Medicine has approximately 15,000 doctors specializing in preventive medicine.¹ Dentistry has zero. The American Dental Association has never established a specialty branch dedicated to disease prevention. Not in its founding years, not during the public health movements of the twentieth century, not now.
The recognised dental specialties — endodontics, periodontics, prosthodontics, orthodontics, oral surgery, pedodontics — all share one structural feature. Every one of them exists to intervene in advanced stages of disease or damage.² Reamers, removers, replacers, pushers, and gum cutters, as Nara put it with characteristic bluntness.² Every specialty treats super-sick teeth that the general practitioner won’t touch. None exists to keep teeth from getting sick in the first place.
The ADA could respond that all dentists practise prevention, and most do. The results speak against this. Nine out of ten Americans have disease in their mouths.³ Periodontal disease affects up to 90 percent of the population worldwide.? If most dentists practise prevention, it doesn’t show — anywhere.³
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The Structure Behind the Silence
The absence of a prevention specialty is not an oversight. It is the predictable outcome of an economic structure that cannot accommodate prevention without destroying itself.
A dentist graduating today carries substantial educational debt. The practice has rent, equipment costs, staff salaries, insurance, and supplies. Revenue comes from procedures. The more complex the procedure, the higher the reimbursement. A root canal pays more than a filling. A crown pays more than a root canal. An implant pays more than a crown. The economic incentive flows in one direction: toward greater intervention on sicker teeth.
Nagel described this plainly. The dentist with medical school debt, a family to support, staff to pay, needs to make significant money to stay in business. The more teeth that are drilled and filled, the more money is made. There is not much incentive in this system for curing and preventing cavities, because without the drilling and filling business model it becomes a challenge to turn dentistry into a profitable career.?
Breiner identified the specific mechanism that locks this in place: the insurance reimbursement structure. Treatment decisions have become skewed by what he called the “drill, fill, and bill” game — procedures selected based on what will be reimbursed by insurance, rather than on the intrinsic value of the procedure.? Many patients have relinquished responsibility for their own health by agreeing to anything as long as it is “covered.”?
This is not an accusation of individual malice. It is a description of structural incentives. A dentist who spends forty-five minutes educating a patient about nutrition, monitoring remineralisation, and adjusting dietary protocols generates no billable procedure code. A dentist who spends forty-five minutes drilling and placing a crown generates a substantial one. Insurance reimburses hardware — fillings, crowns, root canals, extractions, implants — not education, not nutritional counselling, not monitoring. The fee-for-service model does not have a category for keeping teeth healthy.
How Insurance Shapes Clinical Decisions
The mechanics of dental insurance make the prevention problem concrete at the chair level.
Dental insurance operates as a separate product from medical insurance, a structural separation that itself reflects and reinforces the isolation of the mouth from the body. Within this separate system, reimbursement codes are built around interventions. There are codes for amalgam restorations, composite fillings, crown preparations, root canal therapy, extractions, and implant placements. There are codes for cleanings and fluoride applications — the profession’s token gestures toward prevention. There is no code for assessing a patient’s nutritional status and its relationship to dental health. No code for monitoring dentinal fluid function. No code for counselling a patient on the dietary changes that could halt or reverse early decay.
Arnett, who spent seventeen years as a dental hygienist in a holistic practice, observed this from inside the system. Frequency of care and restorations are sometimes based on the amount the patient’s insurance will allow.? The insurance company, not the clinical picture, dictates the treatment timeline. Stainless steel crowns, for example, are favoured by paediatric dentists partly because insurance coverage is better for them than for alternative approaches.?
Levy documented how far this influence extends. Insurance companies have played a major role in causing modern dentistry to simply deny that certain dental conditions exist, because acknowledging them would require paying for their treatment.? Aetna’s clinical policy bulletin, for instance, declared the surgical debridement of cavitations “experimental and investigational,” effectively making it economically impossible for dentists to treat a condition that multiple researchers have documented with pathology reports and bacterial cultures.? When an insurance company can define the dental standard of care and question the legitimacy of dental science, the economic tail is wagging the clinical dog.
The separation of dental insurance from medical insurance matters beyond the billing department. It reinforces a conceptual boundary — the mouth is not part of the body — that makes systemic prevention invisible. Medical insurance covers preventive screenings: blood panels, cardiovascular risk assessments, cancer screenings. These exist because medicine, whatever its own failures, at least recognises that preventing disease is a category of care worth reimbursing. Dental insurance has no equivalent. The closest it gets is paying for two cleanings a year and occasional X-rays. These are surveillance activities, not prevention. They detect disease that has already progressed far enough to be visible on film or palpable under an instrument.
The result is a system where the patient sits in the chair, hears what is “covered,” and consents to whatever that is. Breiner was direct about this: patients have become conditioned to view fillings and repairs as normal, as problems that are part of the ageing process, and their ongoing treatments as something they deserve.? The possibility that their teeth could be maintained through systemic health rather than serial repair never enters the conversation, because no one in the room is paid to have it.
The Prevention That Isn’t
Sealants, fluoride treatments, and biannual cleanings are marketed as prevention. They are nothing of the kind. They are interventions performed on teeth in a dental office for a fee — hardware-paradigm activities dressed in prevention language.
Twice-yearly cleanings address accumulated plaque and calculus. They do not address why plaque and calculus are accumulating. Fluoride treatments coat the tooth surface with a chemical agent. They do not address what is happening inside the tooth. Sealants fill pits and fissures with resin. They do not address the systemic conditions that make those pits and fissures vulnerable to decay in the first place.
These procedures share the defining characteristic of the hardware paradigm: they are things done to teeth. They generate procedure codes. They keep the patient returning to the office. They maintain the revenue cycle. What they do not do is prevent disease. The disease rates confirm this. After decades of sealants, fluoride, and cleanings, nine out of ten Americans still have oral disease.³
Munro-Hall, who practised dentistry for thirty-five years, named the pattern directly: many dental remuneration systems are based on the drill, fill, and bill basis, where the dentist is encouraged to see teeth as individual items in need of repair.? He identified the consequence as “supervised neglect” — the patient receives routine care that does not address the underlying dental problems, leading to greater dental and general health problems because the root causes are never solved.?
What Actual Prevention Would Look Like
The terrain paradigm reveals what genuine prevention requires — and why the profession cannot accommodate it.
Forty years of research by dentist Ralph Steinman and endocrinologist John Leonora documented that tooth decay is regulated by an internal system, not caused by external bacterial attack.¹? Teeth contain a constant microscopic flow of fluid through their dentinal tubules — a nutrient-rich lymph that originates from the blood supply, flows outward through the tooth, and emerges on the enamel surface.¹? This fluid flushes toxins, delivers minerals for constant rebuilding, and repels microbial biofilm.¹¹
This flow is regulated by the hypothalamic-parotid gland endocrine axis. The hypothalamus signals the parotid gland to release a hormone that controls the direction and volume of dentinal fluid.¹¹ When the system functions properly, teeth are self-cleaning and self-repairing. When the system is disrupted — by diets high in refined sugar and processed carbohydrates, by nutritional deficiencies, by hormonal imbalance, by stress — the fluid flow reverses.¹¹ Instead of flowing outward protectively, it draws bacteria and acids inward from the mouth. Decay follows.¹²
In the 1940s, at a meeting of the International Association of Dental Research, the acid/bacterial theory of decay was adopted as the official explanation — by vote, not by conclusive evidence.¹² The competing proteolysis-chelation theory, which pointed to diet, trace elements, and hormonal balance as the key factors, was sidelined.¹² Steinman and Leonora spent the next four decades producing hundreds of studies demonstrating that the bacterial theory was wrong and the systemic mechanism was real.¹¹ Their work was published. It was not refuted. It was ignored.
Prevention built on this understanding would look nothing like what dentistry currently offers. It would involve assessing the patient’s nutritional status, their hormonal balance, their sugar and refined carbohydrate intake, and the factors affecting their hypothalamic-parotid axis. It would involve dietary intervention — Steinman showed that simply changing the diet could restore dentinal fluid flow, and that the addition of key minerals to a sugar-producing diet nearly abolished the decay rate.¹³ It would involve monitoring, education, and ongoing support for systemic health.
It would also make most dental procedures unnecessary. If the body’s own maintenance system is functioning — if the invisible toothbrush, as Steinman’s work is sometimes described, is doing its job — then the progression from early demineralisation to cavity to filling to crown to root canal to extraction to implant does not occur. The entire escalation ladder that generates the profession’s revenue collapses.
This is the structural impossibility at the core of the profession. Actual prevention — restoring the internal terrain through nutrition so that the body’s own systems maintain the teeth — would eliminate the need for most of what dentists do. It would make most dental specialties unnecessary. The endodontist, the periodontist, the prosthodontist, the oral surgeon all exist to address advanced stages of a disease that the profession’s economic structure ensures will never be prevented.
Nagel saw where this leads. The future of dentistry lies in disease prevention through proper nutrition and body chemistry balancing, along with minimally invasive methods. Dentists could still earn decent livings by analysing blood chemistry, examining teeth, offering nutritional consulting, and repairing bite imbalances non-surgically.? But as long as a dentist’s income is tied to performing invasive treatments, where more severe treatments mean greater profit, the current state will remain.?
The Person in the Chair
The structural analysis matters because it lands on a specific person: you, the next time you sit in a dental chair.
When your dentist presents a treatment plan, that plan has been shaped by forces you cannot see. The procedures recommended are the procedures that generate revenue and that insurance will reimburse. The options not mentioned — nutritional intervention, monitoring for remineralisation, assessment of your systemic health as it relates to your teeth — are not mentioned because no one is paid to mention them. Your dentist was not trained in them. The insurance company will not cover them. The ADA has not recognised them.
You will not find a preventive dentist in your community. You cannot, because the profession has made it structurally impossible for one to exist.¹? It is a violation of dental professional ethics — and in many jurisdictions, of state law — to advertise a specialisation in prevention, because prevention is not a recognised specialty.¹? When Robert Nara placed a two-line advertisement in the Yellow Pages reading “Specializing in Oramedics — For people with teeth who want to keep them,” it cost him his membership in the ADA and resulted in a twelve-month suspension of his licence.¹?
The dental board that suspended him had first sent his case to a hearing examiner, who found no violation of dental law on the advertising charge.¹? The board voted 6-2 to suspend him anyway.¹? One of the two dissenting members voted against the suspension because he wanted it to be longer.¹?
Nara asked the question that the profession has never answered: which is more important — your health, or the dentist’s income?³ The ADA answered that question with its structure. It built a profession with specialties for every stage of disease and no specialty for preventing it. It built a reimbursement system that pays for drilling into teeth but not for keeping them whole. It adopted a theory of decay — by vote — that locates the problem in the mouth rather than in the body, ensuring that the solution would always require a dentist, a drill, and a bill.
When Nara tried to change this from within — teaching patients to prevent disease, advertising that prevention was possible — the profession responded not with evidence but with punishment. His licence was suspended. His membership was revoked. The message to every other dentist was clear: prevention is not your job. Your job is to wait for the disease to progress and then bill for the repair.
Yoho, a retired physician who turned his investigative attention to dentistry, described what he found: a profession where dental practices operate for profit in a way that produces a significant percentage of health problems, where patients return year after year with repairs becoming constantly more extensive, and where dental visits function as a maintenance system that does not stop the disease but simply keeps the symptoms within limits the consumer agrees to accept.¹?
The structure is visible. The specialties are listed. The insurance codes are published. And the number in the prevention column is zero.
Original article online at: https://unbekoming.substack.com/p/drill-fill-and-bill-why-dentistry