By Nancy LeBrun
The exposé by reporter Ferris Jabr in the May 19th issue of The Atlantic, The Truth About Dentistry, doubtless set many teeth on edge in the dental profession.
The author charged, among other faults, that dentistry is insufficiently evidence-based, lags in comparison with the medical profession as a science, is rife with overtreatment and overcharging, and empowers dentists at the expense of their patients.
“Common dental procedures are not always as safe, effective, or durable as we are meant to believe,” Jabr contended. “Many standard dental treatments—to say nothing of all the recent innovations and cosmetic extravagances — are likewise not well substantiated by research.”
To which many of the dental profession’s leaders and professionals responded, “Hooey,” or words rather less genteel.
Jeffrey M. Cole, DDS, MBA, president of the American Dental Association, led the chorus of objectors to Jabr’s article, describing it as “very far from the truth.”
In a letter to The Atlantic, Dr. Cole wrote:
“As a dentist for 32 years, I was utterly disappointed in the author’s reinforcement of inaccurate, negative stereotypes about dentists, and the use of one example of alleged professional misconduct to make blanket statements about the entire dental profession.”
Not in recent memory, if ever, has a mainstream publication such as The Atlantic challenged the ethics and very legitimacy of the dental profession in the manner that Jabr did.
Jabr, 31, is not readily dismissed as a crank reporter, either. A freelancer with a master’s degree in Science, Health, and Environmental Reporting from New York University, he has contributed major stories to The New York Times Magazine and Scientific America.
How much enduring impact Jabr’s article will have on the dental profession remains unknown. The ADA’s Dr. Cole encouraged members not to “let an isolated article such as this shake our patients’ faith in us as dedicated practitioners.”
Yet while he and many oral health professionals quickly dismissed the validity of The Atlantic story, others in the profession said it resonated with them.
Kansas City area family and cosmetic dentist H. Grant Ritchey, Jr., who also writes for the blog Science-Based Medicine, told Incisor he thought The Atlantic article, “raised some very good points. It’s easy for us as dentists to get defensive because it seemed like a bit of an attack and the language was a little disparaging, but some of the underlying premises were spot on, so I’m glad it got out there.”
Other outlets were glad it got out there as well, including Boing Boing, which cited The Atlantic piece in an article entitled, Dentistry's evidentiary vacuum allows profiteering butchers to raid our mouths for millions. The weblog described current trends in dentistry as a “perfect storm of grifty [sic], late-stage capitalism.”
Jabr opened his article by recapping an incident concerning John R. Lund, DDS, of San Jose, California.
According to The Atlantic, one of Dr. Lund’s patients, Terry Mitchell, paid the dentist about $50,000 for questionable root canals and crowns.
Dr. Brendon J. Zeidler, who purchased Dr. Lund’s practice when he retired in 2012, quickly became suspicious of Dr. Lund’s methods when his own patient billings amounted to only a fraction – 10 to 25 percent – of what Dr. Lund’s books showed the retired dentist had billed.
Over a period of months, Dr. Zeidler poured over five years’ worth of Dr. Lund’s patient records and bills. “What he uncovered was appalling,” Jabr wrote.
In short, Dr. Zeidler concluded that Dr. Lund padded his production by performing unnecessary procedures and even charging patients for treatments he never actually administered.
Not surprisingly, Dr. Zeidler sued Dr. Lund, arguing – according to The Atlantic – that Dr. Lund’s reported annual income, which came close to $1 million some years, was “a result of fraudulent billing activity, billing for treatment that was unnecessary, and billing for treatment which was never performed.”
28 Counts of Fraud
Jabr wrote that the suit was settled for an undisclosed amount. Moreover, ten of Dr. Lund’s former patients, including Mitchell, sued for a variety of grievances and collectively reached a settlement with Dr. Lund’s insurance carrier of almost $3 million.
“Lund did not admit to any wrongdoing,” Jabr noted, although in May 2016 – more than four years after he sold his practice – the retired dentist was arrested and charged with 28 counts of insurance fraud, which he has denied. The legal case, apparently, is still pending.
It is on the foundation of Dr. Lund’s alleged mistreatment of his patients that Jabr builds his assertion that dentistry is “much less scientific – and more prone to gratuitous procedures – than you may think.”
Jeffrey H. Camm, DMD, a retired pediatric dentist, sounded a warning about overtreatment in a 2013 editorial, MyView: Creative diagnosis, first published in the Washington Dental Association News and then in the ADA News.
Dr. Camm told Incisor that he sees it this way: “That person [Dr. Lund] seemed beyond contempt [but] I was not particularly shocked. I was like, ‘Oh yeah, I know three guys like that.’ Now, I may know 20 guys who are not like that, but I wasn’t surprised at all by the article. It’s happening – we need a little bit of a watch guard here.”
Jabr pinned his assertion about a lack of scientific rigor mainly on the “isolation” of dentistry from the medical profession. “As a profession, dentistry has not yet applied the same level of self-scrutiny as medicine, or embraced as sweeping an emphasis on scientific evidence,” Jabr wrote.
Dr. Ritchey, the blogger for Science-Based Medicine, responded: “I think the premise of dentists just being tooth carpenters or gum gardeners is a bit flawed. This is where I think the article gets it wrong – because there’s research in dentistry being done all the time,” he added.
Alan Mead, DDS, who practices in Saginaw, MI, sees it somewhat differently, as he wrote in a post for The Dental Hacks, a podcast which he co-hosts:
“I think the author [Jabr] has some points that the profession needs to look at. The evidence base for much of dental treatment isn’t that solid. In fact, many dental school educations don’t spend enough time explaining the evidence base as it is or even how to read and interpret a scientific paper. Dentistry falls short here.”
The ADA’s Dr. Cole, on the other hand, countered, “The ADA is dedicated to evidence-based dentistry. Evidence-based dentistry integrates the dentist’s clinical expertise, the patient’s needs and preferences, and the most current, clinically relevant scientific evidence. All three are part of the decision-making process for patient care.”
Making the Best Decisions
How different is the approach Dr. Cole describes from how physicians make treatment choices?
“More and more physicians are finding ways to incorporate evidence into their practices, but in many cases, we find that the accuracy and applicability of the evidence aren't what they should be. We've been taught for years that randomized controlled trials are the gold standard on which to base clinical decisions, but the limitations of these studies, particularly in their generalizability to patients with comorbid conditions, are increasingly well-known.”
Dr. Woolever continued, “To ensure that we make the best decisions possible, we need to deliberately incorporate our knowledge and experience, including lessons learned from mistakes, and conscientiously revisit and reconsider the medical “truths” that we learn at various stages of our medical training.”
The Atlantic article asserted that dentistry has suffered from its isolation from medicine, and there is a sort of evolutionary split during training. Both would-be dentists and physicians take many of the same science courses, as Dr. Ritchey pointed out in his blog.
“Once in dental school, our basic science education mirrors the training found in medical schools, encompassing anatomy, physiology, immunology, embryology, histology, pathology, pathophysiology, microbiology, biochemistry, neuroanatomy, and so on,” he wrote. The training diverges, though, when doctors undertake residencies while dentists go directly to taking the boards and demonstrating competency.
Dr. Camm noted that the board certification process has dropped from a “four-part process that took half a decade, to a two-step process that can be done in six months.”
There are rumblings of change in how dentists become licensed, however. A committee of the Joint Commission on National Dental Examinations is developing an Integrated National Board Dental Examination (INBDE). The Commission says it will “integrate content from the biomedical, behavioral, and clinical sciences,” and will “assist dental boards in determining the qualifications of individuals who seek licensure to practice dentistry.”
Dental associations threw their collective weight behind the Commission’s work, stating, “In support of this process, a joint task force of the American Dental Association, the American Dental Education Association and the American Student Dental Association released its groundbreaking report supporting the modernization of the dental licensure process, which is the culmination of over two years of research, discussion and collaboration between the organizations.” The Commission hopes to offer the new exam in late 2020.
Of course, unspoken by Jabr and even the INBDE, is the fact that laws and regulations seldom restrain unscrupulous healthcare professionals, no matter what their field, from preying on their patients or committing insurance fraud.
Jabr asserted that when the incidence of tooth decay plummeted after home oral care improved and fluoride was introduced, dentists began to cast about for other sources of income.
“In the 1980s, with fewer genuine problems to treat, some practitioners turned to the newly flourishing industry of cosmetic dentistry, promoting elective procedures such as bleaching, teeth filing and straightening, gum lifts, and veneers,” Jabr wrote.
It’s reasonable to view less tooth decay as a good thing, and it is also reasonable to draw a comparison between cosmetic dentistry and cosmetic dermatology, where practitioners provide services their patients want and choose to have and pay for, even when they are not medically necessary.
Jabr did find support for his overtreatment thesis from Dr. Camm’s 2013 editorial. In it, Dr. Camm wrote, “There is no doubt that the dental profession is under assault from insurance companies—reduced reimbursements, decreased benefits, and diminishing coverage for some procedures are all issues we have to face in our practices. Because of this, we all face financial pressures and threats to our bottom line. In response to these issues, I believe I've noticed an increase in the skill of what I call ‘creative diagnosis.’ I hope this is not a trend for our profession.”
When Incisor recently spoke to Dr. Camm about The Atlantic piece, he stood by his earlier position, telling us, “My overwhelming feeling is that the majority of dentists are fine. However, there’s an increasing group, I think, that may not be playing by the rules or may be overcharging, and I think it’s nice to call foul when you see it happen.”
Jabr also challenged the notion that dental patients should be seen every six months. “Today,” Jabr wrote, “an increasing number of dentists acknowledge that adults with good oral hygiene need to see a dentist only once every 12 to 16 months.”
On this, the jury is still out. The Cochrane Library, in a 2013 review, Recall intervals for oral health in primary care patients, drew no conclusions about the six-month interval other than a need to do a better, bigger study about the optimal recall time. The debate is likely to continue in the absence of strong clinical evidence.
Jabr’s article in The Atlantic falls somewhere between investigative reporting and advocacy journalism, and it does seem lopsided in its criticism of the profession.
The journalist fails to point out, for example, the many medical advances that originated in the dental profession, such as the introduction of anesthesia.
As the NYU College of Dentistry noted in an article recapping Technology in Dentistry, Though the Ages, the profession has a “long and distinguished history of discoveries, technological innovations, and transformations in the stature of the profession that have made dentistry a progressive force for improved public health.”
The ADA’s Dr. Cole, in his response to The Atlantic, observed that the “overwhelming majority of dentists are ethical practitioners, and that’s why dentists are consistently ranked among the most honest and ethical professionals.” He added, “Every profession unfortunately has some individuals with questionable ethics. This is as true in journalism as it is in dentistry.”
Author: Contributing writer Nancy LeBrun is a veteran health and wellness writer, and an Emmy-winning video producer. A former editorial staff member at WebMD, she is based in Roswell, GA.
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