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Creative diagnosis: A new dental skill?
Dr. Jeffrey Camm
Fircrest Children’s Dentistry

There is no doubt that the dental profession is under assault from insurance companies — reduced reimbursements, decreased benefits and diminishing coverage for some procedures are all issues we have to face in our practices. Because of this, we all face financial pressures and threats to our bottom line. In response to these issues, I believe I’ve noticed an increase in the skill of what I call “creative diagnosis.”  I hope this is not a trend for our profession.

As a board certified pediatric dentist, who has practiced 34 years with both a military and civilian career, I feel I understand the wide range of differences in teaching programs and dental schools across the country. I realize that diagnosis of decay is somewhat subjective, and recall the old joke about any two periodontists who agree on a patient should form their own society. But the disparity of diagnosis I have seen recently is alarming.

Consider the 16 year old who graduated from my practice and sought care at her mother’s general dentist. The phone call I received from that dentist asking how I could miss 16 cavities (with a treatment plan of more than $3,000) was alarming. The mother’s call to me was also alarming — what had I been doing all these years? After inviting the mother and daughter back to my office and taking new radiographs I again came up with a diagnosis of NO decay. There were a few incipient lesions in the enamel, some of which had been there five or six years. We reviewed the old radiographs and I showed the mother that some of these incipiencies had actually decreased in size as the patient had aged and started mouth rinses and flossing. At this point, questioning my own skills I showed the radiographs to five fellow dentists representing three different specialties. The range of opinions was zero to four cavities they would restore. The number 16 was off the chart. This same diagnostician had recommended these restorations before the end of the year because of the imminent possibility of endodontics! 

Another patient brought their daughter to our office for a second opinion. Her two-year old had a full mouth series of radiographs (six X-rays on a two-year old!) and was diagnosed with a cavity requiring restoration and sedation. To begin with, I can envision no scenario with a two-year old and no visual decay requiring full mouth radiographs. The American Academy of Pediatric Dentistry states “Radiographs should be taken only when there is an expectation that the diagnosis will affect patient care”. This child had no teeth with contact points, you could see all her interproximal surfaces — in fact, her maxillary second molars had not yet erupted! My board-certified partner and I found no decay. And speaking of radiographs, the criteria for panoramic X-rays is not: will the child stand still and is it a covered benefit? Referrals of four year olds to us with “panos” is maddening- there is no indication for it.

Our practice is often referred children who are medically compromised or of a pre-cooperative age requiring general anesthesia for treatment. These are wonderful referrals and a great service to the parents and children. In the past six months my partner and I have been referred three children with extensive treatment plans that we can can find minimal or no decay. I have to wonder what the criteria for caries has become. Many parents come to us on their own seeking second opinions regarding general anesthesia. The majority have minimal decay.
Nowhere is creative diagnosis more evident than the occlusal surfaces of permanent first molars. I can identify a patient’s prior dentist by the fact that all the first molars are always restored on every patient I see coming out of that office. I attended a lecture at a national meeting a few years ago on differentiating between sealants and occlusal caries. The take home message from the lecture was — when in doubt always do restorations. Seriously? Whatever happened to minimally invasive dentistry? There is ample evidence based literature that proves minimal decay (if in fact there was decay at all) with a sealant will not progress. If there is a question, I suggest placing a sealant with future evaluations expected. Maybe not as financially beneficial for the dentist, but certainly less invasive for the child. 

The difficult task for me with all this creative diagnosing is trying to explain to the parent why my treatment plan is hundreds (thousands?) of dollars different than someone else’s treatment plan. I can only cover-up so much with my explanation of different treatment criteria, sharper explorers, conservative vs more aggressive therapy, blah, blah blah.

My solution? Look in the mirror. Take radiographs that are necessary, not just covered by insurance. Find decay that you realize another dentist who was looking over your shoulder would agree with. Treat your patient exactly as you would wish you or your family was treated. And as Hippocrates said- “first of all do no harm”. Are you increasing the creative diagnosis portion of your practice? Is creative diagnosing become a new skill in the dental profession? I hope not- for the sake of our patients and profession.


Reader Comments (4)

What a great editorial, Dr. Cramm. Unfortunately it is not limited to the pediatric population. We need to remember that we can't improve on Mother Nature and all restorations weaken the tooth as a side effect. We should be sure the treatment benefits outweigh the risk. As a profession we need to make every effort to keep on top of the changing science effecting patient care and make ethical evidence based treatment recommendations. Want to discuss these types of issues with a panel or have your own ethical/legal issues? Please join us at the PNDC Friday June 14th at 8:00-11:00 AM. You are also encouraged to ask your questions ahead of time at

05.24.2013 | Unregistered CommenterRod Wentworth


Thanks for putting in writing something I (and I suspect many others) have been concerned about for some time. Seeing patients for a second opinion and being unable to find the caries that has been diagnosed is one of the most uncomfortable situations I encounter, in addition to making me question my own diagnostic abilities. While we try to explain to patients that treatment plans from different dentists do not always agree 100%, and there is more than one way to "skin a cat", I worry about the future of dentistry, what used to be one of the most trusted professions.

Ward Morris

05.24.2013 | Unregistered CommenterWard Morris

Dr. Cramm. I read your editorial in the October ADA Newsletter (if you saw my desk you would understand why I just got to that one). My question to you is this......... where have you been for the last 20 years? Maybe things are better in Washington than they are here in Southern California...BUT..... Most people that go to a new office around here are an automatic 4 quadrant SRP (about 90% of which are unnecessary according to the hygienists I know). Better not go to a new office with any silver in your mouth 'cause it's getting replaced with "better", "safer", "healthier" white ones. Crowns placed 5 or more years ago?......time for replacement and don't worry, we'll find a reason. I heard a story from my son's HR person about the dentist they have been assigned to. The patient was told she needed a crown and her HMO copayment was about $250. By the time the tooth was prepped and temporized, her out of pocket fee was over $2300 with all the trumped up add-ons such as crown lengthening, crown build-up, etc. I've got tons more stories just like these ones that are almost beyond belief. So if the colleagues in your area are taking a few extra radiographs and diagnosing an extra cavity or two, consider yourself and your patients lucky!!!

12.3.2013 | Unregistered CommenterDavid H Ward DDS

What a refreshing article. I thought I was alone in my thoughts that are right in line with Dr.Camm . Too often I am hearing about levels of sedation and hardly ever about the kindness and dedicated time from the doctor and the staff in trying to achieve practical goals with patience and not dictated by insurance reimbursements and time constraints.I have always tried to treatment plan in a pragmatic and cost effective manner, and it seems to almost always work out well. One of my mentors told me 28 years ago"do the right thing, and the money will always be there." He was right! Our specialty is privileged to be treating children who by their very nature are our most prized possessions and we should never forget that. I am tired of hearing how parents have been intimidated and actually scared into doing what is" right for their child" even though the presentation that was given to them was flawed and aggressive. Sedation is wonderful when used appropriately and with discretion but it should never be taken for granted.I hope many in our specialty will read this article and take it to heart. It really made my day!

11.23.2014 | Unregistered CommenterKeith Gjebre,DMD

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