本文最初发表于 Undark。
当牙医告诉 Corrine Rivera，她 7 岁的女儿在例行检查时需要做乳牙根管治疗时，Rivera 并不知道“乳牙”指的是牙齿，而不是手术的大小。她以为就像小份的冰淇淋——比成人的少，只是做一点点根管治疗。Rivera 的女儿除了洗牙之外，还没有接受过任何牙科治疗，所以 Rivera 并不了解她将面临什么。
Rivera 回忆说，牙医当即就进行了根管治疗。这对她的女儿来说很痛苦，她不得不在令人意外的一个半小时的手术中忍受嘴里的大型器械，这对 Rivera 来说也很痛苦。“当时我只想为我女儿的牙齿做最好的事，”她谈到 2017 年在纽约州奥尔巴尼儿科牙科的经历时说道。“不幸的是，”她补充道，“这项手术导致了更多的问题。”
几个月后，Rivera 说她的女儿出现了感染，一家不同诊所的一位新牙医向她解释说，乳牙根管治疗，也称为牙髓切断术，是针对乳牙的根管治疗，而不是“迷你”手术。
Rivera 仍然怀疑她的女儿是否一开始就需要根管治疗，而事实证明，州和联邦检察官后来回应了关于同一牙科诊所的其他牙髓切断术病例都是不必要的医疗指控。2022 年 10 月，奥尔巴尼儿科牙科及其 12 家附属诊所——所有这些诊所都由儿科牙医 Barry L. Jacobson 及其公司 HQRC Management Services, LLC 经营——与纽约州总检察长的医疗补助欺诈控制部门和美国新泽西州地方法院检察官办公室达成了一项 和解协议，金额超过 75 万美元。
这项州和联邦调查是由一位前 Jacobson 在纽约州北部五家诊所的经理于 2017 年提起的 举报人诉讼 推动的。该前雇员声称，诊所的员工进行了不必要的治疗，并受到压力，要求增加患者和手术量，以达到每月 18 万美元的收入目标。
HQRC 的一位发言人拒绝就诉状中的具体说法发表评论，但坚称该和解协议并不意味着该公司从业人员提供的牙科护理不当；而是说，支持有限数量的特定手术所需的记录不完整。“HQRC 一直否认这些指控，”发言人表示，并补充说，该公司“全力配合了随后进行的为期五年的政府调查，并最终就几年前在其少数几个办公室发生、现已得到处理和纠正的记录保存和计费问题达成了和解。”
根据和解 协议，Jacobson 及其公司承认，“在某些情况下，在 2011 年至 2018 年之间，一些与 HQRC 有关联的牙医为医疗补助（Medicaid）进行了治疗性牙髓切断术（therapeutic pulpotomies）并进行了收费，但这些手术并未得到 HQRC 关联牙科诊所维护的病历支持。”
纽约州官员 尚未披露 在 HQRC 旗下进行的被调查手术的确切数量，而 Rivera 和她女儿的经历，至少在 Rivera 所知范围内，并未被纳入诉讼和随后的和解协议进行审查。这可能意味着，尽管她们的经历如此，但这次特殊的“乳牙根管治疗”在医学上是必要的。
根据接受 Undark 采访的专家表示，虽然一些患者可能接受比其他患者更多的治疗，但儿科牙科的主要目标是促进口腔卫生、缓解疼痛，并保持乳牙健康，直到恒牙长出，唐纳德·齐（Donald Chi），一位儿科牙医和华盛顿大学口腔健康科学教授说。
一些专家表示，这种持续浑浊的、不完整的科学和经济激励以及令人担忧的诉讼，可能会给整个职业蒙上阴影。.
然而，如何治疗年幼的牙科患者并非总是直截了当，而证据和临床指导的 相对缺乏，与医学研究相比，使这一挑战更加复杂。牙科研究的范围要小得多，并且经常受到资金偏见的影响。虽然有充分的证据表明，比填充物侵入性更小的替代方法在儿童身上效果很好，但这些替代方法尚未得到广泛采用。几位牙科专家还强调，并非所有病例都相同——对一个孩子有效的方法可能对另一个孩子无效。
专家们表示，问题在于，存在强烈的经济激励措施来侧重于干预措施，尤其是在服务于医疗补助（Medicaid）或儿童健康保险计划（CHIP）的诊所，这些计划在许多州都有极低的报销率。这可能导致一些诊所转向 私募股权公司，让投资公司介入医疗实践的运营，并可能鼓励不必要的治疗。（一家私募股权公司投资了 HQRC Management。根据原告的起诉书，这些诊所的收入主要来自医疗补助。）
一些专家表示，这种持续浑浊的、不完整的科学和经济激励以及令人担忧的诉讼，可能会给整个职业蒙上阴影。这使得像 Rivera 这样的患者不得不猜测和担心他们自己孩子的牙科治疗是否是出于善意的医疗决策，还是其他原因。
Baby teeth are, of course, temporary. And anyone who has ever tried to brush a reluctant toddler’s teeth knows firsthand that those tiny molars don’t always get high-quality home care. But their impermanence doesn’t mean that care isn’t important — if those teeth get ignored, it’s likely to cause problems with adult teeth later on.
As a specialty, pediatric dentistry is a little more than a century old. In 1909, about 70 years after the first U.S. dentistry college opened, a dentist named Minnie Evangeline Jordon established the first practice just for children. A few years later, she wrote that her male colleagues were glad to be rid of their pediatric patients “so that they could settle down to the serious work of dentistry — the making of bridges and plates.”
Today, although any dentist can treat kids, there is a thriving subspecialty of practices specializing in pediatric dentistry. There are more than 200,000 dentists in the country, about 8,000 of whom are pediatric specialists — a full-fledged discipline, with specialized training, a national professional organization, and journals like Pediatric Dentistry Journal and Journal of Clinical Pediatric Dentistry, where dentists publish their research into best practices into the field. Some of that research has bolstered longstanding claims: Regular brushing with fluoride toothpaste helps prevent cavities, early dental visits (before age four) reduce the amount of treatment needed later, and fluoride treatments such as gels, varnish, and mouth rinses may be valuable.
These measures are engaged in a sustained battle with the bacteria that create acids that corrode teeth. By physically removing stuck food that feeds the bacteria, and by strengthening the enamel with fluoride, these measures can prevent cavities and the proliferation of the decay-causing bacteria that can linger in a child’s mouth far past when their baby teeth fall out.
But, some experts say, it’s difficult for dentists to translate pediatric dentistry research to practice. Review articles, which evaluate a body of research on a particular subject, conclude that findings regarding pediatric dentistry have low certainty. For one thing, much of the relevant research that does exist has a high risk of bias, according to Shaun Sellars, a general dentist in Suffolk in the United Kingdom, because it is paid for by players in the industry, such as manufacturers of dental materials. Dentists “don’t do a lot of practice-based research either,” said Sellars, who is also the ethics columnist for the British Dental Journal. “There’s the funding issue there,” he added. “Because dentists, if they’re not hands in mouth, they’re not making money.”
Still, research on evidence-based practices and technology are advancing, and quickly. In dentistry schools “half of what we teach is out of date in five years,” said David Johnsen, a professor of dentistry at the University of Iowa. This can make it hard for providers to keep up with new findings. According to Sellars, many dentists face barriers to making evidence-based decisions, such as not having enough time to follow new studies or not having access to research articles behind paywalls. And even if dentists do read the literature, Sellars said, “not enough of it is relevant to what we actually do in practice.” Oftentimes, he added, “dentists will find what works for them, or what they believe works for them, and just continue to apply that.”
Recently, research has called into question common procedures used to fight cavities in kids. Evidence shows that fillings aren’t necessarily better than noninvasive alternatives, such as silver diamine fluoride, an inexpensive liquid that can slow decay, or caps that can be pushed onto the tooth (sometimes called the “Hall Technique”). Neither of these alternatives require drilling, filing down a tooth, or using anesthetics, said Nicola Innes, a professor of pediatric dentistry at Cardiff University.
Sellars lamented that there aren’t many resources, such as clinical guidelines, that would help dentists navigate the complex situations they face every day in an evidence-based way.
Dentistry decisions aren’t always straightforward. There are a wide range of approaches over how to treat dental cavities — one of the most common disease treatments in a dental office — in kids, including the kind of baby root canal that Rivera’s daughter received. As Johnsen put it: “If you get 10 really good dentists around a patient or a case and you say, ‘What’s the right treatment plan?’ you may get six or 10 or 11 different opinions.”
When a child comes in to see a dentist with a cavity, deciding how to treat a child’s cavity can be complicated, Chi told Undark. The dentist has to consider: How deep is the cavity? How much has it progressed since the patient’s last visit? Does the child appear to have regular brushing habits? Does the child have a risk factor for tooth decay? Might the tooth fall out soon?
If the cavity is not too deep and the tooth might fall out soon, the dentist might opt to do nothing and check again in six months. Or the dentist might slow the decay by painting on diamine fluoride to halt or slow decay (a downside: the material stains the tooth black).
If a dentist believes the cavity needs more intervention, many may choose fillings. “The problem with fillings is that they don’t do very well in children’s teeth,” said Innes, because baby teeth are small and wet, and kids tend to wiggle. Injecting anesthesia and drilling can also be unpleasant. There’s solid evidence, from her research and others, that fillings aren’t necessarily better than the noninvasive alternatives: silver diamine fluoride or caps.
When a cavity becomes so deep that a tooth’s pulp becomes infected, options include pulling the tooth or performing a root canal. Both have downsides, Innes said. A gap left from a pulled tooth can allow teeth to twist and migrate, which can lead to a need for orthodontia later. For a root canal, a child needs to be able to sit for a long time, first during the root canal and again when the tooth is shaved down and a crown is put on. Baby root canals come with a risk of infection, as Rivera said happened with her daughter in New York state. For instance, the Centers for Disease Control and Prevention recently issued a health advisory because multiple outbreaks of nontuberculous mycobacteria infections have occurred in children who received pulpotomies in pediatric dental clinics where the dental treatment water contained high levels of bacteria.
For many children, extensive dental work such as multiple root canals or fillings may require general anesthesia. But it’s uncomfortable to have a tooth pulled, even when a child is anesthetized and the procedure is painless, Innes said.
Anesthesia is also expensive, and it can have real risks for kids, including, in very rare cases, serious injury and death. More commonly in the short term, “they can have some attachment disorders, some night terrors, bedwetting, things like that,” said Innes. “And in the longer term, there was a very small amount of evidence that it probably doesn’t do them any good neurologically.”
Most dental treatments, several experts stressed to Undark, should be preventative. “I’d much rather spend my time telling people and helping people remain healthy than treating someone for a root canal, said Margherita Fontana, a professor at the University of Michigan School of Dentistry, adding: “They’re not having fun, and I’m not having fun. I mean, it’s not a fun thing to do to something to someone that you know is in pain.”
Unfortunately, Fontana said, there’s little data to indicate which patients are most at risk for dental disease, and how to best prevent it. “We need better prediction tools, in general, for children and for adults,” she added. “Many times, we are reactive to the damage rather than trying to prevent the damage.”
Part of the issue of prioritizing prevention, Fontana and other experts say, is an incentive system that offers few rewards for prevention-centered approaches — and large payouts for interventions.
Fontana’s research focuses on predicting dental health risks and using easy interventions like silver diamine fluoride, but generally requires routine dental visits to keep an eye on whether the cavity is progressing.
“The problem with fillings is that they don’t do very well in children’s teeth,” said Innes, because baby teeth are small and wet, and kids tend to wiggle.
“I just have happy kids sitting in the chair. I’m doing things and testing things that I think are going to be super easy, fast, and accessible,” she said. “But then I know that at the time to get translated into practice is going to be difficult, because there’s no good way for people to get reimbursed to do those things.”
When more robust research supports a particular dentistry tool or technique, there may still be financial barriers for widespread use. In many states in the U.S., less invasive treatments and preventative measures, including fluoride varnish and silver diamine fluoride, are reimbursed at a much lower rate than more invasive ones, which may make them less likely to be adopted into practices. And dentists don’t get paid at all for taking time to walk a patient through their potential treatment options. If dentists “don’t physically do something in your mouth, they do not get reimbursed,” said Fontana.
Reimbursement can be particularly difficult for dentists who accept Medicaid or the Children’s Health Insurance Program, which serve more than 41 million kids and tend to have much lower reimbursement rates than private insurance or private pay rates. While overhead costs are increasing due to inflation, data indicate that Medicaid reimbursement rates have failed to keep up. Those problems can be especially acute in practices that are under pressure from owners or investors to make cash.
“You’re fighting a system where the driver is doing something — dentists don’t get paid to prevent disease,” Fontana added. “I don’t think it’s ever going to change if the system doesn’t change.”
With low reimbursement rates for preventative measures like cleanings and fluoride applications, it’s hard to imagine how pediatric dentists earn more than general dentists. But Chi said that a key component of pediatric dentistry “is to provide high quality care as quickly as possible. And the main reason for that is that children have short attention spans.” That also means that a pediatric dentist can potentially book more patients in a day than a general dentist can, which may lead to more income.
Dentists that accept Medicaid or CHIP face other challenges in billing and running a practice. Medicaid is a joint federal-state program, but it varies from state to state, explained Jason Ray, a Texas lawyer with experience in Medicaid dentistry-related lawsuits. In addition to low reimbursement rates, some Medicaid programs also require dentists to do more paperwork than the state’s dental board generally does, such as getting consent for each visit and each procedure, which could add to administrative costs. Medicaid audits can also be time consuming.
Ideally, a dentist would have a mix of patients, some who pay with private insurance, others out-of-pocket, and some Medicaid patients. However, dentists often don’t achieve a good balance. Research shows that dentists who treat more Medicaid patients are more likely to be located in a majority non-White zip code, a rural area, or high-poverty zip code. Because of Medicaid’s low reimbursement rates, Ray pointed out, one way for a dentist to make money is to see a high number of patients and do a large number of procedures.
There’s no doubt that this could lead to incentives to do procedures that may not be necessary, Ray said. An analysis of California’s Medicaid program in 2012 indicated that about 8 percent of dentists reviewed that provided Medicaid services to children met certain thresholds for questionable billing. The average general dentist performs root canals on 5 percent of pediatric patients. In the sample reviewed, the threshold of questionable billing was 18 percent, which about 2 percent of the Medicaid dentists exceeded.
A 2022 analysis of dentists found that about 33 percent treat at least one Medicaid patient. Those that do may also be tempted by the offers of private equity firms, which can lead to big payouts, but might also encourage practices to prioritize profits over evidence-based care. (Firms often don’t pay penalties in cases of fraud.) A 2013 report prepared by a U.S. Senate committee noted that corporate-managed “clinics tend to focus on low-income children eligible for Medicaid. However, these clinics have been cited for conducting unnecessary treatments.”
Whether Rivera’s daughter’s procedure was one of those unnecessary treatments is something that she and her family may never truly know. But she told Undark that the experience has left her rattled — even though she and her daughter, now 13, have found a Medicaid-accepting dental practice that they say they’re generally happy with.
Still, Rivera says that ever since her daughter received that “baby root canal” six years ago, she has deeply hated going to the dentist. “She remembers that day,” Rivera said, “very clearly.”
Christina Szalinski is a freelance science writer with a Ph.D. in cell biology based near Philadelphia.
This article was originally published on Undark. Read the original article.
