A shifting paradigm in oral health: When is it overuse?

By Matt Allen, DDS

I have a friend in her mid-thirties who recently came to me dejected and disappointed that her lifelong run without a filling was over. She had been to the dentist and had three cavities filled, despite impeccable dietary and oral hygiene habits and regular visits to the dentist throughout her life. While she was sad, I was skeptical. Did she really need all three of those fillings? While I wasn’t in the room, my guess is probably not.

I was skeptical. Did she really need all three of those fillings?

Matt Allen, DDS

We often think of dental caries, i.e. cavities, as a simple diagnosis with a simple solution – if you have a cavity, you get it filled. In reality, the diagnosis and treatment of caries is much more nuanced. Dental caries is a chronic disease, a constant battle in our mouth between protective forces that keep the disease from needing surgical intervention and pathologic factors that accelerate its progression. Teeth are made up of a mineral structure, and are essentially being demineralized or remineralized at any given moment. Only once the demineralization leads to a hole in the tooth is a restoration/filling required. Think of how rust on a metal surface progresses for a reasonably accurate analogy, except that in this case the rust can be reversed.

Almost everyone in the dental profession understands this disease mechanism, but it saddens me to see the lack of agreement about the treatment options once the disease is seen. Despite a mountain of evidence showing that teeth are surprisingly resilient in their capacity to remineralize, many dentists were taught that even the slightest hint of demineralization requires maximum intervention, usually via the whir of a dental “drill” that cuts the caries out of the tooth.

Dentists practice in two ways: how they learned in dental school and how they get paid.

Even those who weren’t taught this way often learn it indirectly, as the current payment systems in dentistry allow for the greatest reimbursement to come from cutting a cavity out of the tooth. Dentists generally receive little to no money for attempting to help the remineralization process heal the tooth without cutting it. I have a colleague who likes to say that dentists practice in two ways: how they learned in dental school and how they get paid. Unfortunately, education and insurance have fallen short in leading this paradigm change, and dentistry has become embedded in a cycle of overuse.

My 30-something friend who got her first fillings is by just one of countless examples of overuse I have seen throughout my career. I have other friends whose kids have certainly received unnecessary care, sometimes in the hospital operating room under general anesthesia, when many less invasive and less risky options were available. But while it’s easy to point the finger at others, I myself am not above these faults. I frequently see patients for recall examinations and look back at fillings I placed when I was simply practicing what I learned in dental school. It pains me how I could have done things differently.

Fortunately, dentistry is changing, from a definition of health largely stuck in Era 1.0 thinking (e.g. “My patient is healthy if I cut this cavity out of their tooth”) into an era that will allow patients to be co-creators of their own oral health. But not everything changes at once. In his 1962 work Diffusion of Innovations, Everett Rogers proposed that people accept change at different rates – some are innovators or early adopters, and others only change after everyone else has (There’s a nice little video of this theory here.)

At what point are the dentists who have not adopted this new model of care overtreating their patients?

As this paradigm shift propagates throughout the profession, and dentists begin to adopt a management approach for caries consistent with the most up-to-date and evidence-based literature in cariology, a reasonable question becomes, “At what point are the dentists who have not adopted this new model of care overtreating their patients?” In my ignorance of the front line of change, was I complicit in the problem (even if I likely fall in the early adaptor category)? What about those who may not or choose not to know of the changing norms for months or years more, or those who resist the change? And perhaps more importantly, how can patients know where their dental professional falls along the bell curve? Are they receiving care that most of the population perceives as normal, but scientifically speaking is overuse?

These are hard questions, probably without one best answer. Though I’m asking them about oral health, they pertain to health care in general as we strive towards Era 3.0 – and future eras beyond. Demanding improvement as profession – relationally, scientifically, technically – ensures that this is a dilemma that we will never move past. So, are there solutions other than education and payment reform? I think so. More on that in Part 2 of this blog (stay tuned!)

Matthew Allen, D.D.S. is the president of M David MI LLC, a consulting and coaching firm specializing in motivational interviewing for oral health professionals. Dr. Allen is the only US-based dentist member of MINT, the Motivational Interviewing Network of Trainers. Previously, Dr. Allen was the clinic dental director at Clinica Family Health, a nationally recognized federally qualified community health center serving the Denver metropolitan area, where he remains active in clinical practice.  He also serves as part time volunteer faculty at the University of Colorado School of Dental Medicine.

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