Overtreatment in dentistry

Dr Alexander Holden didn’t set out to study overtreatment in dentistry, but quickly found it is weighing on the minds of many. But how big is the problem? And can it be fixed? By Rob Johnson

Talking about overtreatment as a ‘spectre’ in dentistry sounds vague and dramatic. But the word is appropriate for a topic that everyone seems to know about, but no-one has a handle on. “There’s just no data,” explains Dr Alexander Holden, a senior lecturer at the University of Sydney. 

“You would need a large group of practices with computer systems interlinked. While there are large groups, they don’t necessarily have interlinked data collection. Also, there’s no diagnostic coding used in dentistry. So you can get a collection of item numbers to understand what it is that somebody has had done. But you don’t know why they’ve had it done.”

Nonetheless, last year Dr Holden published an article in The Conversation about overtreatment. He’d done qualitative research into dentists’ perspectives on commercial practices in private dentistry. It was based on questionnaires and interviews with 20 dentists. “We didn’t specifically ask about overtreatment,” he adds. “We asked, ‘What do you think are the impacts of commercialism in dentistry?’”

Their answers and insights revealed overtreatment is definitely an issue in the profession. But more telling was that when Dr Holden published this finding, no-one complained. “I’ve been really surprised with the positive reaction my work has received,” he says. “I was expecting a negative response. I’ve had a couple of people say, ‘It worries me what this might say about us. But it’s good to talk about this’.”

Notes versus reality

There is an inevitable grey area when looking at different dentists’ treatment plans. Data (if it was available) may only help you quantify the extent of overtreatment in one place relative to norms elsewhere. 

“One of the problems with overtreatment as a phenomenon in dentistry is that it’s always spoken about with a tone of innuendo,” says Dr Holden. “People suspect it’s happening, and people have encountered it. And you find this in the grey literature, the non-academic literature as well, where people are talking about this.”

He also found it in his own experience. At the start of his career, after graduating, he went to work for a corporate provider in the UK. “Within my first week I was aware that something wasn’t quite right with the practice,” he recalls. “I was seeing people who’d lost gold inlays. And you’d look in the notes at which tooth they’d put in this gold inlay, a matter of days before. And when you looked in the mouth all that was there was a rotten stump with an imprint of where an inlay had been.

I’ve been really surprised with the positive reaction my work has received. I was expecting a negative response. I’ve had a people say, ‘It worries me what this might say about us. But it’s good to talk about this’.

Dr Alexander Holden, senior lecturer, University of Sydney

“They were clearly doing very strange dentistry. I heard practitioners saying, ‘The only way you will meet your targets here is if every patient gets a crown, or a denture.’ So that was the culture of the practice. And all the other practitioners who were working there were playing to those rules.”

He left that position when he realised there was no way to meet his targets without overtreating. “That was, I have to say, quite a damaging experience quite early on in one’s career. Because it taints your view of dentistry if you’re not careful. I was lucky I could then go and work for people who had a more traditional view of what a dentist should do.”

Good and bad eggs

Even though that practice was a corporate, Dr Holden says it would be a mistake to think that mattered. A corporate culture of profits over people doesn’t create the phenomenon of overtreatment.

“A lot of the behaviours that we criticise corporate dentists for are there in the independent sector as well,” he says. “There’s another paper that I’ve got coming out in the British Dental Journal on this. It looks at different experiences around dentistry. It also examines how dentists experience and perceive corporate dentistry.

“It’s more pertinent to look at this drive towards rationalisation of health services. Dentists and practice owners are not stupid people. They see something working in a different sector. It would be stupid not to consider whether it might work for their practice as well. 

“The best illustration of this was one participant in the study. He wasn’t sure whether the practice he worked for was corporate or independent. When you get situations like that, it shows you that the difference between the two sectors is only skin deep. When we scratch beneath the surface, the corporate dental sector and the independent dental sector are behaving more or less the same. You get good eggs and bad eggs in each group.”

Back to values

So how do you solve a problem when you don’t know the size of it or where it’s happening? Dr Holden suspects part of the answer lies in ‘why’ it’s happening. Dental patients are more empowered now, he says. They can shop around and request particular treatments. Dentists may feel justified in responding to their requests despite a lack of clinical need.

“There was an element of ‘buyer beware’ creeping in,” he says. “And dentists were quite comfortable with that idea being established in dentistry. Rather than going back to the notion of traditional professionalism whereby a dentist might say, ‘I don’t feel this is the right thing for you. And so I’m not going to do it or suggest it’.

I was seeing people who’d lost gold inlays. And you’d look in the notes at which tooth they’d put in this gold inlay, a matter of days before. And when you looked in the mouth all that was there was a rotten stump with an imprint of where an inlay had been.

Dr Alexander Holden, senior lecturer, University of Sydney

“But it’s not enough for a patient to say, ‘I want this done.’ You also have to use your professional judgement to say, ‘Is this the right thing? Yes, it’s the right thing for me and as a business transaction. But is this the right thing to be doing both for me as a dentist, and also for you as a patient and your own health?’”

Another possible solution—albeit one that he admits may be very hard to implement—lies in fee structures. “There are many ways to skin a cat when it comes to deciding how to pay dentists and other practitioners for their services. The predominant model in Australia is fee for service, which is activity-based. And I guess one of the reasons why it’s so popular and so dominant is that it’s easy.

“Talking about other metrics to use to determine how a practitioner should be paid, it becomes a little bit more difficult. So, I imagine most dentists would very much protest the idea of being put on a salary. It would be interesting though, if they were told, ‘Let’s look at your figures from last year. If that’s the amount you would get as your salary, would you be prepared to work on that basis?’ A lot would consider it. And it would then be interesting to look at, well, what happens then to activity.”

Blended alternatives

One of the outcomes of doing that, he suggests, is dentists would become less busy. “I had three years of working on a capitation-based system in the UK. And I felt it worked well because you didn’t discuss payments with patients. They paid a monthly fee based on that [patient’s] oral health. And the only thing they ever paid for is if they had anything involving lab work, they just paid the lab bill. So whatever you paid, they paid, which meant that a crown became quite cheap. And it was because your time and the materials are bought and paid for. The patient only paid the lab fee. So that worked well in the sense of patients quite liked it.”

The downside of that scheme was well patients tended to leave because they didn’t understand what they were paying their monthly fee for. “But one of the nice things was it meant that you could spend the time that you needed to spend with those patients. You could get them to the level where their oral health was good.”

Such a scheme could also encourage under-servicing, he says. A possible solution lies in a blended scheme, where the government covers part of the cost and a monthly fee covers another part. In any case, “we’re still in the stage where most of these other schemes that I’m talking about have only been piloted. No one’s actually gone and fully embraced a blended scheme.

“Fee for service is here for the immediate future. But my understanding is that dentists would not be averse to changing. They’d want to understand whether that change would mean an improvement for patients and for their own conditions. Dentists don’t want to create a rod for their own back either. So that’s the challenge. 

“Ultimately it’s easy to stay in the status quo because it’s something you know. It might be an imperfect system, but ultimately it’s comfortable.”