Are we choosing wisely?
Realistic Dentistry is not about doing less; it is about doing what matters most
Dentistry often operates in shades of grey, with clinical decisions rarely black-and-white and multiple treatment options that may all be appropriate. This uncertainty can challenge both patients and dental teams, from weighing potential risks and benefits to navigating patient preferences and expectations.
Realistic Dentistry, grounded in the principles of Realistic Medicine, provides a framework to navigate these complexities. By placing patients at the centre of care and focusing on outcomes that matter most, it supports evidence-based, personalised decision-making that is clinically sound, sustainable, equitable and professionally fulfilling.
Effective treatment planning requires careful consideration of the Benefits, Risks and Alternatives and the consequences of Doing Nothing (BRAN), a framework that helps ensure decisions are transparent, patient-centred and aligned with best practice.
At the Scottish Dental Show 2025, we delivered a workshop introducing Realistic Dentistry, with a particular focus on shared decision-making in primary care. Designed for all members of the dental team, the session was very well attended.
We used a world café-style approach, applying the BRAN framework to explore three common scenarios: paediatric caries, recall intervals and antibiotic prescribing – all supported by relevant Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance to reinforce evidence-based practice.
Discussions were focused on three scenarios and are summarised here:
Scenario 1: Paediatric caries
Nina, aged seven, from a Scottish Index of Multiple Deprivation (SIMD) 1 area, has dental anxiety and multiple carious lesions; early caries in eight deciduous teeth and extensive decay in one requiring extraction. Medically fit, she is pre-cooperative for extractions in the dental chair. She has three siblings, and the nearest public dental service (PDS) clinic is a 50-minute bus journey. Her first permanent molars have recently erupted. Nina has been placed on the general anaesthetic (GA) waiting list with an estimated one-year wait.
Children presenting with advanced dental caries face immediate pain, infection, and collateral effects on wellbeing, schooling and family dynamics. Prompt intervention offers tangible benefits such as pain relief, infection control, avoidance of antibiotics and emergency visits and improved quality of life. GA allows comprehensive treatment in a single session but entails inherent risks, potential delays and the possibility of otherwise restorable teeth deteriorating further.
SDCEP’s Prevention and Management of Dental Caries in Children guidance advises a risk-based recall strategy: children at higher caries risk should receive enhanced prevention (such as fluoride varnish) every three months, while others may be seen every six months, with flexibility for longer intervals when justified and documented.
Alternatives, including Hall crowns, silver diamine fluoride, pulpotomies, sedation-assisted extractions, plus preventive measures, can stabilise disease while building trust. Doing nothing risks recurrent pain, complex infections, potential hospitalisation and developmental tooth damage, potentially causing greater disruption to the child and their family.
Scenario 2: Realistic recall
Jennifer, 48, attends as a new patient. Medically, Jennifer is fit and well, doesn’t smoke, drinks alcohol well within recommended limits, and has a good diet. On examination, you note exemplary oral hygiene, with Code 0s during the BPE. You communicate this to Jennifer, who asks if she is getting a scale and polish today – her previous dentist did one every six months. Jennifer does not like them at all but knows they have been part of her care.
Tailoring dental recall intervals to individual risk offers clear Benefits: low-risk patients can safely have longer recalls, improving convenience, reducing costs, prioritising dental professional time and boosting satisfaction while avoiding unnecessary scaling or polishing that can damage enamel. Risks include misclassifying patient risk, delayed detection of caries, periodontal disease or oral cancer, but also the potential for overtreatment or unnecessary invasive procedures, setting precedents for future care.
Alternative strategies, such as electric toothbrush use, targeted oral hygiene instruction, selective hygienist referral, praising good oral hygiene or offering an initial six-month review, may maintain standards and motivate patients. Doing nothing in the form of universal six-month appointments, or simply giving the patient what they want, may avoid immediate conflict but risks inefficient NHS resource use and unnecessary treatment.
Scenario 3: Antibiotic prescribing
Umar, 32, attends for an emergency appointment. Umar is fit and well with generally good dental health but has a recently placed large restoration in his lower left first molar. You diagnose irreversible pulpitis. Umar is insistent on receiving antibiotics – he wants out of pain. However, there are no indications.
When faced with acute dental pain, some patients expect antibiotics as a quick remedy. The benefits of this are transient relief, patient satisfaction and building trust to allow the clinician time to listen, explain treatment options and help the patient absorb information about the need for extraction. Prescribing antibiotics without addressing the cause, however, carries significant risks, such as antimicrobial resistance, adverse drug effects, postponement of definitive treatment and setting patient expectation precedents. SDCEP’s Drug Prescribing for Dentistry guidance5 emphasises accessing up-to-date prescribing information via the SDCEP Dental Prescribing website, aligning with BNF/BNFC standards.
Alternatives include extraction, pulpotomy, root canal treatment or the use of analgesics or sedation for anxious patients. Clinicians can also provide counselling about the limited role of antibiotics, advice on pain relief and create time for the patient to consider their options by numbing them up to enable informed decision-making without pain. Doing nothing in relation to a toothache was considered unethical. Without intervention infection can progress rapidly to abscess, systemic spread, and potential hospital admission.
Conclusion
The BRAN framework underscores the importance of informed, evidence-based decision-making in dentistry. This workshop demonstrated how BRAN can be applied in practice to support shared decision-making conversations between patients and their dental teams across a variety of clinical scenarios.
Whether managing childhood caries, planning recall intervals, or responding to requests for antibiotics, clinicians must carefully weigh the Benefits, Risks, Alternatives or whether they can Do Nothing, while communicating openly and empathetically with patients.
It is important to note that these insights were generated during a one-hour session without direct patient involvement. Further options and perspectives may emerge during real-world patient and clinician conversations.
Realistic Dentistry is not about doing less; it is about doing what matters most. By aligning care with patients’ needs and national guidance, clinicians can deliver treatment that is evidence-based, patient-centred, equitable and sustainable.
Do you have a scenario that you would like to share about successful shared decision-making? If so, please let us know by contacting Heather Cassie.
Acknowledgements
Many thanks to those who attended the workshop and contributed to the discussions and thank you to members of the Realistic Dentistry group who helped to develop the case study scenarios.
This work forms part of a research fellowship with The Healthcare Improvement Studies (THIS) Institute awarded to Dr Heather Cassie. The fellowship was funded by the Health Foundation as part of a grant to the University of Cambridge supporting THIS Institute.
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