I was prompted to write this after I read an article indicating the increasing number of U.S. citizens who are crossing the border into Mexico and flying to other countries outside the U.S. to have dental treatment, known as “Dental Tourism.” Also by questions I am sometimes asked about my take on the relative quality of U.S. dentistry compared to that performed outside the U.S.
The reason for this exodus I’m sure is a matter of perceived economics. If I were a retired dentist being asked this question (therefore, my answer not ostensibly being self-serving), I would say, “It depends.” I’d tell them that here in the U.S. there are definitely some levels, or tiers of dentistry where treatment is performed of similar or less quality than some that I have seen from Mexico and other places outside the U.S., all of which I’ve observed so far being what I’d consider sub-par. The following will give you my perspective on the status quo of U.S. dentistry in general that might be important to a person who values their oral and overall health, prior to making a “trip South.”
The first thing I would tell them is that there are four distinct levels, or tiers of dentistry that have evolved over time in the U.S. One is that of basically “putting out fires” such as tooth extractions, patchwork fillings, pain elimination procedures, etc. This tier of dentistry is heavily driven by the dental insurance industry in that most all insurance companies allow some type of benefits for dentistry at this basic level.
Another tier is mainly repair/replacement/cosmetic technology commodity-driven, i.e., fillings, crowns, implants, cosmetic porcelain crowns and veneers, partial and full dentures which basically address the results of dental disease or improve a smile. There are various levels of quality within this predominant tier of dentistry in the U.S. which is substantially influenced by dental insurance industry policy as well. The procedures leading up to the finished teeth replacement and cosmetic enhancement procedures involve a manufacturing process that engages both a dentist and laboratory technician. The resultant product can be of varying qualities based on the relative commitment to quality held by each, and the nature of their relationship. The best dental lab technician’s efforts are only as good as what they receive from the dentist, and correspondingly if the dentist’s efforts are tops and those of the lab are poor, the result will also be compromised. As important as it is to have properly designed restorations to repair and replace teeth, even the best of these efforts only address the results, or symptoms of disease, not their cause(s). This important cause/effect distinction leads us to a third and fourth tier of dentistry that require patient participation – similar to a physician who provides his patients medications for their high cholesterol and blood pressure, as opposed to one who is health-centered and would counsel them about the influence of their life style choices and holding them accountable for making healthy changes.
A third and rare tier of dentistry takes reparative and teeth replacement technology to a higher level. The dentist is talented, trained and quite capable of providing the finest in technology such as crowns, implants, etc., and uses only the services of a top quality laboratory technician. He realizes, however, that the teeth are singular elements of a vast network of muscles, bone, nerves and ligaments that comprise a biological system unique to each individual. Dentists practicing within this tier have had advanced training wherein they comprehend the intimate association between the way the teeth fit together and their relationship with the jaw joints, or "TMJ's." They have learned to diagnose the function of the entire oral system and discover the causes of teeth wear, past dental failures, bite-related migraines, head, neck and shoulder pain. They correct the mismatch between teeth and TMJ's prior to making any teeth repairs. The teeth repairs/replacements are then designed to support the gained health and function of the entire oral system, i.e., the new healthy biology directs the form of the restorative technology. This tier of dentistry includes patient education and a high degree of patient participation.
A fourth, and most rare type of dentistry is essentially health-centered and relationship-based, two elements that are quite intertwined. Very few dentists practice within this tier - probably less than one percent. These individuals have travelled through the other three tiers and realize that even the best of dental repair/replacement/cosmetic technologies can fail if the causes for their need aren’t first addressed. Also recognized is the direct relationship between oral and general health, and that oral health is not a commodity that is "installed" as is with the other tiers. Dentists practicing within this tier recognize the uniqueness of people, their mouths, teeth and the way they function, therefore their health development requirements may vary considerably They have discovered that without the interest and ensuing cooperation of the patient, healthy oral changes cannot occur - similar to the above-mentioned health-centered physician who would educate his patient, define their mutual accountability roles compared to one who would simply prescribe symptom controlling meds. His practice purpose is holistic in helping people improve their dental, emotional and overall health, and he knows that he is hand-tied in doing so without first developing a trusting relationship with his patient. This relationship development and emphasis on patient learning is the core of what has been called the “health-centered” dental practice. Through the learning process, the patient is able to understand the positives and negatives relative to the state of their oral health, and through the gained information become empowered in directing it to the state of health that they would wish. During the learning, oral assessment and preventive processes an affinity akin to any trusting relationship develops. This assuages past dental fears and sets the stage for the dentist to provide his very best care.
Any dentist practicing within any tier will tell you that even with many years of experience, some treatment procedures are quite demanding of the dentist as well as the person being treated – it can be an emotional experience for both. One of the compelling factors that drove me towards developing a Tier 4 level practice was a realization that I couldn't perform my best care on a patient with whom I didn't have a trusting relationship. Performing fine dentistry is like an intimate “dance” requiring mutual trust, and if trust is missing on the part of either partner, the result will be negatively affected. In traveling through the earlier tiers I was placed in a position to treat non-dentally educated, sometimes fearful patients with unhealthy oral environments. As my own educational experiences continued, I became inspired to develop a relationship-based, educational practice - a huge paradigm shift with more time allotted for the educational process and corresponding development of a physical environment and like-minded team to accommodate this shift. My patients become educated partners in health, not solely recipients of “body parts” such as teeth repairs and cosmetics. They learn the essentials of their own unique oral system and have elected to have a dental future of health rather than be in a continual unpredictable, reactive, fix-it mode. A well-developed relationship between dentist and patient serves them both as the trust engendered along the educational path allows the negative emotions to be assuaged - a key factor in a “dance of mutual trust” that allows top-notch care. The end result is a patient who has first developed a healthy oral environment with subsequent general health improvement; this sets the stage for healthy functional, natural appearing and long lasting restorative treatment
From what I can gather, Dental Tourism is commodity-driven, "fix-it" treatments, addressing one-time repairs and maybe cosmetic treatment, not a time-involved, relationship-based approach with coincidental development of oral and systemic health. So, the trip down south could be at least on a par with some levels of quality within the first two tiers of dentistry in the U.S. Therefore, this comparison needs to address quality differences basically relating to the dentist and the dental laboratory. Having seen much of tier 1 and 2 dentistry through the years from several countries, I’d take my chances with a reputable Tier 2 U.S. dentist before I’d go down south, as cheaper isn’t necessarily better.
Unlike a fine diamond that can be assessed for its quality, the relative quality of “dental work” cannot be determined readily by a patient, at least immediately, but later on it can become more costly in pain, time and finances when it fails completely. Without a gauge for the patient to determine the relative quality of their “work,” I can see why some people may go outside the U.S. for their treatment. Not knowing of the above factors may be one reason that patients may think that they can get a bargain outside the U.S., and I think we all know that some people will do most anything for a bargain.
It is quite ironic and sad that some of the finest dentists who graduated from dental school with honors have a difficult time getting enough patients because of a basic introverted personality, while a dentist at the bottom of his class who performs substandard care, but with an engaging personality that can put a scared patient at ease will have a flourishing practice. In other words, quality of “dental work” is not easy to judge by patients. I have more than one patient who had a previous retired dentist for whom they had a high regard, exclaiming that he was a great dentist having had mal-fitting repairs, poor bites with active gum disease to boot - a true case of “supervised neglect.”
There are many factors having to do with the relative quality of the “dental work,” or final “end product” that goes into the mouth, based on the interplay between the dentist and laboratory technician. The laboratory works in partnership with the dentist and is subject to his instructions that are placed on a prescription form. The ultimate quality of the finished restorative product reflects the co-action between the dentist and laboratory, driven basically by the talent, care and integrity of the dentist. The level of quality of the dentist will usually match that of the laboratory, which can span a very wide latitude. The following is a potential Tier 1 or Tier 2 decision scenario during the teeth repair or cosmetic fabrication process from dentist to lab, back to dentist and then to the patient’s mouth:
- Excellently designed and well-fitting dental restorations require meticulous attention to detail on the part of both dentist and laboratory technician. Scenario: The dentist shapes the tooth for the particular repair (talent involved here); retracts the gum tissue away from the future repair/tooth junction (margin) – (care/skill involved here); takes an impression replica of this effort. Let’s say he sees a defect in it. He is running behind schedule, has another patient waiting and has a decision to make: does he re-appoint the patient for another attempt to get a flawless impression with another anesthetic injection, and attendant time to remove the temporary crown, re-pack the gum tissue, take the impression, replace the temporary crown - or send it to the lab as is? The answer to this question is based on the integrity of the dentist as he assesses the situation. Another appointment is expensive in that it may take about as much time as the original appointment, as well as another costly impression. The dentist, feeling the time pressure, might just send the defective impression to the lab and hope for the best. This cutting corners leads to a less than ideal final product. This is, I believe, one of the reasons why most dental restorations I see daily are mediocre, and any top dentist and laboratory would agree with this quality assessment. Most always, until the mediocre dentistry causes a problem the patient doesn’t know the difference.
- As previously indicated, there are vast differences in the quality of dental laboratories – in the U.S. as well as those outside it - and real cheap from China. Laboratory fees can range from 3 - 4 times plus or minus “the norm.” Dental laboratory revenues are also based on time, which can inspire quantity over quality depending on the philosophy and integrity of the laboratory owner and the type of dentist he wishes to work with - high quantity or high quality. As mentioned earlier, the result of even the best dental lab technician’s efforts are only as good as the relative quality of the dentist sending the prescription. The truth is that water seems to seek its own level in this area. A poor dentist will select cheap labs, and an excellent dentist will only seek the finest quality dental laboratory, as they would want to dignify their efforts with the very best – all fabrications pre-planned, well-designed and fitting the teeth properly!
Note: When that impression with its imperfection(s) gets to the lab and used to fabricate the restoration, its defects are magnified from one step to another through the many steps taken along the manufacturing process. If the dentist knew of the imperfection, but the ethics level is such that he will give it a pass even though a flaw is observed because he is running behind in his appointment schedule, the next step falls on the laboratory. If the truth be told, many laboratories are placed on the spot when they see the imperfection(s), and when/if they call the dentist, they will most often be told “Do the best you can with it.” If the dentist is a good account and pays his bills on time, the integrity of the lab may be influenced by the reality of economics.
Then the finished product comes back to the dental office and is placed in the mouth. As indicated, most of the time the patient isn’t aware of the deficiency, but it will surely manifest into a problem over time. Most dentistry performed today is replacing failed previous dental treatment. Frankly, most dentistry I see today is well below excellent.
I think that before anyone takes a trip to the dentist in any area in or out of the U.S., they might want to travel through this information so that they can make an educated choice. This started out with a seemingly simple question about a trip outside the U.S. which is more complex under its surface than it might sound. Hopefully, this information can assist a person who may be contemplating a trip to the dentist anywhere, inside or outside the U.S.