Unconventional Dentistry: Part V. Professional Issues, Concerns and Uses

Professional Concerns

As scientific medicine and dentistry make dramatic advances, irrational and unproven practices are increasingly promoted and accepted. Conventional practitioners have expressed numerous concerns about patient risk, patient harm and professional risks (Table 1). Scientific research projects and studies have been stimulated by these concerns and the health care costs involved. Meaningful practical results usually evolve over a period of time based on published studies.

“Complementary” and “Integrative” UD

What dental services and products can be combined with or even substituted for conventional dentistry? Any such decisions are necessarily complex, and they are especially difficult in the absence of scientific evidence. Unconventional practices must be investigated for scientific evidence that may already exist and can be appropriately applied to individual patient needs. Where scientific evidence of harm or ineffectiveness exists, the practices must be rejected. The ability to gain access to the wide range of information available now requires discriminating literature and computer searches. The practitioner must clearly identify goals to be achieved, and the patient’s desires and needs must be analysed as part of this process. The practitioner must attempt to minimize the risks and be willing to accept professional responsibility for prescribing, providing or recommending UD. Dentists owe a duty to their patients that supercedes any self-interest.

These decisions require critical thinking, adequate investigation and an informed practitioner who is up to date with today’s rapidly changing and increasing scientific knowledge. In many cases, only anecdotal or biased commercial information is available, thereby leaving the practitioner in a difficult position — making decisions without scientific evidence and relying on information and intuition that is suspect. Because many UD practices relate to medical disorders and may involve invasive procedures, all dentists performing unconventional services should understand and conform to appropriate standards of practice (Table 2).

Decision Making for UD

Common conditions that are often associated with UD are chronic or relapsing disorders, such as chronic pain (TMD, fibromyalgia, autoimmune arthritis), and serious life-threatening conditions, such as multiple sclerosis and cancer. Any condition that is medically incurable or that is associated with serious adverse effects from conventional treatments may produce an unhappy, desperate or noncompliant patient willing to believe in methods promoted to be simple and effective, especially when afforded caring personalized attention in contrast to the model of impersonal conventional medicine and dentistry.

Identifying patients who use UD and UM requires the time and ability to obtain an adequate history. Patients should be asked about UM use, diet, non-prescription drug or “natural” remedy use and attitudes toward expectations of therapy and reasons for use. Dentists must be supportive of patients’ choices and may be helpful in guiding dental care to complement and benefit the individual patient. Dentists may decline to provide care deemed inadvisable, yet continue to advise appropriate patient choices.

Benefits of UD

By definition there are no scientifically proven benefits of UD — scientifically proven practices are not unconventional. Undeniably, however, large numbers of patients with and without health problems perceive benefits from UM and UD. Speculation about the reasons for these beliefs and perceptions range from unknown or unproven theoretical mechanisms of physiologic effects to romanticism. Most observers offer psychological explanations for patient claims of benefit from UM. The placebo effect is recognized as an important factor in conventional medicine and dentistry.³ Some sources cite the placebo effect as the exclusive therapeutic principle of UM.⁴ Recent evidence has documented improved quality of life for patients with multiple sclerosis who use UM,⁵ illustrating the need to acknowledge the patient’s whole experience of disease and providing limited evidence of a benefit from UM.

Scientific evidence of benefit from UD is lacking. Anecdotal stories and commercial promotions abound without real evidence of efficacy. Any placebo effect from UD may give the patient the perception of benefit, which should not be trivialized. Dentists may consider the reported benefits of unproven but reversible and harmless treatments for individual patients. The health care practitioner’s goal is primarily to help the patient. If, in individual cases, unproven treatments are not physically, mentally or financially harmful and are deemed effective, dentists may find the benefit adequate justification for use. Some UD may be less expensive than other treatments.

The natural course of a disease or condition must be understood, because many chronic conditions fluctuate and may improve over time, with improvement unrelated to an intervention. Invasive dental practices, however, may be unrelated to medical conditions and may directly or indirectly cause harm and worsen a patient’s fragile balance of health and wellness. Dentists must be cautious in using UD.

Example — Unconventional TMD Treatment

“Temporomandibular joint dysfunction” is a well-recognized area of both unconventional practices and out-and-out quackery.⁶ In spite of scientific advances and the current understanding of most TMD as non-dental biopsychosocial chronic pain disorders,⁷ the promotion of unproven methods continues to proliferate. For example, traditional Chinese medicine, according to a contemporary source, considers TMD to be a “mechanical” problem as well as a “source of energetic Yin Yang disharmony,” assessed by measuring the length of the legs to determine the side of TMJ dysfunction and requiring “vital alignment” of the TMJ by a jaw manipulation in an acupuncture/acupressure protocol lasting one year.⁸

Unlike medicine, dentistry deals mostly with structural conditions that are treated with physical modalities, and the problems are usually and expectedly cured. The public, however, presents to both dentists and physicians with complex oral-facial conditions such as TMD that may not be structural or easily cured; these may resemble structural problems that have proper structural treatments and require accurate diagnosis to avoid inappropriate treatments.

Because dentists have been predominately trained to diagnose and treat structural dental problems, they may have difficulty in effectively dealing with non-structural and non-dental problems presenting as orofacial pain. When a dentist cannot adequately deal with a patient’s problems and concerns, the patient may lose confidence and seek help and advice from sources outside traditional scientific dental practice. Also, the temptation to provide costly dental procedures for non-dental conditions may be great in today’s society. Dental treatments may cause iatrogenic harm rather than merely being ineffective or coinciding with improvement. The most common dental therapy in TMD, the occlusal splint, has been demonstrated to have a significant placebo effect.⁹ Studies have shown no scientific basis to explain the clinical efficacy of splints for TMD,^10,11 yet some splint therapies are aimed at producing irreversible changes that require extensive and expensive dentistry to correct.¹² TMD management, at the least, should be conservative and reversible.⁷

Dental treatment for TMD is an example where conventional care of a condition is more conservative, safer, less invasive and less costly than UD. Some dental practices for TMD may be fraudulent UD, considering contemporary science-based knowledge.

Conclusions

Cancer patients have been advised, “If alternative therapies make you feel better physically or psychologically, use them. But realize that there may not be any evidence for the therapies’ safety or effectiveness and that tested therapies still offer the most hope. Be particularly aware of claimed cures; traditional medicine expends huge efforts in finding cures for cancer.”¹³ Such advice pertains to any patient considering UM for an incurable life-threatening condition. The majority of UD users, however, are not in life-threatening situations, and licensed health care practitioners have the responsibility to advise and guide patients in harm and risk reduction and in maximizing potential benefits of any treatment.

Poor dental work has always been a problem, but the incidences of misdiagnosis, overtreatment and the application of unfounded and disproved techniques are increasing.¹⁴ UD has challenged the dental profession to confront issues in professional integrity and accountability. UD may have limited promise for specific conditions under special circumstances. Dentists must be particularly cautious due to the known potential for harm from unconventional care in general and from unproven dental procedures, in particular, which may worsen an individual’s quality of life. The range of known complications in dentistry that can magnify physical and psychosocial distress in a vulnerable individual include inflicting pain, altering the ability to eat, and prolonging or worsening an unrelated medical condition. Dentists must be knowledgeable about UD and UM in order to practise competently, effectively and ethically.

Acknowledgments: The author thanks Dr. Joel Epstein for his helpful comments and valuable contribution to the paper.

References

1. Wetzel MS, Eisenberg DM, Kaptchuk TJ. Courses involving complementary and alternative medicine at US medical schools. JAMA 1998; 280:784-7.

2. Ruedy J, Kaufman DM, MacLeod H. Alternative and complementary medicine in Canadian medical schools: a survey. CMAJ 1999; 160:816-7.

3. Epstein, JB. Understanding placebos in dentistry. JADA 1984; 109:71-4.

4. Happle R. The essence of alternative medicine. A dermatologist’s view from Germany. Arch Dermatol 1998; 134:1455-60.

5. Husted C, Pham L, Hekking A, Niederman R. Improving quality of life for people with chronic conditions: the example of t’ai chi and multiple sclerosis. Altern Ther Health Med 1999; 5:70-4.

6. Berry JH. Emphasis. Questionable care : what can be done about dental quackery? JADA 1987; 115:679-85.

7. Goldstein BH. Temporomandibular disorders: a review of current understanding. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 88:379-85.

8. Aung SK. The treatment of temporomandibular joint dysfunction & distress: a Chinese traditional medical approach utilizing acupuncture, massage and manipulation. Am J Acupuncture 1996; 24:255-67.

9. Greene CS, Laskin DM. Splint therapy for the myofascial pain- dysfunction (MPD) syndrome: a comparative study. JADA 1972; 84:624-8.

10. Marbach JJ, Raphael KG. Treatment of orofacial pain using evidence-based medicine: the case for intraoral appliances. In: Campbell, J.N. (ed) Pain 1996 - An Updated Review. Refresher course syllabus. Seattle: IASP Press; 1996:413-22.

11. Dao TT, Lavigne GJ. Oral splints: the crutches for temporomandibular disorders and bruxism? Crit Rev Oral Biol Med 1998; 9:345-61.

12. Gelb H. Effective management and treatment of the craniomandibular system. In: Gelb H, editor. Clinical management of head, neck and TMJ pain and dysfunction. 2nd ed. Philadelphia: W.B. Saunders Co.; 1985. p. 325-33.

13. Nutrition News Focus. Complementary medicine and cancer patients. July 6, 1999. Available from URL: http://www.nutritionnewsfocus.com/archive/CompMedCanc.html    (Accessed July 6, 1999).

14. Dodes JE. Millenium: Healthcare. Dentistry. American Council on Science and Health Web Site. Volume 10 Numbers 2 & 3,1998. Available from URL: www.acsh.org/publications/priorities/1002/milcare.html   (Accessed January 4, 2000).

15. Zollman C, Vickers A. ABC of complementary medicine: complementary medicine and the doctor. Brit Med J 1999; 319:1558-61.