A Closer Look at Teeth May
Mean More Fillings
Ritchie King
New York Times
November 28, 20112
http://www.nytimes.com/2011/11/29/health/a-closer-look-at-teeth-may-mean-more-fillings-by-dentists.html?pagewanted=1&ref=health&src=me
New dentist, 5 fillings
• Until 2010, Amelia Nuwer, 22, visited the same dentist
every year in Biloxi, Miss., her hometown. And every
year she came back with a clean bill of dental health: no
fillings necessary.
• Then, as a junior at the University of Alabama, she saw a
new dentist who delivered her first negative diagnosis:
two cavities. Six months later, the dentist told her she
had two more. Earlier this year, he once again had bad
news: yet another cavity.
• Somehow, in 12 months she had gone from perfect oral
health to five fillings. “It felt wrong to me,” she said.
Hometown dentist
• Her hometown dentist, Dr. Francis Janus, was
surprised, too. He examined his longtime patient
after she graduated. Ms. Nuwer’s so-called
cavities, he concluded, had actually been
“incipient carious lesions,” a form of early-stage
decay that some dentists call “microcavities.”
• “He said that he wouldn’t have filled them,” she
recalled. “I was so upset and angry.” The five
fillings cost her almost $500 out of pocket.
Proactive … or unnecessary?
• With increasingly sophisticated detection
technology, dentists are finding — and treating
— tooth abnormalities that may or may not
develop into cavities. While some describe their
efforts as a proactive strategy to protect patients
from harm, critics say the procedures are
unnecessary and painful, and are driving up the
costs of care.
• “A better approach is watchful waiting,” said Dr.
James Bader, a research professor at the
University of North Carolina School of Dentistry.
“Examine it again in six months.”
So, what’s happening?
• An incipient carious lesion is the
initial stage of structural damage to
the enamel, usually caused by a
bacterial infection that produces
tooth-dissolving acid.
• The lesion doesn’t always lead to a
full-blown cavity, which entails
decay of the layer right beneath the
enamel, called dentin. Mineralcontaining saliva can repair these
lesions, especially when bolstered
with fluoride.
• Many experts think it doesn’t make
sense to operate in the early stages
of decay. “If you don’t have any kind
of demonstrable collapse of the
enamel wall, then you shouldn’t put
in a filling,” Dr. Bader said.
Aggregate Expenditures
• Yet a majority of practitioners are inclined to do so.
According to a 2010 National Institutes of Health survey,
63 percent of more than 500 practicing dentists said they
would operate on a tooth with decay that had not
progressed beyond the enamel, even if the patient had a
history of good dental hygiene.
• Such operations typically cost $88 to $350 per filling,
according to a 2007 survey in the magazine Dental
Economics. According to the American Dental
Association, about 175 million filling operations are
performed in the United States every year.
• Insurance plans cover all fillings, whether for
microcavities or full-blown cavities, because dentists bill
based on the work they’ve done, not the symptoms
they’ve observed.
• 175,000,000 fillings * $200/filling = $35B in expenditures!
Bad teeth can be bad
• Looks bad.
• Can lose teeth, which makes nutritious
behavior more difficult.
• Can lead to abscesses (poison), which
can make you sick or kill you.
• So … obviously some major portion of
fillings are beneficial.
The Economics
$
• If there is no
damage then there
are no benefits.
• But what if there is
damage … and
what if there are
benefits?
• Is it good medicine,
or SID?
MC
MB
# of Fillings