LOW COST CLINICS AND DENTAL TOURISM: INTERVIEW WITH NERI PINZUTI

Dr. Neri Pinzuti answers the most common questions about low cost dental centres and the so-called dental tourism. Enjoy the reading!

Nowadays low cost dental centers have spread all over Italy: how much has the financial crisis helped this phenomenon increase?

The financial and economic crisis has undoubtedly been the trigger of this phenomenon, as it has led to a decline in employment and consumer spending. People are more and more keen on setting money aside and have the tendency of cutting down on expenditures in order to protect themselves from an uncertain future.

Low cost and healthcare is a much-debated topic … it almost seems like an oxymoron

Since health care costs, in a country where there is a large, even if not total health coverage, some treatments remain out of the list and completely at the expenses of the patients.

Among these treatments we find unfortunately the dental assistance. Over 90% of dentists in our country are freelancers. The position of the “public dentist” is not very common in Italy, the waiting lists are often extremely long and inevitably people have to go to private structures which, of course, are quite expensive.

Is there anyone who cannot cure himself in any way because of the crisis?

ISTAT has shown that only 40% of the population had dental treatments last year, 50% have not gone to the dentist for over 1 year and 12% have never been to the dentist at all. This leads to several reflections: first of all it is evident that it is not yet very clear to the population how important it is to make a correct diagnosis, detect the problems at their very intial stage, not only to benefit from a treatment that can prevent you from feeling toothache but also to save up money because the operation will be not that invasive and complicated.

In this scenario, low-cost dental clinics and travel companies has recently started organizing real pilgrimages to Romania, Croatia, Poland and neighboring countries to cut back on medical care expenditures.

How were these low-cost centres born?

The first low-cost centers that originally settled in Italy are all Spanish but to date there are 6-7 Italian chains as well. Mainly these are large corporations that invest large sums of money in advertising and marketing aiming to attract the greatest number of patients by relying on the seemingly lower prices; the control of the inner dynamics of the clinics is only in the hands of the investors, that means that doctors can’t even quote nor estimate the prices for their treatments.

Although the services offered are absolutely the same as in any private dental practice, the objectives are not the same ones: in these centers everything must comply with strict economic rules, the fillings must be made in a predetermined number of minutes, they cut back on materials and the amount of time for dental implant surgery and the patient is never followed by the same dentist, making it difficult to identify, in the event of litigation, the real perpetrators of a possible error.

I understand that the role played by the patient is very important to you, beyond the economic aspect. The patient is always at the heart of my treatment plan; I have clients who call me at any time of the day and even at night. Whenever I can, I always try to make myself available.

Do you think that paying these attractive prices applied by low-cost dental centres is synonym with being ripped-off?

No, not necessarily. When they offer tartar ablation for 45 euros (against the average of 80-100 euros in normal dental practices), it is actually that price that the patient pays. No rip-offs. The only difference lies in the fact that in 1 hour in my dental practice I have only one session because this is the time required to provide a truly effective treatment, while in these low cost centers they do between 2 or 3 sessions per hour. From a clinical point of view a superficial ablation has no positive influence when it comes to preventing from severe diseases of the oral cavity in the long term. Not to mention their slogans; As a professional I am not personally able to understand what they are selling exactly, so I can’t even imagine what an inexperienced and unprepared patient might understand.

Is it risky for a patient to undergo dental care in these low cost centers?

I start from the assumption that I do not want to talk about those crime-prone realities in which the secretaries work as hygienists, prostheses are made in China or India, sterilization protocols are zero, general practitioners implant prostheses … it is a reality (that unfortunately exists) that should be investigated only by the police. Speaking of regularly accredited and certified low cost centers, I can report my experience as I constantly treat and operate patients who at first have been treated by doctors from these centers: insufficient in-depth diagnostic, poorly positioned implants, oral surgery sinus perforation not treated within 72 hours…these are just some examples of the several problems that I had to deal with. Starting from the assumption that anyone can make a mistake, all the patients who turned to me complained of a total inadequacy in the management of the delicate doctor-patient relationship in critical moments; the health professionals were responsible for iatrogenic damage in most cases: instead of listening to and assisting the patient, perhaps by entrusting him to a more experienced colleague, they just abandoned him and sometimes refused even to receive him at the clinic. That all lead the patient to turn to somebody else.

As I said before, filing lawsuits against these centers is often a waste of time. Further examples of malpractice that I have encountered in the past were the lack or total inadequacy of the written estimate, the subsequent unplanned economic requests, the injunctions for the failed final balance and the failure to reimburse the amount spent by the patient for ineffective treatments.

Are the prices really so advantageous as shown by advertising slogans?

It depends on what a person wants to get by undergoing a dental treatment: I know by heart all the dental materials companies and the prices that are applied by the suppliers of the ‘raw material’. If one of my implants costs twice as much as another, it is because it has a higher quality. There is nothing else to add. I choose to give my patients only the best, in terms of quality of implants and professional skills because I don’t want them to come back unhappy or with a rejected implant.

What about Groupon?

Groupon is a website on which I would not even buy massage sessions; after seeing dental veneers for 100 euros I had nothing else to do but wish the unfortunate patients “good luck”.

Another much-debated topic is the so-called dental tourism. What drives it and how do you judge those who decide to seek treatment abroad?

There are two types of patients who come across health tourism (including dental tourism): those who go abroad in search of the greatest specialists in the sector, and who are obviously not attracted by low prices but rather by the talent of these professionals, and those who go abroad to spend less and get treatment faster. Unfortunately the second type of dental tourism scares me a lot and does not convince me in any of its forms.

It seems that these centres located mainly in Croatia, Poland, Bulgaria etc. manage to offer dental services at a discounted rate of up to 90% thanks to lower material costs and a much more favorable taxation regime compared to Italy

It is true that when we talk about low-cost foreign centres the different taxation has a great influence on how they set their final prices; but we should remember that the regulations for both patient and employees safety are also very different abroad. The costs for materials, certifications, equipment, professional updating trainings are all subject to less controlled legislations compared to Italy. Even the sanitary regulations, according to what Codacons has recently highlighted, are much lighter than the Italian ones, which are instead among the most guaranteed within the European Community. It is clear that the patient will certainly be less protected.

Is a patient who decides to seek treatment abroad at these low-cost centers less protected than the prospect of being treated in Italy?

Of course, it is less protected even when a dispute arises; since the legislation is very different and it is difficult to identify the real culprit of an error in clinics where the personnel changes constantly, it becomes difficult to bring lawsuits. The medical records will all be written in the language of the country where the interventions were carried out, thus lengthening the process times and determining additional costs of the causes for the need to have translators.

Furthermore, Italian dentists who should solve the problems created by foreign colleagues do not do so in order not to become legally responsible for the damage caused. Even the Italian “insurance policy” promised by some of these tour operators that organize trips is worth nothing..

Who goes to these low-cost foreign centers how do they get in touch with the structure?

There are travel agencies that recruit patients in Italy, they organize real tours (transportation, board and lodging all inclusive) that end with the hospitalization in the affiliated dental clinics before returning home.

We always rely on the tour operator who will probably be good at choosing the best trip and clinic, but I hardly believe he has the necessary skills to indicate the most competent dentist to treat the dysfunctions of the patients.

What are the most requested operations abroad?

Those who go abroad to undergo dental treatment certainly do not want to have their wisdom tooth removed or be treated for two cavities; the interventions are all forms of implantology, that is quite complex, long and very pricey operations.

We also know with certainty that these centers earn only when they manage to treat patients quickly (I assure you, in a very short lenght of time!) so as to contain costs. The timing marks the success of these structures, each complication is a real cause of turnover loss.

I deduce that in these clinics the staff is much more specialized than in Italy to be able to guarantee successful interventions in such tight times …

Respecting clinical times is probably the most controversial aspect when it comes to talking about dental tourism; since they are often treatments with a high specialist content, the high cost-effectiveness and short treatment of the therapies cannot work well together, as both the quality of the traatment and the patient’s health risks increase. Oral surgery, especially those involving bones, needs specific biological times to bring about healing that is considered effective. Just as a dental laboratory needs time to make adequate dental prostheses. This means that if I have to implant a prosthesis but the patient is suffering from infections, caries, old reconstructions I must first treat all the prosthetic pillars of rehabilitation and then move on to the prosthesis. All this is not feasible in a week. The human body says it.

Is it easy for a patient to understand the type of intervention that a doctor will perform and the benefits of a therapy rather than another?

Absolutely not; the patient in most cases is not able to evaluate all the technical parameters of a treatment plan; if, for example, the prosthesis holds for several years meeting the full satisfaction of the patient, there might be asymptomatic infectious problems under that rehabilitation and that doesn’t mean that the work was the best that a dentist could have done.

Maybe the paradontite that afflicts many adult patients has not been considered at all, and that is the basis of the failure of so many rehabilitations, both on teeth and on implants!

For this reason, I spend a lot of time explaining the treatment plan before intervening in such a way that my patient will be clear from the beginning about all the stages that will have to face.

Are there really interventions that can be done in a day?

Absolutely, but only if the patient is the perfect candidate, in other words without any periodontal disease or other dysfunctions of any kind.
For example, it is possible to implant more teeth with immediate loading; but if the teeth to be replaced are still to be extracted, this will probably cause bone infections with the consequent impossibility of firmly screwing a screw to be able to load it immediately. At first the system will also be stable … but it won’t last much!

In my clinic, if the patient is suffering from periodontal disease, the course of preparation for the intervention can last even a month; the prosthesis will be implanted only when the tissues are perfectly healed and only after having tried chewing, the pronunciation of some words, the aesthetic yield etc.

Subsequently I would put a provisional one (not used and considered superfluous in most of the foreign clinics), I would remove the points after a week so as to be ready to implant the definitive prosthesis. Again, if the patient is the perfect candidate, all these steps can be concentrated even in a single session. Having said that, there are not many interventions they can perform in a single day and there are no complex rehabilitations that can be done in a week.

And post-operation check-ups? Are they compulsory? How often do we need to do them?

After the intervention the patient must do a check-up every month for at least 6 months. They are mandatory. I highly doubt that those who do dental tourism can rely on regular check-ups, considering also the travel expenses to sustain that are not included in the budget of the low-cost centres.

Even the TV programme “Striscia la notizia” has repeatedly dealt with these extraterritorial realities; once a Croatian dental technician was interviewed and stated that the resin temporary was totally useless, as it lengthened the therapy and could also cause further problems to the teeth.

As mentioned before in most of the foreign clinics the temporary is used very little; we tend to immediately implant the reinforced prosthesis in the hope that it will hold over time. I personally believe that in a treatment plan that includes a prosthetic phase the temporary is of fundamental importance both for the stabilization of the abutments and for the protection of the exposed dentin that could make the tooth very sensitive; it also allows a preview of the final aesthetic result.

Are all dental ceramics the same?

No. There are different types of ceramics and also the baking methods and the manufacturing technique are important because they affect the characteristics of the product. The duration of a prosthesis depends mainly on the materials used. In general, the world market of the implants is divided into premium-price, medium price and low-cost. The first gives the clients all the facilities supported by adequate quality scientific evidence and clinical experimentation, while the third is synonym of implants which rely on low prices, sometimes exploiting expired patents of larger companies and copying them to create real clones without any control. Obviously, based on the final cost of the estimate, the patient can easily deduce what kind of implant he will be offered.

What guarantees should foreign clinics leave to the patient at the end of the treatment plan?

The guarantees are universal and it is a matter of real certification of conformity of the materials used. I always give my patients the implant passport, which is a document in which labels explicitely indicate what operation has been carried out (implants, abutments, screws..), the material used, the operation date, the position of the implant in the mouth up to very detailed details, such as the item code and the lot number of the implant. By looking at these data, any dentist in any part of the world can have a precise clinical picture of the patient’s mouth and adjust it accordingly for interventions or maintenance procedures. The patient who is not given these guarantees should be very skeptical towards the dentist who has performed the operation.

What advice would you give to all those who, attracted by these new realities, want to undergo treatments abroad in search of cheaper rates?

Medicine is a expensive, that’s true, because especially at high levels it requires considerable specialization of all the people involved, as well as the right treatment time and also expensive equipment at high obsolescence which therefore must be replaced quite frequently . This is why high quality can never fall below certain levels, even in terms of price. I therefore feel that I recommend a careful evaluation of all the options before deciding to go abroad and go into realities that are difficult to manage. Moreover (in this case I like to repeat myself) prevention is the only weapon that each of us can have to limit expenses and to maintain the oral health status over time.