Article
Perhaps I am becoming an agony aunt (uncle really), but I recently seem to see and hear about patients who have been offered treatment about which I am suspicious, ‘Voleurs’ being an example a year or so ago.1 In that regard, I recently saw a patient who had been advised that his UL7 required extraction: surprisingly, it was minimally filled and his dentist advised that its root was fractured, that the tooth required extraction and arranged a consultation with what the patient was told was a dental implantologist (no such person – there is no specialist list for dental implants!) who confirmed that the tooth required extraction, followed by placement of a dental implant. I arranged for this patient to see a specialist endodontist, who confirmed that the tooth did indeed require extraction, but never mentioned the word implant. My conversation with that patient started thus: there is no rule in the dental rulebook that states that a tooth that is lost, automatically requires replacement, notwithstanding whether that is by a denture or an implant. In this patient's case, when I examined the occlusion opposite the UL7, it was clear that teeth opposing the UL7 would be in a stable position occlusally (ie the opposing tooth was not likely to overerupt) if and when that tooth was lost. There, therefore, seemed little or no need for an implant, given that the patient had a functioning 27-tooth dentition.
Weeks later I saw another patient who had been advised that an upper canine tooth required extraction and, again, a consultation was arranged to see a ‘dental implantologist’, with a quotation for £3500. On examination, while there was some loss of bony support around the mesial aspect of the canine, there was no mobility or swelling, and examination of a radiograph from 6 years previously indicated only minor change in support. In short, the patient had been examined by a ‘new’ dentist who decided that the canine was on the slippery slope to extinction. I have subsequently seen two similar cases. The number does not stand up scientifically as a randomized trial, but all had one thing in common, the referring dentist referred the patient to an implant surgeon within the same group. I asked, is this the beginning of a cartel within dentistry?
Let us take a step back and look at what I, and most readers of Dental Update, will be likely to advise patients when they ask whether they should have a dental implant in a given clinical situation and who should they see for the treatment. Readers will all be aware of the clinical conditions favouring a successful dental implant – the absence of pre-operative periodontal disease,2,3 patient being a non-smoker4,5 and the clinical situation with regard to sufficient bone, and so forth. The more difficult advice is regarding how they choose the dentist to place the implant(s). May I suggest the following advice to patients in respect of questions to ask the implant-placing dentist, the second being potentially difficult:
How many dental implants do you place in a given year? If the answer is ‘a handful’, then the patient should reconsider, and attend a dentist who places a substantial number, given that the person who places a large number is likely to be more experienced and have all the necessary equipment.
How were you trained to do this type of treatment? If the answer is ‘a weekend course at a hotel in Gatwick’, this is not enough. Five years' training as a specialist prosthodontist sounds better! Somewhere in between might be ok.
And, what is your success rate at 5 years? Someone asking a patient to part with somewhere in the region of £3500 should be able to answer that question! If they cannot, the patient should think again.
Readers may think of other questions – please send them in!
So, is there a cartel working in dentistry, in which a general dentist is under pressure to refer patients for implant treatment to a clinician who is part of the same group? Rather than referring to a clinician who the referring dentist knows as having provided excellent care for his/her patients in the past? I looked at the websites of twelve corporate groups, from the largest (with 650 practices), to small, with five practices in Surrey. Eight mentioned dental implants in an educational way for patients. One, with 100 practices, advised that they had 80 specialists in the group, while another, with 400 dental practices, stated that 270 of these practices offered dental implants. Might these be examples of what I mentioned at the top of this Comment?
Anyway, what is a cartel? Outwith those with political connotations, a variety of definitions are available, Miriam Webster states: ‘a combination of independent commercial or industrial enterprises designed to limit competition or fix prices.’ That could apply. Wikipedia defines a cartel as ‘a group of independent market participants who collude with each other in order to improve their profits and dominate the market.’ Cartels are usually associations in the same sphere of business, and thus an alliance of rivals. According to the UK Office for Fair Trading,4 which defines a cartel as simply an agreement between businesses not to compete with each other, cartel conduct is a criminal offence, and states that businesses that infringe competition law may face substantial financial penalties of up to 10% of their worldwide turnover, adding, ‘the purpose of cartels is to increase prices by removing or reducing competition and as a result they directly affect the purchasers of the goods or services, whether they are public or private businesses or individuals.’ The OFT add that a cartel may be more likely to exist in an industry where there are few competitors, and the products have similar characteristics (leaving little scope for competition on quality or service). Might this have relevance in dentistry? All of this is interesting because the legality of referring a patient to a clinician chosen because they are part of the same grouping, rather than on clinical grounds, appears, when one looks into it, to be a legal grey area.
There might be one reason why referral within a group is preferable – the referral and appointment administration may be streamlined. On the other hand, when administrative excellence is compared with clinical excellence, there can only be one winner! P.S. It is my pleasure to publish two articles on a clinical scenario that many readers will have encountered, namely, the anterior open bite (AOB) in an adult patient, something that always caused me much head scratching. The lead article, by Kelleher and Ayub, provides a clinically proven minimally interventive approach to the problem, with the outstanding results that readers can see. All written in the Martin Kelleher style, as usual, with plenty of technique tips, ‘Kelleherisms,’ and, above all, pragmatism, with not an enamel prism being cut. A great start to the New Year in Dental Update! The excellent article by Chesterman et al complements this nicely, giving details of the potential causes and management strategies, also including composite bonding (and more complex approaches). Hopefully the next time that a reader encounters such an AOB situation, they will be better equipped to provide a solution. That's what Dental Update is all about!