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Overseas dental work - facts and fears

Getting dental work done overseas can save you thousands, but if things go wrong, there may be a high price to pay.

They buried Melanie Heremaia in her hometown of Waihi last Monday. The 22-year-old died in Noumea two days after having root canal surgery performed in the city she had planned to settle in permanently. Heremaia, a dancer, was on anti­biotics and painkillers after her oral surgery. She died in her sleep after choking on some food, says her brother Matthew Heremaia. The police ruled her death was accidental. “It was a combination of being overworked and overtired [and having] the medication and dental work,” her brother says.

Melanie Heremaia had not gone to Noumea specifically to have dental surgery. But her death in a hotel just two days after such surgery highlights the potential risks as the dental tourism trend takes off – some New Zealand travel agencies are now setting up divisions solely dedicated to the provision of dental care services abroad.

To all appearances, it’s the ideal solution: tourists get their dental work done for noticeably less than they would expect to pay in New Zealand – and a tan on top. But it is very much a case of “buyer beware”, says Donald Schwass, a senior lecturer in the Department of Oral Rehabilitation at the University of Otago School of Dentistry. Schwass recently returned from speaking to the Fiji Dental Association conference on the topic of dental tourism – now beginning to reach that country.

Good work takes time, he says. And dental tourism holidays don’t always allow for that. Citing dental implants, he says that such restorative procedures in New Zealand may take many months from the initial consultation to the final fitting. But when implants are fitted as part of an overseas holiday package, there are time pressures. This may mean the implants are loaded too early, which can compromise the bone healing.

As a result, the implant may fail to integrate, meaning at the very least, the patient could lose the fitting. A worst-case scenario is the patient loses precious bone to infection as well – involving vast remedial surgery and considerable extra expense, not to mention the cost to their health.

Schwass, who had his own dental practice for 20 years before moving into academia, stresses the need to consider that a lot of prosthetic dentistry work, such as crowns, implants and bridges, also requires ongoing maintenance. “The reality is that dentistry is very rarely a one-off, so what are these people going to do? They probably can’t go back, so they’ll go to a local dentist, who will charge a normal fee – and that can incur a large cost [on top of what they’ve already paid].

Even tightening a loose implant screw will be quite costly.” It can be a false economy, says Schwass.

People have always sought cures abroad, an obvious example being the supposed benefits of a visit to Lourdes. And dental tourism is now a global phenomenon, with Germans seeking treatment in Hungary and a noticeable growth in the number of New Zealanders going to, or through, Singapore and Thailand, in particular. But Michael Hall, a professor of marketing in the Department of Management at the University of Canterbury who is editing a book on medical and health tourism, says it’s not good enough to simply look online for dental care.

Some institutions have already sought international accreditation as part of their bid to attract tourists wanting procedures performed, Hall says. “Singapore tends to have particularly good regulations, but Malaysia and Thailand not so much.

Implants are not always as successful as they should be and there are definitely some people who [return] not so happy. The main motivation is price, but it’s price in a narrow context; if things go wrong, it’s very, very expensive.

“I managed to crack a tooth just before the earthquake last September, and given that our house is in the orange zone and we were earthquake refugees waiting for insurance decisions, money is obviously a bit tighter than normal. But there’s [still] no way I would go to a developing country to get it fixed.”

Yet one dentist who did just that is retired Waikato dental surgeon Don Norman. When he needed a new bridge, whom did he turn to? Not his regular dental practice.

Instead, Norman packed his bags and flew to Thailand. There he got the scheduled dentistry work done for considerably less than what he had been quoted at home.

It’s not what Norman would have condoned were he still practising – who wants to encourage a loss of local business? But it comes down to cost, he explains. And having lost his retirement savings to a failed financial company investment scheme, he now relies solely on his pension.

Norman reports that the level of care in Thailand was “excellent. They knew what they were doing and they looked after me very well.” The work, performed three years ago, “has stood the test of time”. Norman now has regular check-ups at his local surgery and each time receives a clean bill of oral health. Would he do it again? “If I could afford it, I would.”

North Harbour Corporate Travel has a dental tourism division dedicated solely to providing the full package deal. Recently, says managing director Richard Trowbridge, “we had a guy come in who needed six teeth capped. He had been quoted $1500 a cap here.” Instead, he chose to go to Thailand.

“We found a dentist who had a 10-day window – including a little bit of down time for the procedure. He did the whole six caps in 10 days.” The client took his wife and paid a total of just under $6000, which included nine nights in four-star accommodation in Phuket, and saved himself some $3000.

He’s but one of a growing number of happy customers, says Trowbridge. “We moved more than 100 people [through dental tourism] last year. Tourism Thailand will be trying to attract 90,000 visitors from New Zealand next year and we’d be very happy if we got 5% of that going for dental work.”

He says his travel company works with specially selected dentists in Phuket and Bangkok who are registered with the Thai Dental Council, the Thai Dental Association and the National Dentistry Association. “These organisations ensure the very highest standard of medical service and maintain a strict sterilisation ­process.” Plus “our key dental suppliers were trained in the US and hold international memberships to the American Operative Dentistry Society”.

Trowbridge says his clients’ motivating factor is money; the holiday comes second. “I don’t know why the cost here is so huge.”

David Crum, chief executive of the New Zealand Dental Association, can offer some explanation. First up there are the course fees. Students graduating from the University of Otago School of Dentistry will have paid between $70,000 and $100,000 for their education. They will have spent a minimum of five years at university to gain their standard dental qualification, then at least an additional three if they chose to undertake specialist courses. Then they may want to establish or buy a practice, for which they’ll be looking at a cost of $250,000-700,000.

Crum further points out that, once a person reaches age 18, there’s no government subsidy for dental treatment. And “dentists have an income similar to a doctor or a lawyer”.

Dentists in New Zealand must be registered, and must meet a number of mandatory clinical and surgery audit requirements to retain their practising certificate. Among these are strict and costly requirements around patient safety, such as proper autoclave sterilisation of dental instruments between patient visits. “These standards are important because they assist to provide safe care, but they cost,” says Crum.

The health costs that can be incurred should these requirements not be met are even greater. Dentistry work brings with it some significant risk of infection – if the person performing it is using instruments that have not been properly sterilised after being in someone else’s mouth. At one end of the scale, there’s measles, mumps and herpes simplex to consider; at the other there’s the potential for viruses including hepatitis B, hepatitis C and HIV.

The Dental Association, to which 96% of the country’s dentists belong, does not have an official written policy on dental tourism, but it would definitely warn people of the risks, Crum says. “Our concerns are around the inability to seek redress when things go wrong.” He points out that patients are not covered by ACC for work performed overseas, nor do they have recourse to disciplinary bodies such as the Dental Council or the Health and Disability Commissioner. As well, he says, the dentist isn’t down the road the following week if things do go wrong.” As indeed they do. “I’ve seen absolute disasters with root-canal fillings; crowns that have huge gaps where decay gets in quickly; bites that have been ruined.”

Schwass says although treatment can certainly be more costly in New Zealand, the fees are also very fair. Someone can be reasonably assured that when they receive complex treatment here, they will get a high standard of care. People coming here with an overseas dental degree from any country that is not recognised in New Zealand may have to sit registration exams. These exams are set at the standards expected of a graduating dentist, not a specialist – but pass rates are “definitely not” 100%, says Schwass.

By comparison, when seeking treatment overseas, it all depends on where the dentists did their training, he says. “With some Southeast Asian countries, there are some very good schools – but there are some schools that don’t generate the same quality of graduate. Generally, the more complex the work is, the greater the likelihood it will need to involve specialists. With dental tourism, some work may be done by non-specialists.”

Schwass points out that especially with bridges, implants and crowns, a large component of the cost lies in the laboratory work – which is locally governed by strict training and registration requirements.

When overseas, patients don’t know about the quality of lab work performed, he says. “There, you could have a lab employing 30 people, of which one person might have good skills.” The patient is responsible for the warranty and maintenance, and it’s not so easy for patients to have any come-back if they have had that treatment overseas, he warns.

The growth in dental tourism can be partly attributed to people keeping their teeth longer. Schwass predicts in a decade or so, people of rest-home age will no longer have dentures, but instead have their own teeth. And with dental longevity comes more demand for prosthodontic work: crowns, implants and bridgework.

At this point, people can take either the sticking plaster approach or the rehabilitative approach. “When you restore the whole mouth, the price becomes more expensive [and] at face value, people think, ‘I can get all that done [overseas] – and have a holiday.’

“Ultimately, you go and see someone to have a complex procedure. You are still responsible for your own health, and if you haven’t been maintaining that regularly, one quick fix won’t address the underlying disease process.”

It’s important to consider the risks associated with undiagnosed and untreated conditions, such as periodontal disease, says Jonathan Leichter, specialist periodontist and senior lecturer at the University of Otago School of Dentistry.

Periodontal disease is like borer in your house, Leichter says: it can go undetected while apparent cosmetic concerns, such as caps, are addressed. “Your dentist should be checking you and screening you [regularly] for periodontal disease.”

He says there is a link between patients who have periodontal disease – a chronic inflammatory disease that can destroy the gum and bone surrounding your teeth – and patients who have cardiovascular disease. Similar links have been
made between periodontal disease and diabetes, respiratory infections and pre-term, low-birthweight babies.

Having work done without having addressed underlying periodontal problems is going to mean trouble – “you better take a picture, because the work won’t last. The bottom line is the consumer needs to investigate who they are going to.

They need to do their homework, and if it’s a significant amount of dental work, they need to consider a second opinion – here or overseas.”

Scott Nepia did take the risk of overseas dental work – twice. The 41-year-old Auckland business analyst made two trips to Thailand for dental care while working for Air New Zealand. The way he saw it, the decision to get his teeth capped in another country was a “no-brainer”: his airline position qualified him for cheap flights and accommodation; the add-on dental costs were less than two-thirds of what he had been quoted in Auckland.

Nepia, who has a bachelor of commerce degree, did his homework. “I based my decision on the references I found online and how professional [the dentistry practices] were in response to my emails.” His inquiries led him to a clinic in Bangkok, which had impressed him with its “thorough and professional” approach.

Despite the leisure lure, there wasn’t much time for a lie-down once he arrived in Thailand. “I literally got off the plane and went straight to the clinic. They managed to squeeze me in for the whole crown within a week – but it was very tight. If I’d arrived any later, they couldn’t have allowed for the time it took for the crown to be made. I would recommend you stay a little longer.”

Nepia, who describes himself as having “sensitive teeth”, got a few fillings done at the same time and left the clinic confident in the knowledge his work was guaranteed for a year. Back in Auckland and still within the warranty period, he found he could not bite on the side of his mouth where his new crown had been fitted. He contacted the clinic, and was invited to return – but even with the travel discounts he enjoyed, he could not afford to within the 12-month time frame.

Instead, he says, he “dealt with” the inconvenience until he had saved enough money to go back. But this time he chose a new clinic – in Phuket. It was a much smaller establishment than the one in Bangkok he had previously visited. In Phuket he had his original crown removed and replaced, as well as two additional crowns fitted. Again, the cost was substantially less than the $1500 a crown he had been quoted in New Zealand.

On the first visit, Nepia went with his mother and a family friend – who both underwent plastic surgery. Nepia says the friend also had a quick dental check-up because she had been having a problem with her gums. The cause was said to be the result of inadequate work performed in New Zealand, he says, and was then remedied.

On the Phuket trip, he was accompanied by his wife and her parents. His father-in-law also had crowns fitted, and his wife had a check-up. That was three years ago and Nepia now sees his Auckland dentist on a regular basis. “She had a look and said there wasn’t enough gap between the tooth and the crown.”

Nepia now no longer works for Air New Zealand and, with a family to support, says he can no longer afford to fly to Thailand for dental care. He is instead looking at having his caps fitted here. Still, he says, he has no misgivings about his overseas experience. “My understanding was there was always the chance something could go wrong. I took that risk.”

He says the services provided were “top-notch. My experience was awesome.” But he does admit the experience would have been “smoother” if the clinic staff had had a better command of English. “But you get there in the end.” Aware of the criticisms of having dental work done overseas, he says, “They’re just crowns; it’s not your midwife.”