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Dental Screening is it Necessary? Part II

May 26, 2015

Filed under: Article — Tags: , , , — Barry @ 10:58 AM




Writing blog posts is an exercise in discovery.  I start with an idea and a few thoughts and then the finished post barely resembles what I set out to write.

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.

Dr. H. Gilbert Welch, the Dartmouth epidemiologist and author of the book Less Medicine More Health, referenced oral cancer and wisdom teeth in his book, as examples of over-diagnosis and over-treatment.  The last blog post discussed the oral cancer issues.

Just to give you an idea about how he feels, at one point he writes, “But I’m not a dentist.  If you’re one, you already know that the topic of too much dentistry could fill a whole book.  Write it.”

Well I’m not going to write a whole book about over-treatment…my last post garnered enough interest to send me numerous articles about that topic.

His point referring to wisdom teeth is that way too many wisdom teeth are removed in this country for prophylactic reasons.  Most of these extractions are on asymptomatic patients.  He claims that there is no data that supports the removal of wisdom teeth prophylactically and that the “UK’s National Institute for Health and Care Excellence and the American Public Health Association – recommend that wisdom teeth not be removed propylactically and should only be removed in patienbts who are experiencing problems.”

After over forty years of practice it’s difficult for me to believe such hard and fast rules—in other words I believe I can exercise a bit more judgement than that.  But I do agree that we take out too many wisdom teeth.

Why?  Well that’s a deep discussion…but dogma may have something to do with it.

For the patient the major concern is risk assessment.  The pros and cons of the procedure.  Whether the procedure is wisdom tooth extraction or placement of veneers or implants, risks should be discussed.  Let’s face it all surgery has risks…believe me I know.

In the last post I referred to my mother’s wisdom tooth…at her age and even way before she passed, surgery would have been risky business.  Then again risk is part of life…everytime I get in my car I am taking a risk, but people don’t usually see it that way.

“Can’t get your wisdom teeth out Lisa?  Stop texting and driving.”

Welch writes about levels of risk in his book:

  1. Patient Autonomy.  As dentists we see a lot of this.  All patients have the right to refuse treatment and accept no risk.  Most dentistry, unlike medicine, is not life-mandated.  We have all seen patients refuse treatment and live long happy lives.  In my history I have seen patients refuse to take medications and also refuse treatment for oral cancer.
  2. Baseline Risk.  This is the old Ben Franklin saw about assessing pros and cons.  Know exactly what the benefits are compared to the possible complications.  How many teeth through the years have been mutilated (not my word—but one used by a very prominent and highly ethical dentist) for the sake of cosmetic dentistry—or foregoing orthodontics for aggressive restorative dentistry (instant ortho anyone?)
  3. Certainty of Benefit.  This is where most of our dentistry should fall.  Our examinations should reveal the obvious benefits and then should be discussed with the patient.  In many cases the patient doesn’t understand the benefits and the doctor’s role is to open that discussion because of his or her experience.
  4. Certainty of Harm.  Now this is the discussion that usually doesn’t get done.  I divide my treatment options into Phase I and Phase II.  Phase II options are irreversible…that could mean more risk.  Sometimes dentists get into heroics without full disclosure to the patient…and real; trouble comes.

My suggestion is to use wise clinical judgement and openly discuss all options and risks with patients.  I am amazed at how many of the “smartest dentists in the world” I meet everyday.  There is very little humility in dentistry – medicine and dentistry could use a bit more humility – or else we will never improve…individually or collectively.  And maybe those articles about over-diagnosis and over-treatment will go away.








Dental Screening is it Necessary? Part I

May 18, 2015

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




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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