Dentists 'drill, thrill and bill'
Everyone has their own dental horror story, where the pain in the mouth is matched only by the pain in the wallet.
You know the feeling. You've just endured the discomfort and indignity of the dentist's chair. Half of your face is numb as you report to the receptionist on the way out.
The bill is already waiting and when you look, it's on the tip of your unruly tongue to say: "There must be some mistake", until you realise that there isn't. Your bank account is about to take a heavy hit – and you can't help wondering why. Why does it cost that much?
Although dentists sometimes privately joke that their role is to "drill, thrill and bill", the ministrations of a good one to someone in pain might not, strictly speaking, be life-saving, but can certainly feel that way.
Yet if you raise the subject of a dentist's bill in any group of New Zealanders you will find that nearly everyone has a story – and usually it's to complain about how much the work cost.
Overseas figures aren't easy to find, and differing health systems around the world make comparisons difficult to analyse. The Consumer Institute says we are "lagging behind other countries in providing basic, affordable dental treatment for those who need it most". It notes that Britain provides free dental care to the over-65s and most beneficiaries, and that there are government refunds in some European countries.
Here, dental care is free until 18 for those who take the trouble to access it, and then you're on your own. It means, particularly for those who don't look after their teeth properly at home, and don't form the habit of having regular checkups, that bills can be a shock – often hundreds of dollars for a single appointment, thousands for a series, especially when the work is complicated.
The price is so high – or perceived that way – that a nationwide Ministry of Health survey released last month found that nearly half of the adults taking part felt that they currently needed dental treatment but had avoided it due to cost. A similar-sized group had gone without recommended routine treatment for the same reason.
"The majority of adults usually used oral health services when they had a dental problem, rather than visiting for routine checkups," the ministry says, unsurprisingly noting that these people had significantly worse oral health than regular users – and that while oral health has improved over time, dental decay remains "the most prevalent chronic (and irreversible) disease in New Zealand".
The professionals are frustrated that it should be this way. Long-established Nelson dentist Andrew Meffan sums it up like this: dentistry works on a one-third, one-third, one-third pattern.
"The third of patients at the top go to the dentist regularly. They're proactive. The third in the middle go when something goes wrong. They're reactive. The third at the bottom only go when the problem is really bad. They're inactive or extractive."
The top third would spend "a couple of hundred a year, tops", Dr Meffan says. "Neglect is expensive, not dentistry."
The New Zealand Dental Association's own figures suggest that Nelson's patients pay about the same as those in other parts of the country. It regularly surveys its members and the latest results give the national average for a checkup with two X-rays at $123, a standard amalgam filling at $125, and a ceramic crown at $1238. Nelson's figures are $117, $106, and $1193; Wellington's are $101, $133 and $1231; Canterbury's are $97, $110, and $1157. However, the overall cost can be large. An hour in the chair will likely cost you $400 or more, and the more aggrieved patients are quick to translate that into a stratospheric income: the crude maths suggests $400 an hour times 40 hours a week for 50 weeks gives a whopping $16,000 a week or $800,000 a year.
The Government's career services website says that dentists on average earn $65,000 in their first year, $100,000 after five years, and up to $250,000 in their own practice. The 2006 Census records their average income at $93,700, and an average 36-hour week.
GPs, in comparison, had an average income of $99,500 for an average 41-hour week.
Dentists particularly don't like being compared with GPs, whose services are heavily subsidised by the Government – and they're quick to point out that they face a high level of costs.
The Dental Association's chief executive, David Crum, a dentist for 30 years, says that 65 per cent of what is billed goes in direct costs – staff, rent, materials, disposable gloves, instrument sterilising. Equipment is expensive – a dentist's chair with all its high-tech accoutrements can cost $130,000. "If you get a bill for $400, that is not what the dentist is putting in their pocket."
But he shows a little irritation when questioned on how a young person, for example, on the average wage or less could cope with a bill for $1000 or more for remedial work – a common experience.
It comes down to personal responsibility, Dr Crum says. If someone like that had taken advantage of free dental care until 18, what had they been doing since then "to rack up a dental situation like that"? If they had been brushing their teeth each day, eating a healthy diet and using a fluoride toothpaste, they wouldn't be spending $1000, he suggests. That's the choice.
"But yes, the treatment does cost money if you need to have it done." That's where dentists in the main are happy to negotiate time payment, he says.
It's "an illogical argument" to say that a big bill represents a bridge too far for many people.
He's also keen to point out that dental care for those who don't make it a part of their annual routine is usually a "grudge purchase". People don't feel the same way if their TV blows up and they have to spend a large sum to replace it. They'll put that on hire purchase without a murmur.
Furthermore, Dr Crum says, the recent New Zealand Household Economic Study showed that the average weekly household spend was $4.70 on dental care, but $29.20 on alcohol and tobacco – six times more.
"New Zealanders spend more on pet food and plants and almost twice as much per week on hairdressing than their teeth."
He says the Ministry of Health survey showed "astronomical" improvements in oral health over a generation, because of the advances in dentistry, and fluoridation.
"People do have a different attitude towards their teeth now. In the main, they look after them. I can't deny that you can go to the dentist and be given a bill for $1000, but then again I guess people could budget for health care as an important part of what they're about, or purchase insurance.
"If you go to a cosmetic surgeon or elective surgery of some sort, then you'll find that dental costs are very reasonable."
The Dental Association's Nelson troubleshooter is Alex Munro, a dentist of 15 years' experience who has practised in Nelson since 2004.
As the branch's complaints officer, he's the first port of call if a dentist and a patient can't solve an issue.
Dr Munro says complaints – a total of 14 in an 18-month period spanning 2008-09 – break down into two groups. The first are about treatment where complications have occurred, the second cover misunderstandings, sometimes about cost, but not enough to create a separate category.
The Health and Disability Commissioner's books contain one 2010 decision where somewhere in New Zealand a patient was refunded $28,000 for crown and bridge work and got an apology for "the pain and suffering, both physical and emotional, that [she] has gone through".
There's been nothing like that in our region, Dr Munro says. He's helped to resolve each of those 14 complaints without any of them having to go any further.
Apart from the obvious step of paying attention to dental care at home, his advice is build a relationship with the dentist and to always discuss payment first, before the treatment begins.
"If they're unhappy with the bill as they leave they should question it, and ask for it to be justified. If there's complaints beyond there, make the complaint to the dentist in writing. If they can't resolve it with the dentist they might come to me."
While unwilling to discuss what dentists might aim for as an hourly rate, he says there is competition and that dentists don't sit around at their branch meetings discussing what they charge or earn. In fact, the spectre of price-fixing means they're discouraged from talking about it at all. The association's website stresses that there's no set scale of fees. Dentistry is market-driven, Dr Munro says.
"If you're a dentist that tries to compete on price, to undercut your competitors, then sure that might work, but you've got to make that compromise somewhere. The reality is, no matter what price a consumer pays, they still expect very high quality treatment. We're all trying to do the best quality we can."
Should someone with a toothache shop around?
"Absolutely. That's my advice when someone phones in. You're not bonded to one dentist."
And while everyone seems to know of a friend or acquaintance who has gone on a "dental escape" to Malaysia or Thailand to combine a cheaply repaired smile with a holiday, Dr Munro, Dr Crum and the Consumer Institute have a united cautionary view.
"It's an idea but what are you going to do next year, the year after and the year after that?," says Dr Crum. "You'd be better to establish yourself with a family dentist, have regular care so you don't need the large amounts of work, and have somebody available half a mile down the road so that if you have a problem, something breaks or needs to be redone, it's easy to do – and you've got consumer protection around that." In other words, perhaps you ought to bite the bullet. Further information available at healthysmiles.org.nz, and if you've got a dentistry story worth telling, email firstname.lastname@example.org.
The Nelson Mail