Oh I totally agree with you. I lose money on all my dentals (8-10 procedures/month). I am at negative production every week on my surgery days because we don't charge appropriately for dentals. But I do them because I believe strongly in the importance of good dentistry, and I put 120% of myself in every dental case and do as much as I safely can to the best of my abilities no matter how little money I make on them (pricing is out of my hands, but quality of care I provide is not).
I spend probably 25% of my free time outside of work reading up on dentistry, and learning from other dental savvy people. I do as much dental CE as I can afford even if it means paying out of pocket. I even spent a day observing at a dental practice to get information on what tools I'm missing that I should have as well as to see the flow in procedures from set up to equipment care to compare to the procedural flow at my hospital to make improvements.
I do full mouths on all dental patients and all post-extraction sites. When I first started, we only had a diptank for dental rads and my techs were not comfortable taking them. So I taught them and made them do full mouths on a majority of patients even without digital until our digital unit arrived. Now it's standard of care to do the full mouth rads in my practice and my techs are very efficient with them.
I talk to each owner about the procedure in depth ahead of time and tell them that I might not be able to finish in one procedure (and they can actually have it finished at a later date for super cheap), that if there is way too much compromise and I don't feel comfortable after taking rads, I may have to refer for some teeth due to risk of jaw fracture. I ask owners if for canines or carnassials if problems are found that may be amenable for endodontic treatment, if they will go for that. I go over all rads with the owners and explain why we did what we did. There are certainly cases where I push my limits and kind of regret it when I'm struggling mid-procedure (I'm pretty aware of what I'm capable and incapable of), and luckily have not had a poor outcome. I know it is absolutely below standard of care to break the jaw during a procedure (and the PLIT newsletter from this summer reinforces this), but it IS a risk with many of our patients. I've never heard of a person worrying about such a complication from dental extractions.
If I break a root, I almost always get it out. There was one case where I had a horrible Kitty mouth with resorptive lesions where i just could not (sorta resorbing but parts of periodontal ligament space definitely present). Owners couldn't afford referral, and I just had to be upfront with them about the retained roots and the problems that may result from them. I lost so much sleep over that one, and I felt awful.
I feel like I do everything I possibly can to do right by my dental patients, and I truly believe that my quality of dental care is above par compared to many of the practices around me, which I'm proud of as a recent grad. And I am as passionate as can be about dentistry.
But there are so many things that can go wrong, and I'm sure I could be doing better. That is quite unnerving to me. My dentals take way more skill, knowledge, and adaptability/ability to work on the fly than any other surgical procedure I do. I feel like it's a ticking time bomb before some complication happens mid-procedure that I personally cannot address, and that is scary. I'm waiting for the day I inadvertently shove a root tip in the mandibular canal and can't get it or something like that. The resulting trip to the dentist and the costs/stresses associated with it is a recipe ripe for a lawsuit/board complaint. All I can keep doing is to continuing to learn as much as I can and doing the best I can for each case... and pray.
But GPs are stuck between a rock and a hard place. The reason why the horrible mouths (that arguably should be referred) come to us is because they couldn't afford years of recommended routine dentistry until it became an emergency. Just as I wouldn't plate a fracture myself and refer that, there are certain things I know I shouldn't attempt in dentistry. But for fractures that can't afford referral, amputation is usually an option. For dentistry, sometimes it comes down to me trying, patient continuing to suffer horribly, or euthanasia. It can be really rough. No matter how much "informed consent" I try to get, we all know how ugly things can get with complications. I hate the anxiety that comes with many dental cases. And even for more routine things, clients expect that their GP can provide dental services at a "reasonable" price. That price is always going to be lower than my services are worth at the level I am performing them. I won't lower my standard of care. But I don't want to price myself outside of being able to provide dentistry for my patients. As their primary care doctor, I need to be able to provide their care. Some people will argue that 20% of your clients generate 80% of your revenue, and so you offer the best and be okay if 80% of your clients decline. I'm not okay with that approach. Dentistry is a huge dilemma in most GP hospitals.
