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MyView: Creative diagnosis

October 21, 2013

By Jeffrey Camm, D.M.D.

There is no doubt that the dental profession is under assault from insurance companies—reduced reimbursements, decreased benefits and diminishing coverage for some procedures are all issues we have to face in our practices. Because of this, we all face financial pressures and threats to our bottom line. In response to these issues, I believe I've noticed an increase in the skill of what I call "creative diagnosis." I hope this is not a trend for our profession.

As a board certified pediatric dentist, who has practiced 34 years with both a military and civilian career, I feel I understand the wide range of differences in teaching programs and dental schools across the country. I realize that diagnosis of decay is somewhat subjective and recall the old joke about any two periodontists who agree on a patient should form their own society. But the disparity of diagnosis I have seen recently is alarming.

Consider the 16-year-old who graduated from my practice and sought care at her mother's general dentist. The phone call I received from that dentist asking how I could miss 16 cavities (with a treatment plan of more than $3,000) was alarming. The mother's call to me was also alarming—what had I been doing all these years? After inviting the mother and daughter back to my office and taking new radiographs I again came up with a diagnosis of no decay. There were a few incipient lesions in the enamel, some of which had been there five or six years. We reviewed the old radiographs and I showed the mother that some of these incipiences had actually decreased in size as the patient had aged and started mouth rinses and flossing. At this point, questioning my own skills I showed the radiographs to five fellow dentists representing three different specialties. The range of opinions was zero to four cavities they would restore. The number 16 was off the chart. The same diagnostician had recommended these restorations before the end of the year because of the imminent possibility of endodontics.

Another patient brought their daughter to our office for a second opinion. Her 2-year-old had a full mouth series of radiographs (six X-rays on a 2-year-old!) and was diagnosed with a cavity requiring restoration and sedation. To begin with, I can't envision a scenario where a 2-year-old with no visual decay requires full mouth radiographs. The American Academy of Pediatric Dentistry states, "Radiographs should be taken only when there is an expectation that the diagnosis will affect patient care." This child had no teeth with contact points, you could see all her interproximal surfaces—in fact, her maxillary second molars had not yet erupted. My board-certified partner and I found no decay. And speaking of radiographs, the criteria for panoramic X-rays is not: will the child stand still and is it a covered benefit? Referrals of 4-year-olds to us with panos is maddening—there is no indication for it.

Our practice is often referred children who are medically compromised or of a pre-cooperative age requiring general anesthesia for treatment. These are wonderful referrals and a great service to the parents and children. In the past six months, my partner and I have been referred three children with extensive treatment plans that we can find minimal or no decay. I have to wonder what the criteria for caries has become. Many parents come to us on their own seeking second opinions regarding general anesthesia. The majority have minimal decay.

Nowhere is creative diagnosis more evident than the occlusal surfaces of permanent first molars. I can identify a patient's prior dentist by the fact that all the first molars are always restored on every patient I see coming out of that office. I attended a lecture at a national meeting a few years ago on differentiating between sealants and occlusal caries. The take home message from the lecture was, when in doubt always do restorations. Seriously? Whatever happened to minimally invasive dentistry? There is ample evidence based literature that proves minimal decay (if in fact there was decay at all) with a sealant will not progress. If there is a question, I suggest placing a sealant with future evaluations expected. Maybe not as financially beneficial for the dentist but certainly less invasive for the child.

The difficult task for me with all this creative diagnosing is trying to explain to the parent why my treatment plan is hundreds (thousands?) of dollars different than someone else's treatment plan. I can only cover up so much with my explanation of different treatment criteria, sharper explorers, conservative vs. more aggressive therapy, blah, blah, blah.

My solution? Look in the mirror. Take radiographs that are necessary, not just covered by insurance. Find decay that another dentist looking over your shoulder would agree with. Treat your patient exactly as you would wish you or your family was treated. And as Hippocrates said, "First, do no harm." Are you increasing the creative diagnosis portion of your practice? Is creative diagnosing becoming a new skill in the dental profession? I hope not—for the sake of our patients and profession.

Dr. Camm practices at Fircrest Children's Dentistry in Fircrest, Wash. His comments, reprinted here with permission, originally appeared in the July issue of the Washington Dental Association News.