An opinion piece recently published in the Journal of the American Medical Association (JAMA) has ignited a significant debate regarding the motivations behind dental care, questioning whether dentists prioritize their patients’ health or financial gain.
Authored by Paulo Nadanovsky, DDS, Ph.D., along with several colleagues, the article titled “Too Much Dentistry” calls for urgent reform in U.S. dental practices, which Nadanovsky argues are falling behind other medical fields that have embraced “evidence-based” treatment protocols.
“Most dental care relies on practice patterns influenced by the economic pressures of running a dental practice, dentists’ professional training and opinions, and patients’ expectations, all of which tend to favor excessive diagnoses and interventions,” Nadanovsky states.
The article highlights a significant decline in tooth decay in the United States since the 1970s, attributed largely to the widespread adoption of fluoride toothpaste. This decrease has had ripple effects on the dental profession.
“The decline in the number of patients’ [cavities] impacted dentists’ workloads and has played a role in overdiagnosis and overtreatment so that dentists can support their practices,” Nadanovsky argues. He contends that, in response, dentists began to recommend routine six-month checkups that may be unnecessary and began treating noncavitated caries lesions—demineralized spots on enamel—with fillings, despite most of these lesions never progressing to cavities.
Nadanovsky also posits that routine scaling and polishing every six months may be excessive for most adults.
The dental community’s reaction to the article has been mixed. While there is broad agreement on the importance of dental health, many professionals emphasize that patient-centered care should remain the top priority.
“The authors forget the importance of preventive dentistry,” remarked Jayro Guimaraes Jr., an associate professor of oral medicine at São Paulo University. “Dentistry isn’t only about cavities and periodontal disease. Oral medicine, oral diseases, and their relationship to systemic diseases are equally important.”
Some experts criticized the authors for not addressing the frequent use of dental X-rays, which subject patients to radiation exposure. Others highlighted that dental offices serve as a rare model in healthcare, functioning as a comprehensive care setting.
“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 place, often by the same care practitioner,” wrote Yehuda Zadik, a professor of dental medicine at the Hebrew University of Jerusalem, in a commentary accompanying the JAMA article. “This model of care delivery prevents external oversight of the entire process.”
In response to these concerns, Nadanovsky advocates for a shift from the current “fee-for-service” model to a “value-based” approach. He suggests that such a model, where dentists are compensated for maintaining oral health rather than performing specific procedures like fillings, cleanings, and fluoride applications, could lead to better patient outcomes.
“Identifying which dental procedures are beneficial and ensuring that relevant dental associations update their guidelines accordingly provides an opportunity to allocate resources to those who need them the most,” he concludes.
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