How Honest Are Dentists?

BY JERRY MACDONALD

THE WHOLE office is buzzing. Upbeat music, upbeat staff -- a small army of receptionists and assistants. As I'm in for a new-patient examination, I am asked to fill out a questionnaire about my oral history. That done, the dentist arrives. Confident. In his late 30s. I offer him my X rays. He wants to take more. I decline. No matter. In no time a miniature movie camera attached to what looks like a screwdriver with a headlight is stuffed into my mouth while overhead a television screen angles in. I'm about to undergo an "intraoral examination," which is like high-tech cave exploration with your mouth as the cave.

       The camera operator focuses on something ugly in my mouth. Click! The TV screen splits into quarters and my first trouble spot becomes a still photo. Soon the doctor has a fistful of photos. We go over them.

       The verdict is not good. Cavity on tooth 42. Fillings failing on 44 and 17. Both need PFMs (porcelain fused to metal crowns). Cost: $1,361.

       However, the doctor says, if I want to enjoy worry-free dental health, all the large fillings in my mouth should be pulled and replaced with crowns. As for my two missing lower-right molars, he recommends implants at a ballpark figure of $3,000. And for my missing front tooth, knocked out in a fistfight in my youth -- the gap now filled with an eight-year-old Maryland bridge -- he suggests another $1,500 implant. Altogether, for a full mouth reconstruction, I should expect to spend $8,000 to $10,000 over the next three to five years.

       Outside, my mind reels. $10,000! I think back to my 1960s childhood, when you only went to a dentist to fix a toothache. But today is Millennium Time. The age of intraoral examinations and cosmetic mouth reconstruction.

I WAS IN Kamloops, B.C., on a fact-finding assignment for Reader's Digest to assess the consistency of Canadian dentistry. My task: Visit 45 dentists picked at random from towns and cities across Canada, show them my teeth and a set of X rays, and ask each doctor what needs to be done.

       At each office my story is the same: I am moving into the area and want to become a new patient. My dental expenses are covered in part under a dental-insurance plan. I am interested in maintaining good oral health and am satisfied with the appearance of my teeth. I want a treatment plan and written cost estimate. Considering that Canadians pay $2.5 billion a year to their dentists -- whose average annual net income, according to the Canadian Institute for Health Information, is $106,661 -- it is an important assignment.

BEFORE setting out on my cross-Canada mission, I visited my own dentist in Quesnel, B.C. I've known Dr. Al Baker for 15 years, and I trust him. He checked me over. Small cavity on tooth 18. A watch on tooth 44. A crown on my five-month-old root canal in the near future. Cost: $665. However, if I was to go for a cosmetic package, I would be looking at another $600 for a crown on tooth 17 and $2,400 for a bridge in my lower-right jaw. Total: $3,665.

       We had talked about the need for this cosmetic prosthetic in 1989 and 1990, but I had begged off because of the expense. We never talked about it again, even though I had since had many checkups. I asked him why.

       "I don't push," Baker replied. "If I make a recommendation and the patient doesn't respond, I back off, unless, of course, I see the condition worsening." Competition, high operating costs and perhaps a lack of proper teaching of ethics, he believes, are steering more and more dentists to sell services.

ARMED with Dr. Baker's diagnosis as a yardstick, I head for Vancouver and my first appointment.

       There's nothing swish about Dr. Allan Addems's office. A two-metre privacy divider separates the doctor from patients waiting on stacking chairs. He probes my mouth. "Your fillings look like they were carved by an artist," he proclaims. He also has kind words for my old Maryland bridge. "Wonderful job." After a 25-minute exam, he concludes: "Your teeth are in good shape. I could recommend an implant for that front bridge of yours, but at $2,000 or so, they cost far too much. And there's no guarantee it won't break. So until we can duplicate the enamel of Mother Nature, you may as well continue with the bridge you have."

       Cost: $95.70 for the exam and a cleaning.

       It's a different story at another dentist across town a few hours later. "For good long-term oral health," she recommends crowns on teeth 15, 16, 17, 26 and 36 and a bridge for the missing molars in my lower-right jaw. Estimated cost: $5,350. She also recommends that I have my teeth cleaned, despite the fact I just had them cleaned four hours earlier!

APPOINTMENTS in Victoria, Pitt Meadows, Kelowna and Kamloops, B.C., follow. And by the time I reach Alberta, I am feeling confused. Take cavities, for example. In Victoria alone, two different dentists spotted totally different teeth with cavities: One said there were cavities on 11, 22 and 23; the other mentioned 41, 42 and 43.

       So far, three of ten dentists have pronounced me cavity-free. But others have spotted cavities on teeth 11, 18, 22, 23, 24, 42, 43 and 44. I have also been told I should have crowns on teeth 15 (two dentists), 16 (three dentists), 17 (four dentists), 26 (six dentists), 36 (three dentists), 44 (two dentists) and on teeth 11, 22 and 47. Six of the ten doctors suggested I needed a bridge.

RELIEF comes when I reach Red Deer, Alta., and the office of Dr. Cheryl Handley, who gives me the most thorough examination yet -- bite, gums, jaw, glands and an oral cancer check. She says I have no cavities but there are signs of gum disease. She suggests that I consider having crowns for my two root canal teeth (17 and 26).

       "Are they necessary?" I ask.

       "No, not really," she replies. "The fillings you have could last you another 20 to 25 years. But the crowns would give your teeth added strength."

       Good news again in Saskatoon. "If they were my teeth," says Dr. Alan Schappert, "I'd stay with what I've got. Your teeth are solid and should last for many years." He recommends a cleaning in a few months time and bills me $50 for the exam.

       In Regina the first dentist I see finds "nothing" and charges $20, advising me to keep "brushing and flossing." A few hours later, I'm in an office that, like so many others I visit, offers lots of pamphlets on happy smiles -- how to get one, how your dentist can help with aesthetic surgery, etc. The doctor does a thorough examination. Cavity on tooth 36 needs a filling, and he puts a watch on 16 and 17. He asks if I have insurance and if I am happy with the appearance of my teeth. I say yes and yes.

       "Well," he says, "let me say straight off that your teeth are healthy. Any recommendations I give are from a long-term dental perspective." He recommends crowns for 17 and 26 -- my root canals -- a bridge for my two lower missing teeth ("You could lose your upper-right molars, which will erupt if you don't bridge that gap"), and should my old Maryland bridge fail, I should consider putting in a "proper" bridge, which would greatly improve my smile. Total estimate: $6,500.

       That bridge for my lower-right jaw keeps coming up. A dentist in Moose Jaw is quite adamant: "If you don't get a bridge, you'll lose those teeth on top. There's nothing to stop them from moving down farther."

       But in Brandon I'm told: "I don't think you need a bridge to replace those two missing molars. You won't lose those upper teeth if you don't have a bridge, it would just even out your bite." But I do have cavities on 16, 36 and 37.

       That's not the opinion I get in Winnipeg. "You will lose those teeth, definitely, if we don't do something with those missing bottom molars," a dentist there says, adding, "I will want to talk to you about implants." But a colleague in the same city doesn't even mention those missing bottom teeth. And he tells me my fillings "could last for years."

BY THE time I'm ready to move on to Central Canada, Iam deeply confused -- and angry. After 16 appointments I have been told I need implants (by three dentists); bridges (by eight dentists); partial plates (by two dentists). But I've also been told by five dentists I have no cavities, and two dentists have told me I need no work at all -- just floss and maintain good oral health.

       Surprising? Concerning cavities, University of Manitoba dentistry professor Blaine Cleghorn says: "You'll probably see some differences between dentists. But it shouldn't be such that one dentist finds you cavity-free and another finds 20 cavities. One may be missing defective fillings or cavities and the other may be diagnosing problems that don't exist. Silver fillings can last the tooth's lifetime and may not require a crown unless the strength of the tooth is compromised."

       As for implants and cosmetic dentistry: "These are big-ticket items, and it's in the best interest of the patient to get a second opinion. The vast majority of cosmetic work is elective. It shouldn't be presented to patients as something that has to be done."

       It's a piece of advice I take to heart when I reach Toronto. Each of the three dentists who examine me -- two of them with intraoral cameras -- recommends work that comes to over $8,000. One doctor's assistant assures me that "cosmetic surgery is the doctor's pride and joy." I'm sure it is.

DENTISTRY, it seems, has become a victim of its own success. There are now more than 16,000 licensed dentists in Canada. Thanks to their advice, people are taking far better care of their teeth -- flossing more, brushing and rinsing after meals, having regular checkups. That, plus cavity-fighting fluorides in our water supplies, has resulted in less demand for drill-fill-and-bill dentistry and more for cosmetic work.

       Maybe that's why in Montreal I get the highest quote yet -- $10,000-plus for work that includes four crowns and three implants at $2,000 apiece. However, moving on to Hull, Dr. Rhéal Charron tells me: "If you ever get rich, talk to me about implants for that lower-right jaw. But it would cost a fortune and it's really not worth it. You won't lose those upper teeth." His verdict: no cavities, no bridge needed, no crowns recommended. Cost: just $47 for the new-patient exam.

IN SAINT JOHN, Fredericton and Moncton, N.B., I'm told my teeth and gums are in good shape. And I have no cavities. But each doctor brings up that old lower-right jaw. One thinks implants may be the answer but suggests I consult a specialist first. Another says, "You will lose those top teeth in time if you don't deal with that gap in your lower-right jaw."

       The dentist in Charlottetown disagrees. He volunteers that "I see a lot of patients who, quite frankly, have been overserviced. I've even seen crowns placed on loose teeth."

       When I open my mouth to a Halifax doctor, the first thing he says is "interesting" followed by an ominous, "hmmmm, too bad." And he goes on to tell me: "You have a high arched palate, like a cathedral. That's why you had overcrowding as a child and had to have some teeth pulled. You should have had braces and a palate expander installed. Now the only way to resolve that problem is to surgically split the roof of your mouth and put the expander in. It would solve the problem of your bite, you would be able to sleep better, and you wouldn't snore as much." He recommends a whole lot of other work that comes to over $8,000 without the palate surgery.

       I retreat to kinder Sydney, N.S., where I'm told: "I don't see anything that requires immediate attention. I would recommend a cleaning, however." Cost of exam: $30.

       And so on to St. John's, Nfld., where a grey-haired dentist remarks: "There's been some heroic work done on your mouth. Most often a dentist would put a crown on root canals, but in your case he saved you hundreds of dollars and went with fillings. And they're fine." He puts a watch on 41. No cavities. Recommends a cleaning in two months time. Cost of exam: $18.

AT THE end of my oral odyssey I ask myself: How can the same mouth yield such wide-ranging diagnoses? And such different fees? Each provincial dental licensing authority sets treatment fees for its members to follow. They are not mandatory and they vary. But overcharging, I believe, is not the problem. Over-treating is -- the recommending of work that is not really necessary. The ideal of the "happy smile," whiter, straighter teeth... no silver in the mouth... no dentures in old age -- it's all for the asking. And the paying.

       So what advice can this much-travelled patient offer?

       First, know what you want before you sit down in the dentist's chair; a fix for a sudden attack of pain? Basic maintenance for a healthy mouth? A cosmetic remake?

       Second, know what you can afford or what treatments are covered in your dental plan and for how much. Ask for a written estimate. If prices seem stiff, get a second or third opinion.

       If you are still unsure about fees or have a complaint, consult your provincial dental association. The old rule in dealing with business -- any business -- applies: Caveat emptor -- let the buyer beware.

       My much-probed mouth can attest to that.