Expert: Mark Bornfeld DDS - 8/5/2006

Question
Dear Dr. Bornfeld,
I feel I have a related situation. I recently received (without full knowledge) a white resin composite two-surface molar filling (D2392, $94 on SmileSaver, plus $25 for Bonding=$119)at an apparent "Mercury-Free" facility. Cost is an issue for me, the facility knew that, and my personal opinion about the ongoing mercury controversy is that I really don't care and I don't think mercury causes much harm. Just put something cheap in that'll do the job well! This "Mercury-Free" policy was never ever verbalized to me, and I did not know that I was getting a white filling in my mouth. Supposedly, they had signs around saying so, but I didn't know that mercury is in amalgam, or what amalgam even was. I remember a sign that mentioned women's (reproductive?) health and mercury, and that mercury is in dental amalgams, but not anything on the wall more specific. I was not aware at the time that there was another choice for a molar other than the dark stuff, the "dark stuff" not being a choice apparently at this facility, so that part of my dental plan was totally ignored and never mentioned to me (I had no codes of my own at the time because my Plan failed to send me my ID card and policy info in a timely manner after signing up), and it was never specified to me at the time of the procedure that what I was getting wasn't gray. It's been 3 months and this tooth has more sensitivity than it did before the procedure, and I need it for chewing. My bite seems alright, so I do not think the filling is "riding high." Since reading the Q&A that I put as this email subject title, I see on my policy that the cost for Sedative Filling is $0 (D2940). I believe you are saying that "sedative filling" IS the "bonding" used for a resin filling? I called my dental plan yesterday to ask about this and they told me they didn't know what sedative filling is and the word "bonding" didn't appear anywhere on the plan (duh)and to ask the dentist! Yeah, right! Was I also over-charged for "bonding" besides getting the wrong filling?  If all resin composites need to be "bonded," I don't see why the $94 charge for the procedure wouldn't include bonding.  I am in the process of disputing the transaction with the credit card company on grounds of service-quality (I think my tooth is worse-off now, and  I was never directed to rinse my mouth during or after the procedure) and lack of full and accurate information, and I think this newer information can help my case all the more.

Thank you for your time and help!

Answer
Dear Theresa,

I sympathize with your problem, but most state laws give dentists some latitude in determining just how much informing of the patient is necessary to satisfy the legal requirement of informed consent. There are tangential considerations that may be more clearly delineated by law-- for example, any unsubstantiated claims to the effect that removal of amalgam fillings can have a therapeutic effect on any disease state. However, that is not at issue here; what you object to is that some available treatment alternatives were not discussed or offered. This is a more tricky area, since the law does not compel a dentist to offer all dental services. You might argue that your current discomfort is at least partially due to the use of composite rather than amalgam (a reasonable assumption), but the burden of proving this would be yours.

A more cloudy question is whether the dentist was justified in breaking out the fee for "bonding". You are quite correct-- all resin fillings are bonded, and the "unbundling" of a separate fee for this step is on ethically shaky ground. (A sedative filling is something completely different from bonding, and does not apply in this situation.)

Another vague issue is whether your dentist has a contractual relationship with your dental insurance plan. If he does, the imposition of fees for non-covered services may or may not be justified. If he is charging for non-covered services merely to circumvent the contractual limitations of the plan, this would probably constitute a violation of his contract with the insurer. However, bear in mind that some insurance plans are unreasonably restrictive, and exclude benefits for some necessary services. Your dentist's first responsibility is to your health, and if a non-covered service is appropriate, this will incur additional out of pocket expense.

As to the fees, I don't think they are excessive, even when including the fee imposed for bonding. However, I am located in New York, and I am accustomed to seeing high fees. If your dentist is a participant in your insurance plan and he has exceeded the scheduled fee, then the fee is excessive by definition. I also agree that it is not customary to charge separately for "bonding". If a total fee of $119 for a two-surface composite resin filling will not fly, there is no justification for charging more by inventing a separate procedure.

Hope this helps...

Mark Bornfeld DDS
www.dentaltwins.com
Brooklyn, NY