree w/ every aspect the authors went to. However, many of the same pressures imposed by private equity control & ownership of healthcare affect both medicine & dentistry.
Dentist at Scott R. Dexter D.D.S.
1 个月Fantastic article on the balance! Only concerns it gives me are that the public is poorly equipped to handle nuance in a specialty subject. Many would read this as "fluoride=sheister" rather than "Fluoride in adult patients as a general practice benefits the practice more than its patients" I'm also concerned with the criticism of peer review. I'll admit that the current iteration of peer review is poorly implemented and needs reform but an effective peer review is the foundation of science. Saying "the peer review process of this article has been compromised" to a general audience that doesn't handle nuance well can easily be misinterpreted as "the peer review process is compromised". If internalized, this statement will cause devolution into magical thought. Thanks for being willing to be overt about the challenges our profession is facing and helping patients gain a framework from which to differentiate practices that serve patient interests over those of the practice.
Today’s Dentistry
1 个月Spot on!!!
Self Employed at Irving Park Dental Center, Ltd
1 个月While this article contains some sweeping generalizations, there is more than just a kernel of truth to the unprofessional influences on dental hygiene departments in dentistry today. (That is to say, hygienists are wonderful, but too many of their entrepreneurial employers are not, and the influence of PPO plans doesn't help one bit, sometimes to the point of being the rationale for the treatment sales schemes highlighted by Dr Davis.)