Why is Dentistry Expensive?

By FDA President David F. Boden, DDS, MS

Really, the question should be: Why is my dentistry expensive? To answer that, I will tell you a story about what happens in your mouth, and mine.

With few exceptions, we are born with the code for great oral health. Our teeth grow and form and eventually say, “Hello,” to the world, hugged nice and tight by healthy gums, ready to do their job for our bodies in helping condition food for digestion. Soon after, they make their premiere, they will be exposed to the enemy of any mammal: bacteria. Bacteria have one purpose: to feed on us and break us down. But they also get a free meal every time we eat. They form colonies of bacteria on our teeth we call plaque, just like they do on high school biology class petri dishes.

Some bacteria convert parts of that food into acids, which allow them to etch into a tooth’s nice, hard, pretty enamel. If they are there long enough, those acids will eat right through into the nerve in the center of that tooth. Our body senses that and registers it in the brain as pain, saying something is very wrong and needs attention. There are other bacteria that make their homes in gums. They feed on tissues, triggering our bodies to fight back with what doctors call an inflammatory reaction. This causes bleeding gums, but unfortunately, the signals sent to our brains are very weak and do not register until a lot of damage has already occurred.

Both cavities and gum disease can cause tooth loss. Unless, of course, you see a dentist. That dentist will attempt to repair tooth damage in numerous ways, depending on the extent of the damage. That can involve fillings, crowns or even root canal treatment. Gum problems — because they are so sneaky and quiet — often are overlooked. Repair can be pretty invasive, including surgery. In health terminology, we refer to reparative procedures as tertiary care. More on that in a moment.

All these repairs are costly because they involve work by a general dentist or dental specialist who has gone through time-consuming, intensive, and very expensive education to perform specialized types of hard-tissue (your teeth) or soft-tissue (your gums) microsurgical techniques using the very best instruments and materials in an extremely clean environment. And, of course, you would not have it any other way.

But it does not have to cost that much. No, I do not mean by getting dental insurance discounts on treatment. High quality dental treatment means a high overhead of costs for the ethical doctor. Deep discounts require cutting corners somewhere in your treatment, and I will let you guess what that means. Actually, it generally means more expense later.

Recall what was mentioned above. Tertiary care is reparative, and repairs are very costly. Why not do something that would avoid those repairs? We know bacteria are the cause of almost all dental problems. If we could only prevent those bacteria from collecting and setting up shop where they do damage, we could prevent the need for repairs!

Prevention is called primary care, and prevention is dirt cheap. Unfortunately, it also requires your dedication. The low-tech toothbrush is the single best invention for doing most of that by disrupting that bacterial plaque from causing trouble. But a brush only cleans half of each tooth. Floss must clean the other half. You must do both, because anywhere you miss cleaning, bacteria will set up shop, grow bigger, and eat and etch to their way to those costly repair procedures. Just insist you have great coaches to train you how to do it well and effectively — your dentist and dental hygienist.

So, why is your dentistry expensive? Because you did not clean off those bacteria. So, get cracking and break out that brush and doggone floss. Every. Single. Day. Because those bugs are sure hoping you’ll leave them alone to feed on you. And to borrow from Smokey the Bear: Remember, only YOU can prevent tooth decay.

Dr. Boden is the FDA president and can be reached dboden@bot.floridadental.org.

Why Can’t I Get My Teeth Cleaned?

By Dr. John Paul, FDA Editor

I hear this question every so often, and I can sympathize with you. I’d like to give you a quick answer that would solve your concern, but there just isn’t one. Health care is a complicated subject.

Without seeing you, I can’t offer specific answers to your questions because every patient has individual conditions and needs. If I can tell you a story about two seemingly similar patients, maybe you can find some answers about yourself.

Jane is 30 years old, has always been fairly healthy, never had many cavities and has no immediate concerns about her teeth. She got a new job with dental benefits and decided now was the time to see a dentist. She scheduled an appointment with an office that seemed popular on social media and local advertising. The staff seemed pleasant and the office was clean. She saw the dentist for a few minutes — he looked at some records on the computer, took a quick look in her mouth, said something to the assistant and left. Mostly Jane talked with staff members who told her about how she would need to start with “deep cleanings,” and they talked about how she could make plans to pay for the treatment. Jane made an appointment for the deep cleanings, but canceled it because she was unsure about the treatment.

She scheduled with my office for a second opinion. We had her X-rays sent from the other office and I performed a thorough evaluation that lasted 20 minutes. We discussed the health of the bone and the gums holding her teeth in her jaw as well as the teeth themselves. There were a few fillings that were OK, no decay and her teeth did not need any other fillings. Her gums bled a little and there was stuff between her teeth because Jane was not the best flosser. The probing depths were all 3mm or less and the bone level was proper in the X-rays. All this was explained to Jane so she knew what a dentist was looking for and what the results might mean. Jane’s diagnosis was gingivitis, with a low risk of caries. The appropriate treatment was dental prophylaxis, which some people refer to as a “regular cleaning,” but is really a maintenance visit to help healthy people stay healthy. I didn’t have complete records from her previous dentist, and I am left to assume I disagreed with their initial diagnosis and treatment plan.

Bill’s also 30 years old, never had a cavity in his entire life, but he was concerned about his bad breath and wanted to get his teeth cleaned to take care of it. I spoke with Bill about how we would review his mouth and teeth. We examined his entire mouth, took X-rays and used these results to form a diagnosis. While Bill had no cavities, the space between his teeth and gums measured at least 6mm and bled at every site. On X-ray, the bone loss at each tooth was significant and most of his teeth were loose. His diagnosis was advanced periodontitis. I referred Bill to a specialist, though he did not go. A year later, Bill came back to my office and without treatment, the disease had advanced. We ended up pulling 28 teeth that had never had a cavity because the bone was too diseased to hold them in his mouth.

From the outside, both patients appeared to be about the same — successful young people without much history at the dentist and no serious concerns. They represent two extremes of what I see in my practice, but I see someone who could be Jane and someone who could be Bill nearly every month.


When choosing a dentist, you may want to call or visit more than one dentist to find the right match for you, as dentists and practices often have different styles to fit patients’ distinctive needs and personalities. Ask trusted friends and family for recommendations or visit floridadental.org/public/find-a-dentist to find a Florida Dental Association member dentist near you.

ADA Sets Record Straight on Status of Petition to Food and Drug Administration Regarding SmileDirectClub

Statement may be attributed to Dr. Chad Gehani, American Dental Association president

The American Dental Association (ADA) believes the public has a right to accurate information concerning the status of its pending  citizen petition submitted to the U.S. Food and Drug Administration (US-FDA) about SmileDirectClub, LLC’s direct-to-consumer plastic teeth aligner business. SmileDirectClub’s (SDC’s) inaccurate public statements that the ADA’s petition has been “shut down” or “dismissed” may deter customers who have experienced clinical problems in connection with SDC’s aligner “treatment therapy” from reporting their negative experiences to the US-FDA.

SDC’s public misstatements, including in its Oct. 4 press release, are apparently based on a May 30, 2019 letter from the US-FDA to the ADA. The letter, which can be viewed at the citizen petition landing page, did not reject or dismiss any substantive aspect of the ADA’s citizen petition. The US-FDA’s letter explains:

“We appreciate the information [the ADA] provided. Such information is often helpful for us to identify problems with marketed products and possible violations of the laws and regulations that we enforce. We take complaints seriously and we will evaluate this matter to determine what follow-up action is appropriate.”

The letter further explains that the US-FDA does not initiate enforcement actions on behalf of petitioners. Instead, the US-FDA reviews the submitted evidence and decides for itself what action to take. All substantive issues raised by the ADA’s citizen petition remain fully before the US-FDA at this time. The comment period for the public to address the petition and for the ADA to supplement the petition is open until Oct. 22 at 11:59 pm.

Further proof of the continuing pendency of the ADA citizen petition is SDC’s acknowledgement of it in the “Risks Related to Legal and Regulatory Matters” section of SDC’s Aug. 12, 2019 S-1 filing with the U.S. Securities and Exchange Commission. Had the US-FDA dismissed the ADA’s citizen petition, there would have been no reason for SDC to mention the petition in its securities filing, and certainly not to identify the regulatory proceeding as one of SDC’s existing “risks.”

The ADA submitted its citizen petition and a complaint letter to the Federal Trade Commission’s (FTC) Bureau of Consumer Protection out of concern for public safety and customer recourse in the event of negative outcomes from SDC’s orthodontic “treatment therapy.” Plastic teeth aligners are designated by the US-FDA as a Class II medical device requiring a prescription. The ADA believes SDC is placing the public at risk by knowingly evading the US-FDA’s “by prescription only” restriction.

In lieu of having dentists review patient dental records or perform any sort of patient exam (whether using teledentistry or otherwise) before prescribing orthodontic treatment, SDC instead requires customers to self-report their dental condition. As the ADA explains in its citizen petition, customer self-reporting does not meet the applicable standard of care because it does not satisfy a dentist’s requisite professional due diligence. Put simply, SDC and the small number of “SDC-affiliated” dentists have no way of knowing whether a lay consumer’s self-reported dental condition is accurate, informed, or true in any respect.

Moving teeth without knowing all aspects of a patient’s oral condition has the potential to cause bone loss, lost teeth, receding gums, bite problems, jaw pain, and other issues. Despite these potentially serious outcomes, SDC requires its customers to hold the company harmless from any negative consequences, as the ADA points out in its US-FDA citizen petition and FTC complaint letter.

In addition to these public health concerns, the ADA’s letter to the FTC cited various SDC practices the ADA believes to be deceptive under section 5 of the Federal Trade Commission Act, including:

  • Informing purchasers they have recourse against SDC via arbitration, when the same document includes a “small print” provision obligating the customer to waive any and all rights the customer “or any third party” may have against SmileDirectClub.
  • Soliciting customers by claiming that SDC aligners will correct their overbite, underbite, and crossbite conditions, or their “extreme” malocclusion. But after customers complain about poor clinical outcomes, SDC invokes other documents stating that its aligners cannot treat bite conditions at all and can only treat mild to moderate teeth misalignment, not “extreme” misalignment.
  • Claiming that SDC customers receive the same level of dental/orthodontic care as actual dental patients, when in fact SDC and its affiliated dentists provide virtually no care and, contrary to its claims, SDC does not use teledentistry.

The ADA considers it our public duty to make the relevant regulatory agencies aware of these facts, so those agencies can be fully informed and consider whatever actions they deem appropriate.

The US-FDA’s MedWatch voluntary reporting form may be used by both consumers and health care professionals to report poor clinical outcomes associated with medical devices, including plastic teeth aligners. The FTC also offers consumers an online form to report complaints about unfair and deceptive business practices on its website.

ADA News Release, originally appeared on Oct. 9, 2019 and can be found here.

Smiles Over 65: Oral Health in Your Golden Years

By Karen Weeks, Elderwellness.net

Many people mistakenly believe that missing teeth and poor oral health is simply par for the course of aging. The truth is that you can have healthy teeth and your own natural smile for a lifetime. To make this happen as you enter your retirement years, it may become necessary to pay even closer attention to your mouth. Healthy dental habits, such as brushing and flossing, are a great start, but you also need to get comfortable in the dentist’s chair.

But it Costs so Much …

One of the most pressing issues with seniors today is that dental care is expensive. And those with original Medicare are left to foot the entire bill when their teeth and gums are on the line. There is good news, however, in that you have choices when it comes to your Medicare coverage. Medicare Advantage plans from companies like Humana offer comprehensive health care coverage, and the majority of these private Medicare policies provide a wide assortment of dental benefits. And considering that your oral health can affect other aspects of your well-being, you can’t afford not to see your dentist.

Healthy Habits

If you’re not brushing and flossing at least twice each day, you should. According to the American Dental Association, cleaning your teeth, or dentures, can help keep bacteria out of your mouth. And when it’s not in your mouth, you have less of a chance of it spreading throughout your body. Flossing is likewise important and is the most efficient way to remove solid food particles from between teeth. Dry mouth is a serious concern for many seniors, so you also should make a point to drink plenty of water and quit smoking.

Potential Problems

Even if you establish a healthy oral hygiene routine, there are still issues that can arise. Sensitive teeth, for example, can happen over time with wear and tear. As the enamel on the outside of your teeth wears down, they may feel discomfort when exposed to heat or cold. Enamel is extremely strong, but it can be damaged by aggressive brushing, receding gums, or an acidic or sugary diet.

Cavities also are cause for concern if you don’t make your teeth a priority. Even though your adult teeth are stronger and more able to fight off decay than baby teeth, certain medical conditions, such as arthritis, can leave you less able to give your mouth the attention it deserves. Regardless of age, untreated cavities can cause pain and can make it difficult to eat like you are supposed to.

Health Conditions Can Affect the Teeth

Taking care of your dental health is exceedingly important if you suffer with age-related medical conditions. High blood pressure and diabetes, for example, are known to cause or contribute to gum disease. Obesity and rheumatoid arthritis also are linked to the health of the soft tissues in your mouth. Surprisingly, even less serious conditions, like acid reflux, can wreak havoc on your teeth. Gastroesophageal reflux disease (GERD) can push acid from your stomach into your mouth, and this acid can quickly wear away at your teeth. Stress, depression and many autoimmune diseases also can take a toll. For these reasons, you should make a point to visit your primary care physician for a full physical every year. Between the screenings they’ll offer and your regular dental checkups, your health care team can identify health problems that affect the teeth and vice versa.

It is possible to enjoy a beautiful smile and uninterrupted eating habits throughout your entire life. But it does take work, and a commitment to whole health. If you’re concerned about money, check your Medicare plan and make sure that you are covered.

Ms. Weeks can be reached at karen@elderwellness.net.