Sealants vs. PRR

A problem that I have never seen addressed is bothering me. The doctor I work with does not believe in placing sealants. Instead, he opens the pits and fissures and places resin fillings. The problem (at least to me) is that sometimes there is no evidence of decay radiographically, visually, or tactilely.

He is the boss, but sometimes I feel he is doing unnecessary dentistry.

Dianne Glasscoe, RDH, BS

Dear Dianne,

A problem that I have never seen addressed is bothering me. The doctor I work with does not believe in placing sealants. Instead, he opens the pits and fissures and places resin fillings. The problem (at least to me) is that sometimes there is no evidence of decay radiographically, visually, or tactilely.

This change all began when the doctor purchased an air-abrasion machine. This technology usually allows for placing fillings with no anesthesia.

As a hygienist, I know that I am not allowed to diagnose, and I do not ever outwardly question the doctor`s diagnosis. However, I have been in dentistry for 15 years and have seen thousands of people with decay. Nor am I blind or stupid! There are times when I feel caught in an ethical dilemma. He is the boss, but sometimes I feel he is doing unnecessary dentistry.

I was trained in school to place "preventive" sealants. The whole purpose is to prevent decay, thus preventing the patient from having restorations in susceptible areas and preserving tooth structure. What he is doing seems counter to the ideal of preserving tooth structure.

Should I talk to the doctor about my feelings?

Wondering in Washington

Dear Wondering,

You have opened a subject that has spurred heated and emotional debate among practicing dentists for some time. Let`s take a closer look at this issue.

The term "preventive resin restoration" (PRR) was coined by Dr. Richard Simonsen of Minnesota in 1977. It was used to describe a minimally invasive procedure that fell somewhere in between a sealant and a Class I amalgam. The PRR was designed to prevent the Class I amalgam, not to allow unscrupulous dentists to enrich themselves at the expense of their trusting patients.

You stated that the shift in thinking came after the doctor purchased his air-abrasion machine. I find this interesting, because any procedure that can be done with air abrasion can be done with a high-speed handpiece and a small bur. In other words, if the doctor felt PRRs were providing better dentistry, why weren`t they being done before the purchase? Marketing by some air-abrasion manufacturers stresses that the PRR area is ideal for air abrasion. However, to use air abrasion routinely as a diagnostic tool seems to cross the line into unnecessary restorations. Since resins are billed at a higher cost than sealants to the patient, there is certainly an increase in production. Here`s a direct quote from an air-abrasion manufacturer: "Convert five sealants to five preventive resin restorations a month and you`ll have happier patients, provide better dentistry, and have enough money to afford a complete MicroDentistry™ System."

Sealants are sometimes unsuccessful. However, they were never intended to be a type of permanent restoration. The original thinking was that if we could somehow seal off the grooves and pits of permanent posterior teeth during the adolescent and teen years and keep them decay-free during this period, there was a strong indication those teeth would remain decay-free, even if the sealant came out later. Studies have shown that it is during those critical years (ages 6 - 20) when most occlusal decay occurs. Placing a posterior resin does not guarantee that a future larger restoration will not be needed. Nothing lasts forever.

However, there are times when every dentist struggles with the decision of whether or not to restore. Sometimes pits are suspicious without being overtly carious. Deciding whether a tooth needs treatment and what treatment would be appropriate happens to be one of the most difficult decisions a dentist has to make.

Dentistry is experiencing many new technological advances that will undoubtedly change the way we operate in the future. Ideally, these advances should make us better clinicians and improve treatment for our patients.

However, it is fraudulent to charge for a restoration when no caries exist. To quote Dr. Simonsen, "To place a restoration (an irreversible, invasive procedure) when a preventive treatment is indicated, is an egregious breach of the trust put in us by our patients. When caries is suspected, an exploratory widening of the fissure with either air abrasion or a small bur to such a point as to be able to say with certainty that there is caries present (and then remove it and place a PRR), or to confirm that caries is not present (either seal or use PRR if enamel has been penetrated) is justified." When no decay is evident or suspected, the treatment should be preventive.

Documented cases exist of patients leaving practices when they felt overtreatment and overbilling were problematic. Dentists also have been prosecuted for overtreating and overbilling. Such abuses contribute to a growing distrust of our profession by the public. The price of this abuse extends to deteriorating employee loyalty and admiration. Further, this abuse works to strengthen the position of those who wish to manage dental care through health-maintenance organizations. Can we not manage ourselves?

I tend to believe that most dentists are hard-working, ethical professionals who try to do the best they can to take care of the people who place their trust in them. However, it is naïve to believe that there are no crooks in the profession. There are crooks in every profession.

I believe you should talk to the doctor and relate how you feel. If you are uncomfortable with the treatment protocol, maybe some communication between the two of you will help you to reconcile in your own mind his decision to change. If you like him and are comfortable working with him, maybe you will come to understand what he is trying to accomplish.

While diagnosis is not in the purview of hygienists, I believe hygienists are certainly in a position to sense when fraud is being committed. Further, when loyalty and trust are lost, it is best to move on.

However, you should not immediately assume that fraud is being committed without first talking with the doctor. I truly hope this is one of those situations where lack of communication is to blame for the uneasy way you feel.

Dianne

Dianne Glasscoe, RDH, BS, is an adjunct instructor in clinical hygiene at Guilford Technical Community College. She holds a bachelor`s degree in human resource management and is a practice-management consultant, writer, and speaker. She may be contacted by e-mail at dglasscoe@northstate.net, phone (336) 472-3515, or fax (336) 472-5567. Visit her Web site at http://www.professionalden talmgmt.com.

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