A fast train is coming. Are you dancing on the tracks?

In pediatric dentistry, these days it is de rigueur, fashionable, in vogue, all the rage, trendsetting,  and chic to avoid dental techniques that the child patient and the parent don’t like.  And, who likes being a restorative dental  patient? 

And what parent likes having their child not like something?

So, the result is the trend away from the customary, conventional, standard restorative treatments, and toward “minimally invasive” and even “non-invasive” treatments.  

These fashionable offerings basically ignore the bacterial etiology of dental decay and soft tissue inflammation and infection, with a nod to making it easier, more acceptable to the child, and thus to the parent.  Certainly those of us who treat children have experienced the question, "Johnnie, do you want to have your tooth fixed today? (Variations; “pulled", "pulled out", "numbed", "have a shot," etc.)  

What child would not answer, “No”?  We could go into the point that’s why children have parents, to make the difficult decisions that will most benefit their children, but even that point is not the point here.

So, it is becoming de rigueur to treatment plan the more acceptable treatments that do not address the bacterial etiology - hear me - as well - and keep everyone happy.  Even our “evidence base” finds the Hall SSC technique of covering a decayed tooth with an SSC (often without any decay removal) as acceptable. 

So the virulent organisms are locked into the tooth where they can travel through dentinal tubules into the pulpal circulation and into the systemic circulation.  My job is not to judge the research, nor the treatment, but to have you consider - and question - what the sequelae to these directions may be.

"Minimally invasive” techniques include diet counseling and sugar substitutes, sealants, antimicrobial agents and chemotherapeutic approaches, remineralization of early lesions, GIC, fluorides, CPP-ACP, and others.  

Let’s think about those first.  Have you many parents in your practice who truly take the information to heart and...
a) change the child’s diet ,
b) actually use the antimicrobial agents, fluorides, and other chemotherapeutic agents over even a short period of time, and regularly? 

​It begs the question, “How’s it workin’ for ya?”

Then the minimal surgical interventions of decay, including ART, chemo-mechanical caries removal (Sodium hypochlorite + mechanical removal), air abrasion, lasers, Hall technique, Silver Diamine Fl, and so on - while these are newer on the scene, how do you feel those approaches transform the child’s history and future of decay?  (An attorney in my family responded that on behalf of all attorneys, he might just mail a thank you note to Dr. Hall, whoever he is, for his technique that makes it just a matter of time before he earns a very good living for attorneys.)

It’s the “How’s it workin’ for ya?” again.

HOWEVER, we as pediatric dentists LOVE to please the parent and child.  Most folks who go into dentistry are... 
a) in it to help people and change lives, and... 
b) approval addicted such that it is a common goal to do whatever possible to get people to LOVE you. (That includes not charging either anything for some procedures, or at least not much, not “bothering the child patient if possible, using GA, sedation, etc.)

So, these less invasive, hated treatments appeal to us as well as to the parents and child.  Sort of.  We convince ourselves it is good.  

That train is carrying other cargo as well.

Think about:

1. Big Pharma continuing to develop chemo-therapeutic agents that may or may not be very effective, but do cost a lot, and with still-to-be-determined side effects and sequelae.
2. ADA is developing new procedure codes to demonstrate these techniques.
3. The insurance companies including Medicaid, perhaps especially Medicaid, are talking in their planning meetings, about how they can cover the “less invasive”  treatments and not the conventional treatments - why?  because they can cover them at a much lower rate, even though they are not necessarily even beneficial.  (Another way the companies siphon off money at the expense of the patient, with poorer and possibly in-effective care, and at the expense of the doctor, who cannot be reimbursed even if a conventional or better therapy is warranted if it’s not “covered”.)
4. The big-box, corporate dental centers who already mandate what procedures their often young and inexperienced dentists are to do, can take advantage of the finances the same way.
5. The doctor is ultimately licensed and responsible to do no harm, to care in the highest and most professional way for each patient and each disease situation. The best treatment for the patient is still the responsibility of the doctor.  The parent expects that, as well as letting their child decide about treatment.  This is a crazy situation.  It certainly is. 
6. With further decreases in “coverage” (insurance-speak for what they will pay,) the participating dentist is locked into missionary work they did not realize was their mission. 

“I hear a train a’comin’. It’s comin’ down the tracks.  And I ain’t seen the sunshine, since I don’t know when…that train keeps rollin’… I bet there’s rich folk eatin’ from a fancy dining car.  They’re probably drinkin’ coffee and smokin’ big cigars.  Well I know I had it comin’ I know I can’t be free.  But those people keep a movin’ and that’s what tortures me.”   
~ Johnny Cash

Doctor, are you dancin’ on the tracks?

---