Dental Treatments are Expensive for no Reason??
There is a huge controversy on dental practices since the day ‘Modern Dentistry’ evolved. As we recall from our past, dentistry has gone through a series of advancements, and it is also going through, since last 50 years. New technologies are pouring in, modifications on previous techniques and instrumentation, new inventions related to more conservative care, and other modalities to replace a missing tooth. Everything is changing except the patient acceptance and social behavior towards a dentist. And this is the main breach among the dentists who can’t pursue their career with modern facilities and here is where the controversy lies.
Rs. 800/-; just for the Consultation fees???
One example can give you a better vision. Few years back I was travelling to a metro city in southern India. It was the first flight of my life. While landing, due to the weather may be, the touch down was so rough that I clattered my jaws severely. This resulted to a broken tooth in my right upper jaw. It was so irritating that I had to postpone my schedule for that day and to visit the nearest Dental clinic from my hotel. That city is really the greatest dental hub I have ever seen. Within a range of 1km radius you can find 10-12 dentists or dental clinics. I was overwhelmed by the variety and concepts of different glow sign boards and clinical setups. I pushed through the doors of a most sophisticated dental clinic as their board was so captivating. It was the longest passage way from the front door to the dental chair that I have ever encountered.
The best part about that clinic was the waiting area and the reception. The decoration was way more minimalist yet with a touch of excellence. The colour pallets were neutral and airy with simple furnishing and no excessive or flamboyant accessories. One guy was cleaning the floors. I think he was mopping the floor hourly as I had to wait there for an hour and seen him twice to clean the elegant white tiles floor at the reception area. With me there was only three other patients with different cases. I started scoring this clinic mentally 7/10 about maintaining the cleanliness in the waiting area. Then I heard my name announced from the reception. There were two young women busy with their computers asked my name and all the details to complete the registration. Well, I must say that this is not a hospital but a simple local dental clinic with the best corporate set up. I gave them 8/10 score for the registration procedure and their professional behavior. Then I was asked to put on the shoe covers and enter the main clinic. The ambiance with warm ceiling lights and textured wall paintings with a timbre of gentle flow of music from unknown source made it completely different from any other clinic. The doctor came in and asked my complaint. After taking my detailed history he examined me with instruments out of the sterile pouches. This is the most important part that I try to maintain at my clinic to use sterile pouches to keep the instruments safe and in good shape. I was hiding my identity as a dentist to go through the process and to feel what they do. Everything was so far the best I have seen. But then raises the concern about the cost. A broken tooth is always treated by restoration or root canal treatment or extraction depending upon how serious the damage is. Mine was the worst but could be restored with RCT followed by a crown. That was not possible then as I am not going to reside there long enough to go through the procedure. He took a radio-graph with RVG (digital radio-graph) and explained me the details. To know the charges I asked him about the cost and it was eight thousand rupees for the RCT only, back in 2017.
Leaving the RCT part there was only one option to get treated with this sudden awkwardness and that is grinding of the sharp edges on my broken tooth. I agreed with the doctor but I was concerned about the charges, so I asked him first. Nine thousand rupees only for root canal treatment is something too alarming for me. So the hesitating self of mine started playing with my mind. The doctor called a staff from the reception and gave her three codes to check the prices. After waiting for another minute or two, the receptionist came up with the charges which are in total 2000/- rupees. It was way too much money for me to spend on the first day of this trip. I asked my doctor to prescribe me something rather than doing the treatment. He agreed and gave me the prescription with a hand written note of codes. I came out of the working area and gave the papers to the receptionist. She entered those codes in the computer and the bill generated was of 1000 rupees. Rs.800/- for the doctor fees and Rs.200/- for the X-ray.
Cheap dentist Vs. Expensive dentist:
That was a great experience with this clinic and then comes the cheap dentist part. I was so bothered with my broken tooth that I came back to the hotel and asked the receptionist to suggest me some dentists. Unfortunately the hotel receptionist guy gave me the same address where I have already visited. Then I asked the room boy who came to serve me my evening tea. According to him the best dental clinic was 1km away from the hotel. He gave me an account of “50 patients per day at that clinic. That’s the reason it’s the best.” I took the details from him and directions to go there. It was not showing in the Google maps so I had to struggle a bit but finally after a half an hour search I found the clinic. It was a complete showcase of General Dental Clinics mostly you can encounter here in Kolkata and in the suburbs. An ordinary glow sign board, a simple entrance, a waiting area with too little room to accommodate ten people at a row and with no reception. You have to go inside and call the assistant who will take your name and will write it in his hand held notebook. Though the place was crowded but the calling was fast. After waiting for an hour and half my name was called, with the horrible pronunciation, and I entered the clinic’s working area. The waiting area was not so good. Many of the patients were waiting outside for their names to be called. The cleanliness was less than average. The working area was totally back-dated and messy.
An idea of sabotaging my identity clicked in my mind. I wanted to notice every move they make and their management of doing works with such a huge crowd outside. It was simple, traditional and useful method to handle a crowd of patients with such efficiency. There were two dental chairs and three dentists working around. (I think the third one was the lab technician as I recall those moments.) The consultant dentist, the aged one, was consulting with the patients. He was not at all bothered about any details other than the patient’s complaint or medical history. The process was fast and unique. I think this uniqueness comes with age and experiences. Those patients who needed medications only were just checked and left the chair. There were two assistants who were the main charm inside the clinic. One of the assistant was sterilizing instruments or setting up the instruments required for the next patient. The one with the notebook of patients’ name was writing the prescriptions. The aged doctor was dictating the details and medications while checking the patient and the assistant was jotting them down. Then the doctor signed it with lighting speed strokes of his pen and the patient leaves after paying the sum. The second assistant rushed to the used chair took the diagnostic instruments and dumped them into the boiling bath. He cleaned the chair and the spittoon with some spray and a cotton rag. Then the new patient enters and the assistant gives the fresh instruments from the boiling bath to the doctor. As I can remember the second doctor was the younger one and he was busy with the root canal treatments. His movement was fast and effective. I think I have spent 15 minutes inside the chamber and he completed BMP (second stage of RCT) of a patient within that time frame. That patient left the chair; he changed his gloves in a rush and hurried to me within a second to do his job. There was a little delay for explaining as the language was a barrier. He noticed the tooth, checked the sharp edges with his finger and grinned it to an agreeable smoothness within a minute and I had to leave the chair. The prescription was ready for me and I had to pay Rs.300/- for the treatment.
I was so astonished with the difference between these two clinics, 1km apart, from each other that this became a hobby for me to explore and to learn. Till date I have visited around 168 dental clinics in different areas of my state and other metro cities. I have intentionally avoided the corporate houses or the hospitals. With my experience from these trips I have learned something that general public is used to differentiate dental clinics as an expensive one and as a cheaper one. 70 people out of 100 believe that cheaper clinics are better than the expensive ones. 20 people out 100 trusts the dentist’s name. They are not even bothered about the expenses. Rest of the people are old and chronic patients who have never changed their dentist since 20 years. It was a joy to encounter one patient who was happy to state that his dentist had pulled his milk teeth during his childhood and now the same dentist has pulled his rotten teeth few months back. He was so happy to wish that the same dentist to pull out his all teeth and do the rehab with prosthesis.
Quality Vs. Quantity or, Skill Vs. Technology???
Here comes the climax of my blog. It is not the services that people seek or give priority to. As a poor country we are as if grown with a mentality to find the cheapest is the best way to survive. And that brings the dentistry perspective into a view. It is not that dentistry is expensive for no reasons. The first clinical set up I have described is the best one a dentist could arrange in a life time. That was expensive for a reason. Charging Rs. 200/- for an X-ray is relevant as a RVG machine costs around 3-4lacs in total. The consultation fees of Rs.800/- was very much relevant after observing the cleanliness inside the clinic, the staffs and the establishment. Individually the establishment is worth for charging 1000/- rupees as consultation fees. Then consider the sterilization process. Each and every instrument was separately packed in sterilizing pouches and immediately discarded for CSSD in a covered bucket. The whole chair was cleaned with IPA and the disposables were discarded properly as biomedical wastes. I have seen the instruments there for RCT and when I came back to Kolkata and started doing my research about these modern things. I came to a conclusion that I must have charged Rs.15, 000/- for every RCT cases as those machines were literally costly instruments that one can afford to have in their clinics. This shows that the dentist was charging low considering the fact that if that machine can serve up to a good number of patients the cost will be adjusted. But that is a probability not a possibility.
This brings me to a conclusion that why there is a difference between dental clinics and how the perspective changes among the patients. I have always tried to find a way to balance this quality vs. quantity dilemma. But unfortunately I have found no ways to balance these entities that completely oppose each other. You can never maintain quality as a private clinic with the huge number of patients. Any of the other will get compromised as a result of the conflict. And there lies the controversy of Cheap vs. Expensive.
The discussions I had with general public who seeks for a better treatment with an affordable price are always in a crisis to choose between two. Those who cannot afford are out of this discussion as they are getting treatments from the Government hospitals for free or with nominal costs. The wealthy and cash rich people will seek their way to their favorite dentists with special appointments or in a private hospital with the dental set up. They are not even bothered about the prices and services they are getting. I have encountered very few rich patients who at all knew about what treatment was going on. They just had a sketch of idea about the procedure and the amount they are paying. They have never considered to judge or to evaluate the procedure or the skill of a dentist from others. I have also left these people out of my considerations as they are not interesting for my research. I have encountered one such patient in my own city Kolkata, who paid around 5 lacs for his full mouth rehab but had no clues regarding the treatment plans. Either he was reluctant or he was just avoiding such interviews. As a dentist I was too jealous to share my thoughts with my fellow dentists, but when I came to know about the procedure I was ashamed of my feelings. The Lab Technician appointed for that job was charging Rs.1.5lacs to the dentist. The picture of expenses came out clear and doing the maths for materials and instrument costs, adding the charges for assistants and other specialists. The dentist is going to get pretty fewer amounts than anticipated from the total value.
Please do consider about your dentists as they are not charging you higher without any reason. They are charging you less if we consider their skills to treat a case. It is the materials that are causing the hike in our profession.
Dr. Arka Bhattacharya
Consultant Dental Surgeon, Kolkata
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