The dental field has been slow to adopt evidence-based care and, as a result, is rife with overdiagnosis and overtreatment that may be more aligned with the financial pressures of keeping a dental practice afloat than what patients actually need. At least, that’s what a trio of health and dental researchers from Brazil and the UK, led by epidemiologist and dentist Paulo Nadanovsky, from the State University of Rio de Janeiro, claims.
In a opinion published Monday in JAMA Internal Medicine, the researchers point out that many common—almost unquestioned—practices in dentistry are not supported by solid data. This includes the standard recommendation that everyone should have a dental checkup every six months. The researchers note that two large clinical trials failed to find a benefit from six-monthly testing compared with longer intervals of up to two years.
A 2020 Cochrane review who evaluated the two clinical trials concluded that “whether adults see their dentist for checkups every six months or at individualized intervals based on their dentist’s assessment of dental disease risk does not affect caries, gum disease, or the quality of life Longer intervals (up to 24 months) between checks may not adversely affect these results. The Cochrane reviewers reported that they were “certain” of little or no difference between six-monthly and risk-based controls and were “moderately confident” that controls up to 24 months would make little or no difference.
Similarly, Nadanovsky and colleagues emphasize that there is no evidence to support the benefit of joint scaling and polishing treatments for adults without periodontitis. And for children, cavities in baby teeth are usually filled, despite evidence from a randomized controlled trial that pain and infection rates are similar—about 40 percent—whether cavities are filled or not.
Regarding the disconnect between common practices and the state of the evidence, the researchers suggest that financial pressures, as well as the education and views of dental practitioners and patient expectations—“all of which tend to favor overdiagnosis and overintervention,” the researchers write. The problem may date from the 1970s and 1980s when fluoridated toothpaste became common and the rate of cavities saw a “tremendous drop”. This left dentists with a financial need to find new ways to keep their offices full, even if the teeth were not needed.
And that created two problems: People were either overtreated or not treated at all, the researchers wrote.
The dominant fee-for-service dental economic model creates an environment of dental overdiagnosis and overtreatment. At the same time, many people without dental insurance cannot afford to pay out-of-pocket for dental care, creating a situation where people with low incomes or who belong to a racial and ethnic minority group are often underdiagnosed and undertreated.
The researchers called for more clinical trials to assess the effectiveness and benefits of the treatments and update dental guidelines accordingly. Then, Nadanovsky and his colleagues said, resources can be allocated to the patients who need them most. “The goal is to reduce overdiagnosis and overtreatment while increasing necessary treatment,” they conclude.
In a lengthy statement to Ars, the American Dental Association responded to the opinion saying it is “dedicated to evidence-based dentistry.” The ADA defined evidence-based dentistry as that which “incorporates the dentist’s clinical expertise, the patient’s needs and preferences, and the most recent, clinically relevant data. All three are part of the decision-making process for patient care.”
The ADA did not immediately respond to questions about the nitty gritty behind common practices and recommendations such as six-monthly checkups. (The ADA does not recommend a specific interval between visits, but recommends visiting a dentist”regularlyInstead, the ADA emphasized that “the dentist-patient relationship is critical.” While noting the “ethical responsibility of dentists,” the ADA focused on the role of patients in their care. According to the ADA, patients should be selective in finding a dentist, get advance estimates of dental care costs, and always ask questions and discuss alternatives statement about the rights and obligations of the dentist.
“Patients always have the option to discuss alternative treatment plans, refuse care, or seek another opinion,” the ADA told Ars.
“The nation’s dentists have long strived to turn the tide of untreated oral disease and advise people to visit their dentist regularly for recommendations specific to their individual needs developed in accordance with the latest available scientific evidence.” , the ADA reported.
