Tooth Story
The little boy bravely tried to sit still during my examination in the Emergency Room. Not the easiest thing to do, with a cavity the size of a pencil-head eraser and the nerve-containing pulp exposed to open air...
It was a familiar story. Like over one-third of all Americans, this little boy and his family had no dental insurance at all. The number of dentists in St. Louis who will accept patients without dental insurance can be counted on one hand. Needless to say, those few dentists are swamped with true emergencies -- and basically do not take patients for routine dental care. Which meant, like most Americans without dental insurance, this little boy never got basic dental care.
When he finally developed a cavity, his family spent hours and hours on the phone to finally find an appointment with a dentist who would help him -- but the first available appointment was weeks into the future. The family tried to soldier along with over-the-counter oral pain medicine, and the little boy stoically endured excruciating pain. But untreated, the giant cavity became an abcess, which gave the boy fevers and chills and began to cause his mouth and jaw to swell badly. And so the family finally brought the pt into the emergency room for further care; because although the dentists could turn the family away, we doctors wouldn't.
A very familiar story. He wasn't even my first dental patient of the day in the Emergency Room.
In America, where the idea that basic lifesaving *medical* care should be equally available to poor and rich alike is an area of vicious, violent debate, basic *dental* care for all Americans isn't even on the table. Rather, it is entirely up to each individual dentist to decide how much -- if any -- charity work they are willing to provide. Entirely up to each individual dentist to set their own rates, charge their own fees, pick their own clients, and turn away whomever they see fit. A dentist has no obligation to see any patient who does not pay what that dentist feels is an appropriate profit for the dentist's hard-won skills. Like almost every other skilled professional, the market price for the service of a dentist is set not by need, but by the ability of a client to pay and a dentist's willingness to provide.
There *are* many dentists who *are* willing to help the less well-off. Many dentists with for-profit practices also volunteer time to serve the working poor. And there are even a few dentists who valiantly try to build entire practices serving those who cannot afford dental -- or even health -- insurance. Our current system of dental care leaves it to each dentist, and each dentist alone, to decide how much -- if any -- dental care to the less well off each dentist wishes to voluntarily contribute. There are no universal dental care reform acts with their subtle (and not so subtle) pressures on dentist's fees. No mandates requiring dentists to see those in dental need. Service to the less well off is left entirely to the conscience and circumstance of each dentist. With the entirely expected result that the amount of charity dental care available vs need is like trying to fight a forest fire with a bucket. The fact that the resulting price for most dental services is out of the reach of millions of Americans is... just the way the cookie crumbles.
Which sorta works as a health care system, because, after all, leave a dental problem untreated for long enough, and it becomes a *doctor's* problem.
Unlike a dentist, some doctor *is*, eventually, obligated to see everyone. Your dentist can turn you away at will. Your public or academic emergency room, however, cannot. When things get bad enough, there will be an emergency room somewhere which will see you even when no dentist will or can. Untreated, dental problems can be very dangerous -- even life-threatening. And when that happens, if no dentist will see you, a doctor *will*. Which is how a future oncologist like me ends up getting taught how to do gum surgery at 3 AM. I'm glad to learn and glad to help, of course, and I do my best. But having me do gum surgery with an #11 blade in my hand is like asking your dentist to do a lumbar tap or a bone marrow biopsy.
(Your dentist probably *could* do those things. Certainly at least as well as I do gum surgery. On the other hand, tell me how you feel about your *dentist* sticking a needle in your spine or drilling a trochar into your pelvis, instead of a well-practiced doctor.)
A New York Times article summed things up very succinctly: Boom Times for Dentists, but Not for Teeth -- and that article was written *before* the current severe economic downturn. In a system where there is no government mandate for dental care, no acknowledged "right" to dental care; in a system where dental care is treated entirely as a market good and dentists are entirely free to set their own rates and pick and choose their own clients as they see fit, you get an inevitable outcome. Dentist's fees and profits skyrocket, while the number of untreated cavities among Americans rises.
In fact, today, the average salary of a dentist is higher than that of a general practice internist, pediatrician, or family practitioner. The average dentist now makes more than an average community doctor like docmom or ayradyss. And if one looks at salaries per work hour, dentists beat doctors -- almost *all* doctors -- hands down. As health care initiatives and health care reform constrict and circumscribe a doctor's financial freedom, dentists remain free to run their businesses as they see fit, and deliver charity on whatever terms (if any) they choose. Meanwhile, millions of Americans endure miserably with tooth pain until they are forced to seek a *doctor's* care.
If you have a heart attack, if your child gets diagnosed with cancer, if you are hit by a drunk driver, rich or poor your nearest public or academic emergency room *will* save your life, no matter how many hundreds of thousands of dollars it costs, and no matter how totaly unable you are to pay it. Eventually, some doctor *will* see you -- will be *required* to see you -- no matter how poor you are; and then it's up to the doctor to figure out how to get paid after the fact. In contrast, if you have a cavity, either you have the money up front to pay a willing dentist to play... or eventually, you might very well end up in a doctor's hands.
Americans often wonder why dentists can't be more like doctors.
And many doctors wonder why we can't be more like dentists.