Expert: Mark Bornfeld DDS - 10/13/2007

Question
I went to a new dentist today, and was told that I have 16 cavities that need to be filled.  I'm 23 years old, I've only ever had one cavity in my life, and I don't feel any pain whatsoever.  I haven't been to a dentist in a little over a year due to a change in insurance, which may contribute to the problem a bit...however, I seem to know several people who've gone many years without dental check-ups and haven't had any problems like this, so I'm feeling a little unsure.

So I'm wondering if identifying tooth decay is a subjective process.  Would you recommend getting a second opinion from a different dentist before I go through with all of these fillings (and the time, money and pain involved)? Or is it more of a black and white situation, that would not be impacted by how cautious (or money-hungry) the dentist is?

Also, is there anything in my diet that could have triggered this?  Is there any harm in consuming artificial sweetners?  In the past year, I've started drinking a lot of crystal light (about a pitcher a day), and that is the only thing I can think of that is different in my diet.  

Thanks for any info you can provide!

Answer
Dear Julia,

You've neatly articulated some of the problem-- that diagnosis is uniformly a subjective process-- not just when detecting tooth decay, but in all diagnostic protocol. All diagnostic symptoms and signs are filtered through normal, human sensory perception, and interpreted according to the collective skills and biases of the individual. And yes, not to be too cynical about it, the doctor's personal financial needs figure in, too.

Whenever there is an inconsistency in what a patient has been led to expect from previous experience, it cannot help but raise some questions. However, the right questions must be asked. For example, the most relevant is whether this inconsistently bad checkup is the result of a true upswing in decay incidence (it does happen). However, I would be more confident of the clinical significance of this change if it were diagnosed by the same dentist you had previously. The fact that this is a new dentist could logically mean one of the following three things:

1. You have experienced a true increase in decay
2. Your new dentist is diagnosing tooth decay more aggressively than your previous dentist
3. Your previous dentist was negligently failing to diagnose decay, and your current situation represents the result of that failure to diagnose.

Now, some decay is equivocal-- after all, every disease process starts from zero, and slowly grows until it surpasses some threshold of detectability. In other words, some decay may be too small to detect, some decay may be conspicuous only to the astute diagnostician, and some is so obvious that to miss it is just bad dentistry. Around the point where decay passes that critical diagnostic threshold is where a dentist can assume a philosophical posture of erring on the side of money, err, treatment, or watch and wait conservatism. It's not necessarily a matter of right or wrong, but in my practice, I have often chosen to NOT treat those equivocal areas, but rather to follow them over time to see if they are stable or progressive. In some cases, these areas will go on to become obvious decay, while in others, they remain unchanged. Not every dentist is as conservative as I am, and sometimes the appropriate level of aggressiveness must be tailored to the practices of the patient-- whether he keeps regular checkup appointments, whether he normally gets many cavities, whether he practices good oral hygiene, etc. For some patients, the danger of failing to treat an equivocal cavity is too great-- by the time he returns for his next checkup in five years, he may need a root canal treatment or worse in that "maybe" cavity. So, there is no one "correct" philosophy; it's a matter of trying to do what's best with one's own value set.

In your case, there is no reliable way to know where your new dentist is coming from, and 16 cavities is indeed more than I would expect after only a 1-year hiatus from dentistry. I think a second opinion would be appropriate, if only to help you develop (or not develop) trust with your new dentist.

Hope this helps...

Mark Bornfeld DDS
www.dentaltwins.com
Brooklyn, NY