A series of recently published opinions and letters in JAMA Internal Medicine present varying perspectives on the current state of US dental care all emphasize the need for evidence-based practices and changes in economic models.
The conversation kicked off in the July issue when Paulo Nadanovsky, DDS, Ph.D. and colleagues presented "Too Much Dentistry," arguing that dental diseases and procedures are highly prevalent, costly, and often exceed spending on other major health conditions such as diabetes and hypertension.
They suggest that dental care in the U.S. is driven more by economic pressures and patient trust than clinical evidence, leading to excessive diagnoses and interventions.
Examples offered in "Too Much Dentistry," include the treatment of noncavitated caries lesions (white spots) and routine fillings in children, practices that lack substantial evidence of benefit in preventing pain or infection. The authors point out that caries have declined with growing public awareness of dental health since the 1970s, with things like brushing regularly and fluoride toothpaste.
According to Nadanovsky, less tooth decay means less work for dental practices, which leads 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 revenue for the practice is pointed to as the driving force behind excessive treatments.
In response to "Too Much Dentistry," Yehuda Zadik, DMD, MHA, acknowledges the issues raised by Nadanovsky and colleagues but emphasizes the advancements in dental technology and preventive measures. Zadik points out that contemporary guidelines now favor minimally invasive treatments over the traditional "drill-and-fill" approach. He also credits regular dental visits with better dental health outcomes and early detection of disease.
A subsequent letter by Zadik expands on themes of 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 remaining health care professions where clinical examination, diagnostic testing including radiographs, diagnosis, treatment planning, and treatment are all performed in one place, often by the same care practitioner. This model of care delivery prevents external oversight of the entire process."
The lack of oversight means there is no way to evaluate if routine procedures are necessary, a common theme in the discussions.
Zadik continues, pointing out that current guidelines "...favor the reduction of patient exposure to diagnostic radiation in dentistry. Improvements in awareness and preventive measures, primarily fluoride use, as well as advancements in dental techniques and materials that enhance the success rate of dental work and the durability of dental restorations, dictate that patients do not need imaging every six months, but rather at longer intervals and based on clinical suspicion."
That last part, "based on clinical suspicion," is key. Current ADA guidelines call for dental X-rays to be performed after a dentist has peered into a patient's mouth, not before, and only if there is a suspected issue are X-rays to be taken.
Sheila Feit, a retired MD, weighs in on the X-ray discussion by addressing the overuse of dental radiography. She cites data showing 320 million dental imaging procedures were performed in the U.S. in 2016, accounting for over 46% of national diagnostic and nuclear medicine imaging.
For reference, the United States Census Bureau estimated the US population to be just over 323 million in 2016. Feit calls for randomized clinical trials to assess the risks and benefits of dental imaging.
The collective viewpoints acknowledge themes of overdiagnosis, the influence of economics on dental practices, and the urgent need for basic evidence-based guidelines.
Another way of phrasing that is, yes, the current state of US dental practice is a somewhat of a scam with some really good outcomes. While perceptions of dentistry often come down to patient confidence and trust in the profession, I offer a few anecdotal tales from the ever-skeptical author of this article as examples.
I was once told that I had eight cavities and was handed a detailed schedule of the order in which the dentist would recommend addressing them. A visit to a new dentist for a (blinded) second opinion revealed that I had zero.
Another dentist (looking quite earnest in the moment) once informed me that I had bacteria in my mouth. Full stop, as though it were a pathologic condition and not a given expectation of being a human being harboring multitudes of bacteria in every internal and external available space.
When my oldest daughter was three, a dentist took X-rays that revealed five cavities. When I looked at the X-rays, I couldn't see anything. I was told it was because I wasn't a dentist. The new dentist she visited later found none.
My youngest daughter's dentist recommended a jaw widening procedure. I mentioned this to another dad, who confided that it had just been recommended for two of his children. Since neither of us had heard of the procedure before, we did a quick online search that didn't explain the procedure, but brought up dental industry news reports that the procedure was being added to insurance coverages in our state.
On the other hand, when I split a tooth after an accident, the replacement tooth was so seamless that I'm no longer sure which tooth it is the dentist replaced.
When I eventually got my first cavity, and it was causing me excruciating irritation, it happened to be in a wisdom tooth that my dentist removed in a quick and painless procedure.
The implications of oversight for dental practices and health care policy are significant. Dental practices need income to survive, and billing insurance for routine procedures is how they get most of their income. Americans are being overly subjected to X-rays and unnecessary routine treatment, and maybe that should stop, but maybe not if it is the only way they will be there when we really need them.
More information: Paulo Nadanovsky et al, Too Much Dentistry, JAMA Internal Medicine (2024). DOI: 10.1001/jamainternmed.2024.0222
Yehuda Zadik, Too Much Dental Radiography—Reply, JAMA Internal Medicine (2024). DOI: 10.1001/jamainternmed.2024.5048
Yehuda Zadik, Reflections on Clinical Decision-Making in Contemporary Dental Practice, JAMA Internal Medicine (2024). DOI: 10.1001/jamainternmed.2024.0291
Sheila Feit, Too Much Dental Radiography, JAMA Internal Medicine (2024). DOI: 10.1001/jamainternmed.2024.5042
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