Who makes the decision in our profession that it is time to change? When will dental schools stop the harmful overtreating of patients as a requirement to graduate their students? When will state dental boards require these new graduates to show proficiency in disease management instead of mechanical amputation of tooth structure? When will dentists abandon the drill as the default way to “treat” tooth decay? Well, I don’t know exactly when, but I do know that the day is coming!
For over 100 years our profession continues to amputate tooth structure as a treatment to control tooth decay. That is archaic and outdated, and it doesn’t work! Every microbiologist and dental cariologist in the world know this. Additionally, the ADA supports and teaches that dental drills do not kill caries-causing bacteria. (1) You would think that after all this time somebody would have discovered a better way to treat tooth decay- and they have! I use it every day, in and outside of my office. It’s a practice called the Medical Management of Caries (MMC) and it relies on a medicinal approach instead of the barbaric mechanical drilling approach to treat the disease.
One of the medicines I use every day is silver diamine fluoride (SDF), a clear liquid that combines the antibacterial effects of silver ions with the re-mineralizing power of fluoride. It is currently approved by the FDA to treat sensitivity, but it is more commonly used off-label as an anticavity medicine. SDF has been granted Breakthrough Status by the FDA and is on track to soon be approved as the first drug ever to treat tooth decay. Another critical medicine used in my MMC office is glass ionomer cement (GIC), which creates an acid resistant zone of chemical fusion that permanently unifies the GIC and the dentin. (2) These two medicines have been classified as Essential by the World Health Organization and when used together, this combination therapy delivers 96% effectiveness for caries prevention. (3) No other dental system or filling material is capable of providing that level of care. These two medicinal treatments are key when following a no-drill, nonrestorative philosophy in one’s disease management protocol. The ADA recommends prioritizing a non-restorative approach as your first consideration when treating caries. That’s as close to a mandate that the ADA will ever put forth because they are beholden to their “drill and fill” dentists and drill-making manufacturers for financial support. All of that money might just dry up if they divide the profession and anger their commercial sponsors. So, it is understandable that the ADA is cautious. Even though I sympathize with them over this dilemma, some action and direction must be taken now!
A step in the right direction would involve requiring dentists to take education in the medical management of caries techniques and re-emphasizing our oath to Do no harm! It wasn’t long ago that our profession was cited for our role in overprescribing opioid painkillers and contributing to the dangerous and deadly harm that it caused for so many. The ADA responded and took corrective action and endorsed updated guidelines on pain management. The state dental boards are also to be lauded for requiring all dentists to take 2 hours of CE on this subject for license renewal. So now, once again at this time, the ADA and the state boards must come to grips and realize that we have an ongoing problem here – and that patients are being harmfully overtreated. It should be clear to all now that another 2 hours of CE on the medical management of caries must be required to open our profession’s eyes to a safer, kinder, and more humane healing option that won’t send teeth into the depressing downward spiral of the drill-fill-repair & replace cycle.
The vast majority of dentists are overtreating their patients and that is causing them great harm. 94% of dentists report that they always drill initial caries lesions that are nearing the middle third of dentin (4) even though those lesions are unlikely to be cavitated. (5) There are international consensus statements and ADA recommendations that tell dentists to not drill into initial lesions! (6) It’s quite clear that the options to medicinally treat and heal these lesions (and much lesser ones) regularly go ignored. That costs our patients unnecessary expenditures and potential pain and suffering that could last indefinitely.
Delta Dental reported that once you drill and fill a molar tooth, you can expect over $6000 in further expenses on that same tooth (7) over the course of a lifetime for retreatment, repairs and replacements. Let’s also consider the patient’s trauma and inconvenience from going through all of that.
Sadly, this is the business model of dentistry. The profession is economically dependent upon generating big money due to the high cost of dental education ($300,000 – $500,000) along with trying to support one of the highest overheads of any business (70-80%). It seems that the temptation (need?) to keep drilling and producing those higher priced procedures will make it challenging for the profession to pivot toward a safer, kinder, gentler, and less costly healing model. Did we forget to “First do no harm”? It feels like that message is being ignored.
Now try to imagine a “million dollar” practice with no shots or drills, no plumbing or suction, and almost no staff or stress. Once you remove the expenses of the common things required in the traditional high overhead practice, you don’t have to produce a million dollars to have the same net take home pay! Your income won’t be eaten up by the high expenses run amok and you can have multiple income streams that offer extremely high returns. Check this out- a 50 cent drop of SDF can treat 5 teeth and bring in over $100 in reimbursement from Delta Dental for insurance code D1354 (Interim caries arresting medicament application). Good golly, it’s the best ROI in dentistry! That’s only one example and there are so many others! It is my hope that this encourages you to join the Movement for the Medical Management of Oral Disease (M3OD) and be a healer and not an amputator.
Working in your quiet, peaceful medicinal care office will be like walking on clouds in Heaven. Finally, you will feel what it is like when every patient loves you because you have dropped the drill! Now you are committed exclusively to kind and humane healing care. Someday soon (like now!) the people we serve will understand that they should have been given a choice to heal their caries or be drilled. The ADA’s Practice Guidelines on Restorative Treatments (July 2023) state that “Clinicians should implement shared decision making with patients or caretakers.” Our patients deserve to be informed of their options! At this moment in time, everyone in our profession has the chance to be on the right side of history in the making! The public is counting on us! Don’t let them down! You can do this…DROP THE DRILL!
A note and offer from Dr. Kammer…
I am about to enter my 5th year of practicing drill-free and shot-free in my simple, low-stress, low-overhead “million dollar” Victorious Dental practice – and I’d love to share my complimentary report “The Ten Things I Love the Most About Dropping the Drill! You can also sign up to receive news updates and future course information on the Movement for the Medical Management of Oral Disease (M3OD) – simply email me at DrChrisKammer@gmail.com
Don’t forget to join my Drop the Drill! Facebook group, too! (https://www.facebook.com/groups/951999165175228)
(1) ref. American Dental Association release of New Clinical Practice Guidelines on Caries Restorations, June 29, 2023
(2) Ngo et al 1997, Sennou et al 1999, and Yamaga et al 2001
(3) Can Dent Assoc J., June 2020, Fontana, et al
(4) JADA 147(5) May 2016
(5) JADA 146(2) February 2015
(6) Clin Oral Investig. Schwendicke 2019, 23\ (10):3691-3703.
(7) The Pew Charitable Trusts. Water Fluoridation: Many Still Don’t Receive Its Benefits [info- graphic]. June 13, 2013. https://www.pewtrusts.org/en/research-and-analysis/data-visualizations/2013/water-fluoridation-many-still-dont-receive-its-benefits
The $6105 cost is from Delta Dental of California’s data of commercially insured patients January – June 2012.
Want to learn more? Check out these additional resources:
Steven Duffin DDS
SMART Oral Health – The Medical Management of Caries (Silver Modified Atraumatic Restorative Technique)
Free book download at:
John Frachella DMD
Pediatric Dentist, Consultant, and ADA and AGD Accredited Dental Educator
Reinventing Dentistry – the Hood River complete presentation.
Part 2: https://youtu.be/FSC8l_Znc7w
Dr.’s Jeanette MacLean and Jeremy Horst Keeper
SDF- Almost a Decade of Use and Knowledge: