I know some really greasy dentists

If you never read this Hell World in which a couple dozen people shared their dental nightmares it's a rough one.

I was rigid in the chair crying from both fear and shame

It was so bad I would sit on a cold winter basement floor in pain swigging whiskey to dull the pain like I was a cowboy

Welcome to Hell WorldLuke O’Neil

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This piece below is originally from 2021.

I just don’t trust dentists man I’m sorry. Especially after a year and a half when they probably saw very few patients and need to get business humming again. This new one I just saw told me I need a few crowns in the back on my old silver fillings from when I was a child and that may or may not be true but do I need them need them or would it just be nice if I got them especially since they are going to cost like two grand each? She and the hygenist asked how I found them and I said I literally just chose the nearest dentist to my house and they said hm and I said I have no idea if you are the best dentist in the area or the worst and they didn’t seem to think that was funny.

There should be a set up where you go to a dentist and make it clear to them that you are 100% not going to give them your business for any work that needs to be done they just have to tell you if the other dentist you just saw was bullshitting or not. I guess you can technically do that already but it feels weird and rude. It’s like please double check this other person’s homework for me.

I posted about not trusting dentists and a few people replied on the subject.

• I once went to the dentist and was told I had twelve cavities that needed filling. I went to a different dentist who told me it was actually just two.
• I haven’t been to a dentist since 2010 because the first dentist told me I had four cavities and I went to a second because he didn't take my insurance and she was like “you have zero, I know that dude he does this all the time.”
• It is so fucking wild to me that dentists will fabricate procedures to get money out of you and our main insurance policy against getting hosed is to get a second opinion.
• Feel like sometimes I got the only good dentist on earth because one time I asked if I should get my wisdom teeth out and about some other work and he just looked at the x-rays and said verbatim “Yeah I guess I could do that but why would you even want it?”
• I have a large cavity on a molar from when I was 14. When I was about 26, my dentist recommended it be crowned. I had zero pain, so I said don’t touch it. He retired. New dentist said the same thing. I declined again. The filling has now survived 21 years since I was told it should be crowned. I brush thoroughly every day — and if it doesn’t hurt — don’t let ‘em touch it.
• I didn't have the slightest idea dentists would bullshit you until I saw some girl on here say hers told her she had a ton of cavities. Her second opinion guy said not a one. Which in turn made me wonder if I really did have seven last time I went. Makes ya think!
• The only dentist I ever trusted had crooked teeth. I told him straight up that I’m strictly a break/fix patient so don’t bother recommending braces/veneers because I can’t afford it and he was like “Yup, gotcha” and gave inexpensive fixes that would hold over 10+ years. Sadly that’s the Best Available Option. Use less good materials that don’t last but also don’t cost $$$$. Better for most of us to pay $ to change out a filling every few years than cough up $$$$ at any one moment. Every hard sell I’ve ever gotten from a dentist ended up in poor work. The guy who spent hours working up a credit scheme to get $5k *today* for a crown disappeared one night and the crown fell off and took half my tooth with it within a year. Even with insurance I had no recourse because the guy just dropped off the radar and now it was “pre-existing” damage which is not covered by insurance.

Then I read this horror story:

And this:

Every time I post about dental shit I get a dentist or two who writes to me defending their industry and saying they’re not all bad etc etc. So I decided to talk to one for today. Our dentist here is relatively new in his career and works for a corporate dental chain in New England. He asked not to use his name for fear of getting in trouble at work which is something he can’t afford to risk since he still has $500,000 in student loans to pay off. We talked about dental chains and the financial pressures of the job and whether or not dentists are all money grubbing scumbags.  

My first question is this: Are you evil?

No… I try not to be. I try to be a good guy. I do work for corporate dentistry right now, so… I guess there is that element to it. But I try to resist their efforts as much as possible. I try to treat other people how I would want to be treated. I was raised as a good old Catholic boy, so that’s one part that still sticks with me.

I’m half kidding, but… When you wrote to me at first you said you realize you’re public enemy number one for a lot of people. Why do you think that is?

There’s a lot going on there. A lot of older patients tell me back in the seventies they weren’t really using anaesthesia. You'd get some nitrous and the dentist would be a pretty heavy handed old dude who probably didn’t treat you too kindly. So there’s a lot of that fear. The sounds. Having a dude’s hand in your mouth. It makes people very uncomfortable and probably brings back a lot of childhood memories. Then there’s also the cost, which is always shitty, and the dental insurance which is also always shitty. I was just talking to my front desk employees and they were saying dentistry as a system has never been overhauled. It doesn’t work like any other medical industry. The insurance doesn’t work like any other medical insurance. It’s a mess. And of course the ADA is fighting it tooth and nail.

They’re fighting any reform?

Oh yeah. I get emails all the time from them saying we can’t let this Medicare update pass to include dentistry. It’s not right. It’s like, what are you talking about? We have to do something for people.

That’s something I was going to ask you about. In Biden’s plan they’re trying to expand dental coverage under Medicare, and the ADA, they’re one of the better funded lobbying groups working against it.

They’re more funded than like any medical group. I guess because dentistry is still a private industry. It’s not federally funded like hospitals or anything like that. So all the richer dentists have more of an impetus to want to keep the system exactly as it is so they can keep raking in the money. That’s one of the questions I have. When dentistry does get reformed, am I going to be a dentist working in some hospital system, you know, when you come in for your physical I give you a look over as well? We were just trying to brainstorm. What countries do have dental care set up better than America? Some European ones I’m not aware of?

I did a piece recently where people talked about getting medical and dental care in other countries, going in and getting seen right away, being really cheap. I think however that even in a lot of countries with much better medical care, dental and medical are still considered different things.

I just had a guy come in and tell me he gets all his dental care in Costa Rica. It’s so cheap and easy. I was looking, and I said it might be cheap and easy, but you’ve got $5,000 of work that’s all going to need to get redone. He said, ok, well, I’ll go back to Costa Rica.

That’s another thing though. I did another piece where people talked about how they always think their dentists are bullshitting them.

Oh yeah, there’s certainly a lot of that. It’s just like any industry. You put a lot of people in a class and you teach them all the same things. At the end of the day a bunch of people are going to get different stuff out of that. Some are going to be conservative. Some will just be out to get money….I know some really greasy dentists. It’s like what the hell are you doing here? It’s really weird to come through school with all these guys, and see what some of my friends are doing.

Some of them are behaving unethically?

I mean… I worked at a dental office where a guy found some workarounds with the state insurance. He pulled a lot of teeth, which was covered by the state insurance, and he found all these other adjunct codes so he could bill up to $1,600 per extraction so he could recoup his losses. I raised the red flag to the company, but I don’t know if anything got changed because I stopped working at that office after that very quickly.

Do dentists have the Hippocratic Oath or something like that?

Yeah it’s like a similar oath you take when you start dental school, like, do no harm. Patient autonomy. Non-malfeasance… It’s the same jist.

Is that why you left that practice?

Yeah. The guy, he was older than me, someone told him he was the director of that practice, so he threw that around everywhere. I was six months out of school at this point. He said, no, no, it’s in the book. You can do whatever you want if it’s in the book. I did a shit ton of research on it, compiled this folder. One thing the American Association of Oral and Maxillofacial Surgeons said is this code cannot be used at the same time as a tooth extraction. This is a code for when you have like a cyst growing in your jaw and you remove that. That’s like $800 of a code, and he put it on pretty much every extraction he did on the state insurance. So I raised all the red flags. I had this whole report I was emailing back and forth with the quality control person at my company. They said, hey, we’ve got another office you’d be great in. I don’t know what happened with that.

I would love to get out of this office as soon as I can, but there’s really no other option. No private practice will hire you until you’ve got three or four years of experience because they just really want you to be able to pump out work really fast and be good at recommending crowns. They look at me and say you’re too slow, too young, I’m going to lose money on you.

So when you graduate dental school you have two options. Working at a public health clinic, which for me wasn’t really an option because they’re all in really rural parts of the state and my fiance has to be near the city. Or bigger clinics, essentially corporate dentists. Aspen Dental and stuff like that. My work is a step below Aspen, but you can tell they’re always trying to ramp up to become like Aspen. We’ll bring on all these new consultants… They say if you know anyone who's selling a practice we’ll buy it.

You work for a “DSO.” What is that?

They call it a Dental Support Organization because it’s a wide network of all these dentists and mentors that are there to support dentists. I think it’s pretty generally known among dentists as just corporate dentistry. You’ve got people behind the scenes who are just making money off of you and trying to get everyone on the exact same wavelength. You see this, you recommend this. It’s like you’ve got a generic barbershop and then a Top Cuts where you go in and order haircut 1 through 5. It’s supposed to be a benefit for the dentists because they have this support.

I used to go to a lot of Aspen free dinners when I was in dental school. I really hated them. At one point they were saying how being such a huge network they get to advocate for prices, like a hospital would. So they get everything for cheap, materials for cheap. They were like, you know, we see ourselves as vital in America’s health care needs. So I would ask, like, what are you going to do if America socializes medicine? And one of the guys who owns like seventeen Aspen dentals, and was three whiskeys deep, started really loudly arguing with me. They didn’t invite me to any events after that.

I guess I can understand how running a bigger network streamlines certain costs for dentists, but how does the piss trickle down on patients’ faces because of these chains?

I know with some they overdiagnose things. You go in and they’ll say you need two dozen fillings. You need this and this. I see a lot of people who get dentures made at a certain DSO, and they’re really shitty, and they don’t fit. If you ever ask for a second opinion from some of these companies they’ll charge your insurance for the exams, but if you go to another dentist, they won’t send any of the x-rays they already took, or they’ll send them all as one file so it’s hard to read…. So you’ll have to get the exams again.

Is Gentle Dental, where I went for years, a similar type of company?

Yeah. I think they’re now going by the name 42 North.

What the fuck does 42 North mean?

I have no idea.

Generally speaking dental insurance doesn’t do anything right?

The best analogy is it works like a gift card. You, or hopefully your employer, pays x amount of dollars. And then you get x amount of work. Let’s say the average benefit is $1500 per year. It’s broken down into three categories: Preventative, cleanings, x-rays, and exams, which are covered at 100%; Minor: fillings, simple extractions, root canals, which is new, and perio cleanings covered at 80%. Usually that means your out of pocket is the additional 20%. Getting a single root canal on a molar will generally eat up that entire year’s insurance benefit, and of course that tooth probably needs a crown on it too now, which is considered Major, along with surgical extractions, dentures etc, and is covered at only 50%.

I honestly just learned that that is specifically how it worked. They never teach you about insurance in dental school, and you are never supposed to talk to patients about it, like dental insurance and finances is some big secret that the dentist doesn't know…

I’m still confused.

It’s like a gift card, but worse, and with limitations. Like yeah your gift card to the grocery store will buy you eggs and milk and cover that, but if you want to get some Frosted Flakes, it'll only cover part of that, so you get a discount on it because your gift card company doesn't think you fully deserve that cereal.

Hmm...

It’s wicked confusing. I mean I'm still learning about it. And there's like sometimes time limits on it, like you gotta have that insurance for a year before they pay for a crown, so that the company doesn't feel like you are just using them to pay for a crown I guess. Like you really gotta deserve it? And most will only pay for two cleanings a year, six months and a day apart, but some will just cover two cleanings a year, no time restrictions, and there is occasionally one that covers four cleanings a year, which is actually kind of cool because just having your teeth professionally cleaned more often is super beneficial to reducing any cavity occurring. But it sucks that you have to have a very niche insurance clause to actually get that benefit. Everyone should just get cleanings every three months. Abolish the military and do that with the money. People would need so much less dental work.

You came out of school with $500,000 in debt?

$50,000 in undergrad and around $450,000 for dental school.

How long is it, four years?

It’s a very intense four years. It’s year round, so you don’t get summers off. You don’t really have an opportunity to have a job. There’s no housing or anything like that. So your loans are also paying for food, gas, rent, car insurance. The tuition itself is only like $70,000 a semester, but the living expenses beyond that were a lot more.

Does that sort of price tag serve as a barrier to people you think? Does it filter people out who aren’t from relatively comfortable upbringings?

Dental school has kind of a legacy aspect to it. A lot of my friends who are dentists, their parents are dentists…. But most people I know took out loans, even the kids of dentists. I’m sure they were more comfortable than others. But everybody was on some type of loans. I’m probably at the higher end of it. Not everybody came from rich backgrounds. One girl I knew worked for quite a few years as a waitress before dental school so she was in the same boat as me…

You see this with doctors as well. The debt incentivizes you to try to make as much money as possible as soon as you start working.

Oh yeah. I think that’s why a lot of DSOs will target new graduates. The average solo guy who owns one practice, he’s not going to hire a new graduate. He knows they’re not going to work fast enough to make him money. Unless it’s your family and they hire you because they want you to take over the practice. But for most people that’s not the situation any more. So with DSO’s they'll say I know you need the extra money, so work Monday through Saturday and you can pay off your loans quicker. Some people I know are doing the public service pay off, which I believe if you put in four years it forgives $200,000 of your loans, which is pretty significant. I looked at that, but you don’t make as much as you would there in a private practice. I talked to my financial advisor and he said if you work at a private practice and put away some money you can pay off your loans quicker. I’m still looking at paying them off maybe by retirement age. It’s a fucking mess.

It sounds like it. And that’s even though you’re making a pretty good living now?

I’m living comfortably. I put $1,500 a month into a specific account that will pay off my loans. Sometimes I’ll put a little extra in…. With the pause on interest on loans, someone I was talking to calculated it out, that will save the average person with dental school debt $40,000.

Over the course of the loan?

Over the course of the one year it was paused.

Jesus Christ. I don’t know man, wouldn’t it be great if… I’m sure, similarly with doctors, there are a lot of dentists just trying to get paid. There are also people who genuinely want to help others. Maybe that’s you! People that like the idea of making people’s lives better. Wouldn’t it be great if anyone who felt that way could enter these professions without this sword of debt hanging over their head the entire time?

If they forgave all the debt then where’s my impetus to make money anymore? I’d happily do public service or work for a smaller clinic. What I really want to do is help people who actually need it, not just give crowns to dudes who drive BMWs. That’s the dream. Forgive the loans and I suddenly don’t need to make over $100,000 a year. I just want to be able to pay my mortgage and get some craft beer every now and again.

Do you think the fact that dental care costs so much for patients as well means that this is all a negative contributor, not only for the health of individuals, but public health in general?

Absolutely. A big thing my company is trying to get us to push for now is this: There’s a certain criteria where technically a tooth with a filling will need a crown at some point. If the filling is too wide it puts the tooth at a high risk of fracture…. They’re always like, point blank, if you see a filling that is greater than ⅓ of the total width of the tooth you recommend a crown. Every young doctor is always like, well what if the patient can’t afford it? The company will say it’s not your job to think about the patient’s wallet. You’re only there for their health. There are payment plans, this and that. I’m like, I’m not letting someone take out a predatory loan so they can get a crown. I’m sorry. I understand the tooth is at a higher risk of fracture, but if it’s not actually fractured I’ll do anything else to help them if they need. I’ve rebuilt teeth that are missing most of the tooth, at an incredibly high risk of fracture. But I’ll do it, and if it fractures again you know where to find me. It does need a crown, but I can’t make you get a crown. I can’t say save up your little social security checks every month and get a crown. That’s not something I’m comfortable with. I came from a relatively poor family. We had our ups and downs. But I got super radicalized into the whole socialism thing when I was in undergrad. My dad was truly homeless. Sleeping on park benches and shit like that. It kind of broke my worldview. So here I am.

Part of me is sitting here thinking, ah, this poor kid. He’s either gonna turn evil eventually or wash out if he holds on to his ethics.

Yeah those are the two options. I was thinking about that recently. With all these drives from the companies to make more money, am I going to turn into one of those dudes? I hope not. I know someone who spent four years working at Aspen, and just the constant drive to do more work, do more work, do faster fillings. He said he couldn’t do it anymore.

You talk about the pressure to do more work. Do these corporate chains want you to just do volume?

They want you to do things faster and do more things. The big thing we’ve had pushed on us recently is same day treatment. If someone comes in, I do an exam, and say you’ve got a cavity. I’m supposed to slide them into my schedule right away. I don’t have time for that in my schedule. I have someone out there who’s been waiting to get a filling for over a month, I gotta do them. I understand if there’s an emergency and I have to squeeze them in… but I don’t want to do that all the time. Our company has been sending all these really weird videos lately. How to talk to patients, do this and that. I thought they were really weird. I looked into the company that was making them. None of the guys are dentists. They’re businessmen who are trying to make dentists more productive. It’s listed as the number one non-profit advocacy group in America. I was like, what is this dystopian shit? It’s called the Crown Council. Their whole thing is to recommend more crowns….

I just Googled it. “The Crown Council is one of the most powerful and focused mastermind families in the world,” it says. What the fuck? So you said you’d need around a million dollars to start your own practice?

It depends on where. If I wanted to be in the city in like a loft, it would probably be more like $1.5-2 million. But I haven’t looked too much because I don’t know if it will ever happen. Of course that’s the dream. Of course I want to be my own boss and answer to nobody and help people however I want. But then you have to think about overheard and paying employees and your business loan.

You are paid on commission?

I make 35% of whatever money I collect. That’s fairly standard across private practices. I know dental specialists, endodontists and oral surgeons it’s a little more complicated than that.

So again that’s incentive to churn and burn.

Absolutely. My company has started sending out a report everyday of every dentist in the company and what their production was the previous day. They’ll shout out all the dentists that had good production. So I’m supposed to be having $3,500-$4,000 of procedures a day, of which I’ll collect 35% of what is paid on that.

And will they put the dude who’s slacking on the list too?

Absolutely. There was one day last week where my name was at the bottom. Everybody in the company sees that.

That’s perverse. Although I guess in my line of work different websites would sometimes have leaderboards of how many clicks your story got. Which is also a really bad incentive.

I hate it. It’s so much pressure. If I have a bad day I know because I don’t get paid as much. I don’t want everyone else in the company to know I had a bad day.

It’s Glengarry Glen Ross shit. I asked some people on the Discontents Discord what they would want to ask a dentist. A lot of it was just how common is it to just be in it for the money, and I guess we sort of covered that.

Another aspect of that is that it gets more common. Everyone who starts out young has stars in their eyes, but the system just beats you down. I feel like a lot of guys probably had good intentions when they started then just said fuck it.

Boats are expensive.

Oh yeah. It’s kind of a joke, but I I first thought about dentistry as a career because I went on a sailing trip with my Boy Scout troop, and I fell with sailing. I thought I’d be a marine biologist, that way I’m always on the water, it will be beautiful. Then my mom looked up what a marine biologist with a PhD makes and she said why don’t you become an orthodontist, and you can buy a boat for fun. I was like… ok. I took physics and realized it sucks, and realized I didn’t want to be an orthodontist. I have a kayak now but I have no desire to own a boat at this point.

Someone wanted to know what the gnarliest thing you’ve seen in someone’s mouth?

Everyone thinks they have gross teeth. I’ve seen so many teeth it’s like whatever. I got one dude who keeps coming in. He must have an allergic reaction to tomato sauce, but he loves eating Italian food, so he’s got all these ulcers in his mouth. I have to keep giving him prescription mouth rinse. There was one lady, when I was doing an externship, and she had really bad M.S. and couldn’t brush her own teeth. All her teeth were these little rotted off nubs of roots in there. I told her she had thirty active infections in her mouth and we should pull them all out. So we did…. I drained all the abscesses and sewed her up, got her on an antibiotic. I followed that case for a while. She was supposed to get dentures made. That was around February of 2020 then Covid hit so I don’t know what happened to her. I do know when we followed up later her daughter said honestly I haven’t seen her this happy in years. She has a mouthful of bloody gauze but she’s smiling. It was just nasty. The puss and shit in there. She was living with that for years. It was heartbreaking. But I liked doing that. People who actually need the work.