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| SUNDAY, JULY 26, 2026
Cavities Don’t Always Need A Filling
(PHOTO COURTESY OF ISTOCK IMAGES)
By Erik Vance
layer of the tooth, called the dentin, then it’s a judgment call whether to intervene, said Getting a filling at the dentist can be painful, expensive Dr. Sara Stuefen, a dentist in Vinton, Iowa, and a spokesand generally miserable. A person for the American crown or a root canal is even worse. Still, you do it because Dental Association. “Sometimes we still have your dentist says you should. a chance,” she said. Better But in a surprising number of cases, you might have brushing and flossing, plus cutting back on sweets or cofanother choice. Where one dentist sees a crown, another fee, could stop the damage. might see just a filling. And “A lot of our patients don’t where one recommends realize that you can actually reverse a carie when it’s in drilling, another might suggest trying some prescrip- its earliest stages,” added Dr. tion toothpaste first. In other Diana K. Nguyen, an associate clinical professor of dentistry words, a dentist’s prognosis is not always the final word. at the University of California, Training, personal philosophy San Francisco. and economics can all play a Once the decay gets into the softer dentin layer, most role. dentists will immediately “A dentist that graduates in 2026 versus a dentist that recommend a filling. But even graduates in 1999, they might then, approaches differ. Some have two completely different dentists will use a crown once treatment plans,” said Shelbey 50% of a tooth is gone or Arevalo, the chief executive filled. Others might set that of National Dental Advocacy threshold higher. Program, which helps patients navigate the dental healthcare Standards of care are changing. system. So how do you know if you Like any branch of medihave gotten the right progno- cine, dentistry is constantly sis for you? And when should evolving. One of the biggest trends is toward minimally inyou seek a second opinion? vasive dentistry, which limits Here is what you need to know for your next visit. drilling when possible. “In the last 50 or 60 years, Not all dentists we have gotten much more agree when to drill. conservative than we were Cavities (called caries by before,” said Dr. Margherdentists) are any damage to a ita Fontana, a professor of tooth’s surface caused by acid dentistry at the University of produced by bacteria in your Michigan. “There are a lot of mouth. The deeper the decay preventive interventions that goes, the bigger the problem. cost very little.” For example, we’ve known While this may sound clearcut, it often isn’t. for decades that prescription-strength fluoride toothIf the acid is wearing paste and mouthwash can through the outside enamel help halt and reverse early but hasn’t gotten to the next The New York Times
tooth decay, Nguyen said. Dentists can also sometimes stop cavities with fluoride varnishes and prevent them with dental sealants, which were once recommended only for children, Fontana said. There are also newer, less-studied products that can help rebuild a tooth. One is Curodont, a liquid that dentists apply to a problem spot that attracts calcium and phosphate from saliva, reconstructing tooth enamel. Another is MI paste, which releases minerals into a person’s teeth, Nguyen said. Dentists have also developed alternatives to root canals over the decades, Fontana added. Sometimes a deep cavity close to a tooth’s nerve can be sealed off, a little like an Egyptian tomb, in an approach called selective caries removal. It’s worth noting that newer prevention treatments might not be covered by insurance, Fontana said. And while these practices are spreading, not all dentists are familiar with them, Stuefen said. And new dentists can receive mixed messages in their training, Fontana added. Dental schools tend to emphasize conservative treatment, yet when the students take the test for most dentistry licenses, not treating a cavity that is halfway through the enamel generally means failure.
Money plays a role. Of course, dentistry is not just medicine: It’s also a business. And fillings and crowns are more lucrative than cleanings, which can create
unconscious incentives to drill a tooth with a borderline cavity. “The more surgical intervention you do, the greater the financial payout,” Nguyen said. “You can’t bill out for watching something over and over.” Another trend in dentistry is the rise of dental support organizations, or DSOs. These are corporate institutions that partner with or buy dentist offices and manage their administration. While DSOs are generally barred from directly influencing medical decisions, several states have brought lawsuits citing a corporate culture that pressures dentists to maximize profit. California recently passed legislation meant to limit DSOs’ power and New York has been considering a similar law. “They promise high salaries but they also expect a certain level of productivity that may not necessarily align with a more conservative practice of dentistry,” Nguyen said.
What should you do? Ask questions.
To get a feel for a new dentist, the experts recommended asking about their philosophy or approach before starting treatment. It’s a good sign when a dentist is familiar with preventive measures, looks for minimalist approaches and communicates clearly, Nguyen said. “If the dentist is rushing and says, ‘I don’t have time to explain this to you, you can speak to one of my staff,’” she said, “I would consider that a
red flag.” When you have a cavity, make sure you understand the prognosis, said Arevalo of the National Dental Advocacy Program. Ask if there are any preventive options you might try before drilling. Is there a way to avoid replacing the whole tooth? Are there more affordable materials for a crown?
but Arevalo recommended not sharing the prognosis, so as to get an unbiased opinion.
Build trust.
It’s helpful to develop a relationship with your dentist, the experts said, where they listen to you and know your history, and where you trust their advice. And you need to do the work at home. Remember that dentists How to get a make judgments based in second opinion. part on patient history. If you If you have any doubt about have immaculate teeth and a diagnosis and are not in im- excellent habits, your dentist mediate pain, you can always may be more inclined to hold get a second opinion. Telling off drilling, said Nguyen. But your dentist that you want if you don’t come in as often, this can be awkward, Arevalo have a mouthful of fillings acknowledged. But if a dentist and crowns or take medicadissuades you from getting tions that might dry out your mouth, that can influence the one, Nguyen said, that’s anprognosis. other red flag. Either way, a second opin“You come to us, what, ion means going to another twice a year?” Fontana said, adding: “I can recommend office and sitting for another examination. Simply sending products that work. I can use X-rays to a second dentist is things in office to help prolong the prognosis of everything not enough, she added. we’re going to do. But ultiSome dental insurance plans will cover second opin- mately, it’s up to you.” ions; others will not. Sending your X-rays (which you have the right to request) will save some money,