Dental care

Going to the dentist is no one's idea of a good time, but the 51,768 Consumer Reports subscribers who told us about their oral health were nevertheless overwhelmingly satisfied with their dental care. In fact, they rated it higher than most other services and on a par with the care they got from their doctors. What's more, few readers reported experiencing anything beyond mild pain—even for the infamous root canal.

That doesn't mean all is well. Our survey revealed these problems:

• Only about a third of readers brushed and flossed as often as they should.
• Cost was the No. 1 reason they delayed dental care.
• Some patients might be paying for cosmetic treatments they don't need.
  

The experiences of our subscribers are most likely more positive than those of the public at large, in part because many of them are much better insured. Seventy-one percent of those who had at least one dental procedure in the last five years said they had dental insurance, but only 57 percent of the general public is covered, according to the National Association of Dental Plans, an trade group. "This segment of the population really appears to be getting very good dental care," says Jay W. Friedman, D.D.S., M.P.H., an expert on dental public health and quality standards from Los Angeles.

Recent research suggests that poor dental health can affect a lot more than your smile. The plaque-causing bacteria on your teeth and gums, for example, could enter your bloodstream and clog arteries. People with diabetes and poor blood glucose control are at higher risk for tooth and gum problems, and that in turn can worsen diabetes. And oral infections left untreated can spread to other parts of the jaw and skull, causing major complications including brain injury and death.

Good oral hygiene can help prevent those problems. But our readers get mixed grades in preventive care. In fact, they show a tendency to leave the job to their dentists rather than doing it themselves.

Overall, 70 percent of respondents said they went to a dentist for a checkup or cleaning at least twice in the previous year. Another 19 percent went once, and 11 percent didn't go at all.

Home care was a different story. Only 34 percent reported consistent, all-around good hygiene, which we defined as brushing at least 14 times a week and flossing at least 7 times a week. Fifty-seven percent reported brushing at least twice a day with a regular or electric toothbrush, and 53 percent said they flossed every day. But 30 percent said they never flossed, and 4 percent didn't brush their teeth daily.

If you assume that getting your teeth cleaned every six months will compensate for lax home hygiene, think again. "There's no evidence that it does," says James Bader, D.D.S., a research professor at the University of North Carolina at Chapel Hill. But it might improve gum health for some, he adds. And it's a good idea to get plaque and tartar professionally cleaned from your teeth from time to time. (But there's no harm in twice-a-year cleaning if you want it.)

Paradoxically, those in our survey who maintained consistent home hygiene were also more likely than others to go to the dentist at least twice a year for routine checkups or cleaning. But that might be overkill, Friedman says. "There are many people who really don't need to see a dentist more than once a year," he says. People with good dental hygiene who don't develop tartar quickly or have obvious problems, like gum disease or frequent cavities, can get by with an examination and cleaning every 12 to 18 months.

The most painful of the procedures we asked about turned out to be tooth extraction. That makes sense, Friedman says, because having a tooth pulled leaves you with a healing wound. Even so, only 6 percent of the respondents said the pain was severe; 61 percent reported mild pain. (For more on what readers said about pain, see Relax—this will only hurt a bit.)

Forty-four percent of those who had root-canal surgery experienced mild pain afterward, and 5 percent reported severe pain. "The pain you have associated with a root canal is largely the toothache preceding it," Friedman says, adding that the treatment itself usually isn't painful because it's done under local anesthetic.

For mild pain after a tooth extraction, root canal, or other procedure, an over-the-counter pain medication usually does the trick after the local anesthetic wears off, Friedman advises. For severe pain, your dentist might prescribe a narcotic such as codeine.

It's normal for mild pain or discomfort to linger for a few weeks after root-canal surgery. But if a dull ache continues longer than that or it still hurts to chew—or if the symptoms worsen—additional surgery might be required.

Swelling and pain is common for a day or two after an extraction. If the pain persists, gets worse, develops into a dull ache, or doesn't go away after a couple of days, check with your dentist.

Readers who had dental procedures for health reasons in the previous five years reported few serious problems and little more than mild pain or discomfort.

If you fear the dentist, your best strategy is to keep up with your regular cleaning and home hygiene so you don't have to go as often. "It's a self-perpetuating cycle," says Albert H. Guay, D.M.D., chief policy adviser for the American Dental Association. "You avoid going because you fear it being difficult or painful, but that allows your problem to become more severe and require more extensive treatment, which reinforces the original fear."

If you need a cavity filled or root-canal surgery, tell your dentist and his assistants that you're an anxious patient so they can give you choices to deal with pain and discomfort. You can even arrange a hand signal that lets them know you need to take a break during a procedure.

If all else fails, an antianxiety drug might be an option, although it's best to use it sparingly. General anesthesia should almost always be avoided, Friedman advises, because it can increase the risk of complications, including jaw injury if the dentist needs to force your mouth open.

And our survey suggests there's another reason to deal with anxiety: Readers who delayed getting care were less satisfied with their dental work than those who got prompt care.

Among our readers, the most common problem after mild pain was poorly fitting dentures. Twenty-three percent with full dentures reported this. So did 18 percent of those who had a denture adjustment or repair, and 13 percent who received partial dentures. By contrast, only 6 percent of the respondents who got a bridge said it didn't fit properly.

Ill-fitting partial dentures are not only uncomfortable but can also create sores on your gums and loosen your remaining teeth. Sometimes all it takes to restore a good fit is to have your dentist grind them down at certain pressure points. But if you continue to have discomfort or gum sores, ask your dentist for a realignment or even a full replacement.

Full dentures should be checked for fit every year even if you're not feeling discomfort. Grinding might relieve minor pressure points, but if you're still having problems, ask about having the dentures relined. "Dentures need maintenance just like teeth," Guay says.

If you can afford it, opt for dental implants. More people in our survey got them instead of full dentures, and just 2 percent reported problems with the way they fit. Only 3 percent reported severe pain or discomfort with implants, half the rate of those who got full dentures, though slightly more reported mild pain or discomfort.

Seventeen percent of the respondents who had a dental procedure for health reasons said they had delayed it. That's a much lower percentage than in nationally representative surveys, in part because our
respondents are better insured than the population at large.

Still, the biggest reason for delay, cited by 43 percent, was cost. Those without dental insurance were more likely to mention this than those who had it.

But even many of the people with insurance put off a treatment they needed; 23 percent because insurance wouldn't cover the procedure, and 24 percent because they had already used up the maximum that their insurance plan would cover for the year.

Only about 2 percent of our respondents said their dentist recommended a treatment they thought might be unnecessary. But about half of those who had a cosmetic procedure said they did so at the suggestion of their dentist. Our dental consultant, Jay W. Friedman, D.D.S., of Los Angeles, says that some practice-management courses train dentists to push cosmetic treatments to boost their bottom line.

"Every time a patient sits down in that chair you've got to generate a certain amount of income," Friedman says.

Even noncosmetic procedures can be overused, especially when a dentist is paid by the procedure. "There is an economic incentive to do something rather than nothing," says James Bader, D.D.S, a research professor at the University of North Carolina.

Some treatments to be wary of:

Teeth whitening. Your yellowish teeth are probably fine the way they are. "If the natural tooth is white, it suggests that the tooth is not as well calcified as one that has a light yellow coloration," Friedman says. Ordinary cleaning will remove stains from coffee, tea, or tobacco, he adds.

Respondents who bleached their teeth at home using a tray made by their dentist were more satisfied than those who had their teeth whitened in a dentist's office. Readers paid an average of about $260 for a custom tray and spent an average of about $250 for an ultraviolet in-office whitening treatment. Over-the-counter whitening kits cost considerably less. Our tests found that whitening strips produce the best results.

Amalgam filling replacement. Thirteen percent of our survey respondents had a mercury amalgam filling replaced with a composite filling solely for cosmetic reasons. But "every time you replace a filling, you have to take more tooth structure away to hold the new filling," says Albert H. Guay, D.D.S, chief policy adviser for the American Dental Association. And composite fillings aren't as strong or durable as amalgam fillings. Amalgam fillings do contain mercury that is chemically bound to other metals, but they haven't been linked to health problems.

Unnecessary restorations. Some dentists say their advanced diagnostic equipment can detect microscopic defects on the outer portion of a tooth, but it's not clear whether those "microcavities" will develop into invasive decay. The minerals in saliva can sometimes repair your teeth, especially when aided by fluoride. "The last thing you should do is open the tooth up and fill it," Bader says. He recommends monitoring the decay to see whether it advances to the point of needing treatment. And fiberoptic cameras that photograph teeth in extreme close-ups to show "fractured" enamel that supposedly requires a crown or filling might really show superficial cracks that don't need treatment. Ask your dentist if the fracture is enough to cause decay. If it is, a simple filling might suffice. Even if you do need a crown, if it's for a back tooth that's not very visible, a metal one is more durable than one made of ceramic porcelain.

‘Precautionary' removal of wisdom teeth. Unless they're causing problems, they can be left alone.

X-rays. An annual bitewing X-ray is fine for many patients, but those who rarely get cavities can go 18 months or longer.

TMJ surgery. Temporomandibular joint disorder can be painful, but surgical treatments haven't proved to be helpful. "The real cure for TMJ is waiting until it goes away," Friedman says. Meanwhile, a night guard might provide some relief.

Having dental insurance is better than not having it, especially if you get it through a job. But don't expect free or nearly-free care. Our survey found that of the 71 percent of respondents who had dental insurance, 90 percent received some sort of coverage for a procedure. But only 46 percent said it covered more than half the cost.

Dental plans are structured to promote the prevention of serious dental disease to avoid expensive fixes down the line. So they might provide complete or partial coverage for such preventive treatments as cleanings and oral exams, 80 percent for fillings and other first-line treatment, and 50 percent for last-ditch treatments including crowns or bridges, often with an annual benefit cap.

The scope of your dental coverage depends to a major extent on whether it comes with your job or you purchase an individual policy on your own.

Employer-sponsored insurance

Of the 57 percent of Americans with dental coverage, 98 percent get it through their employer or a group such as AARP, according to the National Association of Dental Plans. That's usually a good deal, because most employers cover some or all of the premiums.

Types of insurance

Dental PPOs. Preferred provider organizations are the most common type by far, accounting for about 74 percent of dental plans. Like their medical analogs, PPOs offer more generous coverage for in-network dentists but allow you to use out-of-network providers if you're willing to pay a bigger share of the cost. There's usually an annual coverage cap of between $1,000 and $2,000.

Dental HMOs. A dental health maintenance organization pays dentists a fixed annual amount for each patient rather than for each service provided. Dental HMOs have the most generous coverage and usually place no annual limit on the care you receive. But you can't use nonparticipating dentists and might have to wait for an appointment.

Indemnity plans. Those plans cover services the same way a PPO does, often with an annual deductible of $50 to $150. The difference is that you can go to any dentist you want. But premiums are high and some procedures are usually excluded.

Individual insurance

Individual plans make up less than 4 percent of the marketplace. And 39 percent of the enrollees let their coverage lapse each year, meaning that they're "buying it, using it, and dropping it," according to Evelyn Ireland, executive director of the National Association of Dental Plans. That suggests that people are signing up for the insurance only when they need expensive care, which leads to higher premiums and more-limited coverage for everyone. It's one reason few individual plans cover orthodontic treatment.

Are individual plans worth it? It depends on your needs. We looked at four Chicago-area plans offered on eHealthinsurance.com, a national insurance shopping site, and compared the coverage offered with what you'd pay on your own based on estimates from HealthcareBlueBook.com, a nonprofit that provides the average costs of various procedures paid by major insurers and large employer plans.

Three of the four plans had premiums that were less than the cost of annual cleanings, checkups, and one set of X-rays. One, an HMO, could offer savings for more-significant dental work as long as the procedures were on its list of covered services and you didn't need a specialist to do them.

The others had annual caps from $500 to $1,200, which you would probably crash against if you needed significant work—and our survey suggested that major procedures tended to come in spurts. What's more, two imposed waiting periods of six months for basic procedures like fillings and up to 18 months for root canals, crowns, and other major work. In other words, you might have to pay an annual premium of about $450 for 18 months to get partial coverage for a root canal.

Dental discount plans

For an annual membership fee of around $50 to $100, you get access to a network of dentists who have agreed to discounted rates. But watch out for pricey add-ons and extra procedures you don't need.

Public insurance programs

Original Medicare doesn't cover ordinary dental care. Some private Medicare Advantage plans offer limited coverage. Medicaid and the Children's Health Insurance Program offer dental care for children, and some state Medicaid plans cover adults.

Paying without insurance

Shopping and bargaining. Look up typical insurance-paid rates in your area at FairHealthConsumer.org and HealthCareBlueBook.com, then ask providers to accept that amount, or less, as a cash payment. Readers who negotiated for lower fees were often successful, especially for costly procedures including implants and dentures.

Free and low-cost clinics and health centers. Some community health centers offer dental care with fees based on the ability to pay. Call your local health department to find one near you. But expect to encounter waiting lists in some locations.

Dental and dental-hygienist schools. If you're willing to be treated by supervised students, many of these schools offer free or discounted care to the public. A list of schools is at www.ada.org/267.aspx.

Here's the average out-of-pocket cost (and the range) reported by readers for procedures they received during the previous five years.