Bias in dentistry

By Tabitha Acret, BOH, Grad.Cert (Public Health), current master’s student

Dental recommendations are an essential aspect of oral health care.

Patients trust dental professionals to provide accurate and unbiased recommendations on how to maintain good oral health. However, biases can influence dental recommendations, leading to suboptimal care and outcomes. Bias comes in many forms - from confirmation, cultural, gender and financial. It’s important to understand bias so that we can put strategies in place to avoid it.

Confirmation bias

Confirmation bias is a type of bias that occurs when dental professionals rely on their preconceived notions or beliefs rather than objective evidence to make recommendations.

A form of confirmation bias in dentistry is the way we make decisions on what we recommend to patients. An example of this is interdental cleaning. Many dental professionals recommend floss as their number one go-to tool for interdental cleaning. However, floss has very limited evidence to support its use and there is clear evidence that interdental brushes, where they fit, are better for biofilm removal and reduction in inflammation. A systematic review from Slot et al in 2020 showed interdental brushes to be superior to floss for interdental cleaning.

However, despite strong evidence, many dental professionals continue to recommend floss. Why do they do this? Confirmation Bias. This is the tendency to make decisions that support our preconceived beliefs while ignoring or discrediting those that do not. We believe that floss is the correct choice because of historical evidence and what advertising and other colleagues are doing.

We can also have confirmation bias when reading literature and evidence, in other words we believe what we want to believe; the way we take in the information, sort through it and use it in the clinical setting can also come with bias.

previous studies, including one that indicated women are more likely to be given sedatives for their pain and men given pain medication and concluded that women were more likely to be inadequately treated by healthcare providers.

Financial Bias

Financial bias can also influence dental recommendations. Dental professionals may recommend procedures or treatments that are not necessary to generate more income. In a study from Ghoneim et al, it showed that dentists’ clinical decisions were directly influenced their recommendations on clinical evidence and not being influenced by external factors such as financial incentives.

In conclusion, biases can significantly influence dental recommendations, leading to suboptimal care and outcomes. Confirmation bias, cultural bias, gender bias and financial bias are some of the types of bias that can occur. Strategies to mitigate bias include training, use of evidence-based guidelines, patient-centred care and professional autonomy. By recognising and mitigating bias, dental professionals can improve the quality of care provided, leading to better oral health outcomes for patients.

References

1. Iske, J., Davis, D. M., Frances, C. & Gelbier, S. 1998. The emotional effects of tooth loss in edentulous people. British Dental Journal, 184, 90-93.

2. Ghoneim, A., Yu, B., Lawrence, H., Glogauer, M., Shankardass, K. & Quiñonez, C. 2020. What influences the clinical decision-making of dentists? A cross-sectional study. PLoS One, 15, e0233652.

3. Hoffmann, Diane E. and Tarzian, Anita J., The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain (2001). Available at SSRN: https://ssrn.com/ abstract=383803 or http://dx.doi.org/10.2139/ssrn.383803

4. Nickerson, R. S. 1998. Confirmation Bias: A Ubiquitous Phenomenon in Many Guises. Review of General Psychology, 2, 175-220.

Cultural bias

Cultural bias can influence dental recommendations. For example, dental professionals may recommend certain dental procedures based on cultural norms rather than clinical evidence. A study in 2019 from Patel et al, found that cultural beliefs and practices influenced dental recommendations. The study found that dental professionals were more likely to recommend extractions rather than restorative procedures for patients from certain cultural groups.

Gender bias

Gender bias can also play a role in dental recommendations. Dental professionals may recommend different treatments or procedures based on the patient’s gender. In 2001, University of Maryland academics Diane Hoffman and Anita Tarzian published The Girl Who Cried Pain, an analysis of the ways gender bias plays out in clinical pain management. They examined several by the financial challenges such as educational debt and large practice loans. The study suggests facing financial hardships, dentists may overtreat or recommend unnecessary procedures to alleviate some of their financial pressures, leading to overdiagnosis and overtreatment.

Strategies to mitigate bias

Training dental professionals on how to recognise and mitigate bias is essential. Training on cultural sensitivity, unconscious bias and implicit bias can improve the quality of care provided. Using evidence-based guidelines can also help mitigate bias in dental recommendations.

Evidence-based guidelines consider the latest research and provide a standardised approach to diagnosis and treatment.

Patient-centred care can also help mitigate bias in dental recommendations. Patient-centred care considers the patient’s preferences, values and beliefs in the decision-making process.

Finally, we should strive to maintain professional autonomy. This means basing

5. Patel, N., Patel, S., Cotti, E., Bardini, G. & Mannocci, F. 2019. Unconscious Racial Bias May Affect Dentists’ Clinical Decisions on Tooth Restorability: A Randomized Clinical Trial. JDR Clin Trans Res, 4, 19-28.

6. Slot, D. E., Valkenburg, C. & Van Der Weijden, G. A. F. 2020. Mechanical plaque removal of periodontal maintenance patients: A systematic review and network meta-analysis. J Clin Periodontol, 47 Suppl 22, 107-124.

About the author

Tabitha Acret graduated from Newcastle University with a Bachelor of Oral Health and is currently studying her Masters in Public Health. She was previously the National Vice-President for the DHAA. Tabitha currently works as a clinical educator for implant maintenance and non-surgical periodontal therapy and lectures nationally and internationally on motivating patients, implant maintenance, disease prevention and periodontal therapy. Outside of her busy work life of lecturing and working clinically in private practice, Tabitha enjoys volunteering both locally and internationally to raise awareness and education of the benefits of good oral health. She was the winner of the 2018 leadership award in dental hygiene and 2019 award for clinical excellence.

DQuestion 1. Relying on preconceived notions or beliefs rather than objective evidence to make recommendations leads to: a. Confirmation bias b. Cultural bias c. Gender bias d. Financial bias e. All of the above

Question 2. Recommending extractions rather than restorative procedures for patients from certain ethnic groups is termed: a. Confirmation bias b. Cultural bias c. Gender bias d. Financial bias e. All of the above

Question 3. A study indicating women are more likely to be given sedatives for their pain and men pain medication is an example of: a. Confirmation bias b. Cultural bias c. Gender bias d. Financial bias e. All of the above

Question 4. A clinician who overtreats or recommends unnecessary procedures to increase their income is an example of: a. Confirmation bias b. Cultural bias c. Gender bias d. Financial bias e. All of the above

Question 5. Bias can lead to suboptimal care and outcomes: a. True b. False a. 12% b. 27% c. 41% d. 50% e. 62% a. Arthritic Disability Level b. Activities of Daily Living c. Acute Diabetic Lymphangitis d. Activities for Diabetic Living a. Salivary gland hypofunction. b. Gingival overgrowth. c. Unprogrammed coughing. d. All of the above. a. Prescription oral medications. b. Non-oral prescription medications such as inhalers, patches, injections, etc. c. Over-the-counter medicines purchased at a pharmacy. d. Alternative health products. e. All of the above. a. 73 years b. 79 years c. 80 years d. 84 years

Question 6. What percentage of men over 65 suffer from arthritis?

Question 7. ADL stands for...

Question 8. Prescription medicines used to manage hypertension can cause...

Question 9. A key element of the successful oral health management of elderly patients is to analyse the impact on oral health of...

Question 10. In 2021, the life expectancy at birth for men is over...

Part 1 -

Question 11. Being able to recognise the environmental impacts of health care provision is an expected new graduate competency detailed in a statement from the: a. Australian Dental Association b. Australian Dental Council c. Australian Health Practitioner Regulation Agency d. Dental Board of Australia a. Chemically breaking down plastics to a biodegradable compound. b. Treating plastics in preparation for recycling. c. Misleading product labelling to make it seem more biodegradable. d. Using biodegradable detergents in a washing machine.

Question 12. Greenwashing is...

Question 13. A bioplastic is typically made from: a. Plants b. Natural polymers c. Natural monomers used to create polymers. d. Any of the above a. Polyhyroxyalkanoates b. Polycaprolactone c. Polybutylene succinate d. Polyglycolic acid a. 30% b. 50% c. 70% d. 90% a. Job prospects. b. Marks at school. c. Social life. d. Overall systemic health.

Question 14. A biodegradable plastic made using starch and sugar is...

Question 15. What percentage of a plastic must be converted into carbon dioxide gas within 6 months to satisfy ISO 13432?

WQuestion 16. A teenager typically cares about having a healthy smile because it helps improve their...

Question 17. Smoking and vaping can lead to: a. Bad breath. b. Tooth staining. c. Periodontal disease. d. Oral and throat cancers. e. All of the above.

Question 18. A good food to recommend to teenagers is: a. Whole-grain products, such as cereals, breads and crackers. b. Dairy products, such as milk, cheese and unsweetened yogurt. c. Meats, fish, chicken and eggs. d. Legumes and nuts. e. All of the above.

Question 19. A teenagers oral health can be affected by: a. Consuming energy drinks. b. Vaping. c. Tongue piercings. d. Orthodontic brackets and appliances. e. All of the above. a. 8% b. 11% c. 13% d. 18%

Question 20. According to the article, what percentage of teens have untreated cavities that could lead to infection?