The high cost of cut-price dentistry
Written by Ailin Quinlan and published on 16 June 2014 in the Health and Living Section of The Irish Independent
Lured by the promise of cheap treatment, many opt to travel abroad for dental work, only to pay dearly - sometimes years later.
CHRONIC ulcers, cysts, infections, bleeding gums, cracked crowns and loose implants – just some of the hair-raising problems being reported by patients who have received cheap dental treatment abroad.
"I've seen people with pus running down the inside of their faces," says Anne O'Donoghue, periodontist (gum specialist) and lecturer in dentistry at Trinity College Dublin.
"They literally have pus running down inside their nose because of infections in the sinus.
"We see a lot of patients with chronic ulcers caused by ill-fitting crowns, implants or veneers," says O'Donoghue, a dentist for 30 years.
Increasingly, she says, she's dealing with patients who have travelled abroad for dental treatment and are now reporting everything from infections and swelling to bleeding gums, bad breath, chipping or cracking crowns and implants falling out.
Large numbers of Irish people are opting for cosmetic dental treatments overseas, and they're travelling to clinics in countries like Spain, Portugal, Turkey and throughout Eastern Europe, which are offering savings of up to 70 per cent on prices in Dublin.
Prices for dental treatment are higher here, acknowledges the Irish Dentists' Association, but it says that's partly because of the overall cost of living, but also because of recession-era cutbacks in state aid such as changes in tax reliefs and PRSI allowances and the restriction of medical card dental care to patients.
Many patients are happy with the low-priced dental treatment they receive abroad, but others can pay dearly for their decision to go outside Ireland.
According to a survey carried out by the Irish Dentists' Association, some 6,000 patients a year are presenting to Irish dentists seeking remedial treatment following dental work carried out in foreign clinics.
Over time, they may experience problems as a result of poor materials or workmanship, because work is carried out on top of existing infections or because complex procedures are shoe-horned into too little time.
Part of the problem is that people are so anxious to get a low price that they're not carrying out thorough checks on the clinic they choose and are failing to make informed decisions about their treatment, believes Davor Mekterovic MD, of Dental Hungary, which has been operating in Ireland since 2005.
"It amazes me that people just go with price rather than finding out who is doing the work – they put more effort into researching and buying a new car than they do into who is doing their teeth," he says.
On the ground, the problems resulting from dental tourism seem to be on the increase – eight years ago such patients made up just 5 per cent of O'Donoghue's practice at the Northumberland Institute of Dental Medicine in Dublin, which provides a range of specialised services from root canals to crowns, veneers, implants, bridges and orthodontics.
Now they account for about 25 per cent of her client base.
"This trend has increased significantly in the last four or five years.
"I've seen people with half their jaws missing from infection.
"They can develop a huge cyst around a badly fitting implant for example, the device falls out and people are left with a hole in the jawbone. –––
"If you have a badly-executed implant the body recognises it as an alien presence and creates an inflammation in the form of pus to push it out," she explains. "The pus eats a hole in the jawbone to push out the implant and, in so doing, can take half the jawbone with it."
Patients have also sought help for problems resulting from poorly executed veneers, which, she reports, have caused nerve problems, swellings and infection.
"They will go on the internet and see an advertisement, for example, for crowns for significantly less than they would cost in Ireland," says O'Donoghue.
"They (the crowns) have the appearance of being much cheaper but the crown isn't always made of porcelain, which is necessary to prevent infection, but of plastic.
"Plastic as a material is very porous and bacteria will gather and cause an infection."
This can result in serious problems down the road, she explains.
"If someone gets an implant or a crown which is poorly manufactured, badly fitted, or made of inferior material, the body over time will want to expel it."
An infection will occur around the soft skin and the gum will become inflamed and infected.
"Infection is the biggest thing we see, for example in a badly-fitted crown or a badly executed root canal."
Waterford City dentist Donal Blackwell has seen patients spending up to €14,000 on dental work abroad. "They're being over-treated; getting treatment they don't need.
"I'm seeing huge amounts of teeth being interfered with in some cases, and I'm certain that some of the teeth done didn't need treatment at all – looking at a patient's records or their X-rays will show you this," he says.
"Massive amounts of teeth are being dealt with in one fell swoop. The standard of work that I'm seeing is not good, and the outcome for the patient is poor."
Says Blackwell, who runs a specialist practice dealing with crowns, implants and bridges: "Not a week goes by but we're asked to see someone with problems related to overseas dentistry.
"Patients come in who have had a wholesale reconstruction of up to 30 teeth done in their mouth.In a nutshell, you're looking at huge amounts of work being shoehorned into a small number of visits, and massive amounts of teeth being treated in unrealistic treatment times.
"There is poor execution and poor technique – it results in teeth deteriorating quicker than they should as well as gum, bone and root canal infection."
In some cases complex work is being done in too little time, agrees O'Donoghue. "Doing eight crowns and a root canal in eight days is horrendous. It's being rushed to fit it with the patient's stay.
"I've have seen people come back with lisps because the crowned teeth were not made to replicate their original teeth. There must be time to decide on whether the procedure has affected your speech because of changing the tongue position, as your jaw joint can be affected by incorrect bite alignment."
What is most shocking, emphasises O'Donoghue, is "the repeated destruction of the natural teeth and jaws."
One issue, she believes, is that patients are not being sold proper ongoing health-care but "fee-per-item dentistry".
Con O'Leary, a dentist who practises in Cork city and Kenmare has seen "a surprising number of patients with major problems following dental work carried out abroad".
"Usually more work is required to correct the problem than would have been the case prior to the patient going abroad for the treatment"
Robin Foyle a dentist in Wexford, recalls the ordeal of one patient who had treatment abroad, but the dentist did the work on top of an underlying infection. "This caused problems within a matter of months and the patient experienced pain. Basically the procedure had to be undone by the foreign dentist, who then refused to treat the underlying problem, which will be treated by me.
"But the original procedure should not have been carried out on top of an underlying infection."
This is something he has seen repeatedly, he says. "People will have an underlying gum disease, and sometimes the foreign dentists will go ahead with a procedure because it takes too long to treat gum disease, so the cosmetic work is carried out anyway."
If a patient requests treatment from a dentist who is abroad and who provides only certain complex high-end treatments, he says, that dentist may not be able to treat underlying problems such as gum disease, as "this requires several visits over a period of time."
Foyle knows of another patient who went abroad for expensive cosmetic treatment which, he says, "bonded his teeth together, making them very difficult to clean, which has the potential to cause him serious problems in the future."
Yet, says Foyle, a simpler treatment available in Ireland would have been cheaper and more appropriate. "He didn't realise this and was mis-sold dental treatment which I think will cause him trouble in a few years."
Patients may initially be pleased with the work, but problems can take a few years to materialise, says O'Donoghue. "Generally when we ask the question, people will look back and say, for example, that the crowns started falling out, the veneer started chipping or the implants were causing pain and jaw shrinkage and falling out. It seems to take up to four or five years for the problem to become visible to the extent that somebody seeks help."
A significant number of people who had dental treatment overseas in the past five or six years now seem to be reporting problems, agrees Brian O'Connell, professor of restorative dentistry at Dublin Dental Hospital, Trinity College. "Five or six years ago it seemed like a lot of people in Ireland were travelling abroad (for dental treatment).
"We are in a different phase now. The phase we're in now is that people are reporting problems. A lot of these patients would be referred to the dental hospital. I get referrals on a weekly basis of patients who have had extensive treatment abroad and who are having problems."
Ten years ago, Mary Flanagan had extensive work carried out by Kreativ Dental, a clinic based in Budapest. She was so happy with the work, she became a representative for the firm.
Flanagan says she's aware of the problems which can result from dental tourism and believes the causes include the use of under-qualified dentists, and rushed or inferior work.
"There are cowboys out there," she says, adding that, since Kreativ Dental opened 17 years ago, many more clinics have been established:
"Since it opened, hundreds more have opened up all over Europe, but not always to a similar standard."
Unlike Kreativ Dental, which carries out all consultations at its clinic in Budapest, she says some foreign clinics will send what Flanagan describes as "young, inexperienced dentists" to carry out initial consultations in Ireland.
"They're carrying out consultations and taking X-rays in rented rooms and in hotels."
Kreativ Dental has repaired the poor work done by some other clinics, says Flanagan, who cites problems with crowns falling out, too many teeth on a bridge, implants placed where there is insufficient bone or too much work done too quickly.
In some clinics, says Flanagan, dentists may not even be fully qualified. "They're not oral surgeons so the work involved in dental implants and crowns will not be up to scratch."
Although some people are just unlucky, others are "going solely on price", which she says is not always a good idea. "Some clinics will advertise eight implants for the price of six, or even half-price implants – this is not a good sign, but people are doing it, the Irish people are looking at it and going 'wow'.
"I say to people that you wouldn't go to a heart surgeon who is offering a half price surgery!" she declares.
Customers need to do the research before opting for a particular clinic, but, blinded by the lure of low prices, many don't, says Davor Mekterovic.
"Customers need to make an educated decision; find out what the background is of the people who are doing the work. Do the research, ask for references, make an educated, informed decision," he advises.
Whatever the reason, problems resulting from past dental tourism are a growing issue for Michael Kilcoyne, of the Dental Complaints Resolution Service. "Perhaps they got crowns or implants done but over a period of time the work has started to deteriorate; something that should last 20 years or so is starting to fall apart after two or three years."
In the two years since the service was set up by the Irish Dental Association, Kilcoyne has received a litany of complaints about everything from crowns and implants falling out, to people whose gums are shrinking and one or two cases where damage was done to the jaw bone.
Patients have reported having consultations carried out in hotel rooms, he says.
"Somebody would arrive, look at their teeth and make arrangements for them to go abroad to have dental work carried out."
O'Donoghue says she's seen patients who didn't even have a consultation with a qualified dentist. They went abroad seeking treatment, she says, "based on a consultation with a clinical coordinator, and flew out to a foreign dental clinic with an X-ray."
A significant number of problems have been reported by patients who travelled to Eastern Europe for treatment says Kilcoyne – and, he's discovered, resolving problems is not always simple.
"I have no jurisdiction over these areas but I wrote to the dentists concerned and in two years only one overseas dental practice cooperated with us, dealt with the complications, brought the patient back and sorted it out."
It's a familiar complaint says Professor O'Connell. "We find that, with the people we see, they seem to have very little recourse if they have problems.
"If you've had treatment abroad and have spent a lot of money, it's not really feasible to go and get satisfaction from a care provider who is thousands of miles away; they don't understand the language or the system and they find it very difficult to get remediation or satisfaction," he says.
"They're left with a problem and nobody to look after them."
Legislation in this area is inadequate, Kilcoyne complains.
"There's no legislation to protect these consumers and the laws are different in many of the members states.
"There are more and more people complaining that they had dental work done abroad and are now in terrible pain," he warns.
GOING ABROAD CAN BE CHEAPER, BUT ARE THE RISKS WORTH IT?
IN JUNE 2007 businessman John O'Mahony* travelled to a clinic in Hungary for dental implants.
A year earlier, his local dentist had suggested he get eight in total – but advised that John first get a course of dental hygiene treatments.
On investigation, he learned this would cost €3,000.
"I told my dentist that was too expensive, so I was sent to another guy, who did six sessions for about €1,000."
However, when O'Mahony arrived at his dentist following the hygiene sessions, the dentist felt further hygiene treatment was required before he could start work on the implants – but the businessman discovered this would have cost him a further €1,200 on top of the €1,000 he had already spent.
When he inquired about the cost of the implants, the estimate was between €4,000 and €5,000 per implant. "I was looking at a figure of well over €30,000 – this was crazy," he declared.
An acquaintance of his had significant dental work, including a number of implants, done in Hungary, and recommended the dentist who carried out the work.
"I met the Hungarian dentist who did the work at a clinic in Ireland – he came over regularly to meet prospective patients and provide after-care.
"He looked at my mouth and drew up a plan for eight implants plus the hygiene work, all of which would be done at the clinic in Hungary."
In June 2007, O'Mahony spent eight days in the clinic – he had the hygiene treatments, the implants and a root canal: "It was a short space of time to do a lot of work, so it was very intensive."
The cost was about €16,000 – half what he had been quoted in Ireland – and he went home a happy man, with temporary crowns which were to be left in place for six months.
In January 2008 he returned to the clinic on schedule for another eight days, during which he was fitted with permanent crowns.
For the following 12 months, everything was fine, but in 2009 he got an infection in one of the implants. He went for after-care in the Irish clinic run by the Hungarian dentist.
The treatment was not successful – John was left with bad breath and sore, bleeding gums.
"Eventually they told me the best thing was to remove the implant and just have a false crown or bridge, but I didn't want that."
He consulted his own dentist who diagnosed a severe infection and warned him his jawbone was starting to shrink:
"I have long road ahead. I have to have several implants removed because of the bone shrinkage – it would affect existing teeth if it is not done.
"I think I will have to have bone grafting to combat the shrinking, so there will be surgery and removal of the implants as well as the infection will have to be dealt with."
John has been in touch with the Dental Complaints Resolution Service.
"My advice to anyone going abroad for dental treatment is to think about the fact that there may simply be too much work being done in a very short space of time.
"I had eight implants, a root canal and crowns – all done in a total of 16 days."
* Not his real name
'I HAD VERY LITTLE TIME TO MAKE THE DECISION, WHICH I NOW REALLY REGRET'
BACK in 2004, Martina O'Brien* was advised by her dentist that she needed extensive dental work which included several crowns and a number of implants.
She was referred to a specialist who told her the work to be done was very significant – so Martina decided to go abroad. "It would have cost thousands and I felt I wouldn't be able to afford it, so I decided to fly to a clinic in Hungary for a consultation."
She did – and following the consultation, Martina visited the clinic on several occasions over a period of about 18 months. "I got several crowns and a number of implants and also had bridging work done. I had crowns put on healthy teeth to match the colour of the other crowns.
"I had very little time to make the decision, which I now really regret, but it was made very quickly," she says.
The work cost €24,000 and was completed in 2006/2007.
However, within a few years, she says, she was having problems. "There was an infection in the implants and pus was coming from my gum."
"I went to an Irish dentist who said the implants were poorly done and that there was a problem with the bridge-work. He said the problems were significant. Since then I've had a lot of remedial work done, which I would estimate has cost in the region of €10,000 so far.
"I was also told that the jaw bone had shrunk where the implants were, and that the implant would have to be taken out, because the infection had caused me to lose bone."
"Now I have dentures instead of implants, which is what I wanted to avoid in the first place. My gum has shrunk up and when I take out the dentures I look like a very elderly person. I'm very embarrassed about it."
*Not her real name