This is the second column my series about the state of dental insurance in our country. The information presented is intended to explain “dental insurance” from a perspective which may be different than most consumer’s view of insurance. I encourage you to read all the columns in this series. If you missed any they can be found at I hope the information helps you to make more informed decisions about your dental health.

One of the statistics I presented last week was the fact that dental “insurance”, unlike medical insurance, has a yearly monetary limit that the company will pay out. For the majority of dental plans this number has not changed since the 1970’s. I know I don’t need to point out that you could get a lot more with $1000 in 1970 than you can today. So, why hasn’t the limit increased?

There are many answers to this question. The bottom line is that raising the dental insurance limits would be extremely unprofitable for insurance companies. Here are some reasons why:

First is the “use” factor. Many patients who have dental insurance use their insurance right up to that yearly maximum. This is generally not the case with other types of insurance. In fact, the entire dental insurance model is based on a certain percentage of those insured not using their benefits at all. A recent statistic I heard is 48% don’t use any of their benefits. If the yearly benefit was higher, the premiums would need to be much more expensive for the insurance companies to make a profit. This would destroy the model and there would be many fewer employers signing up for those plans.

Another reason dental benefit programs have not changed is pre-existing conditions. Many dental problems are often ignored for years, and patients will often wait until they have “insurance” to take care of their problems. This is why some insurance companies have a “wait period” for certain dental procedures. When that patient finally has dental coverage and the dentist tells them they need three root canals and three crowns, they are shocked to hear that their insurance will only cover a small percentage of the treatment. Again, there is no dental insurance available to cover situations like this because it would be extremely unprofitable for the insurance companies.

In order to run any business, revenue and expenses need to be managed to make a profit. In order for the dental benefit companies to remain profitable (the definition of profitable is debatable), they need to either increase revenue (charge more for premiums) and/or decrease their expenses (pay out less to dentists). They know that employers, or individuals looking for dental coverage, will not like escalating premium costs, so they form “discount plans” to solve the problem. I will explain how that works next week.

Is there a solution to the problem? To provide “full coverage” for dentistry, insurance companies would have to charge more for premiums than most people/employers would deem worth spending. Consumers, especially when it comes to insurance, seem to want to pay the least amount for the most coverage. It makes sense until you factor in quality of care.

To be continued……16664814424_18d932b470_n

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8185813120_61f4429118_nThe Merriam-Webster definition of insurance is “coverage by contract whereby one party undertakes to indemnify or guarantee another against loss by a specified contingency or peril.” We have insurance on our house and car. If our car gets damaged, we usually pay a deductible and the insurance picks up the rest. If our house burns down, we have insurance to help us rebuild it. Unfortunately, that is not the way it works in dentistry.

I have not decided how many columns there are going to be in this series yet but I anticipate 2 or 3, maybe 4. My purpose of this series is to explain how I see the current state of dental insurance, and how its trend is changing the way dental care will be delivered in the future. It may sound like some boring columns, but I encourage you to read them and pass them on for others to read. I feel it is important information to have in choosing how you receive your dental care.

It’s common to hear patients ask, “What does my insurance cover?” followed by “Why is dental insurance so lousy?” And my patients have a point — dental insurance typically is pretty lousy, for the patient and the dentist. There’s not enough coverage, too many things aren’t covered at all, the co-pays are too high, and the limitations are fairly strict. But why is this so?

I am not here to bash dental insurance. It has its place. However, I think the first order of business is to eliminate the word “insurance” after dental in our vocabulary. If you look back at the definition of insurance, dental insurance is not insurance; it is a dental “benefit”. Some may not like to hear that but that is what it is.

Unlike medical insurance, which started being offered in 1850 by the Franklin Health Insurance Company of Massachusetts, dental insurance is a fairly recent phenomenon. Dental insurance was first introduced in California in 1954, and quickly rose in popularity. By the 1970’s, these plans were widely available and usually provided a maximum annual coverage of about $1000 (which is still about the maximum today).

The first plans didn’t distinguish between in-network and out-of-network providers. They simply established usual and customary rates for the area, and would pay (typically) 100% of preventative care, 80% of minor dental work (such as fillings) and 50 percent of major work (like crowns, bridges, etc).

Eventually, insurance companies started offering PPO plans. The way these new plans worked is that in-network providers who signed up for these plans agreed to a reduced fee schedule for their services. Patients could go to an out-of-network provider but would have to pay the difference between the provider’s fees and the insurance reimbursement.

PPO plans peaked in 2011 with 65% market share but have been losing ground ever since. New insurance plans are offering lower and lower payouts. Less and less of your smaller/private dental offices are able to accept these plans because they make it impossible to provide comprehensive care and treat patients the way they should be treated. However, these plans are less expensive for employers.

There are drastic changes coming to the dental benefit world in the near future that will cause quite a stir for both patients and dentists. I will continue next week.

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3439490784_46b2cfd9e3_nDid you know you swallow approximately 2,000 times per day? When you swallow, the upper and lower teeth come together and some level of force is generated. People who have an unstable bite, missing teeth, or poorly aligned teeth can have trouble because the muscles work harder to bring the teeth together, causing strain. People with seemingly good teeth/bite are also susceptible. Pain can also be caused by clenching or grinding teeth, trauma to the head and neck, or poor ergonomics.

Orofacial pain includes a number of clinical problems involving the chewing (masticatory) muscles or temporomandibular joint (TMJ). Problems can include TMJ discomfort, muscle spasms in the head, neck or jaw, migraines, cluster or frequent headaches, pain with the teeth, face or jaw, anxiety and depression.
Temporomandibular disorders (TMD) affect more than 10 million Americans. Your TMJ’s are located where the skull connects your lower jaw to the muscles on the sides of your head and face. They control the joint’s movements. Women between the ages of 20 and 40 are the most frequent sufferers because of the added estrogen in their bodies. Estrogen impacts the body’s natural pain fighters (endorphins), increases inflammation in the temporomandibular joints, and compromises the strength and adaptive ability of all ligaments.

One in eight Americans suffer from headaches. Experts estimate that 80 percent of all headaches are caused by muscle tension, which may be related to the bite. Clenching the jaw muscles creates tension in the muscles that close the jaw, the main one of which is the temporalis muscle. Signs that may indicate a headache from dental origin include: pain behind the eyes, sore jaw muscles or “tired” muscles upon awaking, teeth grinding, clicking or popping of the jaw joints, head and/or scalp is painful to the touch, earaches or ringing, neck and/or shoulder pain, and dizziness.

Sleep disorders can also play a role. If you have gone through treatment and still experience orofacial pain, you may have a sleep disorder, such as bruxism (grinding), or a sleep-related breathing disorder, such as snoring or sleep apnea. I’ll be writing more on this throughout the year, as it is a special area of interest for me.

Your dentist has a variety of treatments that can help relieve your orofacial symptoms. One device is called an orthotic, or splint, that is worn over the teeth to help stabilize the bite. Permanent correction may require equilibration (reshaping teeth), building crowns, or orthodontics. Many use a splint on a daily basis to avoid having these other treatments done.

Other things that can help alleviate pain are using ice on the painful area, eating a softer diet and avoiding chewing gum or ice, being conscious to keep teeth slightly apart except when chewing and swallowing, sleeping on your back and not resting your hand on your chin.

Orofacial pain can range from tolerable to debilitating. Maintaining or correcting your bite ensures optimal health, and proper care will help reduce or eliminate orofacial pain or discomfort. If your dentist can not help you, ask for a referral to a specialist.

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13939412481_bbc18465a5_cDo you have any problems with dental decay (cavities), gum recession, and/or dental erosion (the chemical breakdown of tooth structure)? These dental problems are complicated multifactorial diseases of epidemic levels affecting both children and adults. A healthy mouth sometimes requires more than brushing, flossing, and “fillings”. With current scientific evidence and new technologies, patients and practitioners need to begin to look at these problems not just from a drilling and filling approach but also from a medical (preventive/therapeutic) approach.

There are over 19,000 different bacteria that have been found in mouths and every person has about 1,000 different types. Not all of them cause decay and many of them have also been found to grow on artery walls. The medical/dental systemic connection is real and we must pay more attention to it.

Why the increase in decay? Most of it has to do with dietary trends. We snack more, eat more sugar/carbs, drink more soda, have more gastric reflux, take more mouth-drying medications, etc. Dental caries (decay) is a pH specific disease. The right bacteria, plus sugar, create acid which breaks down the enamel of the teeth. Add an already acidic environment and it is even worse. In most cases it is a preventable disease. The problem is that changing behavior can be very hard to do.

It is time for the dental professional to take a different approach when treating this disease. More focus needs to be shifted to prevention of decay rather just treating it. Filling teeth is treating the result of the disease but does nothing to prevent it. The dentist needs to take a more active role in assessing individual’s risk factors. In the dental world this is referred to as CAMBRA, which stands for Caries Management By Risk Assessment.

Based on assessing an individual’s risk factors such as quality of home care, quality of salivary flow, medication issues, and dietary issues, a caries-preventive strategy can be established. There are many new products on the horizon to help combat and virtually eliminate this disease. However, dentists must take some responsibility and be open to a different management of this disease. They must also be able to motivate people to change habits, which can be challenging. The bottom line is that if you want to be decay-free, you can be.

For those at higher risk, there are some great products currently available and others to come. Everything from new toothpastes and gels with ions in them to rebuild tooth structure, sprays to neutralize pH, and probiotics are on their way. Right now you can use things like the sweetener replacement Xylitol, which by itself is cavity-fighting, but also works synergistically with fluoride. Prescription level toothpastes are also available and there is strong research for the topical application of fluoride varnish, the same stuff the kids get, for adults.

The evidence is very clear – this is a preventable disease. Next time you go to the dentist and find out you have a new cavity, stop blaming the dentist or yourself, and ask to get a specific protocol for prevention of this disease based on your specific risk factors.

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10235075156_01c33847ce_h I was at a continuing education seminar last week and one of the topics being discussed was mouthguards. Although it seems basic, and you would think that everyone who should be wearing one does, this is far from the case. I still see far too many sports related dental injuries in every season which could have been prevented.

Any sport that presents the chance of contact or collision with another person, object, or surface can potentially cause injury to teeth, jaws, and oral soft tissue. These sports include, but are not limited to, football, baseball, basketball, soccer, hockey, field hockey, pond hockey, boxing, lacrosse, biking, inline skating, and skateboarding.

Teeth get in the way. Other than your nose, front teeth are “out there” and your lips only provide minimal protection. For example, a student I saw this past spring from a local private school was playing squash. Squash is a non-contact sport but the game is played in close proximity to another player with a swinging racquet. The student I treated had been hit in the mouth with the other player’s racquet. He required a root canal on one front tooth and a crown. The other front tooth needed to be extracted and replaced with a dental implant. All of this could have been prevented with a mouthguard.5387705493_3505c0f3cf_b

A custom mouthguard made by your dentist covers the upper teeth with a soft, flexible material that can prevent many injuries. It decreases the chance of the lower jaw jamming into the upper jaw or being pushed back into the temporomandibular (jaw) joint. Mouthguards may reduce the severity and incidence of concussions as well.

Custom mouthguards, made by a dentist, fit 100 times better than anything you can buy in a store. This not only improves performance (making it easier to breathe), but also makes it more likely the athlete will keep the mouthguard in.

Custom-made mouthguards may be a little more expensive than over-the-counter versions, but they are far superior, and that is enough reason to consider them. Inform your dentist if you or your child participates in sports or recreational activities. Because mouth injuries can be painful, costly, and life-changing, it is recommended that all athletes take preventative measures at all times.

4544659921_ab733200ec_bAt my seminar this past week the presenter noted that injury to the teeth from sport injuries creates life-long issues that can run in the 10’s of thousands of dollars to maintain over a lifetime. The $100 or so that it costs to have a well-fitting custom guard made, that will be worn more often because it fits well, is worth every penny. It kills me to see children and adults come in with injuries to their once beautiful front teeth. The best dentistry is no dentistry because even the best dentistry needs to be maintained and/or replaced, sometimes multiple times over a lifetime.

Even if it isn’t “cool” to wear a mouthguard in the sport you are playing, strongly consider it anyway. You only get one set of your own teeth. Custom guards can be made with fancy colors and designs. You never know, you may start a trend….and who cares what other people think; these are your teeth!

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16417383222_891c9131ae_kThe most common reason people lose teeth is periodontal “gum” disease, which is a destruction of the bone and other supporting structures. The most common way to replace teeth today is the use of dental implants. Dental implants replace the roots of the teeth and also rely on the bone as a supporting structure.

Dental implant technology has improved steadily over the past few decades as materials and the understanding of bone integration has advanced. So, when does it make sense to abandon treating a natural tooth and replace it with a dental implant?

In a recent article published in the Journal of the American Dental Association (JADA), it was reported that there is a trend towards extracting diseased teeth earlier than in the past, and replacing them with dental implants. This trend might be related to the perceived high implant survival rate and the relatively safe nature of the procedure.

Researchers who completed a systematic review of long-term tooth and implant survival rates believe that a more conservative approach could be warranted that emphasizes treating the tooth over extracting and replacing it. Data from the study indicates that preserving teeth by proper periodontal treatment and a careful and frequent maintenance program may give the same, or even better, results for the long run, without requiring a dental implant placement, which is not without risk.

Dental implants are a great way to replace missing teeth. They have revolutionized dentistry and give many people the enjoyment of tooth replacement that feels as natural as you can get. However, their availability shouldn’t be a cause or reason to extract a tooth rather than treating it. Assessing the tooth in question for the appropriate treatment is complex, with a host of factors influencing the outcome. But all means of treatment should be considered before resorting to extraction and implant placement, according to the researchers.

Tooth loss due to periodontal disease is only one reason teeth are replaced with dental implants. Teeth that are not restorable due to decay, failed root canal treatment, and fractured roots are other reasons.

Just as teeth can fail due to periodontal disease, dental implants also have a short-term and long-term failure rate. Percentages for these vary depending on sources but 10-year implant survival is around 90%.

There are plenty of good reasons to replace teeth with dental implants. The research presented simply suggests considering things such as the patient’s past dental history, amount of bone loss, history of smoking and predictability of tooth retention among others before making the irreversible decision of extracting a tooth.

Although most of the decisions for replacement of teeth with dental implants are pretty straightforward, if there is ever a question, a second opinion from a periodontist or oral surgeon never hurts. People don’t want dental implants; they want what dental implants do. They want them to act like their own teeth. Make sure the reasons for getting rid of your own make sense to you.

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Thanks again to the The Town Common for another great year. At the end of each of the past 11 years, I have used this space to publish these 21 Suggestions for Success authored by H. Jackson Brown, Jr. It is the perfect time to reflect on the year past and prepare for any changes we need to make for the year to come.
How was 2016 for you? While reflecting on the past year is important, thinking forward to the year to come is even more important. The past is in the past.
I thought last year might be the final year for posting this list. However, knowing that readership continues to grow for The Town Common, and realizing how powerful these words can be, I decided to republish. So, cut this out and put it on the refrigerator. Read this list often and take these suggestions to heart. They will be sure to make your 2017 great.
1. Marry the right person. This one decision will determine 90% of your happiness or misery.
2. Work at something you enjoy and that’s worthy of your time and talent.
3. Give people more than they expect and do it cheerfully.
4. Become the most positive and enthusiastic person you know.
5. Be forgiving of yourself and others.
6. Be generous.
7. Have a grateful heart.
8. Persistence, persistence, persistence.
9. Discipline yourself to save money on even the most modest salary.
10. Treat everyone you meet like you want to be treated.
11. Commit yourself to constant improvement.
12. Commit yourself to quality.
13. Understand that happiness is not based on possessions, power or prestige, but on relationships with people you love and respect.
14. Be loyal.
15. Be honest.
16. Be a self-starter.
17. Be decisive even if it means you’ll sometimes be wrong.
18. Stop blaming others if it means you’ll sometimes be wrong.
19. Be loyal and courageous. When you look back on your life, you’ll regret the things you didn’t do more than the ones you did.
20. Take good care of those you love.
21. Don’t do anything that wouldn’t make your Mom proud.
Best wishes for a successful 2017. Happy New Year!

4341884375_427484f6d2Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. If there are certain topics you would like to see written about or questions you have please email them to him at You can view all previously written columns at

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If you missed Part 1 of this series you can check it out at We were talking about what separates the good from the great businesses……no matter what business you are in. This was derived from my recent re-reading of Jim Collin’s classic book “Good To Great: Why some companies make the leap….and others don’t.”

The key currency for any business is not the paper kind; it is intellectual capital. For any business to be successful, intellectual capital must be unleashed. When people are asked how much of their brainpower they actually use, a common response is 20%. The actual percentage is estimated to be much lower. Leaders understand this. They recognize that one of their major challenges is to unleash the latent intellectual capital that already resides within every employee in their organization. In part, this is accomplished by establishing a culture of learning within a business.

Business culture consists of people’s unquestioned assumptions and habits. Culture drives employee behavior. A culture that supports and celebrates learning is essential to developing human capital and releasing the brainpower that already exists within the team. Exceptional leaders help employees to understand that being a continuous student is not an option. It is an expectation!

Even in the best businesses, the journey through change can run into difficulty. Challenges will arise. Failures can occur. The unexpected may happen. Clarity is replaced by cloudiness, and the group becomes lost. This is not uncommon.

But when it happens, exceptional leaders step in and refocus the group. Through their words and actions, they help people to reconnect with the core values of the business. They bring the group back to the meaning and spirit of its purpose. They also review the vision of the business, and help employees to become reconnected with this preferred picture and direction.

As a result, the group finds its way again, and clarity is restored. Refocusing can also be an energizing process, and one of its great byproducts is a sense of renewal.

So, in review, the keys for any business to move from good to great include the following: the ability to deal with the unknown, defining and modeling core values, the leader of the business setting the tone, attracting and retaining employees, unleashing intellectual capital, and the ability to refocus the business in times of change.

These keys are especially important in times like these. Solid businesses which have strong core values, a good leader and good employees are in cruise control during economic downturns. Certain aspects of the business may be down, but the core business remains steady because the fundamental values of the business are strong.

Businesses that have achieved greatness don’t remain idle. They realize that the life of the business is work in progress and are constantly striving for improvement. New technology, continuing education and new techniques are all great, but they must fit into the core principles of the business. Great businesses do not deviate from this. That is what separates the good from the great.

Have a great holiday!14919559392_0e15a755f2_c

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I thought that I would end this year with some stuff that everyone could benefit from. I am honored and humbled to be given this platform each week to bring you information (usually dental in nature). This column and the next may not be “dental” per se, but it is in the sense that it pertains to every business, every employer, and every employee on the planet.

I recently finished re-reading a classic book called “Good to Great: Why some companies make the leap…..and others don’t”, by Jim Collins. No matter what business you are in, whether it is a garage or a dental practice, there are distinct things that separate the average from the great. Number One: a great leader.

Being a great leader is a gift, and for those of us who are not born with that gift, it is a life-long journey to improve our leadership. If you don’t work on improving your leadership, you will always remain average.

So, what are the qualities of a great leader? The first is the ability to deal with the unknown. Leaders must have the courage to go first. Even though the path is not clearly marked, leaders must venture into unexplored territory, search for the new opportunities, and accept the risk of vulnerability.

A leader must define and model core values. The most important question that leaders must answer is: what do we believe in? The answer defines the core values that become the foundation of the business. They drive everything that the business does. The tough part comes next. Leaders must act congruently with these values and demonstrate them in everything they say and do. An even tougher moment comes when a business’ values are tested by the market place. The easy short-term solution may be to abandon these values. However, doing so can have a powerfully negative long-term effect.

A leader attracts and retains employees. This means that leaders must establish a business climate that attracts and retains the finest people available. Increasingly, it is the worker-friendly business that creates a climate of trust, in which employees value their jobs and offer their deepest levels of support and commitment.

Worker-friendly is not just about wages and benefits. It is much more than that. The old-style management days of “command and control” are over. They have been replaced by a style of leadership that places a premium on the leader’s ability to “communicate and influence.”

Of course people want to know how to do their jobs. But today’s exceptional employees also want to know why they are doing them. They want their leaders to answer the question, Why are we in business? The answer to this question energizes a business and its people with a sense of purpose. With purpose comes fulfillment, and from fulfillment comes commitment.

In these circumstances, employees don’t just work for a business. They belong to one. They become members, and with membership comes the most powerful form of ownership – psychological ownership. In effect, the employee becomes a shareholder, and commitment takes on a deeper meaning.

To be continued next week…….10940224335_ac435c38e3_b

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5287027380_e8a8e48d8b_bHere is the scenario: You haven’t been to the dentist in a few years. You decide on a dental office and go for a cleaning, x-rays and examination. The dentist hasn’t told you yet, but you have relatively extensive treatment needs. How do you want to hear the news? Do you want the dentist to tell you everything she finds and present a comprehensive treatment plan to get you back to health, regardless of whether you have any kind of dental “insurance” plan? Or, would you rather her tell you the most significant issues that need to be dealt with first, and break the rest of the news to you at a later date?

A patient’s initial visit with a new provider is an important time in the dentist-patient relationship. That first impression plays a pivotal role in how the rest of the relationship unfolds. What happens to that relationship if the dentist presents an extensive treatment plan at the first visit? Is there a “right” way to handle this situation?

In the American Dental Association Principles of Ethics and Code of Professional Conduct, it states that a dentist will follow “high ethical standards which have the benefit of the patient as their primary goal”, while possessing “qualities of honesty, compassion, kindness, integrity, fairness and charity.” Therefore, it is the dentist’s obligation to be truthful and straightforward with patients for their benefit.

Although an extensive treatment plan may be surprising and even possibly overwhelming in this scenario, it is the dentist’s responsibility to disclose an accurate picture of the patient’s oral health status without leaving out information that could possibly benefit the patient’s oral and even systemic health.

Many of my dental colleagues handle this new patient situation, and sometimes even long-time patients who are in need of treatment, in a relatively systematic way. It is important that the dentist-patient relationship be a mutually respected and trusting relationship. It is often difficult to discuss treatment needs with patients during a hygiene appointment because of time constraints. Inviting the patient back and spending time with a patient is a dentist’s most important gift.

Every patient should have a basic understanding of four areas regarding their dental health. They should know the status of their gums and bone, which is the biology behind a healthy mouth. They should understand, based on their age, how their teeth and other parts of their masticatory system (joints and muscles) are doing. For example, is there any tooth wear or any TMJ issues? They should know the status of decay and the structural integrity of their remaining teeth. And, esthetics should be discussed, regardless if there is any “concern” about how the teeth look.

It is not the dentist’s role to assume a patient will not accept treatment recommendations. The dentist’s role is to present what they see, provide treatment recommendations and alternatives to ideal treatment, help the patient understand the benefits of treatment, and if needed, educate the patient about how to best prioritize the treatment through phasing and sequencing.

Ultimately, it is the patient who has the right to decide which course of treatment best satisfies their goals and values.

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