A Response to “The Trouble with Dentistry”

This post is in response to a recent article published in Atlantic magazine entitled “The Trouble with Dentistry” by science writer Ferris Jabr

By: Bryan Mansfield

Dental Office Manager & AADOM Member

In a recent Atlantic article, Ferris Jabr describes the following horrific scene: “A masked figure looms over your recumbent body, wielding power tools and sharp metal instruments, doing things to your mouth you cannot see.” No, this is not a description of enhanced interrogation methods. It’s a description of a visit to the dentist. While not strictly inaccurate, it’s clear that Jabr (pronounced like neighbor) has calculated his words to conjure a terrifying image of dentists and dentistry. The article doesn’t get any more flattering from there.

Jabr, a science writer and a self-proclaimed naturalist, clearly has strong opinions about dentistry and he backs them up with anecdotes and studies from the Cochrane organization and the Swiss Dental Guidelines. The article’s centerpiece is a single anecdote–a true story about a dishonest dentist named John Roger Lund whose unethical practices resulted in thousands of unnecessary dental procedures which ultimately cost his unsuspecting patients outlandish sums of money. At best, Jabr characterizes dentists as pseudo-doctors who tinker with unpredictable solutions. At worst, he paints them as greedy charlatans whose primary goal is to pay for their Mercedes by scamming you. The problem is that, like any industry, there are excellent dentists and dishonest ones. Jabr’s article makes the dishonest ones the face of the entire industry.

As a dental office manager and a member of AADOM (American Association of Dental Office Management), I disagree with both Jabr’s approach and several of his assertions. But he’s not all wrong. He points out that many dental procedures lack rigorous scientific studies. No one would like to have more such studies of their methods than dentists themselves. Most dentists would enthusiastically welcome increased scientific data to bolster their explanations to their patients about necessary procedures. Jabr also raises the issue of second opinions, placing blame on dentists for their patients not seeking a second opinion. He uncovers a problem that exists in dentistry, which is that sometimes dentists are too quick to move forward with a procedure without fully considering all available options or allowing their patients the chance to make a fully informed decision. In addition, it’s possible for dentists to be overly aggressive in diagnosing dental treatment. These are all strong points that I praise Jabr for observing and bringing to consumers’ attention. Nevertheless, I find much of his approach dishonest and biased.

Jabr’s most egregious error is his unfounded (and incorrect) assumption that the reason dentists don’t do more preventive sealants is because “they are too simple and inexpensive to earn dentists much money.” A simple conversation with anyone who has worked in a dental office could have helped him avoid this error. I’m confident that if polled, 99 out of 100 dental office managers would likely give some variant of the following answer to the question of why dental sealants are not used more frequently: “Patients choose not to get sealants because they don’t want to pay for them. And when it comes to dental sealants, insurance policies have strict limitations.” Understandably, patients don’t want to spend $30+ dollars to protect a single tooth that has shown no signs of problems. If anything, dentists have an incentive to do more dental sealants. They are effective, take little time to place, and are typically placed by a hygienist during a hygiene visit. Jabr’s bad assumption betrays his negative bias toward the entire dental industry.

One relevant challenge facing dentists eludes Jabr’s narrow field of view: The high-risk legal liability assumed by dentists every day simply by doing their job. Early in the article, Jabr says: “Consider the maxim that everyone should visit the dentist twice a year for cleanings. We hear it so often, and from such a young age, that we’ve internalized it as truth. But this…has no scientific grounding…An increasing number of dentists acknowledge that adults with good oral hygiene need to see a dentist only once every 12 to 16 months.” After all, people sometimes go years without visiting the dentist and often have one cavity (or zero). So what’s the big deal? Well, suppose I have a regular dentist and on a recent visit, he diagnoses a cavity. Instead of fixing it right away, he says “let’s watch it for now.” I decide to follow Jabr’s advice and skip my next checkup, waiting a full year (or more) to come back. By that time the decay spreads and gets deep enough to damage the pulp of the tooth. Unfortunately now the problem is worse than before, and could have been prevented by more frequent checkups.

In the middle of the article, Jabr recites a claim made by the Swiss Dental Guidelines that when patients have minor cavities, dentists should not perform fillings, but rather “monitor the decay and encourage the patient to brush regularly, which can reverse the damage.” Most often, decay doesn’t stop by itself. It spreads. A small, simple filling is a safer way to ensure that decay will not spread, thus preventing a larger filling or even a root canal in the future. This is especially important if the patient is following Jabr’s advice to only visit the dentist once every 12-16 months.

As a naturalist, Jabr appears wary of root canals in particular. He describes them as “much more radical” than a filling and cautions “you may want to get a second opinion before getting that root canal.” He’s right that root canals are radical procedures. But what he fails to do is provide a plausible alternative. When a tooth becomes decayed or damaged to the pulp, a patient essentially has three options. The first option is to have the tooth extracted. Losing a tooth is never ideal. In addition to having a gap where the tooth was, extractions also result in loss of bone structure. Maintaining strong, healthy bone is crucial for keeping teeth later in life. The second option is to do nothing. This is likely to be a painful option, and the tooth will eventually be lost one way or another. The third option is to get a root canal. Until a future innovation makes root canals (or maybe teeth altogether) obsolete, they are the only reliable way to save teeth with damaged or dead pulps. Despite some fringe controversy surrounding root canals, they are strongly preferable to the first two options.

The picture painted in Jabr’s article is that dentists select their profession primarily based on its money-making potential. In reality, dentists tend to be hardworking professionals who are well compensated for their labor, but who nevertheless have a difficult job. Most dentists sincerely care about their patients’ well-being and sincerely want to pursue the treatment course that will be in each patient’s best long-term interest. There are dishonest dentists out there, just like there are dishonest people who become lawyers, doctors and even science writers.