Close Encounters of the Dental Kind

When you visit dental care in another country you can get a real taste for their medical culture.

Tony Bennett may have left his heart in San Francisco: I left a much-filled molar in another US city. I will spare you the goriest details. Suffice it to say that an area of decay had developed under the filling and become infected, causing considerable discomfort. On the Friday morning of the conference, I had to decide. Could I put up with this for another week before I went home, with the risk of needing urgent treatment in the very rural part of the USA where I was going to visit some friends? I decided to bite the bullet – metaphorically at least.

The hotel concierge tried to sound hopeful: ‘It’s hard to get to see a dentist here on a Friday because it’s their day for playing golf with each other.’ He produced a card for an emergency dental clinic that operated from a building across the street and called them, fixing me up with a mid-morning appointment.

The building was described as medical-dental, with the plates in the lobby identifying various laboratory and specialist services. It was eerily quiet. Maybe routine health care in this city did come to a halt on Fridays. The suite used by the dental clinic was modern but not ostentatious compared to some private UK dental offices.

I was struck, though, by the small size of the waiting area relative to the number of treatment rooms. This made sense when I heard the woman on the reception desk, who seemed to be some sort of practice manager, quietly, but very firmly, reprimanding the paraprofessional who was supposed to be working me up for the dentist. Her crime – arriving late for work so that, instead of being seen on the dot of the hour, I had been waiting six minutes while she changed from street clothes and cleaned up.

The NHS simply does not have that expectation. Patients will be seen at the convenience of providers and not the other way around. One consequence is that waiting areas have to be large in order to accommodate the accumulating pool of patients. Clinics feel frantic. In contrast, this whole building exuded calm. When you expect to see people promptly, you do not need to allocate a lot of space to them and generate milling crowds. In a private system, the estate costs are transparent, as are the implications of professional working practices for space usage. Does the NHS have good enough internal signals to get the right balance between the costs of waiting and the costs of working?

It would not surprise anyone to observe that my passage through the clinic involve repeated swipes of my credit card as each stage of treatment was discussed and agreed. Having said that, other patients with the right health insurance card only needed to produce this once. Everything then went ahead smoothly without further reference to the billing or their credit status. The overall costs also seemed modest – perhaps 20 percent more than equivalent private treatment in a provincial UK city. Treatment was conducted in a courteous and professional manner, with a clear discussion of the options available and their implications. However, two features seem worth noting.

The first is that I came out with a prescription for a week’s course of antibiotics. I don’t want to push this too far because an NHS dentist might have thought it clinically justified in this case, given that the tooth had been extracted because of an infection. On the other hand, it was presented to me as routine treatment. My observation, that standard NHS care would simply be to rinse the area with a warm saline solution two or three times a day, was clearly considered quaint folk medicine. Since my last blog was on anti-microbial resistance, I found myself wondering how far US health professionals simply prescribed antibiotics on auto-pilot, or possibly because of the perceived litigation risk of not prescribing them.

Does the respect for consumers that I had identified – or at least for those who could pay – mean that professionals feel obliged to send them away with a tangible token of concern? As I asked last time, is there much point in devoting a lot of resources to research on new antibiotics that will be prescribed as casually as those available at present?

My impression would be that most of us Brits expect our visits to the dentist to be accompanied by a degree of pain or discomfort. This is not something to be medicated but to be tolerated as a fact of life

The other feature is my suspicion that Americans do not do pain very well – or that the Brits really are stoic. I don’t think any UK dentist that I have encountered has whacked in so much local anaesthetic as to freeze half my neck as well as the relevant jaw areas for much of the rest of the day. If anything, UK doses seem calibrated to the minimum necessary to survive the procedure and leave the building. After-care is usually a suggestion to take a few paracetamol, if it hurts too much. I left with a second prescription for a couple of days’ worth of a powerful narcotic/analgesic combination. Actually, it gave me a bad headache so I threw most of them away and confined myself to ibuprofen at bedtime. This may just be a cohort effect. My first childhood encounters with dentists were in the days of slow-speed electric drills and the first time I had local anaesthesia for a filling was in my early twenties from a very newly graduated dentist. However, my impression would be that most of us Brits expect our visits to the dentist to be accompanied by a degree of pain or discomfort. This is not something to be medicated but to be tolerated as a fact of life. Maybe we should not accept this but maybe Americans lose something valuable by not dealing with the challenge of pain, as Ivan Illich used to argue.

Comparative studies do not necessarily prove that one approach is right and another is wrong, especially at the level of a single case study. However, they can be a powerful tool for noticing things about the different ways in which the same problem can be dealt with – and for provoking each party to ask why they have chosen one path rather than another.