Dentistry's evidentiary vacuum allows profiteering butchers to raid our mouths for millions

Dentistry has always been medicine's poor cousin, lower in prestige and funding, with much less definitive research; this means that it's harder for someone to point at a procedure and definitively say, "That was unnecessary."

At the same time, better oral hygiene and fluoridation has increased our overall dental health; and as that was happening, dental school tuition was mounting alongside all other forms of student debt.

You can see where this is going: dentists are graduating from university buried by punishing debt; dental patients need a lot fewer money-generating procedures, and it's easy to get away with performing unnecessary procedures. What coul possibly go wrong?

Though this is something of a perfect storm of grifty, late-stage capitalism, the lack of evidence-based standards is a huge piece of the problem. While we're pretty sure that dental sealants are really useful for kids (though few dentists use them because they take a long time and don't generate a lot in billings), and that fluoridation is also good for kids, there just isn't enough evidence to say whether fluoridation benefits adults, whether flossing combats plaque (it is good for your gums though), whether you should have your wisdom teeth removed, etc. And the evidence for other common procedures is really poor or even nonexistent: everything from seeing your dentist twice a year (most people can go once every 12 or 18 months, assuming good oral hygiene); replacing metal fillings with resins, etc.

Incredibly, some of the most invasive, painful and expensive procedures have not been studied in any depth, including whether root-canaled teeth should be repaired with fillings or crowns.

What is increasingly being studied is whether dentists engage in "overtreatment" (a euphemism for unnecessary procedures). For example, 50 out of 180 Zurich dentists in one secret trial recommended totally unnecessary fillings for minor cavities.

The Atlantic's Ferris Jabr's 7,500-word longread about the problems of denistry are hung on a truly ghastly news-peg: in 2012, dentist Brendon Zeidler bought a San Jose, California practice from John Roger Lund, who was retiring. As Zeidler began to see Lund's patients, he realized that Lund had performed a shocking amount of dental surgery on his patients, at enormous expense. Lund was arrested in 2016 and is facing criminal prosecution, though he maintains his innocence.

Jabr is at pains to point out that most dentists are honorable and compassionate, which is undoubtably true. I've had very few bad expenses with dentists (though I was shocked by US dentists' aggressive attempts to sell me tooth-whitening services, often during a medical exam, blending a sales-pitch with the medical advice they were giving me). On the other hand, my mother and her family had most of their teeth drilled out in the 50s and 60s by a dentist who is widely believed to have been a butcher who lined his pockets by mutilating his patients' mouths.

Among other problems, dentistry's struggle to embrace scientific inquiry has left dentists with considerable latitude to advise unnecessary procedures—whether intentionally or not. The standard euphemism for this proclivity is overtreatment. Favored procedures, many of which are elaborate and steeply priced, include root canals, the application of crowns and veneers, teeth whitening and filing, deep cleaning, gum grafts, fillings for "microcavities"—incipient lesions that do not require immediate treatment—and superfluous restorations and replacements, such as swapping old metal fillings for modern resin ones. Whereas medicine has made progress in reckoning with at least some of its own tendencies toward excessive and misguided treatment, dentistry is lagging behind. It remains "largely focused upon surgical procedures to treat the symptoms of disease," Mary Otto writes. "America's dental care system continues to reward those surgical procedures far more than it does prevention."

"Excessive diagnosis and treatment are endemic," says Jeffrey H. Camm, a dentist of more than 35 years who wryly described his peers' penchant for "creative diagnosis" in a 2013 commentary published by the American Dental Association. "I don't want to be damning. I think the majority of dentists are pretty good." But many have "this attitude of 'Oh, here's a spot, I've got to do something.' I've been contacted by all kinds of practitioners who are upset because patients come in and they already have three crowns, or 12 fillings, or another dentist told them that their 2-year-old child has several cavities and needs to be sedated for the procedure."

Trish Walraven, who worked as a dental hygienist for 25 years and now manages a dental-software company with her husband in Texas, recalls many troubling cases: "We would see patients seeking a second opinion, and they had treatment plans telling them they need eight fillings in virgin teeth. We would look at X-rays and say, 'You've got to be kidding me.' It was blatantly overtreatment—drilling into teeth that did not need it whatsoever."

The Truth About Dentistry [Ferris Jabr/The Atlantic]

(via Naked Capitalism)