The paradox of overuse and underuse in dentistry – Part 2

By Judith Garber

Last week, I explored some of the barriers Americans face to accessing basic dental care, including cost, lack of insurance coverage, and the perception that dental care isn’t that important. In fact, the most popular reason young Americans cited for not going to the dentist was that they said they “didn’t need dental care.” To many (especially dentists) this seems grossly irresponsible, given that untreated dental problems can be incredibly painful or even life-threatening.  

Here’s the paradox – some dental care we receive is critically important but some is entirely unnecessary.

But here lies the paradox – some dental care we receive is critically important but some is entirely unnecessary. The fact that many people pay for dental care out-of-pocket means that this distinction is crucial, and yet, it’s very difficult to know whether the procedures we’re being offered are necessary or even appropriate.

Perhaps skepticism of some dental care is rational. To expand on this theory a bit, I offer some examples of systemic overuse in dentistry, and how I encountered these procedures in my own care. 

Brace yourself: Overuse in orthodontics

Like many middle-class kids with wonky teeth, I always knew I would have to get braces. I never questioned the idea; I knew my teeth were “bad.” But when it came time to actually have the painful bits of metal adhered to my teeth (and the rubber bands…oh, the rubber bands), I started to question the usefulness of orthodontics. Were my teeth going to fall out if I didn’t get braces? Would I have trouble breathing or chewing? In my case, the orthodontics were purely cosmetic, but I didn’t know this until it was too late. 

We tend to trust our medical professionals, so when an orthodontist tells us that our child “needs braces,” we assume it is beneficial for their health. When American orthodontists were striving for professional legitimacy in the early 20th century, they began to equate an aesthetically pleasing smile with “normal” dentition, positing that straight teeth lead to better dental health. However, there was no evidence to back up this assertion. In the Journal of Medical Ethics, orthodontist and Harvard professor Dr. Marc Ackerman examines the medical literature (pdf) and finds that orthodontics don’t improve dental health or function. He urges orthodontists to reexamine their marketing of medical orthodontic “need.”

Another problem with orthodontics is that there is no one agreed-upon definition of a “normal” or “perfect” smile. As Ackerman writes in The Huffington Post, “Many of the dental traits that have been labeled orthodontic problems are merely examples of normal human variation.” While many people get psychological and social benefits from having straight teeth, that doesn’t mean that crooked teeth should be a medical diagnosis.

Wisdom tooth extraction – not so wise?

In my last year of college I went to a new dentist who, after one visit, said I needed to get my wisdom teeth removed and recommended an oral surgeon. I went to the specialist who gave me some good news – my wisdom teeth weren’t impacted and they weren’t causing me problems yet, so the procedure should be easy. This confused me. If there weren’t problems with my wisdom teeth, why were they taking them out?

If there weren’t problems with my wisdom teeth, why were they taking them out?

My conversation with their insurance specialist also tipped me off. Although I was on my parent’s insurance, she told me the procedure would be $1000 out of pocket because it was elective and not medically necessary. I canceled the surgery and haven’t had problems with my wisdom teeth since.

Like orthodontics, extracting wisdom teeth is expensive, painful, and often unnecessary. Oral surgeons warn that leaving in wisdom teeth can lead to cysts, infections, and damage to other teeth. However, there is little evidence to support these claims. In a study of 3,700 wisdom teeth that were impacted but left in, only 12% had caused any dental health problems twenty years later. The British National Health Service, finding insufficient evidence to reimburse the procedure, recommends not removing wisdom teeth if they’re not causing any problems.  

Dr. Jay W. Friedman, a vocal opponent of routine wisdom teeth extraction, analyzes the medical literature and estimates that at least 2/3 of these procedures are unnecessary. He also debunks common “wisdom teeth myths,” including the idea that wisdom teeth left in the mouth will “push out” other teeth, using some compelling imagery:

“It is not possible for lower third molars, which develop in the spongy interior tissue of bone with no firm support, to push 14 other teeth with roots implanted vertically like the pegs of a picket fence so that the incisors in the middle twist and overlap.” 

So why so many unnecessary surgeries? Friedman puts it bluntly – Eliminating unnecessary extractions would reduce the average oral surgeon’s annual income by $347,486. 

The Filling Station

Another overused dental procedure is none other than the common filling. As patients, we assume there is a single standard for how large or severe a cavity must be before filling it, but in reality, dentists can have different criteria for which cavities “need” filling. Some dentists choose to fill early-stage decay called “micro-cavities” whereas other dentists leave these alone. Some of these micro-cavities may not ever develop into cavities, so filling them automatically can mean unnecessary pain and cost for patients.

A new preliminary study from the Center of Economic Research in Zurich, Switzerland finds that variation between dentists in deciding to fill micro-cavities is common. One (very unfortunate) test patient who had been previously checked for cavities went to 180 dentists for treatment recommendations. Fifty dentists told him he needed at least one filling, and some said he needed up to six cavities filled. 

When I went to the dentist for the first time in three years, I wasn’t surprised that I needed fillings. But what made me trust this dentist was that he also identified a few micro-cavities that he didn’t think needed filling. I had never had a dentist explain this difference to me before, and it’s why I took his advice on recommendations for my gum health and teeth grinding.

Overuse in dentistry is not only wasteful and expensive – it erodes our trust in providers

The overuse in dentistry, from culturally-driven cosmetic orthodontics to unnecessary extractions to everyday overuse, is not only wasteful and expensive for patients. It also erodes the trust we have in dentists, making it less likely that we will see dentists for services we actually need, like checkups and treating infections.

The paradox of simultaneous overuse and underuse is not unique to dentistry, but dentists’ power and autonomy make it especially difficult to increase access to care or enforce enforce evidence-based guidelines. For right care in dentistry, we need to integrate dental and health insurance, and hold dental care providers and payers accountable for the ubiquity of unnecessary procedures. 

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