Getting to the Root of the Root Canal Controversy: Facts vs Ideology

All truth passes through three stages. 

First, it is ridiculed. Second, it is violently opposed. 

Third, it is accepted as being self-evident.

Arthur Schopenhauer

“Our study underlines the importance of dental health in the prevention of myocardial infarction. It also raises the question about the role of the complication-prone root canal treatment as a possible risk factor.”(Pessi ​​ et al. 2013)

“Even a small contribution to CHD (cardiovascular disease) development by endodontic disease might be important from a public health perspective.”(Caplan et al. 2006)

“ Oral infections have become an increasingly common risk-factor for systemic disease, which clinicians should take into account. Clinicians should increase their knowledge of oral diseases, and dentists must strengthen their understanding of general medicine, in order to avoid unnecessary risks for infection that originate in the mouth.” (Rautemaa, et al. 2007)

Over one hundred years ago Charles Mayo, one of the founders of The Mayo clinic understood the importance of the oral/systemic connection when he wrote:

“It is evident that the next great leap in medical progress in the line of preventive medicine should be made by dentists. The question is, will they do it?” 

This paper will explore the systemic disease risks of oral infections. I will present current peer reviewed scientific research that shows that periodontal disease and poorly performed root canals present a similar set of systemic disease risks due to the spread of bacteria and bacterial toxins to other sites in the body as well as an increase inflammation. 

The preconceived prejudice that dentistry is not really a part of overall general health and medicine presents a barrier to the acceptance of new ideas. Following Newton’s first law of motion, objects, and in this case ideas and belief systems, have an inertia that is very resistant to change. 

To turn a big ship like an aircraft carrier you will need big rudder. And even if you fully turn the rudder, the ship will not turn right away due to inertia. The same is true for long established belief systems. That is why this article will present a lot of peer reviewed scientific evidence. ​​ Because just making a claim that some poorly performed root canals may increase the risk for various systemic diseases, or, as is the position of the dental profession, that root canal teeth can never be a risk factor for any systemic disease, is not good enough. You need to see the what the research actually says and make up your own mind. The more solid science presented, the bigger the “rudder,” and the faster change will take place 

This article is not for everybody. If the current political climate is any indicator, about 40 percent of the people will not change their mind on this issue regardless of the evidence presented. 

Still others do not believe in science and embrace absurd conspiracy ​​ theories. For example, an estimated 2 percent of the population believe that the earth is flat, and about 7 percent think that the Apollo moon landings were faked and filmed in Hollywood! And NASA was so good at faking it that they decided that once was not good enough, so they faked it 5 more times! This article is not for these people either. For all the rest, here we go.

The dental profession is slowly embracing the role of periodontal disease as a risk factor for diseases such as heart disease and some forms of cancer, but they steadfastly refuse to acknowledge, in spite of all the current research to the contrary, that poorly performed root canal teeth may pose a similar risk. 

Whistleblowers rarely get a celebratory dinner. In fact, just the opposite is true. Jeffrey Wigand was fired from the tobacco company Brown and Williamson in 1994 for exposing that high-ranking corporate executives knowingly approved the addition of additives to their cigarettes that were known to be carcinogenic and/or addictive. (Wikipedia). A movie was made about him titled The Insider, starring Russel Crowe, Al Pacino and Christopher Plummer. 

Joseph Rannazzisi ran the United States drug enforcement ​​ agency (DEA) office of diversion control, the division that regulates and investigates the pharmaceutical industry, tells the inside story of how, he says, the opioid crisis was allowed to spread aided by Congress, lobbyists, and a drug distribution industry that shipped, almost unchecked, hundreds of millions of pills to rogue pharmacies and pain clinics-providing the rocket fuel for a crisis that, over the last two decades, has claimed more than 200,000 lives. In 2015 Rannazzisi was put under investigation and pushed aside at the DEA office of Diversion control. “The investigation went nowhere. But, Rannazzisi said, "It destroyed me." [www.cbsnews.com/news/60-minutes-ex-dea-agent-opioid-crisis-fueled-by-drug-industry-and-congress/]

In 2005 the New York State dental board tried to revoke my license to practice dentistry because of my beliefs that a subset of poorly performed root canal teeth may contribute to systemic diseases. They failed. But it nearly destroyed me too. 

All licensing boards have tremendous power. The State dental boards are no exception. Although the majority of what they do is valid and in the interest of public safety, that is not always the case. . [See ​​ Appendix A for the preface of my book with co-author Tom Levy, MD, JD book titled, The Toxic Tooth]

“The "dirty secret behind licensing boards," Allensworth told the House Judiciary Committee on Tuesday afternoon, is that very little of what they do resembles government activity. While growing to become the largest labor institution in American history, they have too often become a self-serving institution that act like cartels instead of protectors of public health and safety. These boards are formed, by law, as cartels," Allensworth ​​ said…” [Yes, Licensing Boards are Cartels. The case for why Congress should get involved. Eric Boehm. Sep. 13, 2017. Reason.com. Hit and Run blog] (see Appendix J for the ​​ complete article)

For over twenty-five years I have been speaking about the link between oral focal infections (periodontal disease, chronically infected teeth and endodontically (root canal) treated teeth) and inflammation in the mouth associated with diseases elsewhere in the body, what is now known as the oral/systemic connection. 

Although periodontal disease has been established by some researchers (Bale and Doneen) as a causative factor in heart disease, the American Academy of Endodontists (AAE) the dentists who specialize in root canal treatment) still refuses to admit that any, even poorly performed root canals (endodontically treated teeth) can cause or contribute to any systemic disease such as heart disease. 

I will present current peer reviewed scientific research that shows that that periodontal disease and poorly performed root canals present the same set of systemic risks, namely:

-the spread of bacteria and bacterial toxins to other sites in the body 

-and an increase in inflammation. 

I will be presenting a lot of scientific information that may seem tedious to wade through. You don’t have to read it all, but it is important that you know that it’s there. Because broad generalized and polarizing statements like, “All root canals are bad”, or “a root canal tooth can never be a risk factor for any systemic disease” are irresponsible unless backed up by sound science, and often supported by good old-fashioned common sense. Yet strict and unwavering ideology is what is propagated by both the dental profession and Stephen Barrett’s quackwatch website, as well as the extreme views by some that oppose all root canals. 

You will see that there are two sides to the root canal controversy that has been raging for 125 years. If it was so simple this issue would have been put to bed a long time ago. ​​ Neither view is 100 percent correct. More importantly, neither extreme view increases the level of care and reduces the level of risk. 

Stephen Barrett of the website quackwatch says that I am “spreading offbeat dental theories.” There is one problem with that statement. These are not my theories all! Everything I present is from peer reviewed and accepted scientific papers so you can see the actual scientific research for yourself. 

In my opinion Barrett either has not read the literature that is presented in this paper, or he has and does not understand it, or he chooses to ignore it all and promote the “offbeat” agenda of the American Dental Association. You can read more on Quackwatch and Barrett later in this paper as well as in the appendix section. Google: “Is Stephen Barrett a quack” and read what others have to say about him then decide for yourself if he can be trusted to present an unbiased viewpoint. 

The summary section will offer conclusions based upon all of the scientific research presented. 

​​ 

Here is what I believe:

Inadequately performed root canals will remain chronically infected with persistent infection in the jaw-bone surrounding the end of the root called apical periodontitis, may release bacteria and bacterial toxins into the body, and potentially raise the level of systemic inflammation. ​​ It is well established that chronic infection and inflammation are a contributor to many systemic diseases such as cardiovascular disease. Therefore, a subset of root canal teeth, and I emphasize some, not all, may cause or contribute to systemic diseases.

Sounds logical, doesn’t it? ​​ Not only is it logical, but this statement is backed up by abundant peer reviewed scientific literature and is supported by established medical principals. 

Yet, the dental profession does not accept it. In fact, they vehemently deny that any root canal tooth could cause or contribute to any systemic diseases such as heart disease. But as you will see, more and more physicians and dentists, are rejecting the flawed dismissal of the focal infection theory (focal infection states that local infection can cause or contribute to disease in another part of the body) by the dental profession, and are coming on board and aligning with this science-based paradigm that chronic infection and inflammation can be a risk factor for, and contribute to, many systemic diseases. “The times they are a changing.” 

“People have raised questions about the system over the years, and they’ve called for reforms periodically. Nearly a century ago, in the 1920s, this biological chemist named William Gies was a kind of prophet. He visited every dental school in the country and in Canada for the Carnegie Foundation, for this big report, and he called for dentistry to be considered an essential part of the healthcare system. He said: “Dentistry can no longer be accepted as mere tooth technology.” He wanted oral health and overall health to be integrated into the same system, but organized dentistry fought to keep dental schools separate. [Dentists] emerged as defenders of the professional autonomy and professional independence of the private practice system that we have here. David Satcher, the [former] surgeon general, he kind of said the same thing when he issued this “Oral Health in America” report in 2000. He said we must recognize that oral health and general health are inseparable. And that too, was a kind of challenge. And it seems like things are changing, but very slowly.”[Mary Otto in an interview by Julie Beck. Why Dentistry is Separate From Medicine. The Atlantic.com. Mar. 2017]

Oral health is integral to overall health. Infection and inflammation in the mouth can have can be a risk factor and contribute to disease elsewhere in the body. ​​ Dentists must know medicine and physicians must understand dentistry. Since everything in the body is connected. I believe dentistry should be a sub-specialty of medicine. ​​ 

“There seems to be a paradigm shift in the field of endodontics—from a field of pain management, tooth preservation, and control of infections toward a perspective where all oral infections are risks for systemic complications (Han and Wang 2013).”

The belief that oral health is an integral part of total health is gaining momentum. Bruce Donoff, D.M.D.M.D., professor of oral and maxillofacial surgery and dean of the Harvard School of Dental Medicine writes:

“Ever since the first dental school was founded in the United States in 1840, dentistry and medicine have been taught as — and viewed as — two separate professions. That artificial division is bad for the public’s health. It’s time to bring the mouth back into the body. As taught in most schools today, dental education produces good clinicians who have a solid understanding of oral health, but often a more limited perspective on overall health. Few dental students are equipped to take a holistic view that may include taking a patient’s vital signs, evaluating their risk of heart disease or stroke, spotting early warning signs of disease…

We cannot drill, fill, and extract our way to better oral and overall health. We need a fundamentally different approach, one that accentuates disease prevention and health management using a multidisciplinary, integrated, and patient-centric approach to overall health. And that means breaking down the wall between dentistry and medicine. [Statnews. 2017][See Appendix B for additional article excerpts]

Physicians recognized the role of oral infection on diseases elsewhere in the body (focal infection). Over 100 years ago. ​​ Unfortunately, much of this early work was falsely debunked and discredited. Fortunately, new research is proving that much of the old research was essentially correct and that focal infection is indeed.

“…since the beginning of time, dentistry and medicine have been considered inherently distinct practices. The two have never been treated the same way by either the medical system or public insurance programs. But as we learn more about how diseases that start in our mouths can ravage the rest of our bodies, it’s a separation that’s increasingly hard to rationalize.”[Olga Kahzan. Why Don’t We Treat Teeth Like the Rest of Our Bodies? The Atlantic.com. ​​ Sep. 2014]

“Multitude of etiologies can cause diseases in various systems. One important etiology is focal sepsis in the oral cavity which has been hypothesized till now to cause various diseases. This hypothesis has now been proved beyond doubt”…” [Journal of Indian Academy of Oral Medicine and Radiology, April-June 2012;24(2):137-141 Systemic Affliction of Oral Focus]

FOCAL INFECTION 

Focal infection theory is the historical concept that many chronic diseases, are caused by focal infections, that is, a localized infection that causes disease elsewhere in the host. There is growing body of evidence linking focal areas of infection and inflammation to many systemic diseases. 

The AAE claims that the focal infection theory in endodontics “was based on long-debunked and poorly designed research conducted nearly a century ago, long before modern medicine understood the causes of many diseases. There is no valid, scientific evidence linking root canal treatment to disease elsewhere in the body.”

I will present the history of focal infection later in this article and you will see that much of the analysis and assumptions used by the AAE to debunk focal infection is flawed. 

Further, modern medicine is indeed learning more about the causes of many diseases, and the role of infection and inflammation as a risk factor has become more significant, not less. 

Finally, there is a lot of current valid scientific evidence linking poorly performed root canal teeth to disease elsewhere in the body. 

“Knowledge is made by oblivion, and to purchase a clear and warrantable body of truth, we must forget and part with much we know” ​​ Sir Thomas Browne (1605–1682) 

​​ “Historically, there was an advent of the focal infection theory, according to which enclosed lesions such as a necrotic pulp, could only drain into the circulation and was considered as the most dangerous foci of infection [6]. Better bacteriological culture techniques and study designs led to the demise of the focal infection theory. However, in the recent years, the concept of focal infection theory has again gained importance. A research conducted on germ free chickens infected with an avian herpes virus had induced an arterial disease resembling human atherosclerosis. Infection induced indirect damage by releasing inflammatory mediators and initiating several immune related pathways.”

“Interest in the relationship of oral health to cardiovascular health is not new, but this association has been reinforced by the researchers only in the last decade. Investigators currently regard inflammation to play a pivotal role in the development of atherosclerosis.

The multifactorial etiology of cardiovascular disease shares many risk factors and associations with that of oral diseases. In 1989, a case-control study found that dental health was significantly worse in patients with a history of acute myocardial infarction than in control subjects. This study renewed the interest of physicians and dental surgeons to explore the relationship between oral and systemic health hazards. Studies have shown the presence of bacteria of oral origin in atherothrombotic plaques and vascular biopsies.” [Paridhi Garg and Chandraker Chaman. Apical Periodontitis - Is It Accountable for Cardiovascular Diseases? J Clin Diad Res. 2016 Aug; 10(8); ZE08-ZE12.]

 “Multitude of etiologies can cause diseases in various systems. One important etiology is focal sepsis in the oral cavity which has been hypothesized till now to cause various diseases. This hypothesis has now been proved beyond doubt”…” [Journal of Indian Academy of Oral Medicine and Radiology, April-June 2012;24(2):137-141 Systemic Affliction of Oral Focus]

“Dental procedures, but more importantly, oral infections and poor oral health can provoke the introduction of oral microorganisms into the bloodstream or the lymphatic system. The subsequent attachment and multiplication of these bacteria on tissues or organs can lead to focal oral infections. Pathogenic agents may also remain at their primary oral site, but the toxins liberated can reach an organ or tissue via the bloodstream and cause metastatic injury. Finally, metastatic inflammation may result from an immunological injury caused by oral bacteria or their soluble products that enter the bloodstream and react with circulating specific antibodies to form macromolecular complexes.” 

[Renee Gendron, Daniel Grenier, Leo-Francois Maheu-Robert. The Oral Cavity as a Reservoir of Bacterial Pathogens for Focal Infections. https://doi.org/10.1016/S1286-4579(00)00391-9 Get rights and content 

To fully understand this subject, it is important to start with the basics. It is not enough to make broad and generalized statements without having a sound understanding of what a root canal actually is and why it is performed, and the mechanisms by which a poorly performed root canal can negatively impact health. 

There are three principal sources of focal infection originating in the oral cavity, the first being periodontal disease, or what is commonly referred to as “gum” disease. When infection in the gum tissue extends to the jaw-bone of the tooth socket it is called periodontal disease. 

The second is an infection of the tooth pulp tissue which occurs when dental decay, or a “cavity,” gets so large, or “deep,” and bacteria infect the normally sterile pulp tissue. This infection can infect both the tooth pulp and progress down the root to infect the jaw-bone at the end of the root. When the infection spreads into the jaw-bone surrounding the end of the tooth root, it is called apical periodontitis. Apical periodontitis can be either painful or totally asymptomatic.

The third contributor to oral infections is poorly performed root canals. A root canal procedure is designed to remove the dead in infected pulp tissue and bacteria in the tooth root system after the tooth has become infected from extensive tooth decay, and then completely seal the root canal. 

A poorly performed root canal will leave dead and infected pulp tissue in the root canal spaces, significant residual bacteria in the tooth, and persistent residual infection in the jaw-bone surrounding the end of the root. 

The mechanisms of action, or how these areas of chronic infection and inflammation in one part of the body can affect another part of the body, are now understood, which adds support to the observational associations that have been reported for well over 100 years. 

Lesions of endodontic (apical periodontitis) origin can occur on teeth that have not had a root canal already, or they can persist after root canal if the root canal is performed poorly with studies showing up to 60 percent or more root canal ​​ teeth show evidence of apical periodontitis on conventional 2D x-ray. ​​ 

CAUSE DOES NOT EQUAL CAUSATION 

"While the very nature of multifactorial, chronic diseases has made it difficult to establish a definitive causal role for periodontal pathobionts in systemic infection, the body of literature supporting an aetiopathological role for these organisms is too substantial to be ignored as merely coincidental. 

“The present consensus thus appears to support a temporal relationship between periodontal and cardiovascular diseases, with oral bacteria playing either a direct or an indirect role in disease causation.”

​​ [Physiol 2017 Jan 15; 595(2): 465–476. Published online 2016 Aug 28.] 

One argument you will often hear when discussing the link between oral infections and systemic diseases such as heart disease is that correlation does not necessarily equate to causation. Just because two conditions occur at the same time does not mean that one caused the other. And that is a valid point because causation is more difficult to prove. Most diseases have multiple causative agents and risk factors, and it often takes years of observing association and correlation to then establish causation. ​​ 

For example, many people believe that if your cholesterol is normal you will not get heart disease. Clearly, elevated cholesterol is one risk factor for heart disease. But since half of all heart attacks occur in people with normal cholesterol, it can’t be the only risk factor. There must be other risk factors to be identified and studied; first by finding correlation, and later, as biological mechanisms of action are further defined, evolving into causation.

One of these additional risk factors is inflammation. Lowering inflammation, independent of lowering cholesterol, ​​ significantly reduced the incidence of cardiovascular deaths, ​​ which means that inflammation is now considered one of the causative factors in cardiovascular disease.

Investigators from Brigham and Women's Hospital, 2017 CANTOS study reported:

“The team reports a significant reduction in risk of recurrent heart attacks, strokes and cardiovascular death among participants who received a targeted anti-inflammatory drug that lowered inflammation but had no effects on cholesterol. “

"These findings represent the end game of more than two decades of research, stemming from a critical observation: Half of heart attacks occur in people who do not have high cholesterol," said Ridker. "For the first time, we've been able to definitively show that lowering inflammation independent of cholesterol reduces cardiovascular risk. This has far-reaching implications. It tells us that by leveraging an entirely new way to treat patients - targeting inflammation - we may be able to significantly improve outcomes for certain very high-risk populations." 

"Cardiologists will need to learn about inflammation today, the same way we learned about cholesterol 30 years ago," said Ridker. 

“In my lifetime, I've gotten to see three broad eras of preventative cardiology. In the first, we recognized the importance of diet, exercise and smoking cessation. In the second, we saw the tremendous value of lipid-lowering drugs such as statins. Now, we're cracking the door open on the third era," said Ridker. "This is very exciting." [Brigham and Woman’s CANTOS 2017]

Inflammation has long been associated with coronary artery disease, but It took over 25 years for inflammation to be recognized as a major causative risk factor for coronary artery disease. ​​ 

Now that inflammation has been established as a causative risk factor for cardiovascular disease, it is easy to see how periodontal disease, which is an infection that causes inflammation, can now be considered a causative risk factor, and not merely an association, because the mechanism of action has become more clearly understood. ​​ 

​​ “There are three accepted essential elements in the pathogenesis of atherosclerosis: lipoprotein serum concentration, endothelial permeability and binding of lipoproteins in the arterial intima. There is scientific evidence that PD (periodontal disease) caused by the high-risk pathogens can influence the pathogenesis triad in an adverse manner. With this appreciation, it is reasonable to state PD (Periodontal disease), due to high-risk pathogens, is a contributory cause of atherosclerosis. Distinguishing this type of PD as causal provides a significant opportunity to reduce arterial disease.”

[Bale, Doneen. High Risk Periodontal Pathogens Contribute to the Pathogenesis of Atherosclerosis. Group.bmj.com. February 24, 2018]

SIMILARITIES BETWEEN PERIODONTAL BACTERIA AND ROOT CANAL BACTERIA AND THE INFALMATORY RESPONSE 

Since similar pathologic conditions exist between periodontal disease and infected teeth with apical periodontitis as well as a percentage of poorly performed root canal teeth with apical periodontitis, a similar risk profile can by hypothesized, with the degree of risk dependent upon the severity of infection and inflammation.

“Lesions of endodontic origin or apical periodontitis may be defined as “acute or chronic inflammatory lesion around the apex of a tooth caused by bacterial infection of the pulp canal system”9 and usually presents in the presence or after restoration of deep caries lesions or fractured teeth.10 Although the etiology for both conditions is different, this condition bears some similarities to chronic periodontal inflammatory disease, viz., similar pathogenic gram-negative microflora and a visible rise in systemic cytokine levels in both the clinical situations. Thus, the systemic effects related to periodontitis may be applicable for lesions of endodontic origin too.”…

​​ [ Lesions of endodontic origin: An emerging risk factor for coronary heart diseases.https://www.sciencedirect.com/science/article/pii/S0019483218300531?via%3Dihub] 

The following article was published in 2012 and shows that the periodontal disease and apical periodontitis share very similar characteristic of infection and inflammation. Corrected for other risk factors such as family history and smoking, this study showed that an increase in the number of teeth with apical periodontitis ​​ increases the risk of heart disease. ​​ 

“Apical periodontitis (AP), as an immune response to chronic bacterial contamination of the endodontic and periradicular spaces, presents significant similarities with the inflammatory response involved in chronic periodontitis (14). Endodontic pathogens, which tend to be the same as those involved in periodontal infections, may reach the atherosclerotic plaques through a mechanism of metastatic infection or may act through the previously mentioned mechanism of molecular mimicry. An increase in proinflammatory cytokines has been reported in the pulp, periapical tissues, and serum of patients with pulpitis and apical periodontitis (15, 16).

Apical periodontitis (AP) presents significant similarities with the inflammatory response involved in periodontitis (14). A recent review of epidemiologic studies (41) reported a prevalence of AP ranging between 14% and 70% of all subjects and 0.6% and 8.5% of all teeth, whereas root-filled teeth were evident in 22% to 78% of subjects and 1.3% to 21.5% of all teeth. Furthermore, it was evidenced that AP is approximately 4 times as common in root-filled teeth as in non–root-filled teeth (41). This tendency was confirmed by another study (42) in which the radiographic evidence of root fillings appeared to be the most important risk indicator of AP in the individual. This unfavorable outcome has been associated with poor quality endodontic therapy, which was found in 44%–86% of treated teeth or roots (43–47)… 

AP has been associated with an increased risk of CHD. However, the systemic manifestations of periapical inflammatory processes remain controversial. Several studies have shown a significant association between CHD and LEOs through multivariate analysis after adjusting for confounding factors (18, 28, 57). This is contradicted by other studies in which no significant associations were observed (36, 58). In this study, the diagnosis of LEOs alone did not show an evident association with an increased risk of CHD. However, the number of LEOs was strongly associated, and the association was still evident and stable after adjusting for confounding factors such as family history and smoking. The findings show that an increase in the number of LEOs may lead to an increased risk for CHD. This outcome is in concordance with the investigation by Caplan et al (18) and in contrast with Frisk et al (58)… 

This study shows that a strong association exists between an increased risk for CHD and the number of LEOs.(Apical Periodontitis) Furthermore, it was possible to identify a typical CHD patient profile as smoker, low compliance to oral preventive strategies, and a higher prevalence of late stage oral diseases. This profile has much to do with lifestyle, suggesting that chronic oral diseases may be considered among unconventional risk factors of CHD”.

Since this study was published, many more studies have been published showing similar associations between poorly performed root canals with apical periodontitis and heart disease. Since heart disease is the number one killer in this country, isn’t this enough evidence to raise the standard for a successful root canal? Shouldn’t dentists recognize apical periodontitis as a potential risk factor for heart disease and take the necessary action to treat it? New technology exists that significantly improves the cleaning and disinfecting of the root canal system. Should all dentists be using it?

The AAE may not embrace this but you, the patient, armed with this information can find a dentist who does. 

HOW CAN ORAL INFECTIONS AFFECT THE HEART?

​​ Here are the proposed mechanisms on how oral focal infection, specifically periodontal disease, can be a risk factor for heart disease. 

“At least Four basic pathogenic mechanisms have been proposed that involve oral inflammations in the pathogenesis of atherosclerosis:

​​ (1) low-level bacteremia by which oral bacteria enter the blood stream and invade the arterial wall.

​​ (2) systemic inflammation induced by inflammatory mediators, which are released from the sites of the oral inflammation into the blood stream.

​​ (3) autoimmunity to host proteins which results from the host immune response to specific components of oral pathogens.

​​ (4) Pro-atherogenic effects resulting from specific bacterial toxins that are produced by oral pathogenic bacteria.” [ Roles of Oral Infections in the Pathomechanism of Atherosclerosis.]

Therefore, one cannot say that bad root canal teeth cause heart disease. Rather, poorly done root canals may add to the risk of cardiovascular disease because of the dead and infected tissue in the root canal space and porous dentin tubules; persistent apical periodontitis which is a chronic infection/inflammatory state in the jaw bone around the end of the tooth root; and the release of bacteria and bacterial toxins into the blood stream that travels to other parts of the body like the heart.

​​ ​​ ​​ ”While the ​​ very nature of multifactorial, chronic diseases has made it difficult to establish a definitive causal role for periodontal pathobionts in systemic infection, the body of literature supporting an aetiopathological role for these organisms is too substantial to be ignored as merely coincidental… 

“The present consensus thus appears to support a temporal relationship between periodontal and cardiovascular diseases, with oral bacteria playing either a direct or an indirect role in disease causation.”

​​ [J Physiol. 2017 Jan15; 595(2): 465-476]

And that is it in a nutshell. I am not against all root canals, just the bad ones. There are new technologies that allow skilled and meticulous dentists and endodontists to perform root canals that will present little if any potential to contribute to disease elsewhere in the body. But as you will see later, this is far from the norm. And until the AAE accepts the fact that poorly performed root canals have the potential to contribute to systemic disease, don’t expect changes to the standard of care any time soon. 

I will be presenting excerpts from peer reviewed articles in support of the role of oral infections on systemic disease, so you don’t need to take my word for it. You will see the scientific studies for yourself. There is evidence, a lot of it, that links oral infection to systemic diseases. 

The time is right again for the public to have this information available to make informed decisions on their health. If somebody wants to keep a root canal tooth with persistent apical periodontitis without having the tooth retreated or extracted, they have every right to do so. But you cannot make an informed decision unless you are fully informed. 

Here is what William Hunter, M.D. said over 100 years ago on the importance of oral infection on systemic disease in a presentation titled, The Role of Sepsis and Antisepsis in Medicine”, delivered at McGill University in Montreal Canada in 1910, that hits the nail right on the head:

“In the foregoing sketch of the chief spheres of the doctor’s work and interest, I omitted any reference to one other portion of the body which constantly comes under his observation; indeed, more often than any other – I mean the mouth. This omission was intentional on my part. ​​ The cases presently to be described – which could be multiplied by thousands and tens of thousands coming under the daily notice of doctors – illustrate how constant this omission is in practice.

 ​​​​ 

​​ What I desire to impress upon you students, and all students entering the profession, and all those already engaged in the practice of the profession is “not a matter of teeth in dentistry.” It is an all-important matter of sepsis and antisepsis that concerns every branch of the medical profession, and concerns very closely the public health of the community. It is not a simple matter of “neglect of the teeth” by the patient, as is so commonly stared, but one of neglect of a great infection by the profession – a great infective disease for which the patient in not primarily responsible any more than he is responsible for the condition of typhoid or tuberculosis. The condition referred to is that which I have given the name, ‘oral sepsis’.”

In the medical profession we have specialists who devote their time and attention to every other part of the body, cave the mouth. ​​ The medical team have side-stepped here and left the mouth to the dental men. (there were only men practicing medicine and dentistry back then) ​​ The medical l men have considered the dental men the oral specialists, and the dental men, almost to a man, have recently failed to grasp the full responsibility which rested upon their shoulders and to realize that upon them rested the importance of proper oral conditions. 

 ​​ ​​ ​​​​ 

​​ Most dentists have been tooth specialists instead of mouth specialists. It is only when the dentist realizes his responsibility in the latter capacity that he assumes his true relation to the public health in his community. 

 ​​ ​​ ​​​​ 

​​ With oral conditions as we find them, and with the influences which they exert upon the public health and general welfare of the human family fully recognized, and with the dental profession alone occupying the field of oral specialist, it is to this profession that we must turn for the correction of the faulty conditions which here exist. …

With the dentist responsible for the health of the mouth, it becomes necessary, in order to establish the true relation of the dentist to the public health of the community, to show what influence the mouth bears in that capacity.”

Unfortunately, much of this early work by researchers was incorrectly analyzed using outdated information and flawed assumptions, which led to focal infection being erroneously discredited. New research is proving that much of the old research was essentially correct and that the focal infection theory should never have been debunked in the first place. Modified yes, as new research led to a better understanding of underlying mechanisms, but totally debunked, NO. 

The following quote is written by Endodontist (root canal specialist) Professor James L. Gutmann DDS in his ​​ 2017 article titled:

​​ Focal Infection Revisited - The Swinging of the Pendulum. 

“Today, systemic diseases that have some level of association with oral infections, in particular inflammatory periodontal disease, include; cardiovascular disease, coronary heart disease including atherosclerosis and myocardial infarction, stroke, infective endocarditis, bacterial pneumonia, infant low birth weight, diabetes mellitus, rheumatoid arthritis, some cancers; and following root canal procedures, and chronic apical periodontitis, that appear to associate independently with coronary artery disease and in particular with acute coronary syndrome. In the most recent systematic review that addressed any relationship between pulp/periapical infections and systemic disease, potential correlations have been identified with cardiovascular disease, chronic liver disease, diabetes mellitus, some blood disorders and bone mineral density. Indeed, the pendulum has swung, however its motion is not based on hearsay, sensationalism or charlatanism, but rather on sound science …”

More and more researchers are recognizing the validity of focal infection as fact, and not a debunked theory. 

“The theory of focal infection, which was promulgated during the 19th and early 20th centuries, stated that “foci” of sepsis were responsible for the initiation and progression of a variety of inflammatory diseases such arthritis, peptic ulcers, and appendicitis. In the oral cavity, therapeutic edentulation ​​ (tooth extraction) was common as a result of the popularity of the focal infection theory. Since many teeth were extracted without evidence of infection, hereby providing no relief of symptoms, the theory was discredited and largely ignored for many years. Recent progress in classification and identification of oral microorganisms and the realization that certain microorganisms are normally found only in the oral cavity have opened the way for a more realistic assessment of the importance of oral focal infection. It has become increasingly clear that the oral cavity can act as the site of origin for dissemination of pathogenic organisms to distant body sites, especially in immunocompromised hosts such as patients suffering from malignancies, diabetes, or rheumatoid arthritis or having corticosteroid or other immunosuppressive treatment. A number of epidemiological studies have suggested that oral infection, especially marginal and apical periodontitis, may be a risk factor for systemic diseases.” [Iaojiing, Li, Kristin M. Kolltveit, Leif Tronstad, Ingar Olsen. Systemic Diseases Caused by Oral Infection. Microbiol Rev 2000 Oct; 13(4): 547-558]

To be clear, is not the root canal treatment itself that is the problem, it is the lingering infection in the tooth and jaw-bone surrounding the tooth root the result of a poorly performed root canal that is the problem. Although it is impossible to eliminate all bacteria and sterilize an infected tooth with root canal treatment, it is possible, using new technologies along with meticulous and thorough procedure, to significantly reduce or eliminate any systemic risk from a root canal tooth.

I must emphasize again that not all root canal teeth will contribute to systemic disease and I certainly do not advocate extracting all root canal teeth. ​​ All root canals are not the same. Although it is impossible to ever sterilize an infected tooth with any root canal procedure, a meticulously performed root canal with no apical periodontitis and therefore no inflammation, should pose little if any systemic disease risk.

The root canal teeth that I am referring to are the “bad boys” of root canal treatment. That is, the inadequately performed root canals with persistent apical periodontitis (non- healed, infected areas in the jaw- bone around the end of the tooth root) that cause increased local and systemic inflammation. 

These teeth may be completely asymptomatic and look fine to most dentists on conventional X-Ray images. But just like high blood pressure, which is often asymptomatic, that does not mean that all is well. Lack of symptoms don’t necessarily equate to lack of disease. The first sign of advanced cardiovascular disease is often a heart attack, with little or no advance symptoms or warning.  ​​​​ 

The key point is that the AAE fails to differentiate between well performed root canals and poorly performed root canals and instead continues to insist that no root canal tooth can ever be a risk factor for disease elsewhere in the body (systemic disease). 

In spite of mounting scientific evidence to the contrary, The American Academy of Endodontists (AAE), the dentists who specialize in performing root canal treatment) state on their website AEE.org.: 

“Information you may find on the Internet or elsewhere, claiming that if you receive a root canal treatment, you’re more likely to become ill or contract a disease in the future simply isn’t true. 

This false claim was based on long-debunked and poorly designed research conducted nearly a century ago, long before modern medicine understood the causes of many diseases. There is no valid, scientific evidence linking root canal treatment to disease elsewhere in the body.”

There is in fact a lot of valid scientific evidence linking poorly performed root canals with disease elsewhere in the body which I will present later. For ease of presentation and consistency, most of the discussion will be centered on the link between oral infection and cardiovascular disease with all statements supported by peer reviewed scientific literature.

ROOT CANAL DOCUMENTARY MOVIE TITLED ROOT CAUSE

The recently released documentary film Root Cause attempts to address the problems with standard root canal treatment but unfortunately falls far short by presenting exaggerations, flawed reasoning, and pseudo-science instead of objectively sticking to sound scientific principles. Although there are truths presented in this movie, they overshadowed by the countless inaccuracies. In addition, many of the dentists and physicians in this movie, let’s call them the Radical Anti-root canal (Anti-RC), state that all root canal teeth are bad and should be extracted. This is not true. You can’t expect the public to take you seriously, especially when challenging existing paradigms, if you make absurd and blatantly false statements. The truth is dramatic enough. 

Here are just two stand out misleading statements from this movie

This movie states that root canals are not the main cause for all heart attacks. Not true. Infection and inflammation the result of a ​​ subset of chronically infected root canal teeth as well as periodontal disease can be risk factors, and maybe a trigger of heart attack in some cases, but they are not necessarily the main cause. More on this later.

Another blatantly misleading statement is “ 97% of women with breast cancer have a root canal on the same side as the breast cancer,” implying that root canals are a main cause of breast cancer. Certainly, increased inflammation and the release of bacterial toxins from poorly done chronically infected root canals may be a contributing factor in causing cancer as we will see with the scientific references presented later in this article, but you cannot imply that root canal teeth are the cause of most breast cancer. You simply just can’t make unsubstantiated claims like.

However, the root canal specialists (AAE) can be just as misleading as the Anti-RC group. The AAE, in a non-sequitur rebuttal to the Anti-RC groups claim that root canal teeth cause cancer, incorrectly summarize an easy to interpret research paper when they state on their website: 

“As recently as 2013, a study published in a journal of the American Medical Association (JAMA Otolaryngology—Head & Neck Surgery) found that a patient’s risk of cancer doesn’t change after having a root canal treatment; in fact, patients with multiple endodontic treatments had a 45 percent reduced risk of cancer.”

The AAE summary of this article implies that root canal teeth reduced the incidence of ​​ all types of cancer, in all parts of the body by 45 percent. This statement is not true. The article did NOT state that. That certainly would be incredible IF it were true, and the AAE would like you to believe it to be true. Unfortunately, it is not. The actual study was looking at how the lactic acid produced by the bacteria that cause dental caries (cavities) reduced the incidence of squamous cell carcinoma in the oral cavity and pharynx – One specific type of cancer in one body location. NOT all types of cancer as the AAE implies. [See Appendix C for the original article]

The only reason that this paper mentioned that patients with endodontic (root canal) treatment had a lower incidence of squamous cell carcinoma in the oral cavity is because people with root canal teeth had a long- standing caries history and therefore generally have more lactic acid producing bacteria that caused the dental decay that created the need for a root canal in the first place! It is this lactic acid producing a positive immune response that causes a decrease in squamous cell carcinoma in the oral pharynx, notthe root canal teeth. The root canal teeth had absolutely nothing to do with mechanism of action studied. 

Either the AAE did not actually read the article or they purposely issued at best a mis-leading conclusion, or at worst, intentional deception. (See Appendix see for the actual article referenced)

Misleading statements like this are just as bad as the Anti-RC statements implying that root canal teeth cause most breast cancers. Both statements are irresponsible and are designed to further an ideology instead of furthering the truth. 

How can two groups (the Anti-RC and the AAE) look at same set of facts and come up with diametrically opposing conclusions? ​​ (I know, it happens in politics all the time, so it should not be too surprising) 

The American Association of Endodontists successfully fought to remove the movie Root Cause from Netflix. Rick Taylor, president of the AAE, in a memo to all root canal specialists’ states: “the AAE has its “crosshairs” on endodontic critics “who seek to undermine the important and successful care we provide to patients worldwide.” ​​ I was in their “crosshairs” in 2005. Here is the actual memo:

Unfortunately, Dr. Taylor’s statement and belief system does the exact opposite of furthering the important and successful care endodontists provide. His statement clearly reflects the goals of the AAE: ​​ To protect the AAE organization at all costs, to maintain the status quo, to crush all critics that objectively evaluate the scientific data that will lead to improved treatments.

A better approach would have been to point out the many deficiencies in the movie, admit some of the truths, and work to improve the root canal procedure while educating the public on the possible systemic risks of chronic oral infections. But he did not do that. ​​ Like the game of whack-a-mole, the AAE uses all of its resources, including state licensing boards, to smack down anyone that dares address health and safety concerns of chronically infected root canal teeth with apical periodontitis. 

I was hoping that this movie Root Cause would be fair, balanced, and scientifically driven. It is not. Therefore, I cannot recommend this movie.

CRITICAL THINKING SKILLS ARE THE KEY TO DECIPERING THE TRUTH

The following is an excerpt from an excellent article by John Khademi, DDS,MS and Gary B. Carr, DDS that Appeared in Todays Dental News, May 21, 2019 titled:

“POOR LOGIC AND CRITICAL THINKING SKILLS ALLOW ROOT CAUSE TO SEEM SO BELIEVEABLE.”

Our own research renders these statements from our professional organizations patently and demonstrably false. Unfortunately, our professional associations have not presented things correctly and are misstating the facts of the issue, bordering on dishonesty. These kinds of mischaracterizations are harmful and only serve to fan the flames of distrust and undermine any evidence and reassurance we might offer.

According to noted cognitive scientist and researcher Gerd Gigerenzer, PhD, of the Harding Center for Risk Literacy, “research has demonstrated that the problem lies less in stable cognitive deficits than in how information is presented to physicians and patients. This includes biased reporting in medical journals, brochures, and the media that uses relative risks and other misleading statistics, motivated by conflicts of interest and defensive medicine that do not promote informed physicians and patients.”5

Who Is Right? The Error in Critical Thinking

There is no shortage of undergraduate and graduate courses in decision-making and critical thinking skills. After graduation, there continue to be academic articles and presentations at national meetings on the topic. Yet the core skills in critical thinking that are obvious once exposed escape clinicians, educators, researchers, and patients alike.

We briefly introducte these issues in Advanced CBCT for Endodontics6 and will introduce a central critical error that has pervaded endodontic thinking for decades, as well as the case presentation of breast cancer in Root Cause noted above. Consider the following example:

• The probability of being an American, given that one is President, is 100%.

• The probability of being the President, given that one is American, is 0.0000003% (one in 300 million)

Or:

• The probability of being a human, given that one is a woman, is 100%.

• The probability of being a woman, given that one is a human, is 50%.

In contrast:

• The probability of a positive mammogram given that one has breast cancer is 80%.

• What is the probability of breast cancer given that one has a positive mammogram?

(Generally speaking, this conditional probability problem is not even recognized as not having enough information to actually solve it. In the pure screening example where we may set prevalence of breast cancer at 1%, the probability of having cancer, given that one has a positive screening, is only about 10%, not 80%. This is given by Bayes’ Theorem.)

These are conditional probability problems, as is the problem with root canals and breast cancer cited in Root Cause. In the first two examples above, as the answers are known, the problems generally aren’t recognized as conditional probability problems. However, the form of the problems in the breast cancer example is identical, yet the second probability is not known. Instead, a seemingly plausible estimate of 80% is substituted or, in Root Cause, 98%.

As the form of the problem is not recognized as a conditional probability problem, this substitution is done by physicians, dentists, and patients alike. Conditional probability problems are not well interpreted by humans. Daniel Kahneman, PhD, won a Nobel Prize in economics by clarifying just how pervasive the problems are with conditional probability in human reasoning, and this includes scientists!

Problems in conditional probability attempt to provide an estimate of the probability of an event in the light of a prior event having already occurred (or is known to be true with certainty). In mathematical terms, it is written as:

P[A] | [B]

This is read as“The probability of A, given that event B has already occurred or is known to be true.”

We say the probability estimate of event A is conditioned upon an event B that we know is true. To use our President/citizen example, the probability of being the President of the United States (A), given that event B (that of being a citizen) has occurred or we know is true, can be calculated with no error if, in fact, we know event B is true with 100% certainty.

In the endodontic domain, we might express the conditional probability as the probability of bacteria being present in the pulp space, given that apical periodontitis (AP) is already known to have occurred. Mathematically, this is expressed as:

P [bacteria] | [AP is present]

or in general terms:

P [of an observation of bacteria] | [disease is known to be present]

Our problem as clinicians is not that we don’t understand some conditional probabilities. They can be as easy to understand as the President/citizen probability. Our problem comes when the conditional probability is reversed. What is the probability of disease given that bacteria are known to be present?

P [disease] | [we know bacteria are present]

This probability is not so obvious and, indeed, requires some very careful, analytical thinking to avoid error and the cognitive illusion that accompanies this error.

It is a sad fact that problems with conditional probability reasoning pervade the endodontic evidential base and have for decades. Unfortunately, this is not the only problem. Other, even more basic problems in formal logic are also quite common.

Modes of Reasoning

These issues have to do with our mode of reasoning, the classification of which was first made by Aristotle in 350 BC in his Organon.7 Our reasoning mode, which of necessity has to be different in the life sciences, means that probabilities like our President/citizen example cannot be used. For example, if one is President, we can maintain, with 100% certainty, that such a person is a US citizen. Such certainty can be made because it uses two “strong” deductive syllogisms:

If A is true, then B is true.

A is true

______________________________

therefore, B is true

And its inverse (contrapositive):

If A is true, then B is true.

B is false

______________________________

therefore, A is false

It is known that to be a President [A], you must be a citizen [B]. Therefore, if you are President [A], we know that you are a citizen [B]. If you are not a citizen [B is false], we know you are not President [A is false].

So with “strong” syllogisms, inverting the conditional is seldom a problem. The attraction and power of deductive reasoning depends upon the premises being known as true. Unfortunately, the problems in the life sciences do not permit us the luxury of such “strong” deductive syllogisms. We must rely on a much weaker kind of syllogism:

If A is true, then B becomes more plausible.

And the inverse:

If B is false, then A becomes less plausible.

For example, if a culture test is negative (no bacteria detected), it becomes more plausible that the canal is “bacteria free,” but we are by no means certain of it. As we shall soon see, “plausible” can be a very long way from “probable,” depending upon a great many other factors.

The important fact to understand is that our form of reasoning in the life sciences is inductive, not deductive, and we are forced to use “weak” syllogisms, not “strong” ones. When you have only “weak” syllogisms, “doing the numbers” correctly as the above mammography/breast cancer example suggests is the only way to avoid cognitive errors or fall prey to what we call “cognitive illusions.”

So perhaps we are just as careless as the Root Cause producers have been with our inferences about disease causation and should be more circumspect and humble about what we think we know with certainty.

In Root Cause, a similar conditional probability statement is made, then a second occultly inverted, then inferred:

• The probability of having had a root canal given that a person has cancer is 98%.

• Therefore, the probability of having cancer given that one has had a root canal is 98%.

While these two statements sound similar, like the mammography example above, they are not. This is a wide and pervasive error in critical thinking. It manifests in understanding how screening tests such as PSA and mammography work, in research conclusions, and in a rife misunderstanding about what statistical significance means and how p-values work. The list is seemingly endless.

In endodontics, a longstanding error is starting with a lack of evidence of bacteria, which does not equal evidence of a lack of bacteria, let alone does it equal bacteria-free. These widespread and longstanding errors in critical thinking force us to explain around the observations and make claims that are not evidence-based. When speaking to patients on the topic, here is a simple example to illustrate the defective logic:

• The probability of having had Romaine lettuce given that a person has cancer is 100%.

• Therefore, Romaine lettuce causes cancer.

Another common cognitive fallacy here is to confuse correlation with causation (Figure 3). Similarly, as Greenland points out, lack of evidence of harm does not equal evidence of safety, nor does it equal safe. Because the language sounds so similar, common cognitive biases and lack of cognitive machinery and the ability to actually compute this inverse probability along with the seeming plausibility allow this to happen unchecked….

…As a general principle, the safety of any medical or dental procedure actually cannot be demonstrated, and in many cases it is unethical to perform a trial designed to find harms. There is no randomized trial demonstrating that cigarette smoking is harmful and causes cancer, nor is there a clinical trial demonstrating safety. It would be unethical to randomize patients into such groups.

Similarly, there are no clinical trials demonstrating the safety of endodontic therapy. Sadly, there are no trials demonstrating its effectiveness over doing nothing or active surveillance. Thus the safety of endodontics cannot be demonstrated, only a lack of evidence or failure to find harm. Even if these kinds of trials were possible, any results would only be meaningful when compared to the alternatives of extraction and any ensuing procedures, or leaving the tooth as it is.

“Despite demands for absolute safety assurance, such assurance is impossible according to modern philosophy of science and its statistical operationalizations. We never accept anything as true, only as un-refuted so far. That includes safety. This means when a patient asks: ‘Is this safe?’ the strongest scientific answer is: ‘So far, no one has shown it to be harmful,’” Greenland noted.

People want assurances of absolute safety, so our professional societies and associations will give those assurances to them. This is unscientific. While we would all like to present our patients with the truth, the whole truth, and nothing but the truth, we are fundamentally unable to discover it in this domain.

The scientific method is fundamentally unable to prove these kinds of hypotheses. We cannot prove that all swans are white with 100, 1,000, or even 1 million swans. Lack of evidence of non-white swans does not prove all swans are white. We can only increase our level of evidence for that hypothesis. In contrast, a single black swan can disprove the hypothesis that all swans are white. Thus the quest for proof of safety is impossible, just as the proof for safety efficacy is impossible.

At a minimum, then, we owe our patients an honest presentation of the evidence, all of the evidence, and our best interpretation of the evidence. This is central to the doctrine of informed consent. Any less is being less than honest in our dealings with our fellow man.”

[Poor Logic and Critical Thinking Skills Allow Root Cause to Seem So Believable

 21 May 2019  John Khademi, DDS, MS, and Gary B. Carr, DDS  

 Todays Dental News]

The authors do an excellent job in illustrating why both the anti-root canal group as well as the dental establishment use flawed reasoning to support their respective positions. I urge everyone to read the article in its entirety. The authors also make a compelling ​​ presentation on the microbiology of a root canal tooth.

(Link: https://www.dentistrytoday.com/news/todays-dental-news/item/4852-poor-logic-and-critical-thinking-skills-allow-root-cause-to-seem-so-believable?hq_e=el&hq_m=1745920&hq_l=9&hq_v=af37c1485b)

Dr. Khademi is a root canal specialist with superb clinical skills at a level that all dentists performing root canal procedures should aspire to. In addition, he is a “scientists” scientist , meaning that his reasoning and analytical skills are at the top end of the spectrum. I have tremendous respect for Dr. Khademi.

Dr. Khademi and I may have differing opinions on several aspects of the root canal controversy as you will see when you read the full article, but that is ok. Because that is how science moves forward. Scientific progress is rarely a straight line event. Instead, a hypothesis is made, then challenged, and finally accepted after presentation of enough supporting evidence.

That does not mean that an accepted conclusion today is set in stone. Because as new discoveries ​​ emerge, our previous hypothesis may need to be altered. ​​ That is the nature of science. ​​ Sometimes old hypothesis and theories need to be totally discarded as new data emerges, but more often than not there is a synthesis, of ideas, a correction if you will, much like driving on a winding road, steering a little left, then a little right as needed.

“Honest disagreement is often a good sign of progress.”

- Gandhi

We were able to land a man on the moon in 1969, ​​ less than 10 years after President Kennedy set that goal, because the scientists and visionaries at NASA during that time were not afraid to challenge paradigms and make the necessary corrections. We need to do the same in medicine and dentistry.

DENTAL RESEARCH - IS IT UP TO MEDICAL STANDARDS?

The following passage is from the article, 

THE TRUTH ABOUT DENTISTRY, IT’S MUCH LESS SCIENTIFIC -AND MORE PRONE TO GRATUITOUS PROCEDURES-THAN YOU MAY THINK.[Ferris Jabr. The atlantic.com ​​ May, 2019]

“Common dental procedures are not always as safe, effective, or durable as we are meant to believe. As a profession, dentistry has not yet applied the same level of self-scrutiny as medicine or embraced as sweeping an emphasis on scientific evidence.

Many standard dental treatments—to say nothing of all the recent innovations and cosmetic extravagances—are likewise not well substantiated by research. Many have never been tested in meticulous clinical trials. And the data that are available are not always reassuring.

The Cochrane organization, a highly respected arbiter of evidence-based medicine, has conducted systematic reviews of oral-health studies since 1999. In these reviews, researchers analyze the scientific literature on a particular dental intervention, focusing on the most rigorous and well-designed studies. In some cases, the findings clearly justify a given procedure.

But most of the Cochrane reviews reach one of two disheartening conclusions: Either the available evidence fails to confirm the purported benefits of a given dental intervention, or there is simply not enough research to say anything substantive one way or another.

The general dearth of rigorous research on dental interventions gives dentists even more leverage over their patients. Should a patient somehow muster the gumption to question an initial diagnosis and consult the scientific literature, she would probably not find much to help her. When we submit to a dentist’s examination, we are putting a great deal of trust in that dentist’s experience and intuition—and, of course, integrity.

Throughout history, many physicians have lamented the segregation of dentistry and medicine. Acting as though oral health is somehow divorced from one’s overall well-being is absurd; the two are inextricably linked. Oral bacteria and the toxins they produce can migrate through the bloodstream and airways, potentially damaging the heart and lungs. Poor oral health is associated with narrowing arteries, cardiovascular disease, stroke, and respiratory disease, possibly due to a complex interplay of oral microbes and the immune system.

Dentistry’s academic and professional isolation has been especially detrimental to its own scientific inquiry. Most major medical associations around the world have long endorsed evidence-based medicine. The idea is to shift focus away from intuition, anecdote, and received wisdom, and toward the conclusions of rigorous clinical research. Although the phrase evidence-based medicine was coined in 1991, the concept began taking shape in the 1960s, if not earlier (some scholars trace its origins all the way back to the 17th century). In contrast, the dental community did not begin having similar conversations until the mid-1990s. There are dozens of journals and organizations devoted to evidence-based medicine, but only a handful devoted to evidence-based dentistry.”(See Appendix K for complete article)

So, Who Can You Trust to Tell the Truth?

It is difficult to know who to trust anymore when it seems like nobody tells the truth. 

TOBACCO INDUSTRY:

In 1994 seven executives of then major tobacco companies testified before Congress that they did not believe that nicotine was addictive. Here they are raising their hands swearing to tell the whole truth. 

​​ 

It is hard to believe that these executives would stand before Congress and flat out lie. But that is exactly what they did. 

PHARMACEUTICAL INDUSTRY:

The pharmaceutical industry has also faced criticism for being less than ethical. Here is what Marcia Angell, M.D., longtime Editor-in-Chief of the New England Journal of Medicine, and author of the book, The Truth About Drug Companies: How They Deceive Us and What To Do About It says about the drug companies:

“It’s truly unbelievable that, in this day and age, education has turned into brainwashing. Science is corrupted, altered, changed, ignored, and swept under the rug just because it threatens the interests of a few powerful people and the corporations they hide behind.

It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine.”   [Dr. Marcia Angell, a physician and longtime Editor-in-Chief of the New England Medical Journal (NEMJ) and author of the book, The Truth About Drug Companies: How They Deceive Us And What To Do About It. PLos Med. 2010 Oct; 7(10); e1000355]

THE OPIOD CRISIS

From TIME.com:

Allegations Against the Maker of Oxycontin Are Piling Up. Here’s What They Could Mean for the Billionaire Family Behind Purdue Pharma

 BY JAMIE DUCHARME  

FEBRUARY 22, 2019

 “…on Thursday, the release of a previously sealed deposition from 2015 showed that Purdue executives knew of OxyContin’s strength long before that $600 million settlement. The deposition, which had been filed in court, revealed that Dr. Richard Sackler — part of the family that founded and controls Purdue, and who has served as Purdue’s president and co-chairman of the board — knew as early as 1997 that OxyContin was much stronger than morphine, but chose not to share that knowledge with doctors.

“We are well aware of the view held by many physicians that oxycodone [the active ingredient in OxyContin] is weaker than morphine. I do not plan to do anything about that,” Purdue’s head of sales and marketing, Michael Friedman, wrote in an email to Sackler, according to the deposition, which was obtained by ProPublica and co-published with STAT. “I agree with you,” Sackler wrote back. “Is there a general agreement, or are there some holdouts?”

According to lawsuit, members of the Sackler family and other Purdue executives purposefully downplayed the addictive properties of OxyContin, and promoted sales tactics meant to encourage doctors to prescribe as much OxyContin, in the highest doses and longest durations, as possible — despite the potential risks for abuse, and despite the terms of Purdue’s prior settlement with the federal government. The suit also details Purdue’s plans to sell addiction treatments, helping them dominate “the pain and addiction spectrum.” Purdue’s board, controlled by the Sackler’s, also voted to pay out $4 billion to the family between 2007 and 2018, the documents show.”

The Newest Opioid Lawsuit Is Going Right After the Sackler Family  by Ed Cara. 3/22/19 Gizmodo.com*

“An enormous federal lawsuit out of New York is the latest and most brazen attempt to explicitly tie the billionaire Sackler family, owners of Purdue Pharma, to the opioid crisis. It accuses them of knowingly misleading the public about the addictiveness of their drugs, as well as turning a blind eye to doctors who were accused of prescribing dangerously high doses or diverting their supply to the black market.

This week, a coalition of over 500 cities, counties, and Native American tribes sued eight members of the Sackler family in the southern district of New York, the Guardian reported.

According to the Guardian, the lawsuit names Richard Sackler, Jonathan Sackler—sons of the late Raymond Sackler, one of the founders of Purdue—as well as Beverly Sackler, Raymond’s widow, and David Sackler, Raymond’s grandson. Ilene Sackler Lefcourt, Kathe Sackler, and Mortimer David Alfons Sackler, children of another founding member, Mortimer Sackler, are also named, as is Theresa Sackler, the widow of Mortimer Sr.

“Eight people in a single family made the choices that caused much of the opioid epidemic,” stated the lawsuit, according to the Guardian. It’s estimated that over 60,000 people died from opioid overdose in 2017 alone, with more than 17,000 deaths involving prescription opioids. 

These same people were named as co-defendants in an ongoing lawsuit by the Massachusetts Attorney General, and some of the same allegations—most notably about former Purdue chairman and president Richard Sackler’s aggressive push to drive up OxyContin sales—have been made public from unsealed court documents in other litigation.”*

Purdue pharm settled for 270 million

“The lawsuit was brought by Hunter against some of the nation's leading makers of opioid pain medications, alleging that deceptive marketing over the past decade fueled the epidemic in the state.

Members of the Sackler family, who own the company but were not defendants in the case, will pay an additional $75 million in personal funds over five years. In 2007, Purdue Pharma and three of its top executives paid more than $630 million in federal fines for their misleading marketing, and the executives were each sentenced to three years of probation and 400 hours of community service. But the latest rounds of lawsuits argue that Purdue continued to market opioids irresponsibly even after the fines.

Beyond the research, we’ve also seen more reports over the past few years about opioid companies aggressively marketing their products, even as it became clearer that the drugs weren’t the safe, effective alternative to other painkillers on the market that they claimed the opioids to be.

Recently, a filing in Massachusetts Attorney General Maura Healey’s lawsuit against Purdue exposed how Richard Sackler, then Purdue’s president and part of the family that owns Purdue, was personally involved in some of those efforts. The filing claims that Sackler pushed to market OxyContin as a “non-narcotic” in other countries, even though it’s an opioid; Robert Kaiko, who created OxyContin, had to talk him down from the idea. 

The company also allegedly overlooked excessive prescribing in the US, even as some of Purdue’s staff warned of pill mills that should have been reported to federal officials.” Maia Szalavitz reported for Tonic.vox.com)

This issue really makes me very angry. Not surprisingly, the website quackwatch, and Stephen Barrett, say nothing about it. And of course, you do not see any of the Sackler’s on the quackwatch website which, in my opinion, tells you all you need to know about Stephen Barrett, his motives, and the main purpose of the quackwatch website. ​​ 

That said, there are many miraculous and life-saving medicines developed by the drug companies that help us all live healthier lives. Just as there are great advancements in dentistry. Being critically objectively of deficiencies does not mean “throwing the baby out with the bath water.” 

Flame Retardant Chemicals: (From HBO.com)

“Chemical flame retardants are everywhere. Our furniture. Our homes. Our bodies. Yet they don’t seem to stop fires. They do, however, seem to make us sick.

TOXIC HOT SEAT takes an in-depth look at a nexus of money, politics and power – and a courageous group of firefighters, mothers, journalists, scientists, politicians and activists as they fight to expose what they assert is a shadowy campaign of deception that has left a toxic legacy in America’s homes and bodies for nearly 40 years.

Set against the backdrop of the award-winning 2012 Chicago Tribune investigative series Playing with Fire, TOXIC HOT SEAT tells an intricate story, detailing how chemical companies that produce flame retardants spend millions of dollars on lobbyists, publicists and influencers, and how Big Tobacco had a hand in convincing fire-safety officials to back a standard that, in effect, requires all furniture to be filled with toxic flame retardants.

Known as California Technical Bulletin 117, the 1975 law was meant to reduce the escalating death rates from house fires caused by cigarettes. It mandated that all fabrics sold in California needed to contain flame retardants. To streamline operations, furniture makers opted to use the fire-retardant chemicals in all polyurethane foam-based furniture sold in the U.S., not just those items intended for sale in California.

TOXIC HOT SEAT shows how a handful of large chemical companies ended up being accused of obscuring public-health risks and misrepresenting chemical safety data by paying “experts” to alarm legislators and the public about the risk of removing chemical flame retardants from homes. In addition, the film highlights the argument that the tobacco industry effectively colluded with chemical companies back in the 1970s, lobbying for the use of chemical flame retardants in furniture, rather than developing a self-extinguishing cigarette, at a time when fires ignited by cigarettes were the main cause of home fires in the U.S.

TOXIC HOT SEAT features interviews with Chicago Tribune journalists and with brave citizens willing to fight for the truth against powerful industries, including:

Tony Stefani, a 30-year veteran of the San Francisco Fire Department who loved his job but had to quit when he found out he had a rare form of cancer. Tony was not alone. Firefighters are particularly vulnerable because of the toxic fumes caused by the burning of flame-retardant chemicals during fires. Among 40- to 50-year-old female firefighters in San Francisco, for example, the breast-cancer rate is six times the national average for that age group.

Dr. Arlene Blum, an award-winning chemist at U.C. Berkeley, who proved in the 1970s that flame retardants in pajamas showed up in children’s urine. Though they were subsequently banned in children’s clothing, flame retardants continue to be used in many other children’s products. High levels of flame retardants are linked to decreased fertility, cancer and learning problems.

Hannah Pingree, a former state representative in Maine, who had her chemical levels tested. Though she lives on a small island off the coast, the testing discovered flame retardants and other chemicals in her body that could harm her health. Her activism against flame retardants in furniture ultimately led to a statewide ban.”

(See Appendix N for the story of the Ford Pinto gas tank expolsion risk that was ignored)

DUPONT CHEMICAL

I highly recommend the movie Dark Waters starring mark Ruffalo. This move illustrates the widespread coverup and corruption behind the toxic dumping of teflon by the Dupont Corp.

As Ronald Reagan said, “Trust but verify.”