The Five Types of Dental “Prevention”
Pivoting the Rest of My Dental Career into Primary Dental “Prevention”
Why It Is Especially Important in This Pandemic Time, and Thereafter... and What COVID19 Has Taught Dentistry
I placed “prevention” in quotes because only the first two types are truly preventive, that is: seeking to prevent problems in the first place.
Types 2 and 3 are actually treatments wrapped in a label of prevention.
Type 4 seeks to prevent overuse and commercialization of types 2 and 3.
The concept of prevention is critical to understand because some things that are touted as “prevention” are not truly preventive and may sometimes be “excuses” for treatment. This is typical in dentistry. In fact, dental cleanings are called preventive, yet, despite about half of Americans visiting the dentist regularly, at least 70% of the American populace has gum problems, and tooth decay is still rampant. Tooth decay is the most common chronic disease in children. Dental problems in general are a silent epidemic in America.
It’s important to understand these concepts because the dental industry was expecting to produce record amounts of production in 2020. However, due to COVID19, losses may run between 30% and 70% this year as dentists will struggle to adapt to drastic new requirements and patients may be reluctant to see a dentist for about 4 to 6 months. (I’ll get back to this paragraph near the end of the article.)
Here are the five known types of dental “prevention” and examples of each:
Type 0. Primordial prevention involves establishing wide-scale factors which are known to reduce the risk of disease for the masses, i.e., mass methods to prevent disease in the first place.
- Dental examples would be communal water fluoridation to prevent tooth decay (although some would argue this leads to other problems), and Dental Public Health, which seeks to educate the masses and make dentistry accessible for everyone.
- General examples would be the worldwide elimination of smallpox, and efforts to eradicate polio and measles.
Type 1. Primary prevention is preventing personal exposure to risk factors and preventing problems to individuals in the first place. Primary prevention seeks to prevent the onset of specific diseases in individuals via risk reduction by altering behaviors or exposures that can lead to disease, or by enhancing resistance to the effects of exposure to a disease agent.
- Dental examples would be education about how to prevent cavities and gum disease, motivational and habit-adopting methods, dietary and medical supplementation, nutritional advice, and personal training about proper oral hygiene and the total user-experience of oral hygiene above and beyond the mere hygiene aspect.
- A general example might be the recent advice about proper handwashing for COVID19. Everyone supposedly knows “about” washing hands. But few people know exactly how to do it like a surgeon, how to clean all hand and digit surfaces, what to touch and not to touch before and after, how to dry hands, and what to wipe down before and after the handwashing. In other words, the pump or bottle of hand cleaner may be dirty. The faucet knobs may be dirty. The towel may be dirty. Doorknobs, light switches, etc. As soon as you REALLY evaluate something supposedly as simple as proper handwashing, (or flossing) you begin to realize why people need training to do it right, and why surgeons must wash their hands even if wearing gloves – because gloves can rip or be punctured.
Type 2. Secondary prevention includes procedures that detect and treat preclinical pathological signs and changes, and thereby control disease progression. Screening procedures are often the first step, leading to early interventions that are more cost effective than intervening after symptoms appear.
- Dental examples include most of dentistry:
- i. Typical dental exams to screen for decay, gum problems, and other oral conditions
- ii. Cleaning teeth to prevent gingivitis.
- iii. Scaling teeth to prevent gum disease from worsening.
- iv. Crowning a slightly cracked tooth in order to prevent tooth breakage.
- v. Performing a root canal on an asymptomatic tooth with a huge decay that will soon be into the pulp.
- vi. Pulling a tooth that is unrestorable and replacing it with an implant or bridge.
Type 3. Tertiary prevention seeks to soften a disease’s chronic impact on the patient's function, longevity, and quality-of-life. It occurs after the disease has developed and has been treated by secondary prevention in its acute clinical phase. It also often seeks to repair damage to secondary preventive efforts, and/or manage or treat the continued progression of disease. For incurable, irreversible conditions, tertiary prevention focuses on rehabilitation, improving quality of life, assisting people to accommodate to disability, and prolonging life expectancy.
- Dental examples would include:
- i. Replacement of failed secondary prevention treatments due to continually recurring decay and/or gum disease, or simply poor treatment.
- ii. Removal of continuously failing teeth and restorations and fabrication of dentures, implants.
- General examples would be rehabilitation programs, artificial limbs, hospice, etc.
Type 4. Quaternary prevention is a “higher” level of prevention defined as preventing over-medicalization (or dentalization), protecting from new medical invasion, and ensuring interventions are ethically acceptable.
· Health activities generally produce benefits, but can also result in harm. Although medical intervention is mainly favorable, quaternary prevention seeks to ensure health activities that achieve more benefit than harm.
· Quaternary prevention seeks to prevent disease mongering, or commercialization of disease.
- Encouraging this sort of prevention requires the development of all the above preventions as well the personal willingness for restraint. It involves separating caregivers from the unnecessary auspices of industry, production goals, insurance dictates, and being critical of our work, not being evil, respecting justice as managers of limited public knowledge, and making caregivers feel responsible for the social cost resulting from medical decisions. It can be summarized as “first, do no harm, and be ethical.”
- Dental examples of disease commercialization or over-dentalization might include cosmetic dental “makeovers” or excessive tooth whitening. While there is nothing inherently wrong with cosmetic dentistry and tooth whitening, there have been cases of dentists claiming to perform minor “facelifts” with dental bonding. Excessive whitening has been shown to affect collagen beneath the enamel surface. Dental veneers are prone to cracking, breaking, falling off, chipping, decaying, and staining – resulting in multiple additional treatments which negate the concept of veneering in the first place.
- I personally saw a case in which front teeth were traumatized from veneering and the pulps died, which turned the teeth dark, which required root canals and internal bleaching to lighten the teeth under the veneers, which made the teeth brittle, which caused the teeth to break off at the gumline, which resulted in the teeth roots needing to be exposed with gum surgery and posts placed and crowns made -- all from the supposedly minimally invasive procedure of “simple” veneers, which turned out to be not so simple, and super-expensive in the long run!
Getting Back to Dental Production Mentioned Above
Americans spent $139.9 billion on dental services in 2019. Yet only about 50% of people visit a dentist regularly. The oral care/oral hygiene market in USA in 2019 was $44.5 billion.
Yet the dental profession was excited to try to exceed that production in 2020! Until COVID19 hit.
These are huge numbers for a set of diseases that are actually 80% preventable. That’s right. Eighty percent of most common dental problems (mostly tooth decay and gum problems) are preventable – easily. There are really only two main dental problems -- tooth decay and gum problems. And most people still don’t know that tooth decay is actually a transmissible microbial disease, and that sugar does not cause decay! Why is that? Because it’s never explained nor taught. It’s easier to just say, “Avoid sweets.” But that hasn’t worked well because nearly half of Americans are now diabetic/pre-diabetic/obese. Or, diabesity, as Dr. Mark Hyman calls it.
What does that tell you?
It tells me that dentistry is currently only focused on type 2 and 3 prevention, which are actually treatments to prevent something already existing from getting worse, and fixing all the things that keep failing and worsening. Dentistry supposedly doesn’t make money from types 0 and 1 which are true preventions. Well, in a way, that is correct. Types 0 and 1 do not make immediate money for dentists. They are more like customer service programs. But they are still necessary, otherwise customers lose faith.
True preventions are the most critically needed because they allow people to keep more teeth for longer so that people can still function properly as lifespan increases. And if people are keeping their teeth longer, then the teeth are more susceptible to natural wearing, tearing, chipping, cracking, breaking, and other failures, which need constant maintenance and fixing – just like any other thing that lasts a long time. True prevention is the main reason for most modern dental advancements. Otherwise, what would be the point of fixing anything? Sure, dentists will always be fixing stuff, but at least with types 0 and 1 prevention, the fixings will be more due to real need, rather than possible over-commercialization/dentalization of disease.
What Dentistry Has Learned from this COVID19 Crisis
Primordial and Primary prevention are of the utmost importance, and especially primary prevention which is type 1 prevention, or true prevention which seeks to prevent problems in the first place in individuals.
Primordial prevention for the masses (fluoridation) worked like magic in the early 1950s and a generation or two thereafter, because dental health was so bad that just about any improvement moved the needle on the gauge. But now, fluoridation is fairly standard and so many dental products are fluoridated that people are actually afraid of getting too much fluoride. And fluoride is not without controversy. Plus, fluoride is a double-edged sword -- it hardens enamel so much that decay can only start in tiny pits and grooves, and the decay goes slowly, until it reaches the underlying dentin, and then it mushrooms quickly. So, despite widespread fluoride use, decay still occurs but it’s not as obvious as it once was when it made huge black holes that you could easily see. Now, the decay is insidiously small and hidden, until it eventually blows up in your face.
So we really need more and better primary prevention, which is on the individual level. Individuals themselves must now be responsible for their own dental health because the primordial prevention has done its best, and can’t do any better. And since dental offices only do types 2 and 3 prevention, that leaves type 4 prevention for the authorities and watchdogs. So, type 1 is the missing link.
Look at all the public knowledge now about simple handwashing. People have always known about handwashing. But now it’s more mainstream than ever. Why? Because people were suddenly taught why and how. The same should happen with oral health. People have long known the importance of cleaning between teeth. Yet only about 20% of Americans floss or clean between teeth in any way, no matter how much they are cautioned to do so. And most people brush incorrectly despite years of dental visits and constant reminders. There may be more (and better) internet videos on handwashing by monkeys, raccoons, cats, and people than there are of brushing and flossing for oral health. This is a shame, because dental problems are a silent epidemic, and not only in America, but all over the world. People need to know that decay and gum problems are actually infectious diseases.
One of my patients had a tooth problem. I told her she had an abscess and needed a referral to the root canal doctor. When she got to the root canal doctor, he told her he could see the infection on the x-ray. She was angry with me that I didn’t tell her she had an “infection”. It’s crazy, but people don’t associate gum problem or abscess with anything important unless you say the word “infection”. Thus everyone on Earth should know right now that tooth decay and gum disease are infections! We should stop dumbing things down. We didn’t dumb down COVID19, (except for some politicians).
Luckily, one good thing that has come of this crisis is the realization to everyone about how a tiny particle can travel the whole world in a few months and cause widespread havoc, yet only 20 seconds of soapy handwashing can kill it. It’s similar with dental problems. However, dental problems affect us in slow-motion, so we don’t see the effects as fast as with COVID19. Gum problems cause chronic subclinical inflammation throughout the body that takes years to run amok. But with COVID19, the chronically damaged systems suddenly become acutely affected. Poor oral health affects heart, vessels, lungs, intestines, and even the brain. COVID19 exacerbates those areas and “POOF!” the chronic suddenly becomes the acute, and now the underlying dental-related problem is exposed.
What I propose is more attention to proper “dentalwashing”. But it can’t be learned in dental offices because dentists are focused on secondary and tertiary prevention treatments. Dentists can’t immediately switch to primary prevention because it doesn’t make immediate money, and the traditional way dentists make money is to produce infectious aerosols by drilling. Furthermore, dental offices are scary places, especially now, considering the tremendous amounts of infectious aerosols that are created all day long. Lastly, the dental office is a terrible place to learn anything. Emotions are too high. Patients just want to get in and get out. But when they get home they have questions and are in the mood to learn.
So, the only thing left to do is to teach primary prevention online with the amazing advances of online courses, easy video production, group coaching with webinars, private social groups and forums, in the comfort of home, and on mobile devices, or anywhere – EXCEPT the dental office.
Dr. Steve Edwards