Overtreatment? What's overtreatment?

Oct. 1, 2001
Let's draw a line! How about this? Overtreatment is a treatment that has no remediable qualities.

Let's draw a line! How about this? Overtreatment is a treatment that has no remediable qualities.

The term overtreatment is just as it implies. Shooting a fly with a bazooka is a good example of overtreatment. Dentally speaking, the term "overtreatment" has been showing up more and more. Lately, the term has been used when discussing nearly every aspect of dentistry and dental hygiene.

For example, a 20-year-old college student presents with no history of decay. The patient has no plaque, flosses multiple times a week, has sealant remnants on the six-year molars, the second molars are sealed soundly, and the rest of the mouth is calculus-free.

Is this patient a candidate for a topical fluoride treatment? Is this patient a candidate for sealant replacements on the first molars and initial placement on the premolars? What if the premolars had those stained grooves? What recare schedule would you have this patient on? Would a biannual recall be considered overtreatment? What about blowing out those stained grooves with a microabrasion unit, then sealing them? How about a fissureotomy? How about a decision to take yearly X-rays? Where is the overtreatment point? What would be considered under treatment? Is there a clear line?

The use of systemic antibiotics in the treatment of periodontal disease is becoming extremely important. Up until the last five years, general dentists would hesitate to jump to that treatment modality. The understanding that periodontal disease is an infection and infections are best treated with antibiotics finally sank in. Timing is everything, they say, and dentistry started embracing antibiotic therapy just around the time the medical community started to campaign against indiscriminate use of that class of drugs.

Now dentistry is in a quandary. Is the use of systemic antibiotics to treat bacterial infections of the mouth an indiscriminate use? Should antibiotics be used for all cases requiring periodontal therapy? Would that be considered overtreatment? If microbial testing is done before the prescription is written, is that overtreatment?

While on the subject of treating periodontal disease, a lot of research refutes the notion of super-smooth roots and root-planing. So, the term SRP is outdated and the nature of the RP portion was shown to be unnecessary. Chemical and mechanical removal of the pathogenic bacteria is all that's necessary to achieve resolution — not recontouring root surfaces. Overinstrumentation of the root surface has unwanted consequences more severe than root sensitivity. Is root-planing overtreatment? Is tossing hand instruments in favor of microsonic root debridement undertreatment?

There also is a movement in dentistry that is picking up speed regarding the timing of restorative enamel surgery. Science says to allow early lesions to "heal themselves." Following specific measures, a patient can treat early decay with a combination of low-dose, long-duration fluoride, chlorhexidine rinses, and xylitol as ingredients in gum and candies that help to remineralize a carious lesion. An early lesion can heal without surgery. Since specific steps are necessary to remineralize the lesion, sending a patient home with nothing other than a recare appointment is not filling the bill.

Would placing small amalgams be considered overtreatment? How about sending a patient home with a "watch" area? Would that be classified as undertreatment? Should we test all excision sites for bacteria levels before "closing the wound?" Should patients with rampant decay have bacteriologic studies done before enamel surgery to ensure a positive outcome? Is that overtreatment?

While one hygienist may suggest periodontal therapy to the doctor, another may try another session of OHI. Opinions are relative to the clinician's education and, unfortunately, experience. While experience is helpful, it is overrated in the field of dental hygiene where science and research must rule when making clinical decisions.

It is my personal clinical experience that patients who use modified hairbrushes to clean their teeth have healthy mouths. I know a couple of hygienists that have that same experience. While it may make for an interesting research study, we cannot go forth and recommend hairbrush modifications for our patients to use in their mouths.

The term overtreatment is nebulous. Like pornography, we know it when we see it, but it's difficult to make hard and fast rules describing it. Its abstract nature makes drawing a line difficult. So now what?

Let's draw a line! How about this? Overtreatment is a treatment that has no remediable qualities. Since one practitioner's overtreatment is another's undertreatment, setting the line here eliminates classifying as overtreatment things like fluoride treatments for adults in any decade of life who exhibit no tendencies toward decay. While not cost-effective or necessary, it certainly is not overtreatment. Neither is yearly perio probing on all adults as a matter of course, or three- month recare appointments on patients with good home care.

However, polishing enamel with coarse paste every three months would be considered overtreatment, since the structure of the enamel is damaged without remedy. The same goes for planing root surfaces at each quarterly maintenance visit. This definition makes the term "overtreatment" more definitive, easy to use, and quantifiable.

Now that the "handle" is there, use it. Are you overtreating your own patients? Is the treatment you are providing remediable? Are your periodontal-maintenance patients overpolished, or overinstrumented? When your patient has an area of incipient decay, do you follow a protocol to remineralize the lesion?

Use science to your patient's benefit ... and feel better than ever about your treatment.

Shirley Gutkowski, RDH, BSDH, has been a full time practicing dental hygienist in Madison, Wis., since 1986. Ms. Gutkowski is published in print and on Internet sites, and speaks to groups through Cross Links Presentations. She can be contacted at [email protected]