Am I Normal? Is my dentist scamming me? (Transcript)

Monday, October 25, 2021

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Mona Chalabi:
I was sitting in a dentist’s chair in Brooklyn, there for a routine checkup. The dentist took some X-rays, poked around in my mouth, and said: “You’re in luck! No cavities. Healthy teeth. But, your teeth are a bit yellow… You could consider bleaching as an option, if it’s something that bothers you.”

Now that he had brought it to my attention… it did bother me! I headed out with an at-home whitening kit, and my pearly yellows started turning a pearly beige. And otherwise my teeth were in pretty good shape.

Flash-forward a few weeks, and I switched jobs. That meant new health insurance, which meant finding a new dentist.

I decided to go in for a cleaning because I didn’t get that done the last time. And this new dentist took a look in my mouth and shook his head. He said: “You’re going to need six fillings…”

SIX. The alarm bells started to go off. How did I go from having healthy teeth to six cavities in less than a month? How could two trained, licensed, credentialed medical professionals look in one mouth and see such hugely different diagnoses? Surely something, or someone, had to be wrong.

Both of my parents were doctors, and both cared a lot about their patients. So I tend to trust medical practitioners. But those medical practitioners have a lot of power. Our lives depend on us being able to trust them: their knowledge, their training, their intentions. So the thought that these two dentists could give me such different diagnoses about my health was deeply concerning.

If I could find out how dentists diagnose stuff, then I could figure out which dentist I could trust.

From the TED Audio Collective, this is Am I Normal? I’m Mona Chalabi. I'm a data journalist, which means that I use numbers to try to understand how the world works.

I have a complicated relationship with my teeth. When I was a kid, my incisors stuck out, and they were kind of high up in my mouth. So they looked like fangs.

Luckily, I was never teased about them. But I’d seen this illustrated book in the kids section at the library called “Mona The Vampire.” Surely it was just a matter of time until Ben the Bully happened upon that piece of adolescent literature, and THEN my life would get hard.

There were cavities too. Me and my dad shared a sweet tooth. So after school every day, we’d share fig cookies, lemon ices, and orange and pink chewy candies.

Soon, I found myself in a dingy back-alley dentist in East London, having my milk teeth drilled. Later, I got braces and backed off the sweets, but I still haven’t been able to totally shake the feeling that my teeth are ugly or on the verge of collapse.

These two dentist appointments made all those old anxieties come rushing back. Now that I’m grown up, I turn to research to help me make sense of things. And in this case, I needed to find out if there was actually something wrong with my teeth. Or was someone just trying to rip me off? Let the Googling begin!

I immediately found out how big of an issue tooth decay is worldwide—an estimated 2.3 billion people have untreated cavities in their permanent teeth, which makes it the most common oral disease worldwide.

At best, a cavity that sits untreated for a while can be painful. At worst, untreated tooth decay, which causes cavities, can lead to other health issues that extend way beyond your mouth—from heart disease to respiratory infections. In rare cases, untreated tooth decay can even be fatal.

But tooth decay is easy to treat, IF you catch it early. And since it’s such a widespread health problem, you would think that there would be clear, proven strategies about exactly how to treat it. You’d think that… but you’d be wrong.

In reality, the study of dentistry is riddled with holes. There isn’t concrete evidence about whether it’s better to do a filling or to put on a crown for a root canal. There’s no solid guidelines about how often people should see their dentist, even though many of us are told to book appointments every six months. And it’s not even proven that pulling your wisdom teeth is useful unless you have an infection or a cavity there.

It was weird… I do this sort of research all the time and it’s pretty rare for me to find such unsatisfying scientific data. And this is for a medical profession! It was starting to seem like this thing that we think of as a science is not really based on data. And those kinds of gaps in the information? Well, they leave room for medical mistakes, AND straight up scams.

I kept searching and searching, trying to figure out what was wrong with dentistry, and which of these dentists was right about MY teeth…

Mona Chalabi (researching):
How do you know when you have a cavity? Do you treat a cavity? How quickly can one develop? What happens if you don't treat a cavity? How do you treat yellow teeth? Why do teeth turn yellow? What's wrong with yellow teeth? Do yellow teeth have anything to do with cavities??

Pretty soon, I was alternating between my mirror and a flashlight, and some— honestly quite unpleasant— Google images of the inside of people’s mouths. Self-diagnosing brings special joys, doesn’t it?

Carlos Quiñonez:
As a general rule, I try to tell patients to stay away from Dr. Google, because that's going to take you into areas that you might not necessarily want to go.

Mona Chalabi:
I stopped the spiral by booking a chat with a third dentist, Dr. Carlos Quiñonez. He’s also a researcher and the director of the Dental Public Health graduate program at the University of Toronto.

Carlos Quiñonez:
How many fillings have you had as an adult?

Mona Chalabi:
I would remember if I had, right?

Carlos Quiñonez:
Oh yeah, I would think. I would think.

Mona Chalabi:
I don't think I've had any as an adult.

Mona Chalabi:
Carlos and I met over Zoom. And although the point of the interview was not to check my teeth, I still managed to squeeze in a quick virtual check-up.

Carlos Quiñonez:
You know, this is not a diagnosis… I’m just making a person-to-person statement. Your teeth, at least those that I can see, they look wonderful.

Mona Chalabi:
I'm really resisting the urge to like, lean into the camera and show you every single tooth, just to double check.

Mona Chalabi:
But I wasn’t really there for a diagnosis. I wanted Carlos to help me figure out what the hell was going on with dentistry. Why was the basic information that I was looking for so hard to find?

Carlos Quiñonez:
Data is a problem in dentistry. I think I can say with confidence that if you compare us to other areas in healthcare, dentistry suffers from a paucity of data. In terms of what people, quote unquote, call “hard data” on how much oral disease, how much gum disease, and what does that mean for their health, because we don't have really strong data to be able to make causal statements, to be able to say this level of poor oral health will increase the risk of you having cardiac disease or cardiovascular disease or respiratory illness. Even things like therapeutic benefit of dental services.

Mona Chalabi:
We don’t know that? That feels pretty basic.

Carlos Quiñonez:
You're right. There are some very basic things in dentistry that, we don't have tons of good evidence.

Mona Chalabi:
I was stunned. Without good data, dentists are essentially flying blind.

Carlos Quiñonez:
Think about it. If you don't have that information, on what basis are you making policy?

Mona Chalabi:
THIS is why it was so hard for me to find clear answers in my research. But, if even the experts don’t have the data they need, how are regular people supposed to make decisions?

One global study I came across said that oral health data is often not collected, and if it is, it isn't integrated with other health data. That can make it hard to track global patterns in oral health.

Why separate oral health from the rest of the healthcare system?

Carlos Quiñonez:
Dentistry is a different profession than medicine. In North American economies, it's always been separate.

Mona Chalabi:
It’s normal to specialize in one part of the body. We have cardiologists, dermatologists, nephrologists. But our healthcare systems treat our mouths like they’re NOT part of our bodies. Dentists have separate schools, different ways of keeping records, and different ways of getting paid.

But last I checked, my teeth definitely are part of my body. So, why not treat them that way?

When I tried to figure out why the healthcare system doesn't treat my mouth like it’s part of my body, I found out that this reasoning goes back a long way.

In medieval Europe, doctors didn’t like to deal with the inside of the body, the gory bits. They left that to the barbers.

See, barbers weren’t just hairdressers— they were also surgeons. So, as well as your bowl cut, they could give you an enema, some stitches, or take a look at your sore tooth.

And then there were people who specialised in drawing teeth. These were traveling salesmen who would set up shop in city squares or taverns, right next to the entertainers and bloodletters, so that they could offer improvised tooth surgeries to relieve pain. But it was medieval: treatments were unstandardized, unsanitary, bloody, and dangerous.

American dentistry evolved and it eventually professionalized in 1840, but that was almost a century after the first American college of medicine was established. As it standardized treatments and best practices, it also pushed to stay separate from the rest of healthcare. There are clear perks to being an independent industry: less regulation and oversight, more professional freedom, and being able to set your own rates.

Eventually, dentistry cemented itself as a private industry, still totally distinct from medicine. Dentists had patients… who were also customers. And that legacy has stuck around.

Carlos Quiñonez:
We've deemed that hospital and physician care are social responsibilities. But when it comes to things like dental care and brushing your teeth and so on, we've said that those are individual responsibilities.

Mona Chalabi:
Minimum health coverage plans rarely cover dental. That means that patients have to pay for the health of their teeth separately, but there is growing evidence that dental problems can worsen other health conditions that those basic insurance plans DO cover.
According to the CDC, in 2017, more than two-thirds of adults 65 and over didn’t have dental insurance.

On top of that, dental insurance is limited in what it does cover. For the most part, anything beyond preventive care—things like getting six fillings—are going to cost you a lot.

In 2013, only 14% of total healthcare costs were paid out-of-pocket, but when it comes to dentistry, that figure rises to almost half.

And a 2019 study found that 1 in 7 of the U.S. population needed dental care but did not get it. And one of the top reasons they cited was that insurance didn’t cover those procedures.

I wanted Carlos to be straight with me.

Mona Chalabi:
Would you say that dentists are more like healthcare providers or business people?

Carlos Quiñonez:
We’ve done a lot of research in this area and I will tell you that they are both.

Mona Chalabi:
I thought you was going to say that.

Carlos Quiñonez:
Dentistry is insanely expensive to conduct for many reasons: the cost of technologies, the cost of infection prevention and control, which has only gotten more expensive because of COVID-19…

There's a lot of dentists that want to provide more care to socially and economically marginalized groups. But they simply can't because if they do, they put at risk the economic viability of their dental practices.

Mona Chalabi:
And the majority of dentists are going it alone. In the U.S., 80% of dental school graduates go into private practice, and that’s just for general dentistry.

Carlos Quiñonez:
You are still fundamentally a healthcare provider first and that can never be forgotten because dentists are regulated healthcare professionals. But the reality of the situation is that they are also business persons in as much as they are business owners. They need to generate a certain amount of revenue to keep the lights on, to pay their staff…

Mona Chalabi:
Finances can get in the way of dentists being the most altruistic medical practitioners.

Carlos Quiñonez:
I would argue that the majority of dentists wake up every morning and try to do the right thing for people. Like nobody's waking up saying, oh, how am I going to screw people over? I don’t think it works that way. But I do think that there's a conflict that can not be resolved between selling and caring.

Mona Chalabi:
So, were these two dentists trying to take care of me? Or were they just trying to sell me something? After that second diagnosis of six cavities, I did feel like someone was trying to screw me over.

So I didn’t treat the cavities. I wasn’t in pain or anything, so I decided to stick with the cheaper, less invasive procedure—the at-home bleaching kit recommended by my first dentist. The amount of money all those fillings would have cost was pretty steep. I could have gone on vacation with that money. Who doesn’t want to go on vacation? Plus, I mean, I just wanted brighter teeth.

Armed with my whitening kit, I had a solid plan to make myself look “better” by Western beauty standards. But with no help from my dentists, I still didn’t know if I had made the call that was right for my health.

After a few weeks of at-home tooth whitening, my smile had gotten noticeably brighter. But something else had changed, too. Smiling on a cold day, a cold drink, ice cream… They all hurt! My teeth were suddenly way more sensitive.

When I took home the kit, I knew it wasn’t for medical reasons. But what I didn’t realize is that there could be a medical cost to my quest for perfectly white teeth.

Tooth sensitivity is a possible side-effect of whitening. The bleach can weaken enamel and cause pain. So I’d essentially gotten the oral equivalent of a trip to the tanning salon. A cosmetic procedure with not-so-great medical side-effects. How come my dentist—a healthcare professional—was pushing a treatment like this?

Carlos Quiñonez:
There's something about dentistry that isn't present in many medical fields. There's certain services that are both healthcare, meaning they're there to treat existential threats—you know, you have pain, you have infection, you know, there can be very serious outcomes if it's not treated. But then there’s other extreme, which was, you know, your tooth whitening. Mona, you weren't going to die. The term that is used in the sociology of health literature is something as healthcare versus something as bodywork.

Mona Chalabi:
Oh wow, bodywork sounds like a car.

Carlos Quiñonez:
Yeah. Whether it's straight white teeth or tooth whitening, you might end up one day in a practice that feels more like a spa than it does a traditional dental care setting. Teeth, because of their status, biologically, psychologically, socially, culturally, even politically, results in something that may not be present in things like cardiac surgery or other forms of healthcare.

Mona Chalabi:
Whitening my teeth was an aesthetic treatment. But, for better or worse, how I look does affect how I move through the world. There are all sorts of stereotypes about teeth… That the straighter and whiter your teeth are, the healthier, richer, and better-looking you are! That is a lot of pressure on a few little teeth, and we can feel it. But the impact of those stereotypes can be even more serious.

Carlos Quiñonez:
If you don't have any front teeth or you have stained and broken teeth, you're going to have challenges finding a good job… That's going to have implications for your ability to be upwardly mobile.

Mona Chalabi:
There is a reason that DIY dentistry, like veneers and tooth filing, is constantly trending on TikTok.

Carlos Quiñonez:
Teeth represent a signal. I mean, you know, when you're dating, “Oh, I really like your smile”, in terms of their ability to, you know, find love, in terms of your self-esteem. I think it's a bit more complicated than just saying all cosmetics are out.

Mona Chalabi:
But there’s a power dynamic involved when a healthcare professional tells you that you should get your teeth whitened. Not because dentists are known arbitrators of beauty, but because—white coat and all—we know that they know more than us. When a dentist tells us that something is right for our mouths, that is largely the advice we tend to follow. It’s just not the same as a high school student working the front desk at a tanning salon, upselling you on a 5-session package deal.

My “cosmetic” prescription was suggested by a dentist immediately after inspecting my teeth for cavities. This dynamic goes both ways—it's not just dentists who fall into the tension between medical and cosmetic services. Patients get caught up in it too.

Carlos Quiñonez:
Now, nobody wants silver fillings: everybody goes for plastic fillings, again, because of this notion of “I want my teeth white. I don't want silver in my mouth” per se. But we know that, with individuals who have significant levels of oral disease in their mouth, that putting a plastic filling in their mouth is probably not the best clinical decision, because those fillings tend to break down more quickly. But the market drives decision-making.

Mona Chalabi:
I went in for a check-up and a cleaning, but some patients show up to a dentist asking for a full set of veneers, even though that involves grinding down the front enamel of someone’s teeth. Medically speaking, that’s not a great plan.

Carlos Quiñonez:
I think there's a tremendous level of complication or issues involved in what people do or desire with their teeth. I mean you’ve heard of people wanting to put diamonds in their teeth?

Mona Chalabi:
Yeah.

Carlos Quiñonez:
But it can be really subjective. Because some people like different smiles. My wife, at one point she had a gap between her front teeth, and I tell her, I wish you still had that gap because I find that really sexy, right? But she got the gap closed because she didn’t like it.

Mona Chalabi:
So there are financial incentives for dentists—as business owners—to sell treatments that patients want to buy. And there are social incentives for us to buy them, even if those aren’t necessarily the best health choices.

Carlos Quiñonez:
I think dentistry itself has some cultural issues within it that it needs to address. Like, being very sober about what is health care, what is bodywork. People don't like this term within dentistry, because it's sort of, it’s sort of like a sacred cow, or to tell a dentist that part of what they do is not, is not healthcare.

Mona Chalabi:
If a system is set up so that you can’t get the information that you need from the experts, and those experts don’t have all the right information to begin with, then that system is broken.

Mona Chalabi:
But I can’t exactly boycott going to the dentist! My health isn’t something I can risk opting out of. This broken system is the only one I’ve got. So, how do I navigate it?

Carlos Quiñonez:
You are going to have to move forward with incomplete information or the information that you have available to you. And I know that's not a satisfying answer, but that's the best one that I can give.

Mona Chalabi:
So I spoke to three dentists, Mr. “You have yellow teeth”, Mr. “You have six cavities”, and Mr. “I can’t see you clearly on this pixelated Zoom screen”, Carlos. Of those three, I trust Carlos. Because he was upfront about not having a perfect answer.

When we say we trust someone, it’s usually because we believe they have the right answers to our questions. Trust in experts is about having information. But I think that being trustworthy—as a scientist, a researcher, or as a whole medical profession—is as much about telling people the answers that you DON’T have.

This whole thing made me think of my mum, and just parents in general. Because when you’re a kid, you naturally think elders have all the answers. But to her credit, my mum never tried to pretend she knew things when she didn't. She would acknowledge the limits of her understanding, and then she’d go look something up, or ask someone else. And all of that made me trust her more.

Maybe researchers and scientists—that includes data journalists and dentists—could learn a lesson from that. That to say what you don’t know doesn’t necessarily diminish you in the eyes of others. It just makes you more trustworthy.

Am I Normal? is part of the TED Audio Collective. It’s hosted and produced by me, Mona Chalabi, and brought to you by TED and Transmitter Media. This episode was produced by Jess Shane. Sara Nics is Transmitter’s Executive Editor, Wilson Sayre and Lacy Roberts are our Managing Producers, and Gretta Cohn is our Executive Producer.

The TED Team is Michelle Quint, Banban Cheng, and Roxanne Hai Lash. Jennifer Nam is our fantastic researcher and fact checker. Additional production by Domino Sound.

The original theme song is by Sasami. Michelle Macklem is our sound designer and mix engineer. Production assistance from Debbie Daughtry.

Special thanks to our most patient contributor, my mum!

For transcripts and research I talk about in the show, check out the link in the description.

We’re back next week with more Am I Normal? Make sure you follow the show in your favorite podcast app so that you can get every episode delivered straight to your device. And if you enjoyed the show and want to support us, well then, you can hit the share button and send it to someone that you know who has a cavity, or who has yellow teeth. Or that auntie of yours who’s a dentist.

You can find more about this episode’s guest, Carlos Quiñonez, at the University of Toronto.