Are dental practices out of control in the United States?

A series of opinions and letters recently published in JAMA Internal Medicine present varied perspectives on the current state of dental care in the United States, all emphasize the need for evidence-based practices and changes in business models.

The conversation began in the July issue when Paulo Nadanovsky, DDS, Ph.D., and colleagues presented “Too Much Dentistry,” arguing that dental diseases and procedures are widespread, costly, and often exceed spending on other major health problems such as diabetes and hypertension.

They suggest that dental care in the United States is driven more by economic pressures and patient confidence than by clinical evidence, leading to an excessive number of diagnoses and interventions.

Examples offered in “Too Much Dentistry” include the treatment of noncavitated carious lesions (white spots) and routine fillings in children, practices that lack substantial evidence of their benefit in preventing pain or infection. The authors point out that cavities have declined with increasing public awareness of dental health since the 1970s, with things like regular brushing and fluoride toothpaste.

According to Nadanovsky, fewer tooth decay means less work for dental offices, leading them to recommend more frequent regular visits (every six months) despite the lack of scientific evidence supporting the need for such frequent checkups. This financial need to maintain practice revenue is considered the driving force behind excessive treatment.

In response to “Too Much Dentistry,” Yehuda Zadik, DMD, MHA, acknowledges the issues raised by Nadanovsky and colleagues but emphasizes advances in dental technology and preventative measures. Zadik points out that contemporary guidelines now favor minimally invasive treatments over the traditional “drill and fill” approach. He also credits regular visits to the dentist with better dental health outcomes and early detection of disease.

A subsequent letter from Zadik expands on the themes of the agreement with Too Much Dentistry, raising concerns about the lack of external oversight in dentistry, which affects all stages of care, including imaging. Zadik reminds us that “…dentistry is among the few health care professions where the clinical examination, diagnostic testing, including x-rays, diagnosis, treatment planning and treatment, are all performed at the same time.” location, often by the same health professional. This model of care delivery prevents external oversight of the entire process.

The lack of oversight means there is no way to assess whether routine procedures are necessary, a recurring theme in discussions.

Zadik goes on to point out that current guidelines “…promote the reduction of patient exposure to diagnostic radiation in dentistry. Improvements in awareness and preventative measures, primarily the use of fluoride, as well as advances in dental techniques and materials that improve the success rate of dental work and the durability of dental restorations require that patients have no no need for imaging every six months, but rather at longer intervals and based on clinical suspicion.

This last part, “based on clinical suspicion”, is essential. Current ADA guidelines require that dental x-rays be taken after a dentist examines a patient’s mouth, not before, and only if a problem is suspected should x-rays be taken .

Sheila Feit, a retired physician, weighs in on the x-ray debate by addressing the overuse of dental x-rays. She cites data showing that 320 million dental imaging procedures were performed in the United States in 2016, representing more than 46 percent of the nation’s diagnostic and nuclear medicine imaging.

For reference, the United States Census Bureau estimated the U.S. population at just over 323 million in 2016. Feit calls for randomized clinical trials to evaluate the risks and benefits of dental imaging .

The collective perspectives recognize the themes of overdiagnosis, the influence of economics on dental practices, and the urgent need for basic evidence-based guidelines.

Another way of putting this is that yes, the current state of dental practice in the United States is somewhat of a scam with some very good results. While perceptions of dentistry often boil down to patient trust and the profession, I offer as examples a few anecdotes from the ever-skeptical author of this article.

I was once told that I had eight cavities and was given a detailed schedule of the order in which the dentist would recommend treating them. A visit to a new dentist for a second opinion (blind) revealed that I had zero.

Another dentist (who seemed pretty serious at the time) once informed me that I had bacteria in my mouth. Period, as if it were a disease state and not a given expectation of being a human being harboring a multitude of bacteria in every available internal and external space.

When my oldest daughter was three, a dentist took X-rays that revealed five cavities. When I looked at the x-rays, I didn’t see anything. I was told it was because I wasn’t a dentist. The new dentist she later saw found none.

My youngest daughter’s dentist recommended a jaw widening procedure. I spoke to another dad about it, who told me that he had just been recommended to two of his children. Since neither of us had heard of the procedure before, we did a quick search online which didn’t explain the procedure but brought up dental industry information that the procedure was being added to coverages insurance in our state.

On the other hand, when I broke a tooth after an accident, the replacement tooth was so seamless that I’m no longer sure which tooth the dentist replaced.

When I finally had my first cavity, and it was causing excruciating irritation, it turned out to be in a wisdom tooth that my dentist removed in a quick and painless procedure.

The implications of surveillance for dental practices and health care policy are significant. Dental practices need revenue to survive, and charging insurance for routine procedures is where they make most of their revenue. Americans are subjected to too much X-rays and unnecessary routine treatments, and maybe that should stop, but maybe not if it’s the only way they can be there when we really need them.

© 2024 Science X Network