The U.S. dental care system has come under scrutiny following a series of discussions in JAMA Internal Medicine. Experts have questioned whether economic pressures are driving excessive dental procedures and treatments, often at the expense of evidence-based care.
This conversation began with the provocative article "Too Much Dentistry" by Paulo Nadanovsky, DDS, Ph.D., and colleagues. The authors argue that the prevalence and costs of dental procedures rival or even exceed those of managing major health conditions like diabetes and hypertension. However, many dental treatments, they claim, are unnecessary, fueled more by financial incentives than clinical need.
Questionable practices in U.S. dentistry
Nadanovsky's article highlights procedures like treating noncavitated caries lesions (white spots) and routine fillings in children, which lack solid evidence for preventing pain or infection. The authors emphasize that caries rates have declined significantly since the 1970s due to improved public awareness and widespread fluoride use. Yet, despite this progress, dental practices promote frequent six-month checkups without strong scientific backing, seemingly to sustain revenue streams rather than address patient needs.
Diverging perspectives: Balancing technology and oversight
Dr. Yehuda Zadik, DMD, MHA, offers a counterpoint, acknowledging the concerns raised while celebrating advancements in dental technology and preventive care. Zadik highlights the shift toward minimally invasive treatments and credits regular dental visits for early disease detection and improved outcomes. However, he shares concerns about the lack of external oversight in dentistry.
Dentistry remains one of the few healthcare fields where clinical examinations, diagnostics, and treatments are often handled entirely by the same practitioner, raising questions about the necessity of certain procedures. Zadik also points out that diagnostic X-rays, which are routinely conducted every six months in many practices, should only be used when there is clinical suspicion of an issue. This aligns with current ADA guidelines.
The overuse of dental x-rays
Sheila Feit, MD, a retired physician, echoes concerns about excessive dental radiography. She notes that in 2016, the U.S. performed 320 million dental imaging procedures, accounting for nearly half of all diagnostic and nuclear medicine imaging nationwide. With the U.S. population just over 323 million that year, the figures suggest widespread overuse. Feit calls for rigorous clinical trials to better understand the risks and benefits of dental imaging.
Personal experiences and broader implications
The critique of U.S. dental practices isn't limited to academic discussions. Anecdotal evidence from patients reveals a pattern of overdiagnosis:
A dentist claimed a patient had eight cavities, only for a second opinion to reveal none.
A parent was told their child had five cavities based on X-rays, but a subsequent dentist found none.
A jaw-widening procedure was recommended for multiple children, coinciding with the procedure’s recent addition to insurance coverage.
While these examples highlight unnecessary interventions, positive outcomes in emergency cases, such as effective tooth replacements and cavity treatments, demonstrate the importance of dental care when it is truly needed.
The need for reform
The discussion underscores the need for evidence-based guidelines and greater oversight in dentistry. Current economic models incentivize unnecessary treatments, leaving patients vulnerable to overdiagnosis. Addressing these issues requires balancing economic realities with patient care, ensuring dental practices remain sustainable without compromising trust or quality.