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Consumer Affairs / One mouth, five opinions
By Rina Rozenberg
Tags: israel news, consumer affairs 

"Know before whom you are opening your mouth - that's it in a nutshell. After all, you wouldn't let just anyone touch your body," says Dr. Haim Neuman, chairman of the Israel Dental Association's ethics committee, about the question facing anyone seeking dental care.

How can we be certain that the dentist we have chosen will in fact give us a credible and correct answer regarding the state of our mouth? We investigated the matter, with the help of two mystery shoppers from Yoram Zil's Keret Information and Services, and found that the answer is not simple.

Keret sent both testers to one of the dental practices run by each of the four health management organizations - Clalit, Maccabi, Meuhedet and Leumit - as well as a branch of the nationwide chain Private Clinic, for a total of five each. Each was equipped with panoramic X-rays of their mouths taken a few days earlier at an X-ray laboratory. Their mission was to undergo a routine dental examination at each place.
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All of the clinics diagnosed the same major problems in each case. Tester A was found to have a problem that required referral to an orthodontist. Tester B was diagnosed with a severe gum infection, and referred to a periodontist.

In every case but one the testers were told to have their teeth cleaned by a dental hygienist. The exception was for Tester A at Clalit Smile. The dentist examined the X-rays but did not look inside his mouth, and therefore did not recommend plaque removal.

There ends the similarity between the diagnoses. When it came to cavities, implants, tooth extractions and gum disease a variety of diagnoses and treatment plans were offered.

In Tester A's case, dentists at three HMOs recommended pulling four impacted wisdom teeth, but said it would have to be done by an orthodontist. The dentists at Private Clinic and MaccabiDent recommended leaving the impacted teeth alone. As for tooth decay, Meuhedet found one cavity; Leumit found four, plus another two they said bore watching; and the other clinics found none. MaccabiDent, Meuhedet, and Private Clinic diagnosed gingivitis. MaccabiDent recommended fluoride treatment and noted the potential for cavities in the future.

In Tester B's case, Clalit Smile, Private Clinic and Meuhedet did not recommend any treatment aside from seeing a periodontist about the gum disease and having her teeth cleaned. MaccabiDent drew up a treatment plan that entailed four fillings as well as an implant and crown (temporary and permanent) for a missing rear tooth. Leumit's dentist recommended the same implant, along with one filling.

When we asked Dr. Amnon Zinger, head of the Clinic for Oral Rehabilitation at Tel Aviv's Sourasky Medical Center, how it is possible to have such glaring differences between diagnoses, we learned that the phenomenon is extremely common.

"It would be hard to find absolute congruence in the treatment recommendations of different dentists," Dr. Zinger said. "It depends on the dentist, their experience, their perspectives." He added, however, that further clarification is necessary when different dentists recommend radically different treatments.

"There is no such thing as a dentist finding a cavity when none exists, but there are different stages in a cavity's development, and each dentist decides when to begin treating it. Some are more aggressive, while others will take a wait-and-see approach. At the polar ends of such a case you have a negligent dentist who doesn't see a cavity when tooth decay is clearly evident, and a dentist who decides there is a cavity requiring treatment when there is no sign of the cavity in the X-ray or clinical examination," Zinger said. He added that complaints about over-treatment are very rare.

Neuman concurs that therapeutic diversity is unavoidable: "In dentistry, as in ordinary medicine, there are different treatment approaches originating in different schools. Each approach would be valid in a large proportion of cases."

The upshot is that a patient could receive as many treatment plans as the number of dentists they see, and wind up in a quandary.

If different treatment approaches are a given, is there any point to a second opinion? Neuman thinks not, generally: "If you pick the right dentist the first time there's no reason to get a second opinion. If you have doubts, however, then it makes sense."

Neuman also cautions against being seduced by offers of free treatments or discounts without ascertaining who stands behind the dentist and who owns the clinic.

"You can't tell what might be hiding behind the sparkling front of a commercial clinic," Neuman says. "Corporate dental clinics do not have to be dentist-owned, as we saw in the case of the Shoresh chain of clinics. An entrepreneur would have no problem closing the place down after three months and vanishing, and then good luck finding someone to sue," Neuman says.

He points out another problem with HMO clinics and many of the commercial clinics: "The dentists work on a percentage basis, without a fixed salary. Consequently, a dentist who does not discover a problem requiring treatment in a patient has essentially wasted half an hour, which will be reflected in their paycheck."

This does not worry Zinger. "The dentists are remunerated according to the type of procedure they perform - the percentages are lower for a filling than for a root canal or a crown," he acknowledges, but denies this means the dentists have an incentive to carry out additional procedures. "Dentists in private practice, where payment is direct and the money goes into their business, also have an incentive to do more procedures because it increases their fees. Ultimately the objective of dentists, whether in private practice or working for HMOs, is to make a good impression so clients keep coming back," Zinger says.

Dr. Oded Gelfan, a senior dentist at Clalit Smile, explains the logic behind the sliding payment scale: "The rationale for per-procedure remuneration is that it is inappropriate to pay the same salary to a dentist who carried out two procedures during a shift as to a dentist who performed a greater number of procedures, who worked diligently to solve the problems of more patients."

Gelfan added that the HMO clinics have oversight systems, and their managers make a point of viewing patient files and treatment plans.

Beyond the varying treatment plans that our mystery shoppers received, they also described different customer experiences at each place. Obviously the experience during a visit to a single dentist at one clinic of an HMO cannot be extended to all the dentists working for that HMO, but it does tell us something about the situations clients face.

At Clalit Smile in Kiryat Ono, for example, Dr. R. did not even bother to have Tester A lie down so he could examine his mouth. He made do with looking at his X-rays. When the tester himself suggested that the dentist look inside his mouth, Dr. R said it wasn't necessary and referred him to an orthodontist to have two impacted wisdom teeth extracted.

"The examination lasted less than five minutes. In contrast to the rest of the dentists, who sent me for a teeth cleaning after I had not been to a dental hygienist in years, Dr. R. did not and I presume it was a direct result of his not even looking inside my mouth," he said.

Tester A's best customer experience was at MaccabiDent. "The dentist spent time going over every tooth and she was thorough, professional and pleasant. She explained to me about the orthodontist, what courses of action are available on the market and what is more and less recommended in my case, but noted that she was merely prepping me and that the orthodontist would explain everything to me."

Meuhedet and Private Clinic also gave him a thorough check-up.

Tester B's best customer experience was at Private Clinic. "The dentist talked to me about oral hygiene and taking care of my gums. He said that my other dental problems are so minor at the moment that there is no need to touch them. He reassured me about the pain and addressed my anxiety about dental treatment."

She added that the dentist introduced himself, told her about his professional training and provided background information about the clinic. "I felt that if I had to commit myself to a lengthy process somewhere, I would do it there."
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