This is getting tedious so I will tighten it up a bit.
Cleanings should be appropriate to your clinical presentation. With excellent hygiene, they will be superficial and perhaps unnecessary except to remove stain (cosmetic). With your level of hygiene, they will be more aggressive and could require local anesthesia if you are experiencing pain or if you have periodontal disease, which sounds plausible.
I assume your polishing paste comments were hyperbolic, although if you develop COPD or silicosis perhaps we should revisit this. I know a great mesothelioma lawyer that I got found from an internet ad.
“I have an intense distrust of dentists, as I have found their "cavity detection rates" differ wildly.”
This is one of the greatest flaws of my field. It is a valid concern. We do not have a standardized approach to intercepting decay, and disparities among treatment plans for the same patient who sees different dentists are common. Sort of like medical doctors, no? (This does not justify it.) When in doubt, get a second opinion, and be open to the possibility that the more aggressive option could actually be better. The default/Bayesian prior should be that it is not. Different attitudes and moral hazard are risks we all take in every interaction during our lives. Literally every person we come up against could be here to help us or screw us. Usually it’s somewhere in the middle, skewed toward help. The only safe path away from rampant paranoia is back to the sanitized closet.
“...connection between gingivitis and coronary atherosclerosis, possibly mediated by inflammation, but this has mostly been discredited.”
The connection (correlation) has NOT been discredited. It is significant. However, causality remains uncertain. Evidence that treating periodontal disease results in reduced cardiovascular or other medical diseases is limited. It is probably strongest for pneumonia at present, and there are a few prospective studies that found improved BP, lipid profile, and vascular endothelial status after treatment. I wouldn’t hang my hat on them.
Okay, enough.
There are three important themes here. First is that patients are heterogeneous. What some consider acceptable risk, others would lose sleep over. Our mission should be to give them our best educated guess at their prognosis and options, and then honor their decision, even if it would not be ours. If you don't want to get your teeth cleaned, don’t. Second is that we are often ignorant, and should admit it. We just don’t know. Are annual bitewings net positive or net negative? Who knows? (I suggest that they are beneficial for people at risk based on their history, and overdone for those of us who haven’t had a cavity for years or decades.) Research is incrementally lighting the way, but even research is often flawed, open to multiple interpretations, or made irrelevant over time as the population and medical/dental care change. Third is the growing human impulse to say “I’m suspicious of my___________.” (doctor, lawyer, spouse, priest, dentist…) Versus “I LOVE my___________.” (acupuncturist, homeopath, yoga instructor, podcaster…). Notice the pattern? Your post feeds into the toxic trend toward dismissing expertise and welcoming woo. Experts are valid targets of criticism, but they play a vital role. Losing them is a true loss. So I think your post asked some great questions but was a net negative for the world.
Also, I guess we could have a debate about the term connection. I see no evidence that periodontal disease causes an increased risk of ASCVD. They are correlated/associated, although even that association goes away (in men) when one takes into account cigarette smoking (https://pubmed.ncbi.nlm.nih.gov/29461088/)
My use of connection in that context to me implies one influences the other, which is more important than an association which does not imply any causal connection and is often explained by unmeasured confounding factors.
Despite the lack of any causal relationship, the weak association of gingivitis and CAD is emphasized, publicized and stressed to patients as a reason to keep up regular visits to the dentist.
I greatly appreciate your comments. Would you be OK with me posting them as a new post. Great to have dentists and periodontists giving me their feedback.
First, thank you for your posts. They are always thoughtful, timely, and well-argued. Like all pursuits, medicine requires constant scrutiny from without and within, bolstered by rigorous data, which are often in short supply. Same for dentistry. Motivated reasoning means that practitioners are often unlikely to base their decisions and protocols on science and instead to defer to tradition, common sense, authority, the mechanistic fallacy, or fad (and, as you noted, the profit motive). I have greatly enjoyed the iconoclastic, rational analyses offered by people like Drs. John Mandrola, Vinay Prasad, Adam Cifu,yourself, Jay Bhattacharaya, Aaron Goodman, Marty Makary, Andrew Foy, Paul Pharoah, Alastair Munro, Paul Offit, etc., despite the fact that I am far from an expert in any of the matters they discuss.
In thanks I hope to reply to your take on dentistry. I sort of am an expert here. I have practiced periodontics for 40+ years, am Board-certified (which requires regular examination of our knowledge of clinical research), and scrutinize our field’s literature constantly. Like you, I am a skeptic, but perhaps a bit less distrusting of people who care for me. Here goes - quoting from your post followed by my comments. (I just posted my reaction to the JAMAIM article.)
“I wasn't asked if I wanted an X-ray or explained the purpose of it, but dental radiography now seems to be the norm. Perhaps I am given one every time I visit a dentist because I go infrequently, much less than annually, and dental insurance tends to pay for an annual X-ray. The dental offices probably assume if it is free, no sane patient will reject it.”
Valid point. Many dental practices treat by insurance benefits, since this requires so little cognitive effort by dentists or patients. If it’s cheap or free, why not? Imagine choosing your cancer therapy or whether to stent an MI based on insurance coverage. And yet, since dentists got in bed with insurers decades ago, this has become SOP. If you want a good dentist, choose one who is NOT contracted with your insurer. Then ask them to make the case for their recommendation based on health or your goals, not insurance benefits.
“More and more, I have become concerned about the radiation from medical radiologic procedures.”
You should. But do your homework and look up radiation doses from single intraoral images (periapical or bitewing). Most are in the 1 uSv range. Less than one day of background radiation from living your life. IMO this is a nothingburger.
“The hygienists are always careful to put a lead apron over my groin and around my neck, which makes me feel a little better, but I can't help but wonder...what is the yield of the x-ray in a patient with no symptoms, what is the risk of developing oral cancer from the procedure if performed every year? And what is the probability that something will be identified that is not really a problem, which may lead to more testing or procedures?”
Lead aprons are no longer recommended for two reasons. First is the extremely low radiation exposure and precise beam collimation, which essentially eliminate radiation of off-target tissues such as thyroid, gonads, and hematopoietic marrow. Scatter is close to undetectable, which is why we no longer use dosimeters and often remain in the room when patients are having x-rays taken. Second is that whatever tiny amount of scatter occurs will be reflected back into the body by a lead apron.
There are no RCTs on people who have annual bitewing x-rays vs. those who do not. This would currently be considered unethical. If decay goes undiagnosed - since it is often asymptomatic and not visually detectable - and leads to a root canal or extraction, there would be many more x-rays as a result, as well as other obvious downsides. We do not currently have a way to predict progression of untreated caries or periodontal disease, so we treat every carious lesion or area of bone loss. Could some of them have waited, perhaps for years? Yes. Same as some people with an A1c of 9 or a BP of 170/100. Would these fall into your category of something that is “not really a problem, which may lead to more testing or procedures?”
“I began worrying about transmission of hepatitis or HIV virus from a previous patient which was now being inserted into my mouth. I began thinking that if one case of hepatitis is created by a routine dental visit, that probably negates the benefits, if any, of the thousand patients that had their teeth cleaned and didn't get hepatitis.”
I assume you mean Hep A due to mode of transmission. Of course accidental transmission is possible, as it is in bathrooms, mass transit, grocery stores, Uber, your house, wherever. Using your logic, I recommended permanently locking yourself in a closet after first sanitizing it. The dental profession has rigorous protocols to minimize risk, and reports of transmission verified by genomic analysis are near zero. Having been in many dozens of dental offices for decades, and many medical offices and hospitals for decades, I can absolutely, if anecdotally, vouch for which are cleaner. Yet I still go to the doctor and hospital without concern. I have never gotten Hep A, just as you will never get it at the dentist’s. But if 1/1000 people do, how does this stack up against the benefits to the other 999 who had their teeth cleaned? You do know the clinical course of Hep A, right? And I am disappointed that an MD would consider HIV transmissible by fomites.
“As she began picking, clawing and scraping away at my teeth, I began to wonder if this could be more harmful for me than helpful. What if this process was somehow damaging the enamel of my teeth and making it more likely that I would have problems?”
No. Enamel is much harder than her “picks” (and seriously, “clawing”??), so damaging it would be like damaging a diamond with glass. Can't be done. OTOH, if you have exposed roots from gum recession, then excessive scaling can cause sensitivity and accelerate recession. So people with recession should not have overly frequent or aggressive cleanings. And they should use an electric toothbrush with a pressure sensor to avoid brushing their gums away.
“...multiple bacteria now swarming in my saliva to gain entry into my bloodstream, perhaps landing on a heart valve and causing an infection, endocarditis, that would then result in a need for valve replacement surgery?”
Infectious endocarditis caused by oral/dental pathogens is exceedingly rare, especially in those without valvular or hemodynamic defects. To the extent that it ever occurs, it is not from saliva but from microbleeds that occur multiple times every day, emanating the gums during brushing, flossing or chewing. These are much commoner in people with gingivitis. As a cardiologist, perhaps you can explain the hemodynamics of salivary blood finding its way into vasculature against a pressure gradient and muscle tension, with a portal of entry <1mm in diameter…
The idea that regular X-rays and exams are some sort of profit center for a dental practice is not based in reality. They're a wash financially - the cheapest two charges a patient will experience.
I used to tease my patients and encourage them to skip X-rays and flossing. "You're just going to send my kids to nicer schools and me on nicer vacations!"
The patients that stay away are the ones who end up with the biggest dental expenses. They get themselves in deep before they notice the fist symptoms.
Why in the world wouldn't you want a clean mouth? Do you clean all the other parts of your body to which you have access?
IRT cleanliness in the dental operator, remind yourself that we use the same protocol when we treat our loved ones as we do when we treat some random cardiologist. If it's not disposable, it's autoclaved. If you're wanting your treatment done with operating-room sterility, I'm sure that could be arranged. It would cost you four figures maybe five.
Educate yourself on what it takes to become a state board licensed dental hygienist before you open your mouth.
There is so much twaddle here, I am now a Skeptical Cardiologist skeptic.
I had seen the connection between heart disease and dental hygiene on a poster at my dentists'. This may have increased my motivation to look after my teeth some unmeasurable amount. Both my parents wound up with dentures and heart disease so it was an easy jump for me to make.
From 17 until I had benefits at 26 I didn't see a dentist. They had me on an increased cleaning frequency plan but I have upped my flossing and require fewer and quicker cleanings.
I have found that Physicians and Dentists make the worst patients. To answer some of your questions. The squirting thing tip is sterilized or single use. The sucking thing is single use so no worries there. The metal part holding the digital sensor for the X-rays is sterilized. There really isn’t a direct relationship between calculus on teeth and bacteria. The calculus can cause recession of the gingival tissue and so depending on how much you produce it should be removed periodically. The once or twice a year concept is a good guess but each person should be treated differently. There is no exact standard for cavity treatment. Some dentists are more aggressive and some less so. Find someone you are comfortable with. The amount of radiation in a few bite wings is very small. The radiation is very well collimated and the lead apron probably isn’t necessary but does make everyone feel better. I was very scrupulous in using one even if I didn’t think it really was necessary. I hope I answered some of your questions. Just as an additional thought. When I started my career we were told by the cardiologist to give all mitral valve murmur patients three days of Amoxicillin as a prophylactic. That was changed to one day then one dose of 2 grams and as I was winding up my practice non at all. So things change.
Thanks for the info. There has definitely been an evolution in endocarditis prophylaxis recommendations over time and most of the evidence-base is weak.
Here is a reply to the study you quoted. More to come in direct response to your post.
The Perio Perspective
July 2024
Too Much Dentistry
That was the headline of a recent Viewpoint posted in JAMA Internal Medicine, the standard-bearing publication of the American Medical Association targeted toward primary care doctors. It has been read by many thousands of doctors.
First of all, WTF?! The article was written by 2 dentist epidemiologists from Brazil and a PhD from England (Drs. Nadanovsky, dos Santos and Nunan). I doubt that any of them ever practiced or researched clinical dentistry or did anything at all in the US, for what that’s worth. And I clap back to our medical “colleagues” who published the hatchet job for their attack on patient confidence in our profession, which is already eroding in this era of mistrust and alternate sources of “truth”. And what about Too Much Medicine ?
I must have missed the part where they discussed the massive overuse of knee arthroplasty, coronary artery stenting, mammograms, colonoscopies, Covid vaccines, prescription medication (statins, antidepressants, SSRIs, anxiolytics, ADHD meds…) and more.
The editors were fair-minded enough to publish a rebuttal - from a “real” dentist, Dr. Zadik. Well, sort of - he’s in Oral Medicine, which is, let’s say, dental-adjacent. At least he sees patients instead of just reading graphs and doing math all day. Of note is that his entry received <1/10 the number of reads as the first article. Sigh.
Other than being aggravated, what is my point?
My point is that we should take the critique seriously and see if it has merit. Just because medicine is often practiced irrationally or counterproductively doesn’t mean that the same is not true for us. Is it? Here are the claims and my responses.
-”Dental diseases and procedures are common, troublesome, and expensive.” Common, yes. Troublesome, not so much. Our treatment has become drastically less stressful and painful than it was fifty years ago. Ninety-plus percent of our surgical patients take a few Advil and go back to work. Can’t say that about many medical procedures. Expensive? Compared to what? Saving or replacing a major chewing tooth or a front tooth costs less than a week’s vacation for a couple or small family, and lasts for years to decades. An entire jaw of “permanent” teeth costs less than a decent car. Both cost less than the majority of medical surgery.
-”Little progress has been made on using data from clinical trials to determine best practices.” Really? What was the state of dentistry when I started my career?
-No implants (unless you consider blades and subperiosteals, which had frequent and sometimes disastrous failures).
-Most crowns were gold and most fillings were silver. Composite restorations stained and decayed in a few years. Porcelain crowns were opaque. No veneers. Esthetic dentistry was not a thing.
-Orthodontics was bands, not brackets, with high risk of decementing, decalcification, and decay underneath. There was no aligner therapy (Invisalign).
-Endodontics was mechanical - files and horizontal or vertical condensation. No ultrasonics or GentleWave or thermal filling, so more root fractures and uninstrumented canals and failures.
-Adhesives were poor, so pins and posts were routine. Large restorations often fractured or fell out.
-Perio surgery was medieval. Free gingival grafts and aggressive bony recontouring. Emphasis on therapy over maintenance, which is backwards.
-There was no management of bone and soft tissue to preserve esthetics (stable papillae and gingival margins).
-No lasers.
-No articaine. Incomplete anesthesia was common. Therefore:
-Everything hurt. This was assumed to be SOP. Most surgical and endodontic patients needed opioids for a few days. Perioperative NSAIDs were not used. The result - generations of phobic patients - is still slowly reverberating away.
-This is a very incomplete list. And all the advances were the result of rigorous research, usually RCTs. So I call BS on Drs. Nadanovsky, dos Santos and Nunan.
-”Most dental care relies on economic pressures, training and opinions, and patients expectations, all of which tend to favor excessive diagnosis and interventions.” “For example, dentists may treat early noncavitated caries lesions (white spots).” Okay, first of all it’s “carious lesions” not “caries lesions”, which I thought every dentist or hygienist knows. Second, and more importantly, is that of the literally hundreds of dentists I have known, close to zero restore white spots or decay limited to enamel. Restorative dentists and hygienists attempt to arrest or reverse demineralization with fluoride and cations (as the authors would know if they actually saw patients). This is supported by evidence-based research (Slayton, R et al, JADA 2018:149, 837-849). In contrast, the authors’ smear has no citation of supporting research, since there is none. BS.
-”In the 1970s there was a decline in the number of cavitated caries lesions (sic) which affected dentists’ workload and has played a role in overdiagnosis and treatment.” The authors offer a single citation which has no relevance. You can’t just stick in a reference and hope that no one checks it, dude. So no. Most dentists are currently busier than ever, so the pressure to overdiagnose is, if anything, lower. The reduced incidence of decay has been more than compensated by increased esthetic and orthodontic aligner demand and by the need to replace aging restorations or missing teeth. BS.
-”Sealants are frequently overlooked or underused.” Once again, no supportive citation. And once again, I strongly disagree. Sealants are routinely applied in the majority of practices I know about, and have increased dramatically for low-income families over the past 20 years. BS.
-”The standard for dental (checkup) visits remains every six months, despite two RCTs that failed to demonstrate better oral health compared with longer intervals (up to 24 months).” This statement has research support, and I agree. Many patients can go 12 or 24 months with little or no risk. Many can’t. It depends on their level of risk for decay, periodontal disease, fractures due to parafunction and/or reduced dentition, or an extensive prosthetic history requiring frequent evaluation. As a profession, we can do better than to continue with a one-size-fits-all approach to maintenance. Similarly, “There does not appear to be any advantage to scaling and polishing for adults without periodontitis.” Once again, this is backed up by research, and I agree. I have not had my teeth cleaned for longer than I care to admit (don’t ask), but since my oral hygiene and daily fluoride rinsing are meticulous, I have not needed to. Routine checkups for patients with minimal disease risk offer little benefit aside from reinforcing oral hygiene, applying fluoride when indicated, and radiographs on an infrequent basis. The cleaning part of a cleaning is just cosmetic. IF there is absence of disease risk. But see below.
-”Treating periodontitis through root planing (SRP) leads to a slight enhancement in attachment level among individuals with moderate to severe periodontitis.” Excuse me, my hair just caught on fire and I have to go put it out. There are scores of rigorous studies verifying the high value of SRP, which in my opinion is the single most valuable service we provide (tied with restoring active decay). And the authors totally fail to emphasize the benefit of frequent maintenance for patients who have had periodontal treatment. Two huge fails.
Drs. Moe, Larry and Curly, who just went 1 for 7, sum up with an appeal for more RCTs. Well, sure. But to imply that a vast library of these does not already exist, or that somehow we are ignoring them in service of the profit motive, or that we are still in the Dark Ages of the 1970s and earlier, that is not only unsupported, it is mean, and stupid, and harmful to the naive and trusting patients we help.
There are unscrupulous dentists. And doctors. And every other walk of life, including dentist epidemiologists. But those are the minority. To tar the whole enterprise with one brush helps no one. Shame on the authors and JAMA Internal Medicine. To quote Monty Python, “I fart in your general direction.”
Thank you for this. I’ve been skeptical of dentists for many years. My 17 year old who had taken oral fluoride since birth and had beautiful straight teeth with no cavities - was given a no go by the dentist. She was going to Australia as an exchange student and had to pass all the medical and dental tests to get to go. The previous year we had declined sealants on her molars - so this dentist used this to not pass her dental tests. Of course we protested and won but my faith in the dental profession is pretty low. I also find that different dental hygienists find different things.
Definitely a concern. Also, I forgot to mention that the first paper I ever had published was a case report of a patient who went into a hypertensive crisis after receiving an injection of epinephrine/lidocaine in the dentist's chair.
Folks should always ask what is in the injection they are getting.
Wonder if we looked at Europe (esp Britain) who have notoriously bad teeth. Do they have higher rates of bad stuff happening? ( Other than it's not very sightly )
Well, I was born in the UK and lived there for 5 years before coming to the Land of Opportunity. My teeth are "not very sightly" but my sense is the English don't mind the occasional crooked tooth whereas orthodonture is de rigueur in the US. Despite my unsightly teeth, I have had no gingivitis problems or minimal cavities (depending on which dentist I listen to. Perhaps it is all the fluoride in US water :)
This is getting tedious so I will tighten it up a bit.
Cleanings should be appropriate to your clinical presentation. With excellent hygiene, they will be superficial and perhaps unnecessary except to remove stain (cosmetic). With your level of hygiene, they will be more aggressive and could require local anesthesia if you are experiencing pain or if you have periodontal disease, which sounds plausible.
I assume your polishing paste comments were hyperbolic, although if you develop COPD or silicosis perhaps we should revisit this. I know a great mesothelioma lawyer that I got found from an internet ad.
“I have an intense distrust of dentists, as I have found their "cavity detection rates" differ wildly.”
This is one of the greatest flaws of my field. It is a valid concern. We do not have a standardized approach to intercepting decay, and disparities among treatment plans for the same patient who sees different dentists are common. Sort of like medical doctors, no? (This does not justify it.) When in doubt, get a second opinion, and be open to the possibility that the more aggressive option could actually be better. The default/Bayesian prior should be that it is not. Different attitudes and moral hazard are risks we all take in every interaction during our lives. Literally every person we come up against could be here to help us or screw us. Usually it’s somewhere in the middle, skewed toward help. The only safe path away from rampant paranoia is back to the sanitized closet.
“...connection between gingivitis and coronary atherosclerosis, possibly mediated by inflammation, but this has mostly been discredited.”
The connection (correlation) has NOT been discredited. It is significant. However, causality remains uncertain. Evidence that treating periodontal disease results in reduced cardiovascular or other medical diseases is limited. It is probably strongest for pneumonia at present, and there are a few prospective studies that found improved BP, lipid profile, and vascular endothelial status after treatment. I wouldn’t hang my hat on them.
Okay, enough.
There are three important themes here. First is that patients are heterogeneous. What some consider acceptable risk, others would lose sleep over. Our mission should be to give them our best educated guess at their prognosis and options, and then honor their decision, even if it would not be ours. If you don't want to get your teeth cleaned, don’t. Second is that we are often ignorant, and should admit it. We just don’t know. Are annual bitewings net positive or net negative? Who knows? (I suggest that they are beneficial for people at risk based on their history, and overdone for those of us who haven’t had a cavity for years or decades.) Research is incrementally lighting the way, but even research is often flawed, open to multiple interpretations, or made irrelevant over time as the population and medical/dental care change. Third is the growing human impulse to say “I’m suspicious of my___________.” (doctor, lawyer, spouse, priest, dentist…) Versus “I LOVE my___________.” (acupuncturist, homeopath, yoga instructor, podcaster…). Notice the pattern? Your post feeds into the toxic trend toward dismissing expertise and welcoming woo. Experts are valid targets of criticism, but they play a vital role. Losing them is a true loss. So I think your post asked some great questions but was a net negative for the world.
Uncharacteristically for you.
Also, I guess we could have a debate about the term connection. I see no evidence that periodontal disease causes an increased risk of ASCVD. They are correlated/associated, although even that association goes away (in men) when one takes into account cigarette smoking (https://pubmed.ncbi.nlm.nih.gov/29461088/)
My use of connection in that context to me implies one influences the other, which is more important than an association which does not imply any causal connection and is often explained by unmeasured confounding factors.
Despite the lack of any causal relationship, the weak association of gingivitis and CAD is emphasized, publicized and stressed to patients as a reason to keep up regular visits to the dentist.
I greatly appreciate your comments. Would you be OK with me posting them as a new post. Great to have dentists and periodontists giving me their feedback.
Dear Dr. Pearson,
First, thank you for your posts. They are always thoughtful, timely, and well-argued. Like all pursuits, medicine requires constant scrutiny from without and within, bolstered by rigorous data, which are often in short supply. Same for dentistry. Motivated reasoning means that practitioners are often unlikely to base their decisions and protocols on science and instead to defer to tradition, common sense, authority, the mechanistic fallacy, or fad (and, as you noted, the profit motive). I have greatly enjoyed the iconoclastic, rational analyses offered by people like Drs. John Mandrola, Vinay Prasad, Adam Cifu,yourself, Jay Bhattacharaya, Aaron Goodman, Marty Makary, Andrew Foy, Paul Pharoah, Alastair Munro, Paul Offit, etc., despite the fact that I am far from an expert in any of the matters they discuss.
In thanks I hope to reply to your take on dentistry. I sort of am an expert here. I have practiced periodontics for 40+ years, am Board-certified (which requires regular examination of our knowledge of clinical research), and scrutinize our field’s literature constantly. Like you, I am a skeptic, but perhaps a bit less distrusting of people who care for me. Here goes - quoting from your post followed by my comments. (I just posted my reaction to the JAMAIM article.)
“I wasn't asked if I wanted an X-ray or explained the purpose of it, but dental radiography now seems to be the norm. Perhaps I am given one every time I visit a dentist because I go infrequently, much less than annually, and dental insurance tends to pay for an annual X-ray. The dental offices probably assume if it is free, no sane patient will reject it.”
Valid point. Many dental practices treat by insurance benefits, since this requires so little cognitive effort by dentists or patients. If it’s cheap or free, why not? Imagine choosing your cancer therapy or whether to stent an MI based on insurance coverage. And yet, since dentists got in bed with insurers decades ago, this has become SOP. If you want a good dentist, choose one who is NOT contracted with your insurer. Then ask them to make the case for their recommendation based on health or your goals, not insurance benefits.
“More and more, I have become concerned about the radiation from medical radiologic procedures.”
You should. But do your homework and look up radiation doses from single intraoral images (periapical or bitewing). Most are in the 1 uSv range. Less than one day of background radiation from living your life. IMO this is a nothingburger.
“The hygienists are always careful to put a lead apron over my groin and around my neck, which makes me feel a little better, but I can't help but wonder...what is the yield of the x-ray in a patient with no symptoms, what is the risk of developing oral cancer from the procedure if performed every year? And what is the probability that something will be identified that is not really a problem, which may lead to more testing or procedures?”
Lead aprons are no longer recommended for two reasons. First is the extremely low radiation exposure and precise beam collimation, which essentially eliminate radiation of off-target tissues such as thyroid, gonads, and hematopoietic marrow. Scatter is close to undetectable, which is why we no longer use dosimeters and often remain in the room when patients are having x-rays taken. Second is that whatever tiny amount of scatter occurs will be reflected back into the body by a lead apron.
There are no RCTs on people who have annual bitewing x-rays vs. those who do not. This would currently be considered unethical. If decay goes undiagnosed - since it is often asymptomatic and not visually detectable - and leads to a root canal or extraction, there would be many more x-rays as a result, as well as other obvious downsides. We do not currently have a way to predict progression of untreated caries or periodontal disease, so we treat every carious lesion or area of bone loss. Could some of them have waited, perhaps for years? Yes. Same as some people with an A1c of 9 or a BP of 170/100. Would these fall into your category of something that is “not really a problem, which may lead to more testing or procedures?”
“I began worrying about transmission of hepatitis or HIV virus from a previous patient which was now being inserted into my mouth. I began thinking that if one case of hepatitis is created by a routine dental visit, that probably negates the benefits, if any, of the thousand patients that had their teeth cleaned and didn't get hepatitis.”
I assume you mean Hep A due to mode of transmission. Of course accidental transmission is possible, as it is in bathrooms, mass transit, grocery stores, Uber, your house, wherever. Using your logic, I recommended permanently locking yourself in a closet after first sanitizing it. The dental profession has rigorous protocols to minimize risk, and reports of transmission verified by genomic analysis are near zero. Having been in many dozens of dental offices for decades, and many medical offices and hospitals for decades, I can absolutely, if anecdotally, vouch for which are cleaner. Yet I still go to the doctor and hospital without concern. I have never gotten Hep A, just as you will never get it at the dentist’s. But if 1/1000 people do, how does this stack up against the benefits to the other 999 who had their teeth cleaned? You do know the clinical course of Hep A, right? And I am disappointed that an MD would consider HIV transmissible by fomites.
“As she began picking, clawing and scraping away at my teeth, I began to wonder if this could be more harmful for me than helpful. What if this process was somehow damaging the enamel of my teeth and making it more likely that I would have problems?”
No. Enamel is much harder than her “picks” (and seriously, “clawing”??), so damaging it would be like damaging a diamond with glass. Can't be done. OTOH, if you have exposed roots from gum recession, then excessive scaling can cause sensitivity and accelerate recession. So people with recession should not have overly frequent or aggressive cleanings. And they should use an electric toothbrush with a pressure sensor to avoid brushing their gums away.
“...multiple bacteria now swarming in my saliva to gain entry into my bloodstream, perhaps landing on a heart valve and causing an infection, endocarditis, that would then result in a need for valve replacement surgery?”
Infectious endocarditis caused by oral/dental pathogens is exceedingly rare, especially in those without valvular or hemodynamic defects. To the extent that it ever occurs, it is not from saliva but from microbleeds that occur multiple times every day, emanating the gums during brushing, flossing or chewing. These are much commoner in people with gingivitis. As a cardiologist, perhaps you can explain the hemodynamics of salivary blood finding its way into vasculature against a pressure gradient and muscle tension, with a portal of entry <1mm in diameter…
Thank so much for your response. See my other reply. I'd love to put these together and publish your answers to questions from the dentists's chair
Yes feel free. I am eager for pushback/alternate views. Thank you!
The idea that regular X-rays and exams are some sort of profit center for a dental practice is not based in reality. They're a wash financially - the cheapest two charges a patient will experience.
I used to tease my patients and encourage them to skip X-rays and flossing. "You're just going to send my kids to nicer schools and me on nicer vacations!"
The patients that stay away are the ones who end up with the biggest dental expenses. They get themselves in deep before they notice the fist symptoms.
Why in the world wouldn't you want a clean mouth? Do you clean all the other parts of your body to which you have access?
IRT cleanliness in the dental operator, remind yourself that we use the same protocol when we treat our loved ones as we do when we treat some random cardiologist. If it's not disposable, it's autoclaved. If you're wanting your treatment done with operating-room sterility, I'm sure that could be arranged. It would cost you four figures maybe five.
Educate yourself on what it takes to become a state board licensed dental hygienist before you open your mouth.
There is so much twaddle here, I am now a Skeptical Cardiologist skeptic.
Unsubscringly yours,
Matthew
Some comments sent to me from Al at Quizzify
You think too many stents are performed? Stent overuse got nothin' on filling overuse
https://www.quizzify.com/post/great-news-i-got-a-cavity
https://www.quizzify.com/post/quizzify-1-dentistry-0
And as for the cleanings, it's not one-size-fits-all
https://www.quizzify.com/post/should-you-say-no-to-a-biannual-dental-check-up
My dentist coulda killed me:
https://www.quizzify.com/post/how-quizzify-may-have-saved-my-lif
I had seen the connection between heart disease and dental hygiene on a poster at my dentists'. This may have increased my motivation to look after my teeth some unmeasurable amount. Both my parents wound up with dentures and heart disease so it was an easy jump for me to make.
From 17 until I had benefits at 26 I didn't see a dentist. They had me on an increased cleaning frequency plan but I have upped my flossing and require fewer and quicker cleanings.
I have found that Physicians and Dentists make the worst patients. To answer some of your questions. The squirting thing tip is sterilized or single use. The sucking thing is single use so no worries there. The metal part holding the digital sensor for the X-rays is sterilized. There really isn’t a direct relationship between calculus on teeth and bacteria. The calculus can cause recession of the gingival tissue and so depending on how much you produce it should be removed periodically. The once or twice a year concept is a good guess but each person should be treated differently. There is no exact standard for cavity treatment. Some dentists are more aggressive and some less so. Find someone you are comfortable with. The amount of radiation in a few bite wings is very small. The radiation is very well collimated and the lead apron probably isn’t necessary but does make everyone feel better. I was very scrupulous in using one even if I didn’t think it really was necessary. I hope I answered some of your questions. Just as an additional thought. When I started my career we were told by the cardiologist to give all mitral valve murmur patients three days of Amoxicillin as a prophylactic. That was changed to one day then one dose of 2 grams and as I was winding up my practice non at all. So things change.
Thanks for the info. There has definitely been an evolution in endocarditis prophylaxis recommendations over time and most of the evidence-base is weak.
Here is a reply to the study you quoted. More to come in direct response to your post.
The Perio Perspective
July 2024
Too Much Dentistry
That was the headline of a recent Viewpoint posted in JAMA Internal Medicine, the standard-bearing publication of the American Medical Association targeted toward primary care doctors. It has been read by many thousands of doctors.
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2818193?guestAccessKey=3baf87b6-cdd5-4c0c-82b6-dedfcbe00456&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=etoc&utm_term=070224&utm_adv=
First of all, WTF?! The article was written by 2 dentist epidemiologists from Brazil and a PhD from England (Drs. Nadanovsky, dos Santos and Nunan). I doubt that any of them ever practiced or researched clinical dentistry or did anything at all in the US, for what that’s worth. And I clap back to our medical “colleagues” who published the hatchet job for their attack on patient confidence in our profession, which is already eroding in this era of mistrust and alternate sources of “truth”. And what about Too Much Medicine ?
I must have missed the part where they discussed the massive overuse of knee arthroplasty, coronary artery stenting, mammograms, colonoscopies, Covid vaccines, prescription medication (statins, antidepressants, SSRIs, anxiolytics, ADHD meds…) and more.
The editors were fair-minded enough to publish a rebuttal - from a “real” dentist, Dr. Zadik. Well, sort of - he’s in Oral Medicine, which is, let’s say, dental-adjacent. At least he sees patients instead of just reading graphs and doing math all day. Of note is that his entry received <1/10 the number of reads as the first article. Sigh.
Other than being aggravated, what is my point?
My point is that we should take the critique seriously and see if it has merit. Just because medicine is often practiced irrationally or counterproductively doesn’t mean that the same is not true for us. Is it? Here are the claims and my responses.
-”Dental diseases and procedures are common, troublesome, and expensive.” Common, yes. Troublesome, not so much. Our treatment has become drastically less stressful and painful than it was fifty years ago. Ninety-plus percent of our surgical patients take a few Advil and go back to work. Can’t say that about many medical procedures. Expensive? Compared to what? Saving or replacing a major chewing tooth or a front tooth costs less than a week’s vacation for a couple or small family, and lasts for years to decades. An entire jaw of “permanent” teeth costs less than a decent car. Both cost less than the majority of medical surgery.
-”Little progress has been made on using data from clinical trials to determine best practices.” Really? What was the state of dentistry when I started my career?
-No implants (unless you consider blades and subperiosteals, which had frequent and sometimes disastrous failures).
-Most crowns were gold and most fillings were silver. Composite restorations stained and decayed in a few years. Porcelain crowns were opaque. No veneers. Esthetic dentistry was not a thing.
-Orthodontics was bands, not brackets, with high risk of decementing, decalcification, and decay underneath. There was no aligner therapy (Invisalign).
-Endodontics was mechanical - files and horizontal or vertical condensation. No ultrasonics or GentleWave or thermal filling, so more root fractures and uninstrumented canals and failures.
-Adhesives were poor, so pins and posts were routine. Large restorations often fractured or fell out.
-Perio surgery was medieval. Free gingival grafts and aggressive bony recontouring. Emphasis on therapy over maintenance, which is backwards.
-There was no management of bone and soft tissue to preserve esthetics (stable papillae and gingival margins).
-No lasers.
-No articaine. Incomplete anesthesia was common. Therefore:
-Everything hurt. This was assumed to be SOP. Most surgical and endodontic patients needed opioids for a few days. Perioperative NSAIDs were not used. The result - generations of phobic patients - is still slowly reverberating away.
-This is a very incomplete list. And all the advances were the result of rigorous research, usually RCTs. So I call BS on Drs. Nadanovsky, dos Santos and Nunan.
-”Most dental care relies on economic pressures, training and opinions, and patients expectations, all of which tend to favor excessive diagnosis and interventions.” “For example, dentists may treat early noncavitated caries lesions (white spots).” Okay, first of all it’s “carious lesions” not “caries lesions”, which I thought every dentist or hygienist knows. Second, and more importantly, is that of the literally hundreds of dentists I have known, close to zero restore white spots or decay limited to enamel. Restorative dentists and hygienists attempt to arrest or reverse demineralization with fluoride and cations (as the authors would know if they actually saw patients). This is supported by evidence-based research (Slayton, R et al, JADA 2018:149, 837-849). In contrast, the authors’ smear has no citation of supporting research, since there is none. BS.
-”In the 1970s there was a decline in the number of cavitated caries lesions (sic) which affected dentists’ workload and has played a role in overdiagnosis and treatment.” The authors offer a single citation which has no relevance. You can’t just stick in a reference and hope that no one checks it, dude. So no. Most dentists are currently busier than ever, so the pressure to overdiagnose is, if anything, lower. The reduced incidence of decay has been more than compensated by increased esthetic and orthodontic aligner demand and by the need to replace aging restorations or missing teeth. BS.
-”Sealants are frequently overlooked or underused.” Once again, no supportive citation. And once again, I strongly disagree. Sealants are routinely applied in the majority of practices I know about, and have increased dramatically for low-income families over the past 20 years. BS.
https://www.cdc.gov/oralhealth/publications/OHSR-2019-index.html.
-”The standard for dental (checkup) visits remains every six months, despite two RCTs that failed to demonstrate better oral health compared with longer intervals (up to 24 months).” This statement has research support, and I agree. Many patients can go 12 or 24 months with little or no risk. Many can’t. It depends on their level of risk for decay, periodontal disease, fractures due to parafunction and/or reduced dentition, or an extensive prosthetic history requiring frequent evaluation. As a profession, we can do better than to continue with a one-size-fits-all approach to maintenance. Similarly, “There does not appear to be any advantage to scaling and polishing for adults without periodontitis.” Once again, this is backed up by research, and I agree. I have not had my teeth cleaned for longer than I care to admit (don’t ask), but since my oral hygiene and daily fluoride rinsing are meticulous, I have not needed to. Routine checkups for patients with minimal disease risk offer little benefit aside from reinforcing oral hygiene, applying fluoride when indicated, and radiographs on an infrequent basis. The cleaning part of a cleaning is just cosmetic. IF there is absence of disease risk. But see below.
-”Treating periodontitis through root planing (SRP) leads to a slight enhancement in attachment level among individuals with moderate to severe periodontitis.” Excuse me, my hair just caught on fire and I have to go put it out. There are scores of rigorous studies verifying the high value of SRP, which in my opinion is the single most valuable service we provide (tied with restoring active decay). And the authors totally fail to emphasize the benefit of frequent maintenance for patients who have had periodontal treatment. Two huge fails.
Drs. Moe, Larry and Curly, who just went 1 for 7, sum up with an appeal for more RCTs. Well, sure. But to imply that a vast library of these does not already exist, or that somehow we are ignoring them in service of the profit motive, or that we are still in the Dark Ages of the 1970s and earlier, that is not only unsupported, it is mean, and stupid, and harmful to the naive and trusting patients we help.
There are unscrupulous dentists. And doctors. And every other walk of life, including dentist epidemiologists. But those are the minority. To tar the whole enterprise with one brush helps no one. Shame on the authors and JAMA Internal Medicine. To quote Monty Python, “I fart in your general direction.”
David
Thank you for this. I’ve been skeptical of dentists for many years. My 17 year old who had taken oral fluoride since birth and had beautiful straight teeth with no cavities - was given a no go by the dentist. She was going to Australia as an exchange student and had to pass all the medical and dental tests to get to go. The previous year we had declined sealants on her molars - so this dentist used this to not pass her dental tests. Of course we protested and won but my faith in the dental profession is pretty low. I also find that different dental hygienists find different things.
“I sure as heck hope I don’t get IE from this” goes through my head every time I go to dentist.
IE?
infective endocarditis, wherein bacteria that have entered the blood stream land on structures in the heart and infect them
Definitely a concern. Also, I forgot to mention that the first paper I ever had published was a case report of a patient who went into a hypertensive crisis after receiving an injection of epinephrine/lidocaine in the dentist's chair.
Folks should always ask what is in the injection they are getting.
Wonder if we looked at Europe (esp Britain) who have notoriously bad teeth. Do they have higher rates of bad stuff happening? ( Other than it's not very sightly )
Well, I was born in the UK and lived there for 5 years before coming to the Land of Opportunity. My teeth are "not very sightly" but my sense is the English don't mind the occasional crooked tooth whereas orthodonture is de rigueur in the US. Despite my unsightly teeth, I have had no gingivitis problems or minimal cavities (depending on which dentist I listen to. Perhaps it is all the fluoride in US water :)
Ah sorry. No offense intended