Column Editor: Harris Contos
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A Recap from Part 2…..
Dentistry didn’t really shed its folklore-ish conjectures on the causes and treatment of tooth decay (more formally known as “caries”) until the early 20th century, when it took a step into the modern scientific era with the discovery that demineral-ization of tooth enamel – decay - was brought about by bacteria on tooth surfaces producing acids through the fermentation of carbohydrates. An understanding of the bacterial nature of the disease then led to the quest for suitable agents to treat it, one very effective one being a solution of silver nitrate, simply applied to the decayed area of the tooth. It involved little if any removal of tooth structure, no needles, and no drills.
For reasons that are unclear and not fully understood, dentistry for the most part did not continue this scientific inquiry, and instead continued along its historic trajectory of removal of tooth structure to get at decay, and then rebuilding that lost structure. All of this was furthered by the development of new materials, techniques, equipment, and notably local anesthetics, to the point where "cosmetic dentistry" entered the lexicon.1 The opportunity to build upon over a century's worth of research, understanding, knowledge, and clinical application, and thus to refashion dental care, became lost as dentistry defined and confined itself to evermore intricate, involved, and costly mechanical procedures centered upon creating “that perfect smile.”
The scientific inquiry did not entirely cease, however. In more recent years the oral biome has received attention, giving a more encompassing and nuanced view of the oral environment and its contribution to, or protection from, tooth decay. An updated version of silver nitrate has been developed, now incorporating the known antibacterial properties of fluoride along with silver in a new compound silver diamine fluoride, or SDF. And fluoride is also incorporated into a material called glass ionomer cement, or GIC, a material that can be used where, separate from or in conjunction with SDF, restoration of tooth structure is indicated, or for use as a sealant. In both instances, slow release of fluoride over time acts as a preventive on the immediate and surrounding teeth.2
A more refined generation of the science of tooth decay has emerged, vastly different from the arrested science of “drill and fill” from over a century ago.
Part 3 - What Happens Next?
The ground is shifting under the foundations of conventional dentistry. Its “surgical” approach of drilling a cavity is an expensive proposition in both money and time (and for certain, anxiety for the patient) involving all manner of specialized equipment, materials, and techniques, available only in the specialized setting of the dentist’s office. Unnecessarily destructive of tooth structure, its treatments are prone to failure and the need to be redone, at even greater cost. Most particularly, the very notion of a surgical versus a medical approach as front-line treatment of a bacterial infection is unique to dentistry, propelled more by historical momentum than by science. (Even the routine surgical treatment of ulcers and appendicitis has given way to antibiotic treatment as highly effective first-line measures.)
In contrast, treating tooth decay medically, in accord with the microbiological science, involves no specialized equipment, technique, or practice settings, and the materials, SDF and GIC, are inexpensive and easy to use. Application can be done in minutes, with a microbrush in the former case, and with a gloved finger in the latter, by non-dentist personnel who can be readily trained in the simple techniques. But this also illustrates a fundamental, definitional change in dental treatment. No longer is dental care defined as putting the drill to the tooth. Instead, it is applying silver and fluoride to the disease-causing bacteria to arrest the decay.
It’s a wholly different paradigm. Issues of cost and access as barriers to care virtually disappear. A therapeutic drop of SDF costs $0.79 versus $86-$606 for a filling. Cadres of non-dentist personnel, working in venues far outside the dental office, including 200,000 dental hygienists, 290,000 nurse practitioners, and 119,000 physician assistants, not to mention registered nurses, school nurses, pharmacists, even physicians and others, can be easily trained in applying SDF and GIC, making access issues essentially moot. And not to be overlooked, the patient spends but minutes in the chair, experiencing no pain.
Putting these elements together – low cost, easy access, speedy and effective treatment and combined with a better patient experience – means the market for dental care stands to be completely upended. The private, solo, fee-for-service practice, the paradigm of “drill and fill” dentistry and the most prevalent dental business model, will be hard pressed to compete with new, more flexible, more welcoming organizational models responding to consumer demand for affordable, accessible, quality dental care. These models could include:
- Retail clinics offering dental care either through nurse practitioners, physician assistants, or dental hygienists, linked via teledentistry to dentists should consultation or referral be needed.
- Physicians’ offices, particularly pediatricians, also offering dental care, and again linked via teledentistry if needed.
- School-based clinics.
- Mobile dental hygienists, rendering care to the homebound and facility-bound patient, and again data linked.
- At its most sophisticated, a dACO (dental Accountable Care Organization), integrated into an ACO for comprehensiveness of care, alternative payment mechanisms, quality assurance and evaluation of care programs, outcome measures, population health management, and more.
A subtlety needs to be noted. The science extending back over a century that led to the initial understanding of the bacterial nature of tooth decay, and then to its treatment with inexpensive, highly effective substances, since updated, has now laid the groundwork for new organizational models of care. These new models lower cost and geographic, socioeconomic, cultural, and other barriers to care, so that can be seen in a wide variety of venues, or have care taken to patients. Instead of treating teeth after the damage has been done, well organized, responsive, and anticipatory dental care resources will be addressing the disease as it exists in society for whatever reason, and intercept it early. No longer will tooth decay, at least in its most severe forms, be considered inevitable.
How To Get There
The private, solo, fee-for-service dental practice is the predominant model of dental care for a reason: it has been protected economically, organizationally, and even scientifically by state dental practice laws. (The exclusion from Medicare also means dentistry had been outside policy developments shaping the rest of healthcare.) Society has paid the price in terms of high costs, restricted access, and dubious appropriateness and quality of care as a result. In addition to the incomplete and arrested science upon which traditional dentistry has been built, it is these political barriers that stand as impediments to better oral health for the population.
Needless to say, removal of restrictive state dental practice laws can be well nigh impossible given entrenched financial interests. Nonetheless, some entrepreneurial thinking could tip the balance in favor of the public interest:
- Retail clinics could offer dental care through NPs, PAs, or hygienists practicing under their clinic license. Where needed, the clinics could establish affiliations with like-minded dentists for consultative or referral situations.
- WalMart is one example of a major retailer getting into the primary and urgent care markets and offering a number of services in one facility. Customer focus, particularly with regard to affordability and attention to patient needs, is its stated business priority. If it properly responds to dental needs by incorporating the medical management of tooth decay in its offerings, its prominence in the market stands to reshape dental care delivery.
- Executives of healthcare systems should think of developing or affiliating with a “medical management of caries” unit as part of primary care offerings in order to gain competitive advantage in the marketplace. Historically, dental care has been excluded from the rest of medical care, and patients are often at a loss as to where to seek regular dental care. A health system offering dental care could benefit not only by serving as a portal of entry for new patients, but also for integrated care that such patients may also be seeking.
- A group of entrepreneurial dentists, subscribing to the principles of medically managed dental care, could form their own corporation, with satellite facilities staffed by hygienists and set up in store fronts; or hygienists staffing other physician offices; or serving as a training center in the use of SDF and GIC for other non-dentist personnel. Also, such a corporation could affiliate with retail clinics or large healthcare systems for the provision of dental care.
Other arrangements are conceivable, and each would likely encounter some obstruction from state dental boards, but the thought is these obstructions could be legally circumvented by including dental services under a broad medical licensure to practice. The better dental health offerings would then be recognized by the consumer, thus transforming the dental care market.
Much more can be said, perhaps at another time. The takeaway point here is that society has been saddled with narrow and outmoded doctrines, assumptions, and means for obtaining dental care, needlessly enduring the financial and morbidity costs of tooth decay. It can be better served by replacing the existing edifice with a responsive system of dental care delivery, scientifically grounded in modern understanding and treatment of the disease.
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- For more discussion on this, see Alyssa Picard, Making the American Mouth: Dentists and Public Health in the Twentieth Century. New Jersey: Rutgers University Press, 2013; and Mary Otto, Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America. New York: The New Press, 2017
- For more information on the science behind tooth decay and the medical management of caries, an abundance of information can be found at Mmclibrary.com.