This past summer, I had the pleasure of reading an insightful article in the New Yorker by surgeon Atul Gawande, entitled “Overkill.” Its central thesis is that our health care system is wrought with overtreatment and unnecessary care. Dr. Gawande relates that this epidemic is responsible for much of our inflated health care costs, and moreover, actually harms patients. Like Dr. Gawande, I earn my living as a health care provider, and yet this is a concern that has resonated with me.

After reading the article, I have been reflecting on how we can ensure that the dental care that we provide is of high value to patients, and how we can avoid overtreatment. I have always made it a goal to find both the best and most conservative option for each patient. A good dentist walks a line - the least expensive option is not always in the best interests of the patient’s long-term well-being, and yet, the most expensive treatment is not always within their reach. The “Overkill” article inspired me to further evaluate the means to which I arrive at my treatment recommendations every day in my practice.

The Value of Dental Care

The primary directive of dentistry is to prevent pain and disability. Preventing tooth-aches that arise from advanced decay, tooth loss from gum disease, and reducing the risk and early detection of oral cancer can help us avoid lost days at work, difficulty eating and speaking, deficiencies in nutrition and, in rare instances, death. Beyond circumventing a breakdown, dental care truly has the potential to improve our quality of life. Orthodontics and restoration of the teeth can enhance comfort, function, and appearance. Good care and prevention takes us to a level above barest function and pain avoidance - good dental care can bring us into a state of vibrant health.

We must acknowledge that these benefits come with costs - and there are some important economics to the choices a dentist and patient make together. As our understanding of dental disease improves and the sophistication of the care that we are able to provide increases, so do the costs of the new treatments we have within our ability to provide. We are routinely challenged as we try to decide what care holds the highest value for our patients - and yet, this is not always the treatment with the highest price tag attached.

In one example, it was only two generations ago that much of the population accepted the partial disability of living with dentures. Accepting tooth loss as an inevitability, dentures improved quality of life by restoring appearance and the ability to eat. However, dentures only replaced a fraction of the function for these patients. Dentures, it is important to remember, are a prosthetic. As with any prosthetic, the replacement of a natural, functional body part with an artificial one should be a last resort. Any prosthetic will not function so well as the one we are born with. Hence, the question we must ask ourselves with any prospective denture patient is: would dentures represent an improvement in the patient’s long-term health and well-being, or a decline in it? If the answer is that a patient’s quality of life may suffer, then another recommendation, such as implants or an implant denture, might be the better treatment plan. While not the least expensive, an attempt at restoring the existing dentition, or the placement of implants may have more value.

Rabbits, Birds and Turtles

We are now living longer, and most of us are entitled to imagine reaching an advanced age with all or most of our natural teeth intact. We don’t see ourselves wearing dentures like our parents or grandparents did, and with early detection and prevention we can often eliminate the possibility completely. Even so, it is becoming more difficult to determine which conditions or risk factors that we recognize at an early stage have to potential to cause disability or affect quality of life later on. For example, what level of tooth wear at age 35 puts someone at risk of losing their dental function at 80?

When considering conditions and potential treatments, the simple categorization referenced by the author H. Gilbert Welch in his book “Less Medicine, More Health” was helpful:

Rabbits – “We need to catch them before they escape the pen.” In dentistry, this would include gum disease, active decay, oral cancer, and destructive bite conditions. These require immediate attention; these carry the risk of imminent disability or pain.

Birds – “Have already taken flight before we discover them.” Sometimes we encounter dental conditions that are irreparable, and they have advanced to the stage of “last case scenario” treatment. For example, in such a case, dentures might be the best treatment, in order to restore what has already been lost. Dentists carry advanced options, but we do not have the ability to time travel as yet. We must join the patient where she is on her journey, and go with her from there.

Turtles – “They are not going anywhere.” Many dental conditions are like this: tooth wear can irreversibly damage teeth, but at it’s rate of erosion, the disability may not develop until after a patient will no longer need function (in other words, the dentition will “outlive” the patient). This is where decisions about the best and most conservative treatment can be difficult. It is important for a dentist to recognize that not all conditions warrant treatment.

Reducing Information Asymmetry

In a related topic, I have also recently appreciated the discussion of “Information Asymmetry” in medical care. The economist Kenneth Arrow defined information asymmetry as “…the severe disadvantages that buyers have when they know less about a good than the seller does.”
Gawande asserts that “doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting. Doctors, therefore are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it is our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.” While I can recognize the potential truth in this statement, I immediately bristled at the assertion we make treatment recommendations for financial gain. Upon reflection, I simply felt the weight of the position: we must strive to recognize and reduce the asymmetry through good listening, co-diagnosis, and education.

Conclusion

At the end of the day, I see our role in providing high-value, yet judicious dental care to be the following:

1. We must recognize the benefits for prevention-based dental care, as the most conservative method of treatment in all cases.
2. We must recognize what conditions need to be treated, and which do not, and
3. Through honesty and transparency, we must work to reduce information asymmetry in our patient’s dental experiences.

Our commitment is to complete a thorough diagnosis and careful risk assessment so that, with our patient, we can provide a preventative plan to keep them free of disability and offer ways to improve quality of life that are appropriate to their individual situation. Our ethics then dictate that we thoroughly communicate the need for treatment to our patients, without taking advantage of the fact that we are the experts on the subject and they are not. Finally, recognizing the risk of information asymmetry challenges us to provide care in a way that avoids harm to our patients. Doctors will always have the unique responsibility of making decisions with patients that can heal, and as we vow with our Hippocratic oath, to do no harm. We need to take this responsibility seriously, and remain vigilant to avoid overtreatment as we care for our patients. In the end, it is about ethics. This is why it comes down to a solemn vow.