in rants

Delta Dental, crystal balls and ridiculous incentives

I have a few patients with poor oral hygiene. The patients I’m thinking of right now are between the age of 17 and 24 and they’re male. I think of them as my “scuzzies.” Personal hygiene isn’t a priority. I make an effort to encourage them to step up their game. I strenuously suggest that they reduce their intake of sugary and acidy drinks. I even write blog posts about it. I suggest powered toothbrushes. I stop short of actually going to their house and brushing their teeth for them. That would be creepy. The bottom line, the scuzzies are high risk patients for tooth decay.

So let me tell you a little story. I did a two surface restoration on a scuzzy last year. It was radiographically evident (an MO on #14). The distal did not have any radiographic decay. When I was preparing the tooth for a MO restoration, I visually inspected (with a microscope, naturally) the distal marginal ridge. Nada. Nothing. Zilch. So, as an ethical and reasonable dentist…I didn’t prepare the distal.

Fast forward to a year later. The restoration I placed looks great! However, there is radiographically evident decay on the distal of #14. Anyone who participates with insurance knows exactly where this is going.

His insurance wouldn’t pay anything for restoration of #14. You see, I did a restoration on it last year, and they won’t pay for any other restorations on this tooth for a period of years. I think it was three in this case. So the patient will have to pay for this entire restoration out of pocket.

This is part of the contract. I get that. But the patient’s parents (you know, the ones who have money taken out of their paycheck for dental benefits who are going to have to pay for this entire restoration) are frustrated. I frankly don’t blame them. We explained that their child is a scuzzy and we’ve been all over him to reduce his risk factors (e.g.–stop guzzling pop, step a little closer to the toothbrush, figure out what that minty flavored string is all about). Their main question: why didn’t you fill it when you were placing last year’s filling?

Point of fact…this kid is creating cavities fast! He may be a world record holder. But, he’s not alone. This happens most often in the 55 and older crowd when they start taking medications for their blood pressure, their heart and maybe for depression. Combine medication induced dry mouth with the idea of high sugar comfort foods and you’ve got a recipe for some serious tooth decay, and seriously fast.

I cannot know when someone is going to form a cavity. There is no crystal ball technology available although I hear Sirona is working on it. I can help them understand their risk factors, but I can’t tell you when and where a cavity will show up. I’m not going to start second guessing, either. When a representative from a dental benefit company explains to the patient that I probably should have restored that surface when the original restoration was done, it makes my blood boil.

I ended up writing Delta Dental a narrative and sent some photos, but they turned the appeal down. Now the patient thinks I’m a jerk. Awesome!

A high caries risk is not incentive enough for me to overtreat. No matter how good our materials are, natural tooth structure is better. If I can’t see the evidence with a radiograph or my own (incredibly enhanced) eyes, then I’m not going to restore the tooth. Even if the “insurance” company thinks that I should.

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  1. Amazingly succinct exposure of the us vs. them problems w dentists and insurance. Keep up the good fight. Glad you can sleep well at night!

  2. I loved this post! It is true that that age range of males is hard to get to take their dental health seriously. Which is weird because they’re adults or close to adulthood. Why is it hard? As a Park Ridge dentist, I too have “scuzzies”.

  3. Hi Alan,
    You have discussed very important points about dental health most of the people in those age group don’t care about their tooth, but they should care about it as it help us in keeping our smile and healthy and improve our personality and you have discussed these problem in a simple and story telling method it would help people in understanding the complexity of these problem.

  4. Here’s just a tip with insurance, if your office manager or office staff had sent the claim, they would’ve received a denial from insurance that is true. But, if your staff had at least called Delta Dental and asked for the Distal portion of the filling be paid, THEY WOULD HAVE PAID!!! Dental insurance is a joke, there are so many gray areas and loop holes they’ve created to get out of paying for procedures. I deal with this all the time. However, patients are always grateful when we follow up on these claims and get their insurance to pay.

    • Nope. The contract didn’t allow any other surfaces to be paid within 2 or 3 years (I can’t remember which). My amazing office team did try to get this paid. Guess what…no dice. Apparently I need some different diagnostic equipment. A crystal ball or something.