NPR and Dan Ariely on Dentistry
Copyright © 2010 National Public Radio®. For personal, noncommercial use only. See Terms of Use. For other uses, prior permission required.ROBERT SIEGEL, host:
Dan Ariely conducts experiments, too. He’s a professor of psychology and behavioral economics at Duke, where he does research into our predictably irrational behavior. And he comes on the program from time to time to share his research.
Today, Dan Ariely on irrationality at the dentist’s office.
Professor DAN ARIELY (Behavioral Economist, Duke University): So, you know, you go to a dentist and the dentist x-ray your teeth and they try to find cavities. And one of the questions you can ask is, how good are dentists, right?
SIEGEL: Mm-hmm.
Prof. ARIELY: So imagine, you came to a dentist, you got your x-ray and then we took your x-ray and we also gave it to another dentist.
SIEGEL: Right.
Prof. ARIELY: And we asked both dentists to find cavities. And the question is, what would be the match? How many cavities will they find, both people would find in the same teeth?
SIEGEL: And I’d really hope it would be somewhere up around 95-plus percent.
Prof. ARIELY: That’s right. It turns out what Delta Dental tells us is that the probability of this happening is about 50 percent.
SIEGEL: Fifty percent?
Prof. ARIELY: Fifty percent, right. It’s really, really low. It’s amazingly low. Now, these are not cavities that the dentist finds by poking in and kind of actually measuring one. It’s from x-ray. Now, why is it so low? It’s not that one dentist find cavities and one doesn’t, they both find cavities, just find them in different teeth.
(Soundbite of laughter)
Prof. ARIELY: And here is what happens. Imagine you’re a dentist and you see a patient, and you really want to find a cavity because you get paid more if you find cavities and you can fix them. And the patient is already on the chair. He’s already prepped. You might give them the treatment right now, really good marginal income for you. How is this motivation to find cavities will influence your ability?
Now, you look at an x-ray, which is a little fuzzy and unclear and there are shadows and all kinds of things are happening. What happens is this unclarity, thus the x-ray helps in some sense the dentist to interpret noise as signals and find cavities where there aren’t really.
SIEGEL: And fill them?
Prof. ARIELY: And fill them, and drill them, expand them. I don’t think they ever tell their patients, hey, I thought it was a cavity but turns out it was just a mistake.
(Soundbite of laughter)
Prof. ARIELY: But they do fill them.
SIEGEL: You’re describing a very private relationship between patient and dentist.
Prof. ARIELY: Yes.
SIEGEL: You’re telling us we should, on average, expect our dentist to be getting it wrong on the x-rays, but that’s not how people feel about their dentists, right?
Prof. ARIELY: That’s right. And the dentists actually have a tremendous loyalty. People are really loyal to their dentist, much more than other medical profession. And I think one of the reasons we go back to cognitive dissonance. Cognitive dissonance is the idea that when people do something painful, they become more committed to the goal. If we have a fraternity and we haze people in a more difficult way, they become more loyal to the fraternity.
SIEGEL: You have dentistry as a hazing experience right now.
Prof. ARIELY: That’s right. And I think the same thing happen with dentists. Dentistry is basically the unpleasant experience. They poke in your mouth. It’s uncomfortable. It’s painful. It’s unpleasant. You have to keep your mouth open. And I think all of this pain actually causes cognitive dissonance and cause higher loyalty to your dentist. Because who wants to go through this pain and say, I’m not sure if I did it for the right reason. I’m not sure this is the right guy.
(Soundbite of laughter)
Prof. ARIELY: You basically want to convince yourself that you’re doing it for the right reason.
SIEGEL: Every visit to the dentist is an episode in the Stockholm Syndrome here, is what you’re describing. You studied these dental insurance records and you looked at what happens over time as our relationship with the dentist grows over many years, and you find it affects the kinds of decisions the dentist and the patient make, the choices.
Prof. ARIELY: That’s right. So you can imagine that at some point in your dental treatment, you have a choice between things that have the same possible outcome, but one of them is more expensive to you and better financially for the dentist. Which one would you choose and how the duration of relationship be affecting that?
And it turns out that the more time people have seen the same dentist, the more likely the decision is going to go in favor of the dentist. People are going to go for the treatment that is more expensive but has the same outcome. More out of pocket for them, more money for the doctor. So in this case, loyalty actually creates more benefit for the dentists.
SIEGEL: More expensive filling material, for example.
Prof. ARIELY: That’s right. That’s right.
SIEGEL: Well, Dan Ariely, thanks for talking with us again.
Prof. ARIELY: My pleasure.
SIEGEL: Dan Ariely, professor of psychology in behavioral economics at Duke University. His book is “The Upside of Irrationality,” and he talks with us about our rational and irrational decisions from time to time on ALL THINGS CONSIDERED.
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Now…….as you can imagine, this has created quite an uproar among dentists, and especially among those of my colleagues and I who have long considered NPR to be a source of (mostly) unbiased and reliable news, as Professor Ariely, whose field in Behavioral Psychology, in 1 fell swoop, condemns all dentists as money-hungry, greedy, unethical, and incompetent!
- As far as we can tell, Professor Ariely has absolutely NO background in dentistry, nor has anyone been able to learn where he learned to read and evaluate x-rays.
- No one has yet been able to find any published research by Professor Ariely on this topic, so we really don’t know where he’s pulling this stuff out of, except probably his a**. 😦
- Please read the quote below, from Delta Dental’s Director of Public Relations (posted on another blog), especially the underlined text (my emphasis). So……if Delta Dental did not provide the alleged research, where did Professor Ariely get it?
We’re normally fans of Dr. Ariely’s work, but he should not have made reference to Delta Dental when stating that 50 percent of the time dentists will interpret x-rays differently. Delta Dental has no data that could lead to any such conclusion. Delta Dental processes 84 million claims a year for 54 million customers, so obviously we’re interested in making sure those claims are accurate. That’s why we employ dentists throughout the country to review claims for accuracy. Still, we understand that conclusions made in the medical arts, like other arts, are prone to some degree of subjectivity and interpretation. Assuming otherwise would just be irrational.
Dr. Oz talks about Periodontal (Gum) Disease and Total Health
I guess it’s because I don’t watch a lot of TV, but I confess that – until quite recently – I had absolutely no idea who this guy Dr. Oz is. A friend recently told me that Dr. Oz has some really good material about dental health that can be shared, and since it’s sometimes easier to use someone else’s material instead of having to write it all from scratch myself 🙂 , I figured I’d check it out, and WOW! I’m impressed! It’s sad to say, but many physicians really have no idea about how the health of the mouth is connected to the rest of the body, and how valuable their dental colleagues can be in diagnosing a number of medical conditions. Dr. Oz is definitely not one of them! I’ll kick things off here with one of his articles. I have added some bold italics for emphasis (all mine).
The Mouth as a Marker for Disease:
Pocket Watch
One look inside the mouth will reveal that there are bacteria everywhere. For the most, part we cohabitate without a worry – but badly-behaving bacteria can collect in gum pockets to cause swelling, bleeding and bone loss that in turn can cause teeth to loosen and fall out.
People with gum disease (periodontal disease and gingivitis), may harbor up to 500 species of bacteria, and the proximity of that bacteria to the normally sterile bloodstream can be worrisome. Bacteria can enter small blood vessels, travel to other parts of the body and release toxins and trigger inflammatory chemicals that assault arteries and organs. Gum disease and tooth loss is now considered a harbinger for coronary artery disease, infective endocarditis, bacterial pneumonia, diabetes, kidney disease and stroke. Periodontal bacteria have also been detected in the mouths and amniotic fluid of women who have experienced threatening premature labor, miscarriage and may contribute to low-birth weight.
Breath Tests
Breath can be telling too. More than 90% of the time bad breath (halitosis) emanates from bacteria living in gum pockets, under dentures and on the surface of the tongue. It is not only unpleasant to people close to you, but it may also be a clue to other medical conditions.
Oral cancers, lung cancer, certain leukemias and dry mouth syndromes such as Sjogren’s syndrome can cause bacterial overgrowth that contribute to bad breath. And sometimes a systemic disease produces distinct chemical odors:
- Sweet or fruity odor may indicate uncontrolled diabetes
- Mousy ammonia odor may indicate liver disease
- Urine-like fishy odor may indicate chronic kidney failure
- And fecal odor may indicate intestinal blockage.
To find out if you have foul-smelling breath, ask a truthful friend, or lick your hand and smell the saliva.
Tongue Tip-off
Changes in the tongue can also be a tip-off to disease. A pale, smooth, flattened and sometimes tender tongue can point to iron or vitamin B12 deficiency, a hallmark of the common blood disorder, iron-deficiency anemia. People with Crohn’s disease and ulcerative colitis may notice tiny ulcers. If the tongue looks like a geographic map with areas of dark and light it may indicate an autoimmune disorder such as psoriasis or discoid lupus erythematosus. Recurrent episodes of white patches indicate thrush, an overgrowth of the yeast Candida, which may indicate diabetes. Strawberry red swollen tongue with a white coating and big red bumps is a symptom of Kawasaki disease.
Telling Teeth
Hairline cracks in the teeth can indicate tooth-grinding, the sleep disorder bruxism or mental stress. People with bulimia have enamel loss on their front teeth from the assault of stomach acid from repeated vomiting.
Keep Oral Traditions
Keeping up with a good program of oral hygiene and tending to dental and gum problems before they worsen is key to keeping mouths healthy. People with declining dexterity may need to make modifications that assure that good dental care continues. Electric toothbrushes, vibrating gum massagers and dental water jets can help. Routine dental visits are crucial, especially if you are planning to become pregnant or are facing a course of chemotherapy, which can reduce immunity against oral bacteria and cause mouth sores.
Here’s some help for halitosis, guidance for gums and tips for tooth care.
- Investigate any changes in your oral health
- Brush in the morning, at night and after meals with a soft toothbrush or African chew stick
- Use a tongue scraper along the length of the tongue to remove odor-causing bacteria
- Use an antiseptic mouth rinse
- Floss between teeth and inside the crease where the gum and tooth meet
- Keep well hydrated and avoid mouth breathing
- Don’t smoke or be near someone smoking (that can cause smoker’s breath too!)
- Try chewing on neem leaves, green cardamom, cloves, parsley, guava peels and gum mastic for breath control
- Visit the dentist regularly
Does dentistry last forever?
This is a question I’m frequently asked, especially when a patient is considering a significant investment of time and money into some form of cosmetic dentistry, such as:
- Porcelain veneers
- Bonding (tooth-colored fillings)
- Porcelain crowns and bridges
- Teeth whitening
- Even Six-Month Braces
It’s a very understandable question, and the simple answer to the question, “How long will my dental work last, Dr. Payet?” is “It depends.”
Just like a car, your teeth and gums require regular care to ensure that they are working properly. Sure, you can go 10-20,000 miles between oil changes given how improved cars are nowadays, but do you really want to take the risk? Same thing with teeth……….some people go for 5-10 years with no dental check-ups and are fortunate when they come in to find no problems, such as cavities or gum disease. But it’s not many people that are so lucky!
I always remember a quote from some lecturer at a dental conference years ago telling us his response whenever a patient asks the question, and it’s really the most honest, best answer that can be given, “Clearly the teeth that God gave you haven’t lasted your entire life, and since I can assure you that my work is not nearly as good as God’s, unless you die first, the work I do (no matter how excellent) will not last forever either.”
So what can cause your dental work to fail?
- Grinding your teeth — when the human jaw clenches, it can create an amazing amount of force, and over time, enough clenching will cause teeth to crack and break.
- Acidity — anything that increases the acidity in your mouth is good for the bacteria that cause cavities in particular, including Acid Reflux, Sodas, Power drinks (Monster, Red Bull, etc), Sports drinks (Gatorade, Powerade, etc).
- A very sugary diet — the bacteria that cause cavities love sugar. High sugar content means the bacteria feed like crazy, produce acid, and the acid is what eats away the teeth to cause cavities.
- A compromised immune system — your saliva contains important antibodies that help keep the cavity-causing bacteria under control. If your immune system is knocked back due to a disease or some medication, those antibodies will be decreased, allowing the bacteria to grow uncontrolled.
- Decreased saliva (dry-mouth syndrome) — again, due to medications or illness, the amount of saliva may be decreased. With less saliva, there is less “washing” action of the teeth.
- Trauma — obviously. LOL One of my patients a few years ago fainted and fell face-first into a brick wall, shattering a front tooth. Another ran into a pole, shattering another front tooth. Clearly, if you are injured in such a way that your natural teeth would break, any dental work will break, too.
- Bad habits like chewing hard candy or ice regularly — hard candy and ice are just that — HARD! Ice, in particular, is easily as hard as your enamel and as porcelain or bonding. So if you bite down on ice frequently enough and/or hard enough, you can break your teeth and dental work.
That covers most of the major causes of dental work failing. With regular care, use of appropriate mouthrinses and toothpastes, proper brushing and flossing, regularly scheduled check-ups and dental x-rays, using a nightguard, and being aware of diet, etc, your dental work can and should last a very long time.
But always remember — my dental work isn’t as good as the natural teeth God gave you, so my work probably won’t last forever either. 😉
A Complete Smile Makeover with Porcelain Crowns for Teeth Damaged by Bulimia
There are many reasons patients come to see me for cosmetic dentistry. One of the most common reasons is because their teeth are badly worn down from grinding, often in combination with acid erosion that has eaten away at the enamel. Treating these cases can be complex, because if we don’t properly diagnose and solve the problem that caused the worn, eroded teeth in the first place, then any cosmetic dentistry is sure to fail very fast.
When Jenni (not her real name, as she prefers to stay anonymous) first came to see me through a referral back in 2005 for a Smile Makeover consultation, she admitted that she had suffered from bulimia as a teen, about 20 years prior. She had recovered from this debilitating disease and had been leading a healthy, normal life for many years, but her teeth had been so eroded that she was extremely self-conscious and embarrassed by her smile.
Since Jenni’s original issue had been addressed medically, we were safe moving forward with a greatly decreased risk of acid erosion causing problems again, although bulimics are at a much higher risk of GERD/acid reflux, so she is monitored regularly by her physician, and she uses a prescription strength fluoride rinse daily to help protect the teeth under the porcelain.
Due to complicating factors, Jenni’s case was just completed this year; however, I think you’ll see why Jenni is now happy with her smile again, although she doesn’t want everyone to know what she had done, so she has asked me to not use her portrait.
Cosmetic dentist Dr. Charles Payet, of Charlotte NC, performed a Smile Makeover with Porcelain Crowns to Restore these Teeth Damaged by Acid Erosion/Bulimia
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Smiles by Payet Dentistry - Beautiful Smiles. Lifetime Care 
So, according to Professor Ariely, all of our Patient Reviews are just because they were somehow pressured into it? And all of their problems were made up by me so I could make money? Wow, who knew! I thought it was because my team and I do our best to make our patients comfortable, take care of their problems at a time and pace that is comfortable for them? And the lady I referred to another dentist today, because I know he can do better dentures than I can……what in the world was I thinking, doing the right thing for her like that?
Ah well………can you tell I’m fired up? Let me just say in closing: I love dentistry and I love taking care of people. That’s why I invest so much time and money in improving myself and my skills every year, as well as in making sure we have leading technologies and techniques to make appointments faster, more comfortable, and just better. No matter what some Duke Professor says.