Combating overuse in oral health: The lessons of “Flossgate”

This is the second in a guest blog series on right care in dental health by Matt Allen, DDS. Read part one here!

Several years ago, the Associated Press reported that the federal government had removed flossing from its official Dietary Recommendations for Americans, noting the lack of high quality evidence in favor of flossing. Many news outlets picked up on this story, and for those in the dental profession, the reaction from the public was swift and boisterous – one of my colleagues referred to it as “Flossgate.”

It was the single most powerful display of force by the public I have seen about a dental issue, all borne from a single news article.

Every dental professional – myself included – was forced to respond to the question of whether or not flossing was really necessary. And as a serious evaluator of the evidence – not one simply spinning a PR response – I have to admit that the evidence for flossing to prevent cavities is indeed thin. It was the single most powerful display of force by the public I have seen about a dental issue, all borne from a single news article. The ripples of Flossgate are still being felt today.

I tell this story as an example of how patients and the media can put positive pressure on medical professionals to pay attention to the shifting evidence base. In a previous blog, we discussed the shift in diagnosis and treatment of dental caries (cavities), as more and more dentists have realized that not all demineralization requires surgery to fix it. However, this change has not been universal. Dental schools have been inconsistent in teaching new principles to dentists, and payment reform has been slow to incentivize dentists in practicing in accordance with the most up-to-date evidence possible.

How can we help the dental profession more quickly uptake and implement this change? The answer lies in the power of patients.

Given the relative lack of progress in these two high yield arenas, how can we help the dental profession more quickly uptake and implement this change? Like with Flossgate, I believe that the answer lies in the power of the patients.

Whether we like it or not, health care (including oral health) in the United States is a field increasingly viewed as a commodity, with the patient as chief consumer. One simply has to look at the dentist down the street asking for positive Yelp reviews, or notice billboards boasting of ED wait times, or watch a TV ad where a health insurance company uses basketball star Steph Curry to highlight the power of mental fortitude to understand that patients are being courted by providers of all types.

Even if we fundamentally disagree with this manifestation of the health care system, it is important to recognize that it provides patients with power and leverage (especially in dental care, where many patients pay out of pocket). As Dr. Bernard Lown wrote in The Lost Art of Healing, “…the system is eager for the public to view health care as a service industry which considers customer contentment as paramount…allergy to poor publicity affords patients leverage for manipulating the system.” These sentiments, penned before the advent of social media, have only grown in leaps and bounds since they were Dr. Lown wrote them over twenty years ago. As a collective, how are patients to best wield this power?

As we saw with Flossgate, patients can have an exceptional impact simply by asking the right questions.

As we saw with Flossgate, patients can have an exceptional impact simply by asking the right questions. We should help patients walk into their dental office prepared to ask questions like, “Can my cavity be remineralized?” “What are the chances that there is a hole in my tooth?” “Do I really need this filling?”

In doing so, dentists would be forced more and more to provide good answers to those questions. Those ill-equipped and unable to respond well to that informed patient would lose their patronage to one more informed of the current evidence base. And when that happened enough (and for some, even once might be enough), I’d hope that the dentist would start seriously considering change.

But the responsibility is not all on patients to put pressure on dentists to avoid overuse. Major news publications have a crucial role in informing the public about the science and evidence-based best practices in all areas of health care, especially when the practices are not being followed. Most news about dentistry tends to focus on access. Access is a critical issue, but not enough on its own to change the tide.

We need to inform the public not only how to get into a dental chair, but what they should understand and expect once they get there.

To more quickly see the paradigm shift we all desire, we need to inform the public not only how to get into a dental chair, but what they should understand and expect once they get there. Dentistry has the advantage of being a familiar experience for most Americans, unlike heart disease or diabetes, and the power of good information in the hands of the public can be transformative.

Sadly, a shifting paradigm is bound to leave some in any profession behind, clinging to their old ways and longing for the way it used to be, especially if the change has the potential to adversely impact their bottom line. It’s my sincere hope that there are people and resources to wrap around these people and gently lead them in the right direction. But ultimately, health care is about patients. And we need more patients who can make informed decisions founded in high quality evidence, working in partnership with their care team (not just the doctor or dentist) to achieve their goals consistently with their values and preferences.

The voices exist to help give patients power and leverage via good information, thereby effecting change quickly and from within the existing system – we just need them to tell the right stories.

Matthew Allen, D.D.S. is the president of M David MI LLC, a consulting and coaching firm specializing in motivational interviewing for oral health professionals. Dr. Allen is the only US-based dentist member of MINT, the Motivational Interviewing Network of Trainers. Previously, Dr. Allen was the clinic dental director at Clinica Family Health, a nationally recognized federally qualified community health center serving the Denver metropolitan area, where he remains active in clinical practice.  He also serves as part time volunteer faculty at the University of Colorado School of Dental Medicine.