Getting a filling at the dentist can be painful, expensive and generally miserable. A crown or a root canal is even worse. Still, you do it because your dentist has said you should.
But in a surprising number of cases, you might have another choice. Where one dentist sees a crown, another might see just a filling. And where one recommends drilling, another might suggest trying some prescription toothpaste first. In other words, a dentist’s prognosis is not always the final word. Training, personal philosophy and economics can all play a role.
“A dentist who graduates in 2026 versus a dentist who graduated in 1999, they might have two completely different treatment plans,” said Shelbey Arevalo, chief executive of the National Dental Advocacy Program in the US, which helps patients navigate the dental healthcare system.
So how do you know if you have gotten the right prognosis for you? And when should you seek a second opinion? Here is what you need to know for your next visit.
Cavities are any damage to a tooth’s surface caused by acid produced by bacteria in your mouth. The deeper the decay goes, the bigger the problem. While this may sound clear-cut, it often isn’t.
If the acid is wearing through the outside enamel but hasn’t gotten to the next layer of the tooth, called the dentin, then it’s a judgment call whether to intervene, said Dr Sara Stuefen, a dentist in Vinton, Iowa, US, and a spokesperson for the American Dental Association.
“Sometimes we still have a chance,” she said. Better brushing and flossing, plus cutting back on sweets or coffee, could stop the damage.
“A lot of our patients don’t realise that you can actually reverse a carie when it’s in its earliest stages,” added Dr Diana K. Nguyen, an associate clinical professor of dentistry at the University of California, San Francisco, US. Once the decay gets into the softer dentin layer, most dentists will immediately recommend a filling.
Even then, however, approaches differ. Some dentists will use a crown once 50 per cent of a tooth is gone or filled. Others might set that threshold a little higher.
Like any branch of medicine, dentistry is constantly evolving. One of the biggest trends is towards minimally invasive dentistry, which limits drilling when possible.
“In the last 50 or 60 years, we have gotten much more conservative than we were before,” said Dr Margherita Fontana, a professor of dentistry at the University of Michigan in the US. “There are a lot of preventive interventions that cost very little.”
For example, we’ve known for decades that prescription-strength fluoride toothpaste and mouthwash can help halt and reverse early tooth decay, Dr Nguyen said.
Dentists can also sometimes stop cavities with fluoride varnishes and prevent them with dental sealants, which were once recommended only for children, Dr Fontana said.
There are also newer, less-studied products that can help rebuild a tooth. One is Curodont, a liquid that dentists apply to a problem spot that attracts calcium and phosphate from saliva, reconstructing tooth enamel. Another is MI paste, which releases minerals into a person’s teeth, Dr Nguyen said.
Dentists have also developed alternatives to root canals over the decades, Dr Fontana added. Sometimes a deep cavity close to a tooth’s nerve can be sealed off, a little like an Egyptian tomb, in an approach that is called selective caries removal.
Of course, dentistry is not just medicine — it’s also a business. And fillings and crowns are more lucrative than cleanings, which can create unconscious incentives to drill a tooth with a borderline cavity.
“The more surgical intervention you do, the greater the financial payout,” Dr Nguyen said. “You can’t really bill out for just watching something over and over.”
Another trend in dentistry is the rise of dental support organisations, or DSOs. These are corporate institutions that partner with or buy dentist offices and manage their administration. While DSOs are generally barred from directly influencing medical decisions, several states have brought lawsuits citing a corporate culture that pressures dentists to maximise profit.
California recently passed legislation meant to limit DSOs’ power and New York has been considering a similar law.
To get a feel for a new dentist, the experts recommended asking about their philosophy or approach before starting treatment. It’s a good sign when a dentist is familiar with preventive measures, looks for minimalist approaches and communicates clearly, Dr Nguyen said.
If you have any doubt about a diagnosis and are not in immediate pain, you can always get a second opinion. Telling your dentist that you want this can be awkward, Arevalo acknowledged. But if a dentist dissuades you from getting a second opinion, Dr Nguyen said, that’s another red flag.
NYTNS