1. A Closer Look at Teeth May Mean More Fillings Ritchie King New York Times November 28, 20112 http://www.nytimes.com/2011/11/29/health/a-closer-look-at-teeth-may-mean-more-fillings-by-dentists.html?pagewanted=1&ref=health&src=me

2. New dentist, 5 fillings Until 2010, Amelia Nuwer, 22, visited the same dentist every year in Biloxi, Miss., her hometown. And every year she came back with a clean bill of dental health: no fillings necessary. Then, as a junior at the University of Alabama, she saw a new dentist who delivered her first negative diagnosis: two cavities. Six months later, the dentist told her she had two more. Earlier this year, he once again had bad news: yet another cavity. Somehow, in 12 months she had gone from perfect oral health to five fillings. It felt wrong to me, she said.

3. Hometown dentist Her hometown dentist, Dr. Francis Janus, was surprised, too. He examined his longtime patient after she graduated. Ms. Nuwers so-called cavities, he concluded, had actually been incipient carious lesions, a form of early-stage decay that some dentists call microcavities. He said that he wouldnt have filled them, she recalled. I was so upset and angry. The five fillings cost her almost $500 out of pocket.

4. Proactive … or unnecessary? With increasingly sophisticated detection technology, dentists are finding and treating tooth abnormalities that may or may not develop into cavities. While some describe their efforts as a proactive strategy to protect patients from harm, critics say the procedures are unnecessary and painful, and are driving up the costs of care. A better approach is watchful waiting, said Dr. James Bader, a research professor at the University of North Carolina School of Dentistry. Examine it again in six months.

5. So, whats happening? An incipient carious lesion is the initial stage of structural damage to the enamel, usually caused by a bacterial infection that produces tooth-dissolving acid. The lesion doesnt always lead to a full-blown cavity, which entails decay of the layer right beneath the enamel, called dentin. Mineral- containing saliva can repair these lesions, especially when bolstered with fluoride. Many experts think it doesnt make sense to operate in the early stages of decay. If you dont have any kind of demonstrable collapse of the enamel wall, then you shouldnt put in a filling, Dr. Bader said.

6. Aggregate Expenditures Yet a majority of practitioners are inclined to do so. According to a 2010 National Institutes of Health survey, 63 percent of more than 500 practicing dentists said they would operate on a tooth with decay that had not progressed beyond the enamel, even if the patient had a history of good dental hygiene. Such operations typically cost $88 to $350 per filling, according to a 2007 survey in the magazine Dental Economics. According to the American Dental Association, about 175 million filling operations are performed in the United States every year. Insurance plans cover all fillings, whether for microcavities or full-blown cavities, because dentists bill based on the work theyve done, not the symptoms theyve observed. 175,000,000 fillings * $200/filling = $35B in expenditures!

7. Bad teeth can be bad Looks bad. Can lose teeth, which makes nutritious behavior more difficult. Can lead to abscesses (poison), which can make you sick or kill you. So … obviously some major portion of fillings are beneficial.

8. The Economics If there is no damage then there are no benefits. But what if there is damage … and what if there are benefits? Is it good medicine, or SID? MB MC $ # of Fillings