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Dental Screening is it Necessary? Part I

May 18, 2015

Filed under: ARTICLES — Tags: , , , — Barry @ 11:02 AM

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When my mother passed away some years ago she took one of the ugliest wisdom teeth you will ever see to the grave with her.  For years I looked at her x-rays and defied everything I learned in dental school.  I chose to leave it alone…and happily spared her some pretty gruesome surgery.  I wish I knew more about radical prostatectomies a few years ago when I was asked about that choice.  Things have changed in the world of urology since then.  And hopefully they’re changing in the entire world of medicine and dentistry.

From wisdom teeth to breast and prostate cancer, applying wise clinical judgement may be a patient’s best defense.

A recent article in USA Today asked the question about wisdom teeth: Should they stay or should they go?

We live in a time of what Dr. Atul Gawande calls, over-diagnosis….that goes way beyond the question of wisdom teeth.  I have included links below to discussions of Gawande’s recent article in New Yorker magazine, Overkill.

I highly recommend that you click on the link to Gawande’s New Yorker article…it is worth reading, and if you haven’t read his recent bestseller, Being Mortal…I recommend that as well.

What I found most interesting is that Gawande refers to the research of Dr. H. Gilbert Welch, an epidemiologist from Dartmouth University.  Coincidentally I recently read Gilbert’s new book Less Medicine More Health.  It was the impetus behind one of my recent blog posts about managing vs. fixing conditions.

Two things I took away from that book were his excellent metaphor or conceptual model of cancer he calls the  “barnyard pen of cancers.”
Basically Welch claims that all cancers do not kill, and many of us have small cancers “that never bother us during life – particularly cancers of the prostate, breast and thyroid.”  The goal, he says is not to let any of these cancers escape the barnyard pen to become more deadly.  There are three types of animals in the barnyard…turtles, rabbits and birds.  Most of the above mentioned cancers are turtles, and they’re not going anywhere.  You can read more about this model in Gawande’s article or in Welch’s book…fascinating stuff.

But in the meantime, we scan and probe…looking for rabbits and finding and treating turtles.  Forget the birds—-too late.

What I really found interesting in Welch’s book is how many times he referenced dentistry.

In the first instance he writes about the value of screening…asking whether it’s a good idea.  He uses oral cancer as his example.  He chose oral cancer because a health reporter contacted him about an article she was writing about the benefit of oral cancers screenings.  He admits that he doesn’t know much about oral cancer.  Just that about 8000 Americans die from it every year, compared to lung cancer which kills 160,000 people.  It’s number twenty on the list of cancer deaths.  What Welch said he did know something about was screening.

There seemed to be a discrepancy.  In a recent Consumer Reports article it was recommended that only people who were at risk should be screened for bladder, lung, skin and oral cancer…but the Oral Cancer Foundation and the American Dental Association recommends oral cancer screening on everyone.

So what’s the harm?  I guess, as a dentist who actually screens all of my patients, that’s a natural question.  But the answer, according to Welch, reveals much more about screening in general.

I might say, as a dentist, that it doesn’t cost anything, unless the dentists is using fancy screening applications, the number of new cases of people without known risk factors keeps growing (at least that’s what I am being told), and there is evidence that people being diagnosed with early cancer did much better in later stages.

But when I thought about these answers they didn’t jibe with my experience.  In all of my years of visually screening for oral cancer I have found only four cases —and they were all birds.  I couldn’t have missed them.  They were all smokers.  Only one is still living.

Then I thought about another harm.  For a few years I was using more sophisticated methods of screening…and I found a bunch of false positives.  Off to the surgeon for biopsy.  I actually set off a series of events that lead to unnecessary worry, not to mention the cost and the surgery.

I am not blaming myself…nor do I blame the dental community.  This is what we are intuitively lead to believe—that the anecdotes are true, that more treatment is better and better to be safe than sorry.  Welch takes the counter-intuitive view…and after my own medical history and my experiences…I agree.  I still look, but I don’t get carried away.

Welch went on to write about wisdom teeth—but this blog post is too long…to be continued.

 

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8 Comments

  1. I screen every patient at every initial or recall exam. But, it is a visual exam. I take great issue with the gizmos being marketed to dentists as “aids” in cancer screening. Put as bluntly as this sailor can… They’re all bullshit. And, dentists either know it, or they SHOULD know it. There isn’t an oral surgeon or oral pathologist out there that advocates these glow sticks and special lights. They do NOTHING. There is no independent study that demonstrates their effectiveness.

    Worse, is that they are being marketed to dentists as a revenue generator. It bugs the shit out of me. The gizmos are a load of crap, and they make the entire profession look stupid and unscrupulous. That ought to piss off a few of my colleagues! 😀

    I have also found four cancers in my career. One of them was on a good friend’s mother. She died a year and a half later… after undergoing some horrifically disfiguring and painful surgeries.

    Comment by TheDentalWarrior — May 18, 2015 @ 1:11 PM

  2. I couldn’t have said it better myself Mike. The barnyard is a great metaphor. The Oral Cancer Foundation has gone way overboard on this—and I agree with your assessment from oral surgeons. Welch used oral cancer as his example of the negatives of screening—-think of the opther medical implications—prostate, breast and thyroid. Know why there are less prostate cancers in England—they don’t screen.

    Comment by Barry — May 18, 2015 @ 1:16 PM

  3. Mr. Barr:
    The entire “profession” is stupid and unscrupulous. It’s a shame you will never admit to it. or you will never know because you are the man.

    Comment by Roger — May 21, 2015 @ 4:12 AM

  4. I don’t know who “da man” is….but collectively calling a profession unscrupulous and stupid may be taking things a bit far. I see many good dentists who try to get it right. Of course in every industry there are bad apples. This post…about over treating is only partly about ethics…also about misinformation at every level.

    Comment by Barry — May 21, 2015 @ 7:35 AM

  5. My experiences have been very similar. Mike is spot on as well .

    Comment by Don — May 19, 2015 @ 8:32 AM

  6. I really wonder how many dentists have similar experiences and yet we are being taught differently.

    Comment by Barry — May 19, 2015 @ 8:49 AM

  7. It is truly amazing how the dentists in the profession, with all their education, do not truly know about diagnosing and treatment planning for wisdom tooth extraction(s). There is so much misinformation, and outright wrong thinking, with regard to wisdom teeth and whether to extract them or leave them be. For that matter, there are opinions galore on many aspects of dentistry by dentists in the profession. Many passed their exams, graduated and became licensed and they never truly learned the fundamentals of dentistry, and because of that, nor do they fully understand clinical dentistry. It really is a sad state of affairs in dentistry. The only thing that is standardized and agreed upon are film sizes. Patients often state they are afraid of dentists, often because of the reputation for pain. Little do they know how it really is. When they relate their fears like that, I say to myself, yes, I am afraid too, but for other reasons.

    Comment by Roger — May 21, 2015 @ 4:21 AM

  8. […] My last post started off about wisdom teeth and ended up being about over diagnosis, over treatment and cancer.  This week I want to get back to wisdom teeth. […]

    Pingback by Dental Screening is it Necessary? Part II | The TAO of Dentistry — May 26, 2015 @ 10:58 AM

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