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.”

[From slideplayer.com]

The more I know the more I realize how much I don’t know. These issues are complex, multifactorial, and ever changing as new information is gained form ongoing research. The root canal issue, just like many issues in medicine is not a zero-sum game where, for one side to be right, the other side must be wrong. Medicine is not digital, composed of either 0’s or 1’s. Medicine is more analog, where sometimes there is a definitive cause and effect, but more often than not the multifactorial nature of most diseases cannot be simply defined. 

I do not understand why the root canal specialists and the Anti RC group find it necessary to adhere to strict, polar opposite, and often extreme views that defy both science and good old-fashioned common sense. 

For all of this to make sense we will have to wade through a river of “science stuff’” starting with the basics like: What is a root canal and why is it performed. History of focal infection. The historical connection between root canal teeth and systemic diseases. ​​ Current views of the American Dental Association on focal infection and root canal teeth. Current peer reviewed scientific research on focal infection and the oral/systemic link. 

Wherever possible I will use actual quoted excerpts so you can see the information for yourself. You may not be interested in reading through it all, but I feel that it is important to present the actual studies, both old and new. Because just making a claim that all root canal teeth or bad, or 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 on this subject, and not rely on what the Anti-RC, the AAE or I have to say. This may sound overwhelming but don’t worry, I promise I will get you to the other side. 

I must again emphasize again that not all root canal teeth will contribute to systemic disease and certainly do not advocate extracting all root canal teeth. For the purposes of this article I will be referring to 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. 

There are also many well performed root canal teeth, that present no negative health effects whatsoever. The degree of systemic risk for any particular tooth is relative to the level of infection in the tooth and surrounding bone, as well factors such as the health of the patient’s immune system and additional physical stressors. An infected tooth without root canal therapy will have the highest systemic risk, and a well performed root canal with little or no evidence of apical periodontitis will have the lowest. And there are a lot of teeth in between.

I am not against all root canals. Just the bad ones. It all comes back to this:

Inadequately performed root canals will remain chronically infected, 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.

“ 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.” [Oral infections and systemic disease--an emerging problem in medicine. Clin Microbiol Infect. 2007 Nov;13(11):1041-7. Epub 2007 Aug 21.]

If the goal of successful root canal ​​ is eliminating all of the infected tissue and thoroughly disinfecting and sealing the root canal system, ​​ then mediocre root canals are not OK just because they look good on X-ray and are not causing any symptoms. 

For all of this to make sense we will have to wade through a river of “science stuff’” starting with the basics like: What is a root canal and why is it performed. This may sound overwhelming but don’t worry, I promise I will get you to the other side. 

WHAT IS A ROOT CANAL AND WHY IS IT PERFORMED?

How can something that is often the butt of many jokes, a procedure seemingly so benign, have anything to do with serious diseases such as heart disease? The answer is that is I have previously stated it is not the root canal procedure itself that is the problem as some mistakenly believe. It is the lingering infection in the tooth and root after completion of the root canal that is the problem, as well as the incomplete healing and continued infection and inflammation at the end of the tooth root in the surrounding jaw bone where inflammatory mediators, bacteria and bacterial toxins gain access to the blood and lymphatic system and spread throughout the body.

A root canal is a procedure that is performed when the inside hollow portion of the tooth and root become infected by bacteria, usually from a large cavity that became too deep. This infection causes the pulp tissue containing nerves and blood vessels to die. This infection can travel down the root of the tooth, exit the opening at the tip of the root called the root apex, and infect the surrounding jaw- bone causing a condition called apical periodontitis. Although a root canal can sometimes be required when the pulp dies from other causes such as trauma, the vast majority of root canals are due to infection of the tooth pulp. ​​ 

The ​​ root canal procedure uses various size files and disinfecting irrigants in the attempt to remove all of the dead and infected tissue inside the root canal system, kill the bacteria that caused the infection, and seal the tooth and root canal system so that the tooth cannot become re-infected. 

As started by the AAE:

“One major goal of endodontic therapy is the elimination of bacteria – and the tissue substrate that supports growth – from the root canal system…

The practitioner accomplishes bacterial elimination by thorough cleaning, shaping and obturation (filling the canal) of the root canal system in three dimensions.

Research has also shown that the use of bactericidal irrigating solutions during the cleaning and shaping phase of treatment will help eliminate bacteria and bacterial substrate from the root canal and dentinal tubules.”

(AAE Fall /winter publication Endodontics Colleagues For Excellence. See Appendix D for AAE newsletters)

“When a severe infection in a tooth requires endodontic treatment, that treatment is designed to eliminate bacteria from the infected root canal, prevent reinfection of the tooth and save the natural tooth.” 

From the AAE website:

How does endodontic treatment save the tooth?

It’s necessary to have endodontic or root canal treatment when the inside of your tooth (the pulp) becomes inflamed or infected as a result of deep decay, repeated dental procedures, faulty crowns or a crack or chip in the tooth. Trauma to your tooth may also cause pulp damage even if the tooth has no visible chips or cracks. If pulp inflammation or infection is left untreated, it can cause pain or lead to an abscess.

When you undergo a root canal or other endodontic treatment, the inflamed or infected pulp is removed and the inside of the tooth is carefully cleaned and disinfected, then filled and sealed with a rubber-like material called gutta-percha. Afterward, the tooth is restored with a crown or filling for protection and will continue to function like any other tooth.

If all root canal teeth met the stated goals of the AAE, that is, all infected pulp tissue removed, root canal system and porous dentin tubules disinfected, root canal space completely filled and sealed, and residual infection in the bone (apical periodontitis) healed with new healthy bone, I would not be writing this article and there would not be any controversy regarding the safety of root canals. 

There are approximately 25 million root canals performed each year. Unfortunately, ​​ a significant percentage of these root canal teeth are not optimally performed, leaving dead tissue and bacterial infection in both the tooth and surrounding jaw-bone. ​​ 

A PICTURE IS WORTH A THOUSAND WORDS

 Below is a photo of a healthy tooth extracted for orthodontic purposes. The tooth root has a healthy color. There is no foul odor and no evidence of any inflammation. You would not mind putting this tooth back into the jaw-bone.

​​ 

Contrast the above photos to these photos below of extracted root canal teeth. These teeth are blackened by the by-products of bacteria, most had a foul odor which is caused by the small molecule toxins produced by the bacteria still remaining in the tooth, and they show indications of a chronic inflammation. 

Would you want these teeth put back into your jaw-bone? I suspect not.

All of these teeth were extracted by me on patients whose dentists said that these teeth showed no evidence of infection and refused to extract them.

Microscopic examination of these teeth and surrounding bone showed residual dead pulp tissue in the root canal space, incomplete filling and sealing of the root canal space, and inflammation in the bone surrounding the tip of the root (apical periodontitis). On several of the teeth you can still see the infected tissue attached to the end of the tooth root. 

Samples of all areas of apical periodontitis were sent for microbiological  ​​​​ analysis to determine the type of infection and which antibiotics would be effective. 

Results showed all samples to be infected with a variety of bacteria, often with multiple antibiotic resistance, and some samples were infected with fungus. 

The AAE fails to accept that these teeth may be a risk factor for any systemic disease and in 2005 they wanted to revoke my license for extracted teeth like these. 

These photos support the current research which indicates that standard root canal procedure does not routinely achieve the goals for root canal success established by the AAE.

“Debridement focusing on removal of pulp remnants, as well as microorganisms and microbial toxins from the root canal system, is considered essential for endodontic success. However, current endodontic techniques fall short of the goal to remove all infective microorganisms and debris consistently. This shortfall mainly is due to the complex anatomy of the root canal system, the type of bacteria and resistance of bacterial colonization, the limitation of rotary instrumentation to remove all tissue from the surfaces after completion of the preparation and the limited potential for commonly used irrigants to penetrate the dentin walls.” [ Disinfection efficacy of photon-induced photoacoustic streaming on root canals infected with Enterococcus faecalis An ex vivo study Giovanni Olivi, MD, DDS; Enrico DiVito, DDS;Ove Peters, DMD, MS, PhD; Vassilios Kaitsas, DDS; Francesca Angiero, MD, DDS;Antonio Signore, DDS; Stefano Benedicenti, DDS ​​ JADA145(8) http://jada.ada.org August2014 ​​ pp 843-848]

“Bacterial sampling of prepared root canals is used to determine the presence and character of the remaining microbiota. However, it is likely that current sampling techniques only identify organisms in the main branches of the root canal system whereas it is unlikely that they can sample areas beyond the apical end-point of preparation and filling, or in lateral canals, canal extensions, apical ramifications, isthmuses and within dentinal tubules. Thus, it may be impossible by current techniques to identify residual post-treatment root canal infection. In histologic observations of root apices, bacteria have been found in inaccessible inter-canal isthmuses and accessory canals often in the form of biofilms. There is no in vivo evidence to support the assumption that these bacteria can be entombed effectively in the canal system by the root filling and thus be rendered harmless….

Histologic observation of root apices with surrounding bone removed from either patients or human cadavers has demonstrated that post-treatment apical periodontitis is associated with 50-90% of root filled human teeth. Thus, if the objective of root canal treatment is to eliminate apical periodontitis at a histological level, current treatment procedures are inadequate. It is essential that our knowledge of the local and systemic consequences of both residual post-treatment root infection and post-treatment apical periodontitis be improved. The continued development of treatments that can effectively eliminate root infection is therefore a priority in clinical endodontic research. Post-treatment disease following root canal treatment is most often associated with poor quality procedures that do not remove intra-canal infection; this scenario can be corrected via a nonsurgical approach. However, infection remaining in the inaccessible apical areas, extraradicular infection including apically extruded dentine debris with bacteria present in dentinal tubules, true radicular cysts, and foreign body reactions require a surgical intervention.”

[Wu MK, Dummer PM,Wesselink PR. Consequences of and strategies to deal with residual post-treatment root canal infection. Int. Endod J 2006 May;39(5): 343-56.]

​​ “The results show (1) the anatomical complexity of the root canal system of mandibular first molar roots and (2) the organization of the flora as biofilms in inaccessible areas of the canal system that cannot be removed by contemporary instruments and irrigation alone in one-visit treatment. These findings demonstrate the importance of stringent application of all nonantibiotic chemo-mechanical measures to treat teeth with infected and necrotic root canals so as to disrupt the biofilms and reduce the intraradicular microbial load to the lowest possible level so as to expect a highly favorable long-term prognosis of the root canal treatment”

​​ [Nair PN, Henry S, Cano V, Vera J. Microbial status of apical root canal system of human mandibular first molars with primary apical periodontitis after "one-visit" endodontic treatment. Oral Surg Oral Med Oral Path, Oral Radiol Endod, 2005 Feb;99(2):231-52]

All root canals are not the same. It is very easy to do a bad or mediocre root canal, but it is very difficult to do a good one. The root canal procedure is a very technique sensitive procedure that requires meticulous attention to detail and strict adherence to procedure. Some dentists ​​ may not take the time to be as thorough as is required for an optimal treatment results, and many dentists, including endodontists, do not feel that it is necessary to invest in advanced equipment that offers much more complete cleaning and disinfection of the total root canal system. 

 Just like painting a house with peeling paint you, you can simply paint over the peeling paint and hope for the best. The house will look good for a while, but inevitably the new paint will begin to peel very soon after painting. Or, you could meticulously scape off the old peeling paint, sand and prepare the surface, and apply the new paint according to the paint manufactures instructions and the paint job will last trouble free for a very long time. There are good paint jobs and bad paint jobs just like there are good root canals and bad root canals. And there is a world of difference between the good and the bad. Unfortunately, there are a lot of bad root canals out there. 

Some people will refuse a root canal procedure and instead choose to leave an infected tooth untreated, leaving all of the dead an infected pulp tissue and bacteria. That is a big mistake. Even a poorly performed root canal will remove some of the infected pulp tissue and bacteria in the root canal system and is much better than leaving the tooth untreated. 

The problem with a significant percentage of root canal treated teeth is that the root canal procedure was not thoroughly and completely performed, thereby leaving significant dead pulp tissue and bacteria in the root canal system and persistent infection in the jaw-bone surrounding the tip of the tooth root. 

I don’t have an exact number on the poorly performed root canals done each year, but I can definitively say that there are way too many.

“We found a large proportion of endodontically treated teeth with apical periodontitis and a correlation between the quality of endodontic filling and the prevalence of periapical lesions. This all suggests that it is necessary to improve the quality of endodontic treatment in order to reduce the incidence and prevalence of apical periodontitis.”[Jurica Matijevic, et.al. PREVALENCE OF APICAL PERIODONTITIS AND QUALITY OF ROOT CANAL FILLINGS IN POPULATION OF ​​ ZAGREB, CROATIS: A CROSS ​​ SECTIONAL ​​ STUDY . Dental Medicine ​​ Croatia ​​ Croat Med J. 2011; 52: 679-87]

“Of the 120 patients 41% had AP (apical periodontitis) and 61% had received endodontic treatments of which 52% were radiographically unsatisfactory. AP patients were older and half of them were smokers. AP and periodontitis often appeared in the same patient (32.5%). From all hospital diagnoses, cardiovascular diseases (CVD) were most common, showing 20.4% prevalence in AP patients. Regression analyses, controlled for age, gender, income, smoking and periodontitis, showed AP to associate with CVD with odds ratio 3.83 (95% confidence interval 1.18–12.40; p = 0.025)….

​​ “The results confirmed our hypothesis by showing that AP (Apical Periodontitis) statistically associated with cardiovascular diseases. The finding that subjects with AP also often had periodontitis indicates an increased oral inflammatory burden.” [Eunice Virtanen, et.al. Apical periodontitis associates with cardiovascular diseases: a cross-sectional study from Sweden. BMC Oral HealthBMC series – open, inclusive and trusted201717:107]

And this is where the problem lies. A lot has to do with the skills of the dentist and a lot has to do with the techniques employed. That is why there are dentists that do years of post-graduate training to become endodontists (root canal specialists). You will more likely find that an endodontist has invested in the latest equipment that has been shown to greatly improve the cleaning and disinfection of the root canal system because it simply is not cost effective for most general dentists to do so. ​​ Until fairly recently even the most skilled endodontist could not achieve routinely achieve the goals stated by the AAE for root canal success. In addition, dentists do not have much experience doing a lot of root canals in dental school. 

According to one dentist:

(Paraphrase) “There is not enough root canal experience in dental school.

Often times students that are close to graduation have not even competed a single root canal. And the graduation requirement is only three complete root canals on an actual patient.”

Of course, there are some general dentists that are highly skilled and can perform excellent root canals, and many general dentists do take continuing education courses to improve their skills, but the point I am making is that the success of the root canal is highly dependent on both the techniques used, and the skill of the dentist. 

Successful root canal treatment, as defined by The American Academy of Endodontists (AAE), the dentists that specialize in performing the root canal procedure states: 

“One major goal of endodontic therapy is the elimination of bacteria – and the tissue substrate that supports growth – from the root canal system…2 

​​ 

“When a severe infection in a tooth requires endodontic treatment, that treatment is designed to eliminate bacteria from the infected root canal, prevent reinfection of the tooth and save the natural tooth.”3 

You will see that neither of these stated goals, the elimination of bacteria or the tissue substrate, are routinely achieved with certainty by standard root canal technique. The anatomy of the root canal systems makes it extremely difficult to successfully clean and disinfect. And that is the problem. Because if these goals were routinely met there would be no controversy regarding the systemic effects of a subset of root canal treated teeth. 

“What are the obstacles in removing irritants from the root canal system?

The complexity of the root canal system, presence of numerous dentinal tubules in the roots, invasion of the tubules by microorganisms, formation of smear layer during instrumentation and presence of dentin as a tissue are the major obstacles of complete shaping of root canal systems. Microscopic examinations of root canals show that they are irregular and complex systems with many cul-de-sacs, fins, and lateral canals.

Successful endodontic treatment depends upon maximal debridement and disinfection of the entire root canal system. The root canal system must be shaped to a convenience form that permits adequate cleaning and disinfection by elimination of microbes.* The literature is clear that as much as 35 percent or more of the root canal system remains untouched by any instrumentation technique. Essentially no filing technique allows instruments to sculpt all canal walls and remove infected dentin.**”

*Clark D, Khademi JA. Case studies in modern molar ​​ endodontic access and directed dentin conservation, DentClin NorthAM. ​​ 2010:275-289

**Prof. Enrico Diviti, DDS, Prof. Giovanni Olivi, MD, DDS ​​ PIPS Improving Your Outcomes Using Laser Activated Irrigation ​​ 2013

THE ROOT CANAL ANATOMY IS COMPLEX MAKING CLEANING AND DISINFECTING DIFFICULT. 

”A microcomputed image of a mandibular molar illustrating incredibly complex and delicate internal anatomy that needs to be treated to eliminate microbes and organic tissue remnants.

“Asepsis of root canal systems has long been the goal of endodontic treatment. The historic use of chemotherapeutic agents to disinfect intracanal tissues has not been realized, and the efficacy of the medicament is based on the ability to reach infected pulpal tissues in complex anatomy where no instrument is capable of shaping; and secondly, the toxicity the agent possesses will also have an effect on the viable periradicular tissues it contacts, should it pass through any portals of exit.’ 

Enrico DiVito, DDS, Adam Lloyd, BDS,MS ​​ ER:YAG Laser for 3-Dimensional Debridement of Canal Systems: Use of Photon-Induced Photoacoustic Streaming ​​ Dentistry Today, 2018

“Successful treatment of these diseases depends on biofilm removal as well as effective killing of biofilm bacteria. Because bacteria causing endodontic infections are mostly found in the main root canal, chemo- mechanical debridement plays a key role in treating endodontic infections. However, because of the complex root canal anatomy, about 35% of the instrumented root canal area is left untouched when conventional rotary and hand instruments are used. Therefore, elimination and killing of biofilm bacteria from the root canals rely to a great extent on the efficacy of endodontic irrigants.”

D’Arcangelo C, Varvara G, De Fazio P. An evaluation of the action of different root canal irrigants on facultative aerobic-anaerobic, obligate anaerobic, and microaerophilic bacteria. J Endod. 1999;25:351–3. [PubMed: 10530260] 

[Kapil Jhajharia, Abhishek Parolia,1 K Vikram Shetty, and Lata Kiran Mehta2 Biofilm in endodontics: A review J Int Soc Prev Community Dent. 2015 Jan-Feb; 5(1): 1–12. PMCID: PMC4355843 doi: [10.4103/2231-0762.151956: 10.4103/2231-0762.151956] PMID: 25767760]

Some dentists mistakenly believe that even if they do not clean out all of the dead and infected pulp tissue, the use of strong disinfecting agents like sodium hypochlorite (basically full-strength Clorox bleach) to kill the bacteria that are left in the tooth after root canal instrumentation ​​ will solve the problem. the problem.

The AAE states:

“When a severe infection in a tooth requires endodontic treatment, that treatment is designed to eliminate bacteria from the infection root canal and prevent re-infection of the tooth.” ​​ 

Unfortunately, as we have shown, bacteria are not completely eliminated form an infected tooth even after irrigation with sodium hypochlorite. Research shows that bacteria exist inside the root canal system as a biofilm and not as free-standing (planktonic state) bacteria. Bactericidal agents like sodium hypochlorite easily kill bacteria on surfaces in the planktonic state, but they are not very effective at all at eliminated bacteria that exist in a biofilm. 

“The apical biofilm cannot be removed by biomechanical preparation alone as they are inherently resistant to antimicrobial agents.” [ See Biofilm in Endodontics. https://www.ncbi.nih.gov/pmc/articles/PMC4355843]

To make matters worse, the tooth root is made of a material called dentin. Dentin is not a solid structure but is porous like a sponge, made up of millions of hollow dentin tubules. There are so many dentin tubules that if you took all he dentin tubules from a single rooted front tooth and placed them end to end, they would stretch for three miles! These tubules are wide enough to hold bacteria three across their width. So essentially an infected tooth can become “soaked” with bacteria. ​​ Disinfectants used during standard irrigation procedures are useless in killing all of these bacteria because the bacteria penetrate almost ten times further into the dentin tubules than the disinfects placed into the tooth can reach. 

Below is a photo showing the dentin tubules and the bacteria that can fit three across inside the tubules:

An SEM (scanning electron microscope) view to instrumented root canal wall after NaOCl and EDTA irrigation. There are 10.000 — 25.000 dentinal tubules per square millimeter in root canal dentin. These are large enough to harbor bacteria. [Can We Eliminate Microorganisms From The Root Canal System? ​​ Markus Haapasalo, DDS, PhD]*

​​ “…owing to high surface tension, NaOCl (bleach) penetration is limited to about 130 micrometers into dentin tubules, whereas bacteria can colonize the dentin tubules as deeply as 1,100 micrometers from the canal lumen.” 

​​ *[Disinfection efficacy of photon-induced photoacoustic streaming on root canals infected with Enterococcus faecalis An ex vivo study. Giovanni Olivi, MD, DDS; Enrico DiVito, DDS;Ove Peters, DMD, MS, PhD; Vassilios Kaitsas, DDS; Francesca Angiero, MD, DDS;
Antonio Signore, DDS; Stefano Benedicenti, DDS JADA145(8) http://jada.ada.org August2014 ​​ pp 843-848]

Therefore, bacteria biofilms within the root canal cannot be eliminated by using strong disinfecting agents and standard instrumentation methods as once thought. ​​ Bacteria will remain in the main root canal that runs the length of the root as well as all the small canal tributaries called lateral canals that branch off the main root canal, and in the millions of hollow dentin tubules that comprise the entire tooth structure after the root canal is finished. 

In short, necrotic tissue and bacteria will remain in the tooth and the AAE stated goal of elimination of tissue substrate and bacteria will not be consistently met. Even the strongest disinfecting agents cannot predictably kill bacteria that have formed a biofilm. The result is a subset of chronically infected root canal teeth with persistent residual infection in the jaw bone around the tooth root tip. ​​ Some of these teeth will raise systemic inflammatory levels and others will not. ​​ 

One argument that is often heard: “Who cares that bacteria are left inside a root canal tooth. The body is not sterile. After all our bodies are full of bacteria and many of these bacteria, like the good bacteria in or intestines, are essential to good health.” 

Here is the problem with that belief. Yes, we need bacteria to survive. Good bacteria are neutral or beneficial when they are in places where they belong, and maybe not so good when infecting another body part. Just like with real estate it is location, location, location. If we never had to worry about bacteria causing disease no one would ever get bacterial pneumonia, or life-threatening flesh-eating necrotizing bacteria requiring limb amputation, or C-Diff infection in the GI tract, or periodontal disease OR need most root canals, since it is infection of the pulp tissue that kills the pulp and makes a root canal required in the first place. 

Continuing with the flawed logic, food handlers could stop washing their hands after going to the bathroom before handling your food. Surgeons could eliminate washing their hands or sterilizing surgical instruments before surgery and let’s see how that works out. Bacteria are beneficial when they are of the beneficial bacterial species and they are in places where they belong. Normal bacteria that are harmless in the mouth or gut that travel to other parts of the body may not be so harmless. You see, it is not so simple.

Rather than address the problem of residual infection left in the tooth root system after a root canal procedure, the dental profession “moves the goal posts” and state that any bacteria left in the tooth will be become entombed within the tooth and rendered inert. This is absurd. 

BACTERIA REMAINING IN ROOT CANAL TEETH - GOOD OR BAD?

According to root canal specialist Dr. Clifford Ruddle: 

“Advocating purposely leaving bacteria within the root canal system with the hope these micro-organisms will routinely become dormant is negligent, definitely not in the patient’s best interest, and is quackery…. “Quackery can be defined as the promotion of unsubstantiated methods that lack a scientific plausible rationale. ​​ Promotion usually involves a profit motive. Unsubstantiated means either unproven or disproven. Implausible means that it either clashes with well-established facts or makes little sense that it is not worth testing. 

There currently exists a limited number of unscientific articles that dismiss the entire biological essence of the endo (root canal) procedure, namely disinfection. ​​ Complete disinfection is not the goal, but rather the arbitrary reduction of bacterial loads. Although virtually all dentists have seen incomplete endo treatment that is, at times, successful, medical professionals should not aspire to anecdotal “sometimes” events.”

“While it is considered that many such remaining bacteria will remain unable to cause harm once entombed by the obturation material (root canal filling material), there is little evidence for this.”

[Haapasalo M, Udnaes T, Endal U. Persistent, recurrent, and acquired infection of the root canal system post-treatment. Endod Topics 2003; 6:29-56

From: Ingles Endodontics 6. Chap. 7 Microbiology of Endodontic Disease. Page 257]

“The “truth about dentistry,” writes Jabr, is that “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.”[Ferris Jabr. Is Dentistry a Science? The Truth About Dentistry. The Atlantic.com ​​ May 2019]

MY COMMENT:

Even if you could entomb the bacteria inside the root canal system with the root canal filling material, the majority of root canals do not completely fill and seal the root. In addition, bacterial toxins, both endotoxins and potent small molecule exotoxins, can easily make the way out of the root canal tooth and into the body.

​​ “ Endotoxin was able to diffuse through the dentinal tubules towards the cement, reaching the external root surface after the period of 24 h.” [de Oliveira, et al. Diffusion ability of endotoxin through dentinal tubules. Braz Oral Res 2005 Jan-Mar;19(1):5-10]

 “Lesser-quality root fillings were more strongly associated with periapical disease than were higher-quality obturations…

​​ only 42% of the obturations (complete filling and sealing of the root canal) could be considered technically satisfactory. Such data suggests that more research must be directed toward the study of factors that affect treatment outcome.”

[Michael Buckley, L.S.W. Spangberg. The Prevalence and Technical Quality of Endodontic Treatment in an American Population. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endocrinology. 79(1):92-100 February 1995]

“Bacterial sampling of prepared root canals is used to determine the presence and character of the remaining microbiota. However, it is likely that current sampling techniques only identify organisms in the main branches of the root canal system whereas it is unlikely that they can sample areas beyond the apical end-point of preparation and filling, or in lateral canals, canal extensions, apical ramifications, isthmuses and within dentinal tubules. Thus, it may be impossible by current techniques to identify residual post-treatment root canal infection. In histologic observations of root apices, bacteria have been found in inaccessible inter-canal isthmuses and accessory canals often in the form of biofilms. There is no in vivo evidence to support the assumption that these bacteria can be entombed effectively in the canal system by the root filling and thus be rendered harmless….”

“Histologic observation of root apices with surrounding bone removed from either patients or human cadavers has demonstrated that post-treatment apical periodontitis is associated with 50-90% of root filled human teeth. Thus, if the objective of root canal treatment is to eliminate apical periodontitis at a histological level, current treatment procedures are inadequate. It is essential that our knowledge of the local and systemic consequences of both residual post-treatment root infection and post-treatment apical periodontitis be improved. The continued development of treatments that can effectively eliminate root infection is therefore a priority in clinical endodontic research. Post-treatment disease following root canal treatment is most often associated with poor quality procedures that do not remove intra-canal infection; this scenario can be corrected via a nonsurgical approach. However, infection remaining in the inaccessible apical areas, extraradicular infection including apically extruded dentine debris with bacteria present in dentinal tubules, true radicular cysts, and foreign body reactions require a surgical intervention.” [Int. Endod J. 2006 May;39(5):343-56]

As we have shown, standard root canal treatment does not routinely remove all of the dead tissue and bacteria in the root canal system as is the stated goal of root canal treatment, and, in a significant number of root canal treated teeth, infection remains in the jaw-bone around the ends of the tooth root. It is this continued ​​ infection in the tooth and surrounding bone (apical periodontitis) that releases toxins into the circulation to travel to distant body sites, as well as the increase in inflammation, 24/7, day in and day out, that is implicated in a host of medical diseases such as cardiovascular disease.

​​ 

Apical periodontitis that does not resolve after root canal treatment and persists long after root canal treatment is not uncommon. ​​ Studies show that on conventional X-ray up to sixty percent of root canal treated teeth continue to show evidence of apical periodontitis long after root canal completion, (3D cone beam X-ray ​​ CBCT imaging was reported to have twice the odds of detecting a periapical lesion than traditional periapical radiography in endodontic outcome so the actual incidence of apical periodontitis may be higher* ) and that apical periodontitis usually remains chronically infected and not sterile and free form infection as once believed. 

[*J Aminoshariae A1, Kulild JC2, Syed A3.Cone-beam Computed Tomography Compared with Intraoral Radiographic Lesions in Endodontic Outcome Studies: A Systematic Review. Endod. 2018 Nov;44(11):1626-1631. doi: 10.1016/j.joen.2018.08.006.]

[Biofilm in endodontics: A review J Int Soc Prev Community Dent. 2015 Jan-Feb; 5(1): 1–12. PMCID: PMC4355843 doi: 10.4103/2231-0762.151956 PMID: 25767760 ]

[Endodontic Microbiology: Review of Literature. International Journal of Clinical Cases and Investigations 2011. Volume 2 (Issue 6), 24:36, 6th November, 2011]

Dentists often ignore evidence of apical periodontitis on an X-ray if the size does not change and there are no symptoms. They incorrectly assume that it must be a non-infected apical scar. 

The majority of the apical periodontitis lesions are still infected with bacteria. One study states that only 6%-12% ​​ may be a residual peri-apical ​​ scar without infection, and that number has not been recognized by all researchers.

[The post-endodontic periapical lesion: Histologic and etiopathogenic aspects. Med Oral Patol Oral Cir Bucal. 2007 Dec 1;12(8):E585-90. ]

Unresolved apical periodontitis must be considered infected, and not a sterile apical scar, unless proven otherwise. The patient should be informed of the residual infection and given the option of treatment or extraction. 

“It must be emphasized that of all these factors, residual microbes in the apical portion of the root canal system is the major cause of apical periodontitis persisting post‐treatment in both poorly and properly treated cases.”

[P.M.R.Nair. On the Cause of Persistent Apical Periodontitis: A Review. Int. Endodontic Journal. March 10, 2006]

“When faced with a periapical lesion that persists after root canal treatment, even when asymptomatic, the dental surgeon should consider either retreatment of the canal, periapical surgery or extraction of the affected tooth.”

[Carrillo-García C, Vera-Sempere F, Peñarrocha-Diago M, Martí-Bowen E. The post-endodontic periapical lesion: Histologic and etiopathogeniaspects. Med Oral Patol Oral Cir Bucal. 2007 Dec 1;12(8):E585-90. © Medicina Oral S. L. C.I.F. B 96689336 - ISSN 1698-6946] 

But this does not routinely happen because some dentists will do nothing if the tooth is asymptomatic and the size of periapical lesion remains the same. If a patient wants to have the tooth extracted as is one of the treatment options recommended, the dentist can face chargers from the state dental board for gross misconduct and negligence, just like I faced. Which is also absurd because when a person goes to the dentist with an infected tooth, they are given the option of having a root canal or an extraction. But suddenly once the root canal is done, the patient cannot change their mind and have the tooth extracted at a later date without the dentist facing potential misconduct charges from the state dental boards. And in my case, the dental boards wanted to take revoke my license. Now I can see if a dentist promises a cure to various diseases if a root canal tooth is extracted, that would certainly be ​​ irresponsible and is indeed mis-conduct, but that was not the situation in my case. See appendix C for patient letters to the dental board in support of the way I practiced)

Nothing is 100 percent. Even if the root canal was performed perfectly, apical periodontitis may not resolve leaving residual chronic infection in the bone around the root tip. ​​ 

“Even when carrying out a correct cleansing and filling of canals, it is possible that periapical periodontitis will persist in the form of an asymptomatic radiolucency, giving rise to the post-endodontic periapical lesion….”

If a patient has the option to extract an infected tooth before it has a root canal, they should retain the right to have it extracted after the root canal is completed.

With studies showing periapical lesions of up to 60% or greater on X-ray, and 90% or greater when examined after extraction, the majority of root canal teeth should either be retreated, utilizing new advanced techniques designed to thoroughly remove all dead tissue in the root canal system and the majority of bacteria in the lateral canals and dentin tubules, treated surgically, or extracted. Because:

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

[Cotti E, Dessì C, Piras A, Mercuro G. Can a chronic dental infection be considered a cause of cardiovascular disease? A review of the literature. Int J Cardiol. 2010;148(1):4-10.] 

SLOWLY BUT SURELY ‘CHANGE IS A COMING’

“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).”

[J.M. Liljestrand, P. Mäntylä, S. Paju, K. Buhlin, K.A.E. Kopra,
G.R. Persson, M. Hernandez, M.S. Nieminen, J. Sinisalo, L. Tjäderhane, and P.J. Pussinen Association of Endodontic Lesions with Coronary Artery Disease. Journal of Dental Research 2016, Vol. 95(12) 1358–1365]

“ 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.” ​​ [Rhythm Bains, Vivek K. Bains. Lesions of endodontic origin: An emerging risk factor for coronary heart diseases Indian Heart Journal. Volume 70, Supplement 3, December 2018, Pages S431-S434]

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

Focal Infection and Systemic Disease.

EVERYTHING IS CONNECTED!

This next section contains excerpts from numerous peer reviewed scientific papers because it is not enough to say things like “studies show” unless you actually show the studies. Scientific papers don’t make the most exciting reading , but is important to read the conclusions first-hand rather than an interpretation by someone else which may not always be accurate as you will see later. You don’t have to read all of them, but you do need to know that they exist.

The scientific articles presented will focus mainly on the association of oral infections on cardiovascular disease, more specifically apical periodontitis, and cardiovascular disease. Not all of the studies show a clear association, in fact some show no association at all, so it is important to evaluate all studies for the strength, weakness, and limitations of the research methods used.

Although some of the studies specifically specify apical periodontitis associated with root canal teeth as well as untreated infected teeth, other studies do not. 

However, studies show a high prevalence of inflammation in root canal teeth with apical periodontitis. The severity of inflammation will vary on a case by case basis, with some teeth showing little if any inflammation.

“There is currently no solid information available concerning the exact prevalence of endodontic lesions in Europe or elsewhere. However, in several Scandinavian studies, the prevalence of such lesions ranged from 30 to 60%, and increased with age [16,17] These results are in line with more current results from Canada which confirmed the high prevalence of endodontic inflammations in root-filled teeth. Thus, it may be assumed that a significant fraction of most populations is exposed to endodontic inflammations.” [Ghazai Aarabi, Guido Heydecke and Udo Seedorf. Role of Oral Infections in the Pathomechanism of Atherosclerosis.Int J Mol Sci. 2018 Jul; 19(7): 1978]

Apical periodontitis associates with cardiovascular diseases: a cross-sectional study from Sweden

 “Of the 120 patients 41% had AP and 61% had received endodontic treatments of which 52% were radiographically unsatisfactory. AP patients were older and half of them were smokers. AP and periodontitis often appeared in the same patient (32.5%). From all hospital diagnoses, cardiovascular diseases (CVD) were most common, showing 20.4% prevalence in AP patients. Regression analyses, controlled for age, gender, income, smoking and periodontitis, showed AP to associate with CVD with odds ratio 3.83 (95% confidence interval 1.18–12.40; p = 0.025).

Conclusions

The results confirmed our hypothesis by showing that AP statistically associated with cardiovascular diseases. The finding that subjects with AP also often had periodontitis indicates an increased oral inflammatory burden.” [Apical periodontitis associates with cardiovascular diseases: a cross-sectional study from Sweden. BMC Oral HealthBMC series – open, inclusive and trusted201717:107]

Bacterial Signatures in Thrombus Aspirates of Patients With Myocardial Infarction

“Infectious agents, especially bacteria and their components originating from the oral cavity or respiratory tract, have been suggested to contribute to inflammation in the coronary plaque, leading to rupture and the subsequent development of coronary thrombus. We aimed to measure bacterial DNA in thrombus aspirates of patients with ST-segment–elevation myocardial infarction and to check for a possible association between bacteria findings and oral pathology in the same cohort….

In a recent study by Ohki et al, periodontal pathogens were detected in the thrombus aspirates of MI patients. Most studies have focused on the role of periodontal pathogens or periodontal infections as a risk factor for atherosclerosis. We hypothesized that not only typical periodontal bacterial DNA, but also other oral bacterial DNA can be detected in the thrombus aspirates of MI patients and that dental procedures are also linked to bacterial findings in the atherosclerotic tissues. We collected a series of thrombus aspirates from ST-segment–elevation MI patients from 2 heart centers and measured candidate bacterial DNA in these using real-time quantitative PCR. We also aimed to verify the link between periapical abscesses and MI by analyzing the association between bacterial findings and dental pathology in a subset of our patients.”

Figure 1. Dental panoramic tomography of the upper and lower jaws. Arrows indicate periapical abscesses.

MY COMMENT: ​​ This is a tooth with a poorly done root canal. The root canal filling material only partially fills the main root canal space and the arrows point to apical periodontitis in the surrounding bone. Infection persists in both the tooth and in the surrounding jaw-bone with necrotic (dead) pulp tissue most certainly remaining in the canals. Even though this tooth and jaw-bone in the area around the tip of the root are infected, there may be no symptoms at all. This is the type of root canal tooth that can cause or contribute to systemic diseases and should either be retreated or extracted. Failure of the dentist to inform the patient of the presence of infection AND the potential systemic consequences should be considered both gross negligence and malpractice

Unfortunately, some dentists will look at this x-ray, see pathology, and do nothing if the tooth as asymptomatic. They won’t tell the patient that there is a problem. 

As one dentist on an internet website for dentists puts it, 

“If the patient doesn’t complain about pain or discomfort with insufficient Endo (root canal), I don't say anything and I am not frustrated .
If the Endo is asymptomatic, I don't care ...as I'm not obligated to provide an explanation to inquisitive patient because the Endo is trouble free..” 

This tooth is NOT trouble free. There is chronic infection, and most likely elevated inflammation, that can have a negative systemic effect. This comment is extremely disturbing and illustrates why the AAE should take action now to admit that all root canals are NOT the same and that poorly performed root canals can have all of the same systemic risks as untreated infected teeth and periodontal disease. Otherwise thousands upon thousands of bad root canals with chronic oral infection will remain in people’s mouths, the result of supervised neglect of the dentist. 

And in case you think that poorly performed root canals are extremely rare, think again:

“only 42% of the obturations (complete filling and sealing of the root canal) could be considered technically satisfactory. Such data suggests that more research must be directed toward the study of factors that affect treatment outcome.” 10

Bacterial Signatures in Thrombus Aspirates of Patients With Myocardial Infarction, (cont’d.):

“Our results showed that oral bacterial DNA could be detected in coronary thrombus aspirates of MI. Bacterial DNA typical for endodontic infection, mainly oral viridans streptococci, was measured in 78.2% of thrombus aspirates, and periodontal pathogens were measured in 34.7%. A recent study by Ohki et al reported similar percentages of periodontal bacteria found in the thrombus aspirates of MI patients.

During the development of atherosclerotic lesions, which may take many decades, different microorganisms and different populations of T lymphocytes may contribute to the smoldering inflammatory process that characterizes atherosclerotic tissue. Therefore, repeated transient bacteremias after dental procedures and or other bacterial infections during the lifetime may cause an accumulation of pathogens in atherosclerotic plaques, which may act to boost the inflammatory process and to maintain chronic low-grade inflammation. Rupture of a plaque populated by bacteria with a high affinity for platelets could then lead to thrombus formation and subsequently to an acute coronary event”

Dental Pathology and Its Association With Bacterial DNA Findings
The panoramic tomographies (X-rays) of the 30 MI patients showed that the most common dental findings were signs of dental treatment—fillings (1 or more) in 86.7% and previous root canal treatments in 66.7%—and further pathological findings: furcating lesions in 63.3%, vertical bone defects in 50.0%, and periapical abscesses in 46.6% (Table 3). Of the periapical abscesses, 33.3% coincided with previous root canal treatment.

“Our results suggest an association between dental infection and acute coronary events. Because the primary prevention of coronary events is based mainly on lifestyle changes, improvements in dental ​​ health and dental care could be a major goal of preventive efforts.” [Pessi, et.al. Bacterial Signatures in Thrombus Aspirates of Patients With Myocardial Infarction. Circulation. 2013 Mar 19;127(11):1219-28, e1-6. doi: 10.1161/CIRCULATIONAHA.112.001254. Epub 2013 Feb 15.]

MY COMMENT:

This article groups together apical periodontitis from both non-treated and poorly treated root canal teeth. This is important because although poorly performed root canals will remove some of the infected pulp tissue and bacteria, the residual bacterial infectious load within the root canal, as well as the continued apical periodontitis in the surrounding jaw-bone still contribute to cardiovascular risk. 

​​ 

In a response to letters regarding the last article, the authors of the article stress the role of dental health in the prevention of heart attack and particularly mention root canals. 

“… how the chronic oral infection is involved in acute coronary events……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…. It is known that bacteria are sensitive to most antibiotics when they are in the planktonic state in blood during bacteremia. However, this situation changes when bacteria attach to the end organ and start to grow in a biofilm, maintaining chronic infection. Within biofilm, bacteria are resistant to antibiotics and escape innate immune system by liberating extracellular material consisting of protein and polysaccharide, allowing intercellular aggregation.” 

[Pessi, et al. Response to Letters Regarding Article, “Bacterial Signatures in Thrombus Aspirates of Patients With Myocardial Infarction” ​​ Circulation. 2013; 128:e237-e239.]

Regarding Article, “Bacterial Signatures in Thrombus Aspirates of Patients with Myocardial Infarction.

Another response to the above article appeared in the journal Circulation titled, Letter by Ammirati and Maseri Regarding Article, “Bacterial Signatures in Thrombus Aspirates of Patients With Myocardial Infarction”. The authors state:

​​ “Pessi et al. showed in 101 cases of ST-segment elevation myocardial infarction that bacterial DNA typical for endodontic infection was 16 times higher in thrombi than that found in patients’ blood samples. Oral viridans streptococci was measured in 78% of thrombi and periodontal pathogens in 35%. Furthermore, there was a significant association between the presence of periapical abscess and endodontic bacteria in the thrombus aspirates (odds ratio, 7.71) in 30 patients with available dental panoramic tomography. This is an exciting finding that begs the question of how the presence of a chronic oral infection can mediate an acute transition to plaque thrombosis. First, it underscores that the activation of inflammatory pathways in acute coronary syndromes is not confined to coronary lesions but is also contained in the thrombus.”[Enrico Ammirati, Attilio Maseri. Letter by Ammirati and Maseri Regarding Article, “Bacterial Signatures in Thrombus Aspirates of Patients with Myocardial Infarction”. Circulation. 2013;128:e235]

Roles of Oral Infections in the Pathomechanism of Atherosclerosis

Abstract 

“Oral infections occur frequently in humans and often lead to chronic inflammations affecting the teeth (i.e., caries), the gingival tissues surrounding the teeth (i.e., gingivitis and endodontic lesions), and the tooth-supporting structures (i.e., periodontitis).

Besides gingivitis and periodontitis, there are other forms of frequent oral inflammations, most notably endodontic inflammations which typically result from deep dental caries penetrating through the root canal to the apex of the teeth’s root where a periapical abscess is formed. There is currently no solid information available concerning the exact prevalence of endodontic lesions in Europe or elsewhere. However, in several Scandinavian studies, the prevalence of such lesions ranged from 30 to 60%, and increased with age. These results are in line with more current results from Canada which confirmed the high prevalence of endodontic inflammations in root-filled teeth. Thus, it may be assumed that a significant fraction of most populations is exposed to endodontic inflammations.”

Frequent oral inflammations affecting the teeth, gingiva and the periodontium. (A) Shows an example of a severe case of periodontitis. Note the extensive loss of attachment and gingiva recession visible at most teeth; (B) shows a case of gingivitis. Note the soft plaque that covers the entire surface of the teeth and the gingiva reddened by the inflammation; panels (C,D) show examples of teeth affected by root caries, which often lead to the formation of endodontic lesions in the form of periapical abscesses, which can be detected on radiographs as shown in panel (E). Arrows mark the locations of periapical abscesses

“There is currently no solid information available concerning the exact prevalence of endodontic lesions in Europe or elsewhere. However, in several Scandinavian studies, the prevalence of such lesions ranged from 30 to 60%, and increased with age [16,17] These results are in line with more current results from Canada which confirmed the high prevalence of endodontic inflammations in root-filled teeth [18]. Thus, it may be assumed that a significant fraction of most populations is exposed to endodontic inflammations.”

My Comment:

Image E in the above photo shows a tooth with a poorly done root canal. The root canal filling material only partially fills the main root canal space and the arrows point to apical periodontitis in the surrounding bone. Infection persists in both the tooth and in the surrounding jaw-bone with necrotic (dead) pulp tissue most certainly remaining in the canals. Even though this tooth and area around the tip of the root are infected, there may be no symptoms such as pain. This is the type of root canal tooth that can cause or contribute to systemic diseases and should either be retreated or extracted. Failure of the dentist to inform the patient of the presence of infection AND the potential systemic consequences should be considered both gross negligence and malpractice. 

“Heat shock proteins belong to a highly conserved family of molecular chaperones involved in stress protection. Porphyromonas gingivalis and many other bacteria involved in oral infections, contain homologs to human HSPs. The HSP60 homolog of Porphyromonas gingivalis, which is called GroEL,can induce a humoral and cellular immune response in humans. Elevated levels of antibodies and T cells directed against GroEL cross-reacting with HSP60 could be demonstrated in atherosclerotic plaques and periodontal lesions and also in sera from patients with atherosclerosis and periodontitis. The mechanism of HSP60-induced atherosclerosis is schematically illustrated below”:

Figure 2

HSP60-induced atherosclerosis. (1) Healthy arteries are exposed to hemodynamic turbulences leading to shear stress at curves and branching points, which are prone to atherosclerosis; (2) classic risk factors (i.e., high blood pressure) may aggravate the stress response in endothelial cells, which leads to more surface expression of adhesion molecules and HSP60. This, together with secreted HSP60, attracts T cells and other proinflammatory cells to infiltrate the intima. Binding of cross-reactive antibodies to HSP60 to endothelial cells induce an autoimmune response, which promotes endothelial dysfunction and migration of mononuclear cells into the intima; (3) plaques start to develop, when macrophages and vascular smooth muscle are transformed to foam cells and produce proinflammatory cytokines. Soluble HSP60 is further released from damaged cells. If the inflammation persists, the lesion becomes more complex and a necrotic core composed of necrotic and apoptotic cells is formed. Cell debris, cholesterol crystals accumulate, and a fibrous cap is formed; (4) unstable plaques can rupture which leads to exposure of the core to the blood followed by thrombus formation. Abbreviations: HSP, heat shock protein; oxLDL, oxidized LDL; SMC, smooth-muscle cell; VADC, vascular-associated dendritic cell. Adapted from Servier Medical Art. creative commons license

“Oral infections, including gingivitis, periodontitis, and endodontic lesions consistently elevate systemic levels of C-reactive protein (CRP), which is a sensitive biomarker for systemic inflammation. One of the first studies published by Boucher et al. showed higher incidence of positive CRP tests and stronger CRP test reactions in samples from patients with acute and chronic endodontic lesions (alveolar abscesses) than from patients with other forms of oral inflammation. Subsequently, various studies showed that patients with less severe oral infections, such as chronic periodontitis, also have higher serum CRP levels than unaffected subjects. The severity of the infection correlates with the CRP level, and the CRP response was shown to be pathogen-dependent.” [Ghazai Aarabi, Guido Heydecke and Udo Seedorf. Role of Oral Infections in the Pathomechanism of Atherosclerosis.Int J Mol Sci. 2018 Jul; 19(7): 1978]

Lesions of Endodontic Origin and Risk of Coronary Heart Disease.

“Apical periodontitis is “an acute or chronic inflammatory lesion around the apex of a tooth caused by bacterial infection of the pulp canal system” (Eriksen, 1998), and usually is subsequent to the presence or restoration of deep caries lesions or fractured teeth. Apical periodontitis can be acute and painful or chronic and asymptomatic, and though it can be treated (or prevented) by the elimination of bacteria via root canal therapy, it may persist or recur after treatment is completed. Histologically, it is represented by a periapical inflammatory response that arises after resorption of adjacent supporting bone and local infiltration of inflammatory cells. Clinically, it is diagnosed from patient symptoms, clinical signs, and radiographic images; chronic apical periodontitis, in particular, is confirmed through observation of periradicular radiolucencies on affected teeth…

…Our findings of a significant association between incident LEO (Lesions of Endodontic Origin which includes untreated infected teeth and poorly performed root canal teeth with persistent apical periodontitis) and subsequent CHD among younger, but not older, men are consistent with those of prior work related to periodontal inflammation and CHD risk (see Mattila et al., 2000). A relationship might truly exist among all age groups, but might be diluted in older adults, since they have other characteristics even more strongly associated with CHD development. Alternatively, this could represent the “healthy survivor” phenomenon, i.e., older people tend to be healthier than other members of their cohort who died earlier. This might be especially true in the present study: Enrollees were required to be systemically healthy at baseline, implying that older participants were unusually healthy compared with both deceased members of their cohort and also with their living peers. Additionally, acute endodontic inflammation might play a role in CHD risk. We could not assess acute inflammation using the present study design, but younger and older individuals might differ with respect to their acute disease experience, and this might contribute to observed differences between younger and older participants.

…”These findings are consistent with research that suggests relationships between chronic periodontal inflammation and the development of CHD, especially among younger men…

Even a small contribution to CHD development by endodontic disease might be important from a public health perspective.)…. 

…Overall quality of endodontic therapy is generally considered poor, with inadequate fillings reported in 44 to 86% of treated teeth or roots (Dugas et al., 2003; Caplan, 2004).

…Enumerating one's cumulative endodontic infectious burden is not straightforward (Caplan, 2004). Endodontic disease can be acute or chronic, but acute endodontic inflammation is not evident radiographically; thus, the present study quantified only chronic endodontic inflammatory disease…. 

…It is likely that the amount of chronic apical periodontitis was underestimated here. First, due to attrition of participants or teeth, numerous LEO would go unrecorded if teeth were affected after one visit but extracted or successfully treated prior to the next visit. Second, radiographic evidence of the inflammatory process is delayed; substantial bony destruction must occur before the human eye can detect radiographic change (Lutwak, 1969; Manzke et al., 1975). Third, several different case definitions for LEO exist (see Caplan, 2004), and the present case definition was stringent. This strategy was intended to rule out false-positive calls but likely increased the number of false-negative calls. Additional false-negative calls could have resulted from obstruction of radiolucent periapical lesions by anatomic structures like the maxillary sinus, while false-positive calls could have resulted if other, non-inflammatory processes causing apical radiolucencies were counted as LEO (Nair et al., 1990). We would expect any such misclassifications to be non-differential across the subgroups, thus biasing any observed associations toward the null.

Finally, several potentially important variables were not used in the present analysis, e.g., HDL cholesterol was not recorded at baseline, inflammatory mediators were not measured, and bacterial samples were not collected. Further, the variable “pack-year smoking history” had too many missing values, so control for smoking was limited to categories of “current smoker” and “non-smoker”. Inadequate control for smoking might be partly responsible for the observed association (Hujoel et al., 2002a; Spiekerman et al., 2003). 

Future research into the role of endodontic disease and the development of adverse systemic health outcomes should be based on prospective study designs that address these concerns, and, ultimately, the effect of eradication of LEO (through successful endodontic therapy or extraction) on CHD risk should be explored.” [D.J. Caplan,1,* J.B. Chasen,4 E.A. Krall,5 J. Cai,3 S. Kang,3 R.I. Garcia,5 S. Offenbacher,2 and  J.D. Beck1 Lesions of Endodontic Origin and Risk of Coronary Heart Disease. J Dent Res. 2006 Nov; 85(11): 996–1000.]

Association of Endodontic Lesions with Coronary Artery Disease.

“An endodontic lesion (EL) is a common manifestation of endodontic infection where Porphyromonas endodontalis is frequently encountered. EL may associate with increased risk for coronary artery disease (CAD) via similar pathways as marginal periodontitis. The aim of this cross-sectional study was to delineate the associations between EL and CAD. Subgingival P. endodontalis, its immune response, and serum lipopolysaccharide were examined as potential mediators between these 2 diseases. The Finnish Parogene study consists of 508 patients (mean age, 62 y) who underwent coronary angiography and extensive clinical and radiographic oral examination. The cardiovascular outcomes included no significant CAD ( n = 123), stable CAD ( n = 184), and acute coronary syndrome (ACS; n = 169). EL was determined from a panoramic tomography. We combined data of widened periapical spaces (WPSs) and apical rarefactions to a score of EL: 1, no EL ( n = 210); 2, ≥1 WPS per 1 apical rarefaction ( n = 222); 3, ≥2 apical rarefactions ( n = 76). Subgingival P. endodontalis was defined by checkerboard DNA-DNA hybridization analysis, and corresponding serum antibodies were determined by ELISA. In our population, 50.4% had WPSs, and 22.8% apical rarefactions. A total of 51.2% of all teeth with apical rarefactions had received endodontic procedures (Root canal). Subgingival P. endodontalis levels and serum immunoglobulin G were associated with a higher EL score. In the multiadjusted model (age, sex, smoking, diabetes, body mass index, alveolar bone loss, and number of teeth), having WPSs associated with stable CAD (odds ratio [OR] = 1.94, 95% confidence interval [95% CI] = 1.13 to 3.32, P = 0.016) and highest EL score were associated with ACS (OR = 2.46, 95% CI = 1.09 to 5.54, P = 0.030). This association was especially notable in subjects with untreated teeth with apical rarefactions ( n = 59, OR = 2.72, 95% CI = 1.16 to 6.40, P = 0.022). Our findings support the hypothesis that ELs are independently associated with CAD (coronary artery disease) and in particular with ACS (Acute coronary syndrome). This is of high interest from a public health perspective, considering the high prevalence of ELs and CAD.[Liliestrand, JM et.al. Association of Endodontic Lesions with Coronary Artery Disease. J Dent Res 2016 Nov;95(12):1358-1365]

Apical Periodontitis - Is It Accountable for Cardiovascular Diseases?

“Since decades, there have been speculations regarding the systemic and oral health inter-relationship. A logical association can be suggested between oral and systemic diseases; although no clear cause and-effect relationship has been established . There are evidences that chronic infections are a risk factor for many systemic diseases like diabetes, atherosclerosis, osteoporosis, etc. This exploration has escalated the search for chronic infections that cause or aggravate systemic diseases.

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.

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 . 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

Endodontic diseases could act as a confounding variable taking into account high prevalence of apical periodontitis [25]. Hypertension and inflammatory markers have been closely associated in apparently healthy patients. It was found that patients with acute myocardial infarction had a higher number of missing teeth, higher number of radiographic apical lesions and higher periodontal screening index value as compared to individuals without myocardial infarction [49]. Periapical disease and endodontic treatment could be associated with hypertension. Relationship between high blood pressure and periapical status may be due to inflammatory response based on published data suggesting chronic inflammation as independent risk factor for hypertension

Heat Shock Proteins (HSP) released by some bacterial species and immune response induced by bacterial infection is hypothesized to be responsible for the initiation of early atherosclerotic lesions. Kosugi M et al., observed an association between immune responses to HSP produced by oral bacteria, chronic marginal and periapical periodontitis, CMV infection, dental metal allergy, and their combinations

[Paridhi Garg, Chandraker Chaman. Apical Periodontitis - Is It Accountable for Cardiovascular Diseases. J Clin Diagn Res ​​ 2016 Aug; 10(8):ZE08-ZE12]

Lesions of endodontic origin: An emerging risk factor for coronary heart diseases

“A high inflammatory state, such as atherosclerosis, is a major underlying cause of coronary heart diseases (CHDs). Inflammatory mediators are known to lead to endothelial dysfunction and play a key role in initiation, progression, and rupture of atherothrombotic plaque. Chronic inflammatory dental infections such as periodontitis and lesions of endodontic origin or chronic apical periodontitis (CAP) may provide an environment conducive for such events. Atherosclerosis has shown to share a common spectrum of inflammatory markers with apical periodontitis. The possible correlation between CHD and CAP is emerging at microbiological, clinical, inflammatory, and molecular levels. This less recognized fact should be discussed more among the dental and medical fraternity so that more awareness and positive approach toward oral health can be created among patients and health-care providers.”

Lesions of endodontic origin (chronic apical periodontitis)

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.11, 12 Thus, the systemic effects related to periodontitis may be applicable for lesions of endodontic origin too. An overabundant production of localized or systemic inflammatory mediators is seen in response to gram-negative bacteria in certain individuals, which may in turn lead to vascular or cardiovascular damage.13, 14 Detection of Streptococcus mutans, a major bacterial etiopathogen for dental caries in atherogenic plaque is also suggestive of a possible proatherogenic potential of dental caries.15Moreover, a recent multicentric study has shown that the prevalence of teeth with radiographic evidence of apical periodontitis is as high as 65% in Indian urban population. Thus, it is all the more important to recognize and address the effects of endodontic lesions or apical periodontitis on the systemic health, especially relating to the cardiovascular diseases.16

Although studies have shown that CHD and periodontitis are associated independently with the classical risk factors such as arterial hypertension, diabetes mellitus, smoking, and hypertriglyceridemia, only a few studies have explored the potential association between chronic apical periodontitis (CAP) and CHD13, 17 (See Table 1).

MY COMMENT:

This chart below is a good summary of the research articles associating the positive, neutral and negative associations between apical periodontitis and cardiovascular disease. 

Table 1. List of relevant studies.

[Bains, Bains. Lesions of endodontic origin: An emerging risk factor for coronary heart diseases. Indian Heart Journal Volume 70, Supplemental 3, December 2018, Pages S431-S434]

Can a chronic dental infection be considered a cause of cardiovascular disease?

“Apical periodontitis is caused by bacteria (in association with viruses and fungi) residing inside the root canal/s (endodontium) of the diseased teeth, and organized in a biofilm, as a consequence of pulpal infection, which is usually the ultimate result of a deep carious lesion. 

The pathogenesis of apical periodontitis is due to a non-specific inflammatory process and a specific immunologic reaction of the host in the periapical tissues: (cementum of the root, periodontal ligament and alveolar bone) in response to the infection coming from the endodontium. The establishment of this response is believed to be an attempt for the body to prevent the diffusion of the infection into the bone. With time, Apical Periodontitis causes the re-absorption of the periapical bone, its substitution with the inflammatory tissue, and the formation of a radiolucent lesion (periapical lesion). Clinical signs and symptoms associated with the different stages of apical periodontitis are represented by soft tissues swelling (periapical abscess), presence of sinus tract, pain to percussion of the tooth and to palpation of the periapical area. Yet apical periodontitis is usually a chronic infection and, in most cases, remains asymptomatic. Therefore, it is often diagnosed by the radiographic observation of a radiolucent area around the root of the affected tooth (Fig. 2). Over time, apical periodontitis may suffer an acute exacerbation and become symptomatic. Apical periodontitis can be treated by the instrumentation, disinfection and obturation of the radicular canal of the involved tooth (endodontic treatment). Unfortunately, the disease can persist or recur after treatment is completed. ….

Three possible metastatic pathways can be considered responsible for the consequences of oral infections on systemic diseases such as CVD: 

1. metastatic spread of infection from the oral cavity, resulting from a transient bacteremia; 

2. metastatic injury by circulating oral microbial toxins;
3. metastatic inflammation arising from an immune response to oral microorganisms.

4.2. Apical periodontitis (endodontic infection) and CHD 

In 2003, Frisk et al. published the first cross-sectional study that examined the possible association between various components of endodontic disease and CHD. A connection between dental infections, probable cause of vascular abnormalities, and the genesis of atherosclerosis was hypothesized. The study was conducted in Goteborg in 1992–93, on a representative sample of women (n = 1056) aged between 38 and 84 years. The dependent variable was CHD [i.e. angina pectoris and/or a history of myocardial infarction (n = 106)]. The independent variables were number of root-filled teeth, number of teeth with periapical lesions (as radiolucencies seen in the radiographs), tooth loss, age, marital status, smoking, alcohol habits, waist/hip ratio, serum cholesterol and triglyceride concentrations, hypertension and diabetes. By using the multivariate logistic regression analysis, researchers could not prove that endodontic variables were predictive of CHD. Only age and tooth loss were significantly associated with CHD [OR = 1.07 (CI = 1.03–1.12) and OR = 2.70 (CI = 1.49–4.87), respectively]. The bivariate logistic regression analysis showed a significant association between endodontically treated teeth and CHD; conversely, the same analysis did not support any associations between periapical lesions and CHD. 

In 2006, Caplan et al. reported the results of the VA Dental Longitudinal Study, in which 708 participants (all males, mean age 47.4 years) were recruited. In accordance with the evidence that periodontal disease is more manifest in young male patients, the authors hypothesized that also young men with a greater number of endodontic lesions might be more prone to develop CHD. Patients underwent comprehensive medical and dental examinations (including panoramic radiographs) at baseline and every three years for up to 32 years (median 24 years). Cox regression models estimated the relationship between incident lesions of endodontic origin and time to CHD diagnosis. Thirty-five percent of all participants had at least 1 periapical lesion and 23.4% of them were subsequently diagnosed with CHD. Twenty-seven percent of participants aged ≤45 years and 41% of those aged N 45 years had one or more periapical lesions. Among the subjects who were subsequently diagnosed with CHD, the youngest showed a greater number of apical lesions compared to older people. Among participants aged 40 years or younger, incident lesions of endodontic origin were significantly associated with time to CHD diagnosis, after adjustment for covariates of interest, with hazard ratios decreasing as age increased. Among participants aged N40 years, no statistically significant associations were observed. 

Following these results, the authors ​​ asserted that the “mechanisms linking endodontic disease to CHD risk might be similar to those hypothesized for the associations between periodontal disease and CHD, where a localized inflammatory response to bacterial infection leads to the release of cytokines into systemic circulation, with subsequent deleterious vascular effects”. In accordance with the above assertion, the interdependence between CVD and endodontic infection could be demonstrated by the observation that also endodontic disease is produced by gram-negative anaerobes and characterized by the release of cytokines ​​ and high levels of inflammatory mediators. Caplan et al. also explained that this association proves to be more effective among young people since, with time, older subjects may develop other characteristics more strongly associated with CHD pathogenesis. Alternatively, the explanation may lie in the “healthy survivor” phenomenon, meaning that older people tend to be healthier than other members of the same cohort who die before. 

A cross- sectional sample was used for exploring associations between apical periodontitis or socio-economic risk factors and CHD in multivariate logistic regression models. In the Population Study on Oral Health in Jönköping, random samples of women aged 20–70 years were used. Apical periodontitis was radiographically recorded, and the root filling quality was assessed with respect to length and seal. Inadequate root filling quality was predictive of apical periodontitis with a 4.5 OR. On the other hand, the results did not reveal any significant associations between apical periodontitis and CHD nor between socio-economic risk factors and apical periodontitis. 

In a recent study, Caplan et al. evaluated the correlation between self-reported history of endodontic therapy (ET) and CHD prevalence. To that end, they used data derived from oral health questionnaires, medical evaluations and clinical dental examinations of 6.651 dentate participants in the Atherosclerosis Risk in Communities Study. Final multivariable regression models indicated that, among participants with 25 or more teeth, those who reported having undergone two or more ET showed a significantly higher prevalence of CHD than those reporting no history of ET. Among participants with 24 or fewer teeth, no significant differences in CHD prevalence were observed among groups, regardless of their ET history….

…,”scientific rigorousness was not always applied for a better understanding of the relationship between the presence of periapical lesions and CV risk. In trials that have followed each other over time, weak surrogate parameters of risk have been used, several populations of different ages, difficult to compare, were studied and control groups have not been provided at any time….

“Only a few studies have investigated the possible correlation between pulpal inflammation and/or apical periodontitis and CVD. An association has been noted between apical periodontitis and stroke, as well as between a “composite status of oral health” (caries, periapical lesions, number of endodontically treated teeth) and CVD.”

Apical periodontitis is widely present in endodontically treated teeth and is often associated with a poor quality endodontic treatment]. Therefore, it is always more difficult to evaluate the “cumulative endodontic infectious burden” for average patients . 

 Fig. 2. Two examples of periapical bone lesions of endodontic origin (arrowed). 

Conclusions on the correlation between apical periodontitis and CVD. 

While the deep connections between periodontal disease and CVD have been well documented by several studies, the potential CV consequences of apical periodontitis/endodontic disease remain largely unknown and controversial. The issue has been addressed only recently and has produced mixed results, with studies in favor of a positive correlation between apical periodontitis and coronary risk, and other negative or inconclusive. Unfortunately, the necessary scientific rigorousness was not always applied for a better understanding of the relationship between the presence of periapical lesions and CV risk. In trials that have followed each other over time, weak surrogate parameters of risk have been used, several populations of different ages, difficult to compare, were studied and control groups have not been provided at any time. 

On the basis of the still equivocal suggestions of literature (Table 1) we should feel encouraged to better investigate this issue. A more precise understanding of the connection between endodontic infection and inflammation and CV risk would be of great interest not only from a scientific point of view but also from a public health perspective. It is therefore extremely urgent to know whether apical periodontitis represents only the oral component of a systemic disease or shares with it a common etiology. Only a more focused and rigorous scientific research can determine a definitive opinion on the relationship between endodontic disease and CVD. Therefore, it would be important to use dental infection as an independent variable in future CVD research. “ 

[Elisabetta Cotti , Cristina Dessì , Alessandra Piras , Giuseppe Mercuro. Can a chronic dental infection be considered a cause of cardiovascular disease? A review of the literature. International Journal of Cardiology ​​ 148 (2011) 4-10]

ORAL FOCI OF INFECTION LEADING TO SYSTEMIC DISEASES—AN EMERGING PROBLEM IN MEDICINE

“The relationship between oral and general health has been increasingly recognized during the past two decades. Several epidemiological studies have linked poor oral health with cardiovascular disease, poor glycemic control in diabetics, low birth-weight pre-term babies and a number of other conditions, including rheumatoid arthritis and osteoporosis. It is therefore important that the individuals should be made aware of the risks associated with poor oral health. Hence, dentists and medical practitioners should work together to provide comprehensive health care, thereby reducing the morbidity and mortality associated with oral infections. ..

In 1900, William Hunter, a British physician, first suggested that micro-organisms found in the oral diseases were responsible for a wide range of systemic conditions. The concept of focal infection was evolved.[1] The teeth are the only nonshedding surfaces in the body, and bacterial levels can reach more than 10 microorganisms per mg of dental plaque. Human endodontal and periodontal infections are associated with complex microfloras in which approximately 200 species (in apical periodontitis and more than 500 species (in marginal periodontitis) have been encountered. These infections are predominantly anaerobic, with gram- negative rods being the most common isolates. The anatomic closeness of these microfloras to the blood- stream can facilitate bacteremia and systemic spread of bacterial products, components, and immunocomplexes. A

number of epidemiological studies have suggested that oral infection, especially marginal and apical periodontitis, may be a risk factor for systemic diseases. 

Some gram-positive and gram-negative bacteria have the ability to produce diffusible proteins, or exotoxins, which include cytolytic enzymes and dimeric toxins with A and B subunits. The exotoxins have specific pharmacological actions and are considered the most powerful and lethal poisons known. Conversely, endotoxins are part of the outer membranes released after cell death Endotoxin is compositionally a lipopolysaccharide (LPS) that, when introduced into the host, gives rise to a large number of pathological manifestations. LPS is continuously shed from periodontal gram-negative rods during their growth in vivo”

​​ [Dr. Swati Dahiya, Dr. Taranpreet Kaur and Dr. Ankit Srivastava. ORAL FOCI OF INFECTION LEADING TO SYSTEMIC DISEASES—AN EMERGING PROBLEM IN MEDICINE. ejpmr, 2018,5(1), 167-171 ] 

[Xiaojing Li, Kristin MK, Tronstad L, Olsen I. Systemic Diseases Caused by Oral Infection. Clinical Microbiology Reviews, Oct. 2000; 547–558.]

Role of oral foci in systemic diseases: An update 

“A current research disagreement middles about a theorized connection between chronic oral infections and the progress of adverse systemic health conditions. However, the gap between general and dental medicine is quickly closing, due to significant findings supporting the association between dental infections and systemic conditions such as cardiovascular diseases, type 2 diabetes mellitus, respiratory diseases, stroke, adverse pregnancy outcomes, osteoporosis, renal diseases, and gastrointestinal diseases. Relentless efforts have brought light on numerous advances in illuminating their etiopathological links. However, the majority of data about possible role or interlink between the infection and systemic disease is available in the form of case report or summary. As case reports are not the acceptable to many indexed scientific magazines, many these findings undergo unnoticed to researchers. The currently minimal accessible data provide only an indication of the actuality. 

Aim: This article highlights the Role of oral foci in systemic diseases. Conclusion: There is need of sincere work efforts on genetic relatedness of organisms, rather than their phenotypes, sophisticated sampling, detection, and analytical techniques to create the associations. To give insight to recent apprises of different systemic diseases as a consequence of primary oral infections and the pathogenesis link. The odontogenic bacteremia is likely to cause systemic and end organ infections, but such infections can easily resist by body defenses. It is important that role of good oral health and the risks associated with poor oral health should told to the individuals. Clinical significance: Dentists and medical practitioners should work together to provide comprehensive health care, thereby reducing the morbidity and mortality associated with oral infections.

In this era of evidence-based medicine, a vast number of research studies have indicated that oral infection is a possible causal factor which can influence the progression of important systemic diseases. However, the majority are in the form of reports or as a summary of cases. Since they lack originality, a large number of them go unreported. The odontogenic bacteremia is likely to cause systemic and end organ infections, but such infections can easily resist by body defenses. It is important that role of good oral health and the risks associated with poor oral health should told to the individuals. Dentists and medical practitioners should work together to provide comprehensive healthcare, thereby reducing the morbidity and mortality associated with oral infections. There is need of much more work in this area to established strong association of oral microorganism with systemic disease causation. This will provide future direction to prepare guidelines of treatment of oral infection.” ​​ [ Ranjitkumar Patil1, Shailesh M. Gondivkar2, Amol R. Gadbail3, Monal Yuwanati4, Mugdha Mankar (Gadbail)5, Manoj Likhitkar6, Sachin Sarode7, Gargi Sarode7, Shankargouda Patil. Role of oral foci in systemic diseases: An update. International Journal of Contemporary Dental and Medical Reviews (2017), Article ID 040117, 8 pages]

The oral cavity as a reservoir of bacterial pathogens for focal infections 

“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.” [Renée Gendron, Daniel Grenier, Léo-François Maheu-Robert. The oral cavity as a reservoir of bacterial pathogens for focal infections. Microbes and Infection Volume 2, Issue 8, July 2000, Pages 897-906] 

Pulpal Inflammation and Incidence of Coronary Heart Disease

[Author links open overlay panelKaumudi J.JoshipuraScD⁎†‡WaranuchPitiphatScD⁎†§Hsin-ChiaHungScD†∥Walter C.WillettDrPH†¶#Graham A.ColditzScD†#Chester W.DouglassPhD⁎† Pulpal Inflammation and Incidence of Coronary Heart Disease https://doi.org/10.1016/j.joen.2005.10.039Get rights and content]

Abstract

“Pulpal inflammation is primarily caused by coronal caries, and leads to root canal therapy (RCT). Chronic inflammation has been associated with various cardiovascular diseases. This study evaluates the association between pulpal inflammation (using RCT as a surrogate) and incident coronary heart disease (CHD). We report results among males from the Health Professionals Follow-Up Study (HPFS), excluding participants with prior cardiovascular disease or diabetes. We obtained RCT data from the HPFS cohort (n = 34,683). Compared to men without RCT, those with ≥1 RCT had a multivariate RR of 1.21 (95% CI 1.05-1.40) for CHD. The association was limited to dentists (RR = 1.38; 95% CI 1.14-1.67). There was no association among nondentists (RR = 1.03). Dental caries was not associated with CHD. The results suggest a possible modest association between pulpal inflammation and CHD.”

“A number of epidemiological studies have suggested that oral infection, especially marginal and apical periodontitis, may be a risk factor for systemic diseases.[2]

“Within the limitations of the available literature, clinicians should bear in mind that PALs may not only have local manifestations but also systemic ramifications, as has been already shown for periodontitis (Beck et al. 1996, Madianos et al. 2002). “

“A recently published study has revealed more extensive mechanistic detail (Brown et al. 2015). The prevailing theory is that localized oral infections, by increasing systematic inflammation/oxidative stress, exacerbate CVD, contribute to future events or decrease the threshold for CVD events (Lockhart et al. 2012, Gomes et al. 2013, Brown et al. 2015). The presence of AP can be considered an additive risk factor for CVD, along with active periodontal disease. “

“Although the contributing absolute risk to CVD from oral infections may be relatively small, risk factors for CVD are additive. Because PALs are often silent, they may be overlooked during clinical assessment of CVD, despite the fact that they are very common in the age group of patients prone to atherosclerosis. 

If AP truly caused CVD, treatment of oral conditions such as PALs may reduce atherosclerosis development, and sequel such as heart attack and stroke, especially in high-risk populations. Recognition of PALs as a contributory risk factor for systemic inflammatory conditions such as atherosclerosis will provide incentive for prevention and early intervention. Educating dental health professionals, medical professionals, patients and policymakers about the impact of oral inflammation stemming from chronic AP on systemic health will increase awareness of the need to include oral health assessment, treatment and preventive strategies as a means to improve health outcomes in the population worldwide. “

[ Berlin-Broner Y, Febbraio M, Levin L. Association between apical periodontitis and cardiovascular diseases: a systematic review of the literature. Int Endod J. 2017 Sep;50(9):847-859. doi: 10.1111/iej.12710. Epub 2016 Nov 19.]

The Infection Hypothesis Revisited: Oral Infection and Cardiovascular Disease 

​​ “The pathophysiology of cardiovascular disease (CVD) includes inflammation in the development of atherosclerosis and thrombosis. Increasing evidence supports oral infections, and in particular the common periodontal disease, to be associated with CVD development. Periodontal infection is present in populations worldwide and in the moderate to mild form in about 35% of populations according to the World Health Organization. Objective. This review of the literature aims to present cross evidence from medical research disciplines that explore how oral infections can contribute to increase the risk for CVDs and how treatment of oral infections can reduce the risk for CVDs. Design. Review article. Results. Long-term exposure to active nontreated infections of the oral cavity presents an opportunity for bacteria, bacterial products, and viruses to enter the circulation. Toxic bacterial products enter the circulation, affecting atherosclerosis, causing platelet adhesiveness that results in clot formation, and establishing cardiac vegetation. Pathological observations have identified oral bacteria in heart valves, aortic aneurysms, and arterial walls. Clinical intervention studies on periodontal disease reduce the risk level of serological predictors for CVDs. Conclusions. This paper presents evidence across medical research disciplines for oral infections to be considered as one of the risk factors for CVDs.”

[Lise Lund Håheim1,2 Institute of Oral Biology, Dental Faculty, University of Oslo, PB 1052 Blindern, 0316 Oslo, Norway, Institute of Basic Medical Sciences, Medical Faculty, University of Oslo, PB 1110 Blindern, 0317 Oslo, Norway. The Infection Hypothesis Revisited: Oral Infection and Cardiovascular Disease. Received 29 June 2014; Revised 22 September 2014; Accepted 23 September 2014; Published 21 October 2014 ]

Potential Impact of Oral Inflammations on Cardiac Functions and Atrial Fibrillation

“It is well known that oral infections elevate systemic CRP levels consistently [43,44,45,46,47,48]. The highest levels have been observed in patients with acute and chronic endodontic lesions (alveolar abscesses) [49,50]. In addition to CRP, oral inflammation affects the circulating levels of many other inflammatory markers and cytokines (see Table 1 for details) [50,51]. The pro-inflammatory mediator IL-6 stimulates the production of CRP and fibrinogen by the liver, resulting in an acute-phase reaction that has pro-inflammatory and pro-atherogenic effects [46]. Clinical studies have shown that circulating IL-6 is not only elevated in patients with periodontitis, but also in patients with heart failure—a major risk factor for AF (see review by Wollert and Drexler [52]). 

It appears conceivable that cardiac arrhythmias could potentially also be affected by the systemic inflammation, which is known to accompany oral inflammations and/or by autoimmunity against molecular structures expressed in the heart caused by the host immune response to specific oral pathogens. Finally, arrhythmic effects resulting from activation of the autonomic nervous system and from specific bacterial toxins that are produced by oral pathogenic bacteria could also play a role.

Humans are affected by a great number of infections and chronic inflammations. Over a lifetime, oral infections are important, because of their longstanding nature and high frequency in the population.”

[Ghazal Arabi,  Renate B. Schnabel, Guido Heydecke, and  Udo Seedorf. Potential Impact of Oral Inflammations on Cardiac Functions and Atrial Fibrillation. Biomolecules. 2018 Sep; 8(3):66 Published online 2018 Aug 1.] 

The connection between ruptured cerebral aneurysms and odontogenic bacteria

“Bacterial DNA was detected in 21/36 (58%) of specimens. A third of the positive samples contained DNA from both endodontic and periodontal bacteria. DNA from endodontic bacteria were detected in 20/36 (56%) and from periodontal bacteria in 17/36 (47%) of samples…

Conclusions: This is the first report showing evidence that dental infection could be part of pathophysiology in intracranial aneurysm disease.”

 [Pyysalo, MJ, Pyysalo LM, Karhunen PJ, Ohman JE. 2013 Nov;84(11):1214-8. doi: 10.1136/jnnp-2012-304635. Epub 2013 Jun 12.The connection between ruptured cerebral aneurysms and odontogenic bacteria. J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):1214-8. doi: 10.1136/jnnp-2012-304635. Epub 2013 Jun 12.]

Elevated Systemic Inflammatory Burden and Cardiovascular Risk in Young Adults with Endodontic Apical Lesions

Abstract

Introduction

The aim of this study was to assess whether apical lesions are associated with inflammatory serum markers of cardiovascular risk, especially high-sensitivity C-reactive protein (hsCRP), in young adults.

Methods

In this cross-sectional study, otherwise healthy individuals with apical lesions of endodontic origin (ALEOs) and a clinical diagnosis of asymptomatic apical periodontitis and controls aged between 18 and 40 years were included. Patients’ sociodemographic characteristics, medical history, and classic cardiovascular risk factors were recorded, and the pathobiological determinants of atherosclerosis in youth score was calculated. Oral clinical and radiographic examinations were performed. Blood samples were collected to determine the lipid profile, glycated hemoglobin, hsCRP, immunoglobulin G, interleukin (IL)-6, IL-10, IL-12p70, matrix metalloproteinase 8, soluble vascular cellular adhesion molecule-1, soluble intercellular adhesion molecule-1, and soluble E-selectin. Bivariate and multivariate analyses adjusting for oral and classic cardiovascular risk factors were performed.

Results

hsCRP levels were significantly higher in ALEO patients versus controls (median = 2.54 vs 0.78), whereas the pathobiological determinants of atherosclerosis in youth score was comparable among the groups. Also, the levels of IL-6, matrix metalloproteinase 8, and soluble E-selectin were significantly higher in ALEO patients. hsCRP, IL-6, and IL-12 correlated with soluble adhesion molecules. Bivariate analysis based on hsCRP serum concentrations ≥1 mg/L showed an odds ratio (OR) = 6.8, and the risk increased 3.3 times for an additional ALEO. In multivariate analysis, ALEO was significantly associated with hsCRP levels ≥1 mg/L (OR = 5.1–12.8) independently of the adjustment model. ALEO also associated with CRP levels >3 mg/L, which was significant after the adjustment for covariates (OR = 4.0).

Conclusions

ALEO is associated with the systemic inflammatory burden and cardiovascular risk determined by hsCRP, supporting a mechanistic link for cardiovascular diseases in young adults.

[Mauricio Garrido, DDS, Angélica M. Cárdenas, DDS†,‡, Jessica Astorga, BSc†, Francisca Quinlan, BSc† 

Macarena Valdés, MSc, PhD§, Alejandra Chaparro, MSc, DDS¶,Paola Carvajal, MSc, DDS∗

Pirkko Pussinen, PhD‖,Patricia Huamán-Chipana, MSc, DDS∗∗,Jorge E. Jalil, MD††

Marcela Hernández, MSc, DDS, PhD†,‡‡ Elevated Systemic Inflammatory Burden and Cardiovascular Risk in Young Adults with Endodontic Apical Lesions. Journal of Endodontics.Feb. 2019. Vol. 45, Issue 2, Pages 111-115]

sTNF-R Levels: Apical Periodontitis Linked to Coronary Heart Disease.

“CONCLUSION: Elevated levels of sTNF-R1 and sTNF – R2 in apical periodontitis patients indicate an increased independent risk of coronary heart disease.”

[Singhal RK, Rai B. sTNF-R Levels: Apical Periodontitis Linked to Coronary Heart Disease.Open Access Maced J Med Sci. 2017 Mar 15;5(1):68-71. doi: 10.3889/oamjms.2017.010. Epub 2017 Jan 17.]

Association between Chronic Apical Periodontitis and Coronary Artery Disease

​​ “The study comprised 103 patients (52 men, 51 women; mean age, 61.9 years); 31.1% were literate, and 55.3% were married. In the study sample, the prevalence of chronic apical periodontitis was 41.7% and of coronary artery disease, it was 65%. The patients with chronic apical periodontitis had a 2.79 times higher risk of developing coronary artery disease. In these study patients, chronic apical periodontitis was independently associated with coronary artery disease.”

[Tatiana Hassin Rodrigues, et.al. Association between Chronic Apical Periodontitis and Coronary Artery Disease. Journal of Endodontics 40(2): 164-7 February 2014]

Chronic Apical Periodontitis Is More Common in Subjects With Coronary Artery Disease

“…Peterson et al. (2014) for the first time quantified aortic atherosclerotic burden by calcification scoring method and found that it related positively with some teeth with CAP but without any endodontic treatment. Conversely, endodontically treated teeth even with CAP did not contribute to the atherosclerotic burden. In this study, the factor CAP without endodontic treatment was more significant than gender, marginal periodontitis, and caries and about one-fourth as significant as age. Caplan et al. (2009) evaluated the relationship between a self-reported history of endodontic treatment and prevalent CHD in Atherosclerosis Risk in Communities study. Final multivariable regression models indicated that among participants with 25 or more teeth, those reporting having had endodontic treatment two or more times had 1.62 times the odds of prevalent CHD compared with those reporting never having had endodontic treatment.”

 In recent years, a number of observational studies have assessed the association between CVDs and endodontic disease, and both positive and negative results have been reported). The majority of the studies reporting positive associations showed that AP lesions are more frequent and more severe in patients with CVD than patients without CVD). ...

[Daniel J. Caplan. Chronic Apical Periodontitis Is More Common in Subjects With Coronary Artery Disease. Journal of Evidence Based Dental Practice 14(3) September 2014]

MY COMMENT:

Dr. Caplan presents a previous study by Peterson, et.al. that showed no correlation between root canal teeth with apical periodontitis and atherosclerosis, whereas his results showed those reporting having had endodontic treatment two or more times had 1.62 times the odds of prevalent CHD compared with those reporting never having had endodontic treatment. These results may indicate the sliding scale of risk among root canal treated teeth, with some poorly performed root canal with chronic apical periodontitis showing little increase in inflammatory burden.

Total body burden for risk factors may also be a factor. For example, a person with no other risk factors and only one root canal tooth with apical periodontitis may not have any increased risk of heart disease. Their body may be able to handle it. 

However, the same person with four additional poorly performed root canals, or a host of any other risk factors such as diabetes or hypertension may now show increased risk of cardiovascular disease as the risk factors can be additive. 

The following article by Dr. Caplan was published in 2006 and illustrates the difficulties in studying this topic. 

Lesions of Endodontic Origin and Risk of Coronary Heart Disease

…”These findings are consistent with research that suggests relationships between chronic periodontal inflammation and the development of CHD, especially among younger men…

Apical periodontitis is “an acute or chronic inflammatory lesion around the apex of a tooth caused by bacterial infection of the pulp canal system” (Eriksen, 1998), and usually is subsequent to the presence or restoration of deep caries lesions or fractured teeth. Apical periodontitis can be acute and painful or chronic and asymptomatic, and though it can be treated (or prevented) by the elimination of bacteria via root canal therapy, it may persist or recur after treatment is completed. Histologically, it is represented by a periapical inflammatory response that arises after resorption of adjacent supporting bone and local infiltration of inflammatory cells. Clinically, it is diagnosed from patient symptoms, clinical signs, and radiographic images; chronic apical periodontitis, in particular, is confirmed through observation of periradicular radiolucencies on affected teeth…

 …Our findings of a significant association between incident LEO (Lesions of Endodontic Origin which includes untreated infected teeth and poorly performed root canal teeth with persistent apical periodontitis) and subsequent CHD among younger, but not older, men are consistent with those of prior work related to periodontal inflammation and CHD risk (see Mattila et al., 2000). A relationship might truly exist among all age groups, but might be diluted in older adults, since they have other characteristics even more strongly associated with CHD development. Alternatively, this could represent the “healthy survivor” phenomenon, i.e., older people tend to be healthier than other members of their cohort who died earlier. This might be especially true in the present study: Enrollees were required to be systemically healthy at baseline, implying that older participants were unusually healthy compared with both deceased members of their cohort and also with their living peers. Additionally, acute endodontic inflammation might play a role in CHD risk. We could not assess acute inflammation using the present study design, but younger and older individuals might differ with respect to their acute disease experience, and this might contribute to observed differences between younger and older participants.

Even a small contribution to CHD development by endodontic disease might be important from a public health perspective.…. 

…Overall quality of endodontic therapy is generally considered poor, with inadequate fillings reported in 44 to 86% of treated teeth or roots (Dugas et al., 2003; Caplan, 2004).

…Enumerating one's cumulative endodontic infectious burden is not straightforward (Caplan, 2004). Endodontic disease can be acute or chronic, but acute endodontic inflammation is not evident radiographically; thus, the present study quantified only chronic endodontic inflammatory disease…. 

…It is likely that the amount of chronic apical periodontitis was underestimated here. First, due to attrition of participants or teeth, numerous LEO would go unrecorded if teeth were affected after one visit but extracted or successfully treated prior to the next visit. Second, radiographic evidence of the inflammatory process is delayed; substantial bony destruction must occur before the human eye can detect radiographic change (Lutwak, 1969; Manzke et al., 1975). Third, several different case definitions for LEO exist (see Caplan, 2004), and the present case definition was stringent. This strategy was intended to rule out false-positive calls but likely increased the number of false-negative calls. Additional false-negative calls could have resulted from obstruction of radiolucent periapical lesions by anatomic structures like the maxillary sinus, while false-positive calls could have resulted if other, non-inflammatory processes causing apical radiolucencies were counted as LEO (Nair et al., 1990). We would expect any such misclassifications to be non-differential across the subgroups, thus biasing any observed associations toward the null.

Finally, several potentially important variables were not used in the present analysis, e.g., HDL cholesterol was not recorded at baseline, inflammatory mediators were not measured, and bacterial samples were not collected. Further, the variable “pack-year smoking history” had too many missing values, so control for smoking was limited to categories of “current smoker” and “non-smoker”. Inadequate control for smoking might be partly responsible for the observed association (Hujoel et al., 2002a; Spiekerman et al., 2003). Future research into the role of endodontic disease and the development of adverse systemic health outcomes should be based on prospective study designs that address these concerns, and, ultimately, the effect of eradication of LEO (through successful endodontic therapy or extraction) on CHD risk should be explored.”

MY COMMENT:

Here is the take away messages from the above article:

“Apical periodontitis can be acute and painful or chronic and asymptomatic, …it may persist or recur after treatment is completed…”

“Even a small contribution to CHD development by endodontic disease might be important from a public health perspective.”

Apical periodontitis associates with cardiovascular diseases: a cross-sectional study from Sweden

“We found a large proportion of endodontically treated teeth with apical periodontitis (persistent infection in the jaw-bone surrounding the end of the tooth root) ​​ and a correlation between the quality of endodontic filling (filling and sealing the root canal space in the tooth root) and the prevalence of periapical lesions. This all suggests that it is necessary to improve the quality of endodontic treatment in order to reduce the incidence and prevalence of apical periodontitis.”4

“Of the 120 patients 41% had AP (apical periodontitis) and 61% had received endodontic treatments of which 52% were radiographically unsatisfactory. AP patients were older and half of them were smokers. AP and periodontitis often appeared in the same patient (32.5%). From all hospital diagnoses, cardiovascular diseases (CVD) were most common, showing 20.4% prevalence in AP patients. Regression analyses, controlled for age, gender, income, smoking and periodontitis, showed AP to associate with CVD with odds ratio 3.83 (95% confidence interval 1.18–12.40; p = 0.025)….

Conclusions

“The results confirmed our hypothesis by showing that AP statistically associated with cardiovascular diseases. The finding that subjects with AP also often had periodontitis indicates an increased oral inflammatory burden.” 

[Eunice Virtanen, et.al. Apical periodontitis associates with cardiovascular diseases: a cross-sectional study from Sweden. BMC Oral HealthBMC series – open, inclusive and trusted201717:107]

APICAL PERIODONTITIS ‘INDEPENDENTLY ASSOCIATED’ WITH CAD, ACS

 “The research involved 508 individuals of a mean age of 62 years who were part of The Finnish Parogene study and who were experiencing some heart problems.

All patients underwent angiography - an X-ray of the blood vessels. This revealed that 36 percent of the patients had stable CAD, 33 percent had ACS, and 31 percent had no significant CAD.

Using panoramic tomography, the researchers assessed the patients' teeth and jaws. They found that up to 58 percent of the patients had at least one inflammatory lesion, a sign of apical periodontitis.

The results revealed that patients with apical periodontitis were more likely to have CAD or ACS; this association was strongest for patients whose apical periodontitis was untreated and required a root canal, with a 2.7-times greater risk of ACS.

These results remained after accounting for a number of possible confounding factors, including patients' age, sex, smoking, type 2 diabetes, body mass index (BMI), and number of teeth.

Based on their findings, the researchers believe apical periodontitis can be considered a risk factor for heart disease:

"Our findings support the hypothesis that ELs [endodontic lesions] are independently associated with CAD and in particular with ACS. This is of high interest from a public health perspective, considering the high prevalence of ELs and CAD."

Additionally, the team found that patients with apical periodontitis had higher levels of antibodies in their blood that are associated with other common bacteria, further suggesting that oral infections can affect other areas of the body.

In order to protect heart health, the team suggests individuals should adopt strategies to prevent or treat oral infections, which are often asymptomatic.

Atherosclerosis, which is a condition characterized by a high inflammatory state, is a major underlying cause of coronary heart disease (CHD), as it may precipitate myocardial infarction, stroke, or peripheral vascular disease. The disease follows a somewhat silent clinical course, and the first clinical symptom often arises at a well-advanced stage.1, 2 Inflammatory mediators are known to lead to endothelial dysfunction and play a key role in initiation, progression, and rupture of atherothrombotic plaque. Long-standing chronic inflammatory state anywhere in the body is a known contributing factor for many degenerative diseases, and chronic inflammatory dental infections such as dental caries, periodontitis, and endodontic lesions may provide an environment conducive for such events. The microbe-induced inflammatory reaction of the oral connective tissue causes a symptomatic vasodilatation, resulting in an increased permeability of the endothelium that leads to the migration of leukocytes in the perivascular region and also the foray of bacteria.”

 The next excerpts are illustrate the association between infection and cancer, studying the possible mechanism of action of the bacteria Porphyromonas gingivalis and cancer. P. gingivalis is a species of bacteria that is ​​ found in periodontal disease, but it is also found in a percentage of root canal treated teeth with apical periodontitis. This association is clearly not enough to be considered causal, but it emphasizes the importance of performing complete and thorough root canal treatment to eliminate or minimize both apical periodontitis and infection within the root canal system. 

Can apical periodontitis modify systemic levels of inflammatory markers? A systematic review and meta-analysis. 

CONCLUSIONS: “Available evidence is limited but consistent, suggesting that AP is associated with increased levels of CRP, IL-1, IL-2, IL-6, asymmetrical dimethylarginine, IgA, IgG, and IgM in humans. These findings suggest that AP may contribute to a systemic immune response not confined to the localized lesion, potentially leading to increased systemic inflammation.” [Gomes MS,et al. Can Apical Periodontitis Modify Systemic Levels of Inflammatory markers? A Systematic Review and Meta-Analysis. J Endod. 2013 Oct;39(10:1205-17 Epub 2013 Aug 16]

Identification of dominant pathogens in periapical lesions associated with persistent apical periodontitis.

​​ “OBJECTIVE: 

to identify dominant pathogens in the periapical lesions associated with persistent apical periodontitis.

METHODS: 

thirty-three root-filled teeth with persistent apical periodontitis referred for surgical treatment were selected. Microbial samples were collected from the periapical lesions during apical surgery. Microbial identification was performed with species-specific primers prepared according to the sequence analysis data using a 16S rRNA technique.

RESULTS: 

among the 33 cases, in 5 cases none of the target species were detected, 6 cases showed the presence of only one species, and 22 cases showed more than two species. Porphyromonas endodontalis (45% of sample) was the most commonly detected dominant microbial species in the study sample, followed by Actinomyces viscosus (42%), Candida albicans (36%) and Porphyromonas gingivalis (27%). Fusobacterium, Actinomyces israelii and Enterococcus faecalis were also detected in 27%, 21% and 15% of the sample, respectively. The most frequently isolated species, P. endodontalis, was in most cases detected together with Actinomyces (14 cases) and P. gingivalis (6 cases). None of the lesions analyzed in the present study contained Prevotella intermedia. There was no correlation in relation to the presence of sinus tracts and the bacterial species.

CONCLUSION: 

a mixed population of pathogens was found in the endodontic lesions associated with persistent apical periodontitis. P. endodontalis, A. viscosus, C. albicans and P. gingivalis (Porphyromonas gingivalis) were the dominant species identified.”

[Zhang S.et.al. Identification of dominant pathogens in periapical lesions associated with persistent apical periodontitis. Clin J Dent Research. 2010:13(2):115-21]

A New Biomarker Reservoir for Oral and Oropharyngeal Cancers.

“The past decades of biomedical research have yielded massive evidence for the contribution of microbiome in the development of a variety of chronic human diseases. There is emerging evidence that Porphyromonas gingivalis, a well-adapted opportunistic pathogen of the oral mucosa and prominent constituent of oral biofilms, best known for its involvement in periodontitis, may be an important mediator in the development of a number of multifactorial and seemingly unrelated chronic diseases, such as rheumatoid arthritis and oro-digestive ​​ cancers. Oro-digestive cancers represent a big portion of the total malignancies worldwide, and include cancers of the oral cavity, gastro-intestinal tract, and pancreas.”

​​ 

Schematic representation of the complex interrelationships between different human genetic, behavioral and immunologic factors, as well as microbiome-related factors, that are proposed to take part in the multifactorial etiology of orodigestive cancers and other possibly associated chronic diseases. P. gingivalis is implicated to play a specific role in these multi-directional links. Dashed arrows represent plausible associations, based on currently available epidemiologic, clinical, histological, and experimental studies.

Mol Oral Microbiol. Author manuscript; available in PMC 2015 Apr 1.

Published in final edited form as:

Mol Oral Microbiol. 2014 Apr; 29(2): 55–66. 

Published online 2014 Feb 8. doi: 10.1111/omi.12047

“Studies have established that chronic inflammation is responsible for 25% of human malignancies and represents the seventh hallmark in the development of cancers [30]. Chronic inflammatory mediators cause or facilitate increased cell proliferation, mutagenesis, oncogene activation, and angiogenesis that ultimately lead to the loss of normal growth control and cancer [30, 31]. Bacterial infection is one of the major causes of chronic inflammation. The strongest link established between bacterial infection and the development of cancer due to chronic inflammation to date is the association between Helicobacter pylori (H. pylori) and adenocarcinoma of the stomach, while other known associations include Salmonella typhi and gallbladder cancer, Streptococcus bovis and colon cancer, Chlamydia pneumonia and lung cancer, and Bartonella species and vascular tumour formation [26, 31]. In general, studies have shown that bacteria alone are unable to induce cancer; the process is commonly accompanied by chronic inflammation and requires mutations in oncogenic signaling pathways. ….”

[Lim Y, Totsika M, Morrison M, Punyadeera C. Oral Microbiome: A New Biomarker Reservoir for Oral and Oropharyngeal Cancers. Theranostics 2017; 7(17):4313-4321. doi:10.7150/thno.21804. Available from http://www.thno.org/v07p4313.htm ]

​​ 

The New Science Behind America’s Deadliest Diseases

“New research funded by the National Institutes of Health is looking at the relationship of diet, inflammation and cancer.

"Cancer is caused by many different processes and inflammation is one of them, and if you could inhibit that process it would be tremendously helpful," says Young S. Kim, program director in the Nutritional Science Research Group at the National Cancer Institute.”

[Lauro Landero. The New Science Behind America’s Deadliest Diseases. The Wall Street Journal. July 16, 2012]

Even depression has been associated with chronic apical periodontitis 

  “This present study examined the associations among chronic apical periodontitis (CAP), root canal endotoxin levels (lipopolysaccharides, LPS), O&NS (oxidative and nitrosative) pathways. pathways, depressive symptoms, and quality of life… Root canal LPS levels were positively associated with CAP, clinical depression, severity of depression (as measured with the Hamilton Depression Rating Scale (HDRS) and the Beck Depression Inventory) and O&NS biomarkers, especially NOx and TRAP. CAP-related depression was accompanied by increased levels of NOx, LOOH, AOPP, and TRAP. In CAP participants, there was a strong correlation (r = 0.734, p < 0.001) between root canal LPS and the HDRS score. There were significant and positive associations between CAP or root canal endotoxin with the vegetative and physio-somatic symptoms of the HDRS as well as a significant inverse association between root canal endotoxin and quality of life with strong effects on psychological, environmental, and social domains. It is concluded that increased root canal LPS accompanying CAP may cause depression and a lowered quality of life, which may be partly explained by activated O&NS pathways, especially NOx thereby enhancing hypernitrosylation and thus neuroprogressive processes. Dental health and “leaky teeth” may be intimately linked to the etiology and course of depression, while significantly impacting quality of life.”

​​ [Gomes,C., Martinho, F.C., Barbosa, D.S.,et al. Increased Root Canal Endotoxin Levels are Associated with Chronic Apical Periodontitis, Increased Oxidative and Nitrosative Stress, Major Depression, Severity of Depression, and a Lowered Quality of Life. Mol Neurobiol (2018_ 55: 2814]

Our Teeth Are Making Us Sick 

“Oral health is a neglected issue nationally,” said Julia Paradise, associate director of the ​​ program on Medicaid and the uninsured at the Kaiser Family Foundation. “This is a big problem. The mouth and the head – mental health and dental health – somehow remain outside what people think of ads general health.” [Zoe Greenberg. Our Teeth Are Masking Us Sick. The New York Times Opinion Page. May 23, 2017]

Nothing in Life is Risk Free

After reviewing the scientific research presented, the most frequently ​​ asked question should be, “What do I do if I need a root canal?” And the answer involves several components.

First, an infected tooth should not be ignored. It should either be treated with a root canal or extracted. These are the only two medically sound options. Leaving it “as is” or trying unproven alternative therapies should not be an option. 

If your dentist determines that the tooth is salvageable and restorable, the next step is to have the root canal procedure done. Here is where you are presented with a critical choice, because the quality of the root canal procedure is critical, not only for the health of the tooth involved, but also for reducing or eliminating any systemic risks from the completed root canal tooth. 

My recommendation is to seek treatment, preferably from a skilled endodontist (root canal specialist) or expertly trained and skilled general dentist that uses shock wave enhanced emission photoacoustic streaming equipment, that is also well versed on the literature presented in this article. As discussed, there is a huge difference between a well performed root canal and a poorly performed root canal. 

Hopefully in the future physicians and dentists will work more closely together, and any elevation in inflammation measured by high sensitivity CRP blood test can be addressed to see if the inflammation source is of dental origin. 

Most everything that we do in life involves some degree of risk. There is always a chance that when we drive a car that we could have an accident. Driving is risky. But we accept that risk while at the same time doing everything that we can to reduce the risk as much as possible by doing things such as making sure the car tires have enough thread and are properly inflated. That our brakes are in good shape etc. 

In addition, advances in car design and manufacture have made cars both safer and safer in the event of an accident. If we drive the speed limit, don’t drink and drive, don’t text and drive, and generally follow safe driving practices in a well-maintained car, we significantly reduce the chance of having an accident. But the risk will never be zero. 

The same reasoning can be applied to a root canal tooth. The root canal procedure is best performed by a highly skilled dentist using the most advanced technologies to clean the inside of the root canal of infected tissue and bacteria, fully fill and seal the root canal space. Apical periodontitis that shows complete or near complete healing of the surrounding bone jaw-bone and no markers of increased systemic inflammation, should pose little if any systemic risks. 

QUACKWATCH

The classic approach to discredit the message is to attempt to discredit the messenger. The dental boards tried to do it and revoke my license. They failed. (see the preface of The Toxic Tooth in Appendix A ​​ for the complete story). 

The website quackwatch is run by retired psychiatrist Stephen Barrett. Barrett has not practiced medicine in decades and in my opinion is critical of any individual that does not tow the AMA, ADA, and pharmaceutical line. Barrett has written an article about me under the non-recommended sources of health advice. 

Reading Barrett’s article about me on quackwatch does indeed make me look like a quack. ​​ I ​​ guess that is his purpose. And that makes me angry. ​​ Because you can debate me on ideas all day long, but do not question my character, motives and integrity. 

Although I have no respect at all for Barrett, I do agree that there are individuals and organizations listed on quackwatch that should be there. Even a broken clock displays the correct time twice a day. ​​ 

The dental board action against me is explained in Appendix A. ​​ I am only going to address two of Barrett’s comments about me here to illustrate that context and presentation are very important, because you can read more about what others have to say about him ​​ later in this section and decide for yourself if his opinions are objective and unbiased.

(See Appendix F for patient letters of support)

In my opinion Barrett is trying to imply that I recommended natural cures for cancer which is 100 percent false, because when in practice I had link a company that made pharmaceutical grade nutritional supplements for my surgical patients to aid in recovery, NOT to treat cancer, and certainly not as an alternative to conventional cancer therapies. ​​ I never recommended alternative cancer therapies in place of conventional ​​ cancer therapies . I never endorsed these therapies. I never had anything to do with treating cancer period. 

Even the ​​ NYS dental boards understood this and had no issue with it whatsoever. 

The paragraph below is taken from Barrett’s quackwatch page about me and my latest book, The Toxic Tooth, co-authored with Thomas Levy, MD, JD.:

“The Toxic Tooth claims that "Overwhelming scientific evidence shows that virtually all root canal-treated teeth are still infected and slowly and continually leak disease-causing pathogens and toxins into the rest of the body as long as they remain in the mouth." It also claims that root canal procedures increase the possibility of developing coronary artery disease, lung disease, kidney disease, dementia, diabetes, and arthritis. I do not believe that these assertions are valid.”

Barrett ignores all of the scientific reference presented in The Toxic Tooth, many of which are referenced in this article, and he wants you to believe that he is the expert by stating he “does not believe these assertions are valid. “ 

Although my Toxic Tooth co-author Tom Levy, MD wrote the chapter on dietary supplements and he could answer, my name is on the book, so I take responsibility for all of the content, regardless of who wrote that particular section. 

Barrett ​​ writes:

“The Toxic Tooth also recommends huge doses of vitamin C (8,000 to 19,000 mg/day) and beta-carotene (25,000 to 50,000 IU) for everyone. I believe that these dosages are dangerous. Megadoses of vitamin C can cause diarrhea, and beta-carotene supplements are associated with an increase in some forms of cancer.”

Barrett states that he believes these dosages are dangerous. Vitamin C can indeed cause diarrhea and should be dose adjusted. Barrett also claims that beta carotene supplements are associated with an increase in some forms of cancer. What he should tell you but of course did not is that the increase is cancer is with lung cancer and smoking associated cancers, and that non-smokers with high beta carotene levels had a lower risk of cancer. That is the responsible way to report it.

Further, our book is designed to be used as a guide, not in place of individual physician or dentist treatment recommendations. 

“A French study involving adult females published in the Journal of the National Cancer Institute(September 2005 issue) found that smokers with high beta carotene levels had a higher risk of lung cancer and other smoking-related cancers than other smokers. They also found that non-smokers with high beta carotene intake had a lower risk of lung cancer.”

Although my Toxic Tooth co-author Tom Levy, MD wrote the chapter on dietary supplements and could address this topic better than I can, my name is on the book, so I take responsibility for all of the content, regardless of who wrote that particular section. 

I do not object to a healthy exchange of ideas and scientific debate. In fact, I welcome it. This is how science advances.

What I do object to is attempts to discredit or defame an individual for sole purpose of discrediting their message. 

(See Appendix G for patient letters of support)

(see Appendix M for more on quackwatch, Stephen Barrett, and others)

I am in good company on the lists of non-recommended ​​ individuals which includes:

- Deepok Chopra, M.D.

 -Joseph Burrascano M.D.

Dr. Burrascano was one of the first physicians to recognize and treat patients that did not respond to a course of oral antibiotics to treat Lyme disease. Infectious disease physicians insisted that there was no such thing as chronic Lyme disease and that Lyme disease was cured after a course of oral antibiotics. Dr. Burrascano was brought up on charges by the NY state medical board and left his medical practice shortly after. 

 -Andrew Weil, M.D., 

 -Weston Price, DDS (see list of accomplishments and awards ​​ Appendix H). 

 -J.E. Bouquot DDS, MS. (see bio Appendix E) 

-Mehemet Oz, M.D., 

I listed Dr. Oz because he has many critics. ​​ Sometimes false claims are made against a person that, when repeated enough, undergo metamorphosis to perception of fact, when they really are just false claims. 

Here is an interesting article on this regarding Dr. Oz..(See Appendix I for the complete article)

https://www.nytimes.com/2015/04/26/opinion/sunday/dr-oz-is-no-wizard-but-no-quack-either.html

The following is from the website quackpotwatch.org:

Who is Stephen Barrett?

“Involving the case of NACHF vs. Kingbio: 

The Court also declared that top quackbusters Stephen Barrett 

(quackwatch.com), and Wallace Sampson MD (Scientific Review of Alternative and Aberrant Medicine)  "were found to be biased and unworthy of credibility."”

In a Canadian lawsuit (see below) Barrett admitted to the following:

"The sole purpose of the activities of Barrett & Baratz are to discredit and cause damage and harm to health care practitioners, businesses that make alternative health therapies or products available, and advocates of non-allopathic therapies and health freedom."

For instance, Court Documents show:

“The sole purpose of the activities of Barrett & Baratz are to discredit and cause damage and harm to health care practitioners and businesses that make alternative health therapies or products available, and advocates of non-allopathic therapies and health freedom.:

“Barrett and Baratz have falsely and fraudulently held themselves out as experts in the scientific fields of alternative complementary medicine.”

“Barrett uses predatory and deceptive practices designed to cause harm and damage to supporters and providers of alternative health services and products.”

“Both Stephen Barrett and Robert Baratz are vexatious litigants who use the court system to advance their agendas and the agendas of their privately owned businesses, which promote allopathic medicine, and discredit any health care treatment or product that is considered complementary or alternative treatment.”

“NCAHF is the acronym for National Council against Health Fraud. The NCAHF is a front organization used by Barrett, Baratz and their other associates whose purpose is to solicit jobs so that they can act as expert witnesses against doctors who practice alternative and complementary treatment methods.”

“Barrett operates numerous web sites including Quackwatch.com, Chirowatch.com., ratbags.com and Quackwatch.org . The sole purpose of these web sites is to discredit health care professionals who practice alternative and complementary medicine. These web sites discredit complementary medicine and encourage people to report doctors who practice alternative medicine, thus providing Barrett , Baratz and their associates with a constant stream of potential cases that can be prosecuted thus providing them with opportunities to act as expert witnesses on behalf of NCAHF, their privately owned company.”

“Quackwatch.com., Quackwatch.org and Ratbags.com all provide links to NCAHF, and provide the false appearance of NCAHF being an impartial and regulatory type body, when in fact, it is not.”

“The growing popularity of alternative therapy is a constant threat to Barrett, Baratz and their business interests, and the interests of the existing medical and pharmaceutical status quo.”

“The debate over allopathic care vs. alternative health care is and will continue to be the subject of hot and emotional debate, similar to that of politics and religion. Barrett uses the court system and threats of legal action to bait, control and get leverage over what others say about him, his opinions, and qualifications”

About Qualifications...

“Barrett was disqualified as an  expert witness in New York, when he was forced to admit under oath that he was never board certified.”

“Barrett using his NCAHF front led a legal action against 39 Defendants in California, claiming that the 39 defendants were committing fraud, because according to them , alternative medicine proponents do not have scientific proof of their claims.”

Barrett is NOT an expert on expert on dentistry. Frankly, I ​​ am not sure if he is an expert on anything. 

It is ironic that Barrett labels Dr. Jerry Bouquot, who IS an expert on dentistry, a quack. Dr. Jerry Bouqout is a world-renowned oral pathologist and performed microscopic analysis on many of my surgical biopsy specimens. 

(See APPENDIX E for Dr. Bouquot’s bio and see who the real quack is, Barrett or Bouquot.)

There is however one thing that Barrett and I have in common is that we both object to Dr. Hal Huggins extreme views on root canals and other related dental topics. Dr. Huggins views align with the extreme anti-root canal group and do not reflect my opinion. 

However, it is quite normal to have differing opinions on an issue. ​​ Even my co-author Tom Levy, MD, JD and I have differing opinions. Although we agree and compromise on most root canal related issues or we could not have authored a book together, there are some areas where we simply disagree. ​​ And that’s OK. ​​ One day you may find yourself with a medical condition with three different, and sometimes valid, treatment choices. This is normal. 

What is not normal is labeling anybody that presents a viewpoint that is supported by sound medical principle and backed by peer reviewed literature that goes against the AMA, ADA, or Pharmaceutical industry as a quack, in the attempt to discredit their message and promote an agenda. ​​ 

However, the good news is that you don’t need to trust Barrett, or me for that matter, for an expert opinion. You have read the peer reviewed scientific article presented in this article and YOU can decide whether these assertions are valid. 

Although some of the opinion presented on quackwatch is valid, much of it is not. Quackwatch is known for attacking doctors that present dissenting opinions to the AMA, ADA and pharmaceutical industry viewpoint. Of course, the Sackler family and Purdue Pharmaceuticals, makers of the opioid drug oxycontin are not on the quackwatch website in spite of the fact that Purdue pharmaceuticals misled the public.

​​ “The company funded research and paid doctors to make the case that concerns about opioid addiction were overblown, and that OxyContin could safely treat an ever-wider range of maladies.” …*

“Duke University School of Medicine told me. “Their name has been pushed forward as the epitome of good works and of the fruits of the capitalist system. But, when it comes down to it, they’ve earned this fortune at the expense of millions of people who are addicted. It’s shocking how they have gotten away with it.” *

“Few drugs are as dangerous as the opioids,” says David Kessler, the former commissioner of the Food and Drug Administration.”*

“Most of the questionable practices that propelled the pharmaceutical industry into the scourge it is today can be attributed to Arthur Sackler (Purdue Pharmaceuticals).” *

*[Patrick Radden Keefe. The Sackler’s Dynasty Ruthless Marketing of Painkillers Has Generated Billions of Dollars – And Millions of Addicts. The New Yorker. Oct. 23, 2017]

So, is Arthur Sackler’s name on the quackwatch list? ​​ Of course not. You will not find him or anybody else associated with the opioid health crisis. 

The following passage is taken from the website of Ray Sahelian, M.D. and ​​ offers a glimpse into who Stephen Barrett is and what Quack watch is all about. :

“Quackwatch review - Is Stephen Barrett a Quack? Is he fair, balanced, or biased? 
Quackwatch sends an email to Ray Sahelian, M.D. 
April 10 2018 

Over the years I have had many people ask my opinion regarding Stephen Barrett and Quackwatch, but I have been reserved in voicing my thoughts. However, in March 2006 we received an email from someone who claimed that Stephen Barrett had told him negative things about a product I had formulated. And, in June, 2006 my staff received an email from Stephen Barrett (see below). This prompted us to create a page regarding Quackwatch.org in order to present our point of view. According to the Quackwatch website, this is what Stephen Barrett, M.D. says about himself.

"Stephen Barrett, M.D., a retired psychiatrist who resides in Allentown, Pennsylvania, has achieved national renown as an author, editor, and consumer advocate. In addition to heading Quackwatch, he is vice-president of the National Council Against Health Fraud, a scientific advisor to the American Council on Science and Health, and a Fellow of the Committee for the Scientific Investigation of Claims of the Paranormal (CSICOP)."

Is Dr. Stephen Barrett fair in his analysis of nutrition research and those involved in the nutrition industry? 
I have not read every single page or article on Quackwatch and I do not read most of the new pages that are added on the site, but the ones I have read give me the impression that in many cases he has done good research on many of the people involved in the alternative health industry, and has pointed out several instances of inaccuracies and scams (for instance, Hulda Clark and her pitiful book "The Cure for all Cancers"). However, I hardly came across reports on his website regarding some of the scams or inaccurate promotion and marketing practices by the pharmaceutical industry. Why is this? Why has Stephen Barrett, M.D. focused almost all of his attention on the nutritional industry and has hardly spent time pointing out the billions of dollars wasted each year by consumers on certain prescription and non-prescription pharmaceutical drugs? If he truly claims to be a true consumer advocate, isn't it his responsibility to make sure the big scams are addressed first before focusing on the smaller scams? It's like the government putting all of its efforts going after the poor misusing food stamps while certain big companies cheat billions of dollars from consumers with hardly any governmental oversight.
    

​​ Why is there no review of Vioxx on Quackwatch? Why is there no mention on quackwatch.org of the worthless cold and cough medicines sold by pharmaceutical companies and drug stores? Hundreds of millions of dollars are wasted each year by consumers on these worthless and potentially harmful decongestants and cough syrups. Why is there no mention on quackwatch of the dangers of acetaminophen use, including liver damage? There are probably more people who are injured or die from over the counter Tylenol and aspirin use each year than from all the natural supplements people take throughout a year. If Dr. Barrett had focused his career on educating people in reducing the use of useless and dangerous prescription and nonprescription drugs (even just one, acetaminophen) he would have helped many more people than attempting to scare people from the use of supplements. 
    

Another point I would like to make regarding Quackwatch is that Dr. Barrett often, if not the majority of the time, seems to point out the negative outcome of studies with supplements (you can sense his glee and relish when he points out these negative outcomes), and rarely mentions the benefits they provide. A true scientist takes a fair approach, and I don't see this in my review of the Quackwatch website. I subscribe to the Quackwatch newsletter (which often has interesting information) but there is hardly any mention of the benefits of supplements. As an example, see a paragraph from the August, 2006 Quackwatch newsletter mentioned a few paragraphs below.
     Bottom line: Overall, Dr. Barrett does some good in pointing out scams in the alternative health field, but, in my opinion, he is not fair and balanced, and he is not a true objective scientist as he claims to be. Someone who has a website specifically tailored for criticism needs to have a higher and more objective scientific standard, and Barrett fails in this regard. 
     Could Stephen Barrett, M.D. post his thoughts regarding these two topics: 

The first is on the billions of dollars spent on worthless and dangerous Alzheimer's drugs as noted in The New York Times: "Alzheimer’s Drugs Offer No Help, Study Finds" By Benedict Carey, October 12, 2006. The article begins, "The drugs most commonly used to soothe agitation and aggression in people with Alzheimer's disease are no more effective than placebos for most patients, and put them at risk of serious side effects, including confusion, sleepiness and Parkinson’s disease-like symptoms."

The second is on drug company charlatanism by Robert Bazell, a medical correspondent for NBC. http://www.msnbc.msn.com/id/14348176/

Am I, Ray Sahelian, M.D., perfectly fair in my review of supplement research?
I try to be, but this is a very difficult task. I cannot be fully objective, and I don't believe anyone can be. It is well known in psychology that people perceive things according to how they want to see them. We all approach scientific research results with our own bias and interpretation (even actual researchers have their bias or may be influenced by vested interests). But the difference between me and Dr. Barrett is that I don't have a website that primarily focuses on bashing other people or bashing a particular and important aspect of the health industry, such as the nutritional field which holds enormous promise in health and medicine and has long been ignored, and its potential barely tapped.  
     

Apparently Stephen Barrett is a retired psychiatrist. Does he take any supplements himself to learn firsthand how they work? Does he treat patients with nutritional supplements in order to get an insight how these herbs and nutrients influence the body? Anyone who comments about supplements and has not taken them, or has not had feedback for several years from hundreds or thousands of patients, does not have a full understanding of how they work or what benefit or side effects they have. Their opinion cannot be fully relied on, no matter how many articles they have read regarding the effect of these supplements on rodents or in vitro lab studies.

Quackwatch sends a query to Dr. Sahelian 
In June, 2006, my staff informed me that we received an email from Quackwatch. These were the exact words in the email:

"What is your relationship with Physician Formulas? Are you the owner, an owner, a consultant, an employee, or what?"

Stephen Barrett, M.D.
Board Chairman, Quackwatch, Inc.
NCAHF Vice President and Director of Internet Operations
P.O. Box 1747, Allentown, PA 18105
Telephone: (610) 437-1795

  Dr. Sahelian says: I did not feel the need to respond to Stephen Barrett, M.D. It is presumptuous of him to probe in this manner, plus I felt it was a rude way of asking. There was no polite introduction such as "Dr. Sahelian, I hope you are well, would you mind if I ask you a personal question" or ending the request with something like "thanks for your time," or 'sincerely' etc. Ending the email with "or what?" is extremely impolite and shows lack of manners and sensitivity. Didn't Stephen Barrett's mother, father, or schoolteacher teach him the proper way to address a letter? If he had addressed the letter politely, I would have asked my staff to respond to him.
   

I write a newsletter for Physician Formulas and formulate products and review new research on vitamins and herbs. Why is my role with www.PhysicianFormulas.com any of the business of Dr. Stephen Barrett of Quackwatch? What if someone emailed Stephen Barrett and asked him to report personal information such as an itemized list of his sources of income? Where does Quackwatch get funding, anyway? Quackwatch has been involved in a number of lawsuits and apparently Stephen Barrett had lost one or more lawsuits where the judge made him pay the opposing attorneys fees. Where does he get his funding? He is a retired psychiatrist; how can he afford getting involved in so many lawsuits and pay all the legal bills?
 

 I felt his approach by the above email was abrupt and not appropriate and indicates a great deal about the actual personality of the man. If Stephen Barrett does read this, I hope he realizes the rudeness of his email. I would appreciate a letter of apology.

Email received in March 2006
Q. Hi, I was told by Dr. Stephen Barrett, M.D. from Quackwatch that Passion Rx is not safe. Why would he say that?
  A. Passion Rx is a sexual enhancement product comprised of several herbs. No herb or herbal product, including garlic, is completely safe -- just as no medicine is completely safe. However, when used properly, herbs are generally safer than drugs. If someone has sexual dysfunction, they are often willing to take the risk of taking a pill in order to improve their condition even if it has some side effects. Passion Rx has much fewer side effects than pharmaceutical drugs. If Stephen Barrett, M.D. believes Passion Rx is not safe, he should present such evidence. If he believes Viagra is safer than Passion Rx, he should present such evidence. We doubt he has gone through the effort of doing a double blind, placebo-controlled  study comparing the two. If he recommends people take Viagra, with the possibility, albeit uncommon, of complete vision loss or a serious heart problem, then that is his choice. You have the option to follow Dr. Barrett's advice, or perhaps consider the fact that his understanding of herbal medicine, and clinical experience in nutritional medicine, is quite limited. Your choice.
     Stephen Barrett is probably not aware that Passion Rx, in addition to enhancing erectile function, improves genital sensation and increases libido. Viagra only works for erectile dysfunction and has no effect on genital sensation and little or no effect on libido. The advantage of Viagra is that it works quickly, within a few hours whereas Passion Rx takes a few days for maximal effect.

From Quackwatch Newsletter, August, 2006
Pancreatitis associated with saw palmetto use - The Southern Medical Journal has reported a case of s 55-year-old man who developed acute hepatitis and pancreatitis in response to taking saw palmetto for benign prostatic enlargement. The patient improved after he stopped taking the herb, [Jibrin I and others. Saw palmetto-induced pancreatitis. Southern Medical Journal 99: 611-612, 2006] 

Dr. Sahelian says: There was no mention of a positive study on another supplement in this Stephen Barrett newsletter, only one negative case report which may or may not be accurate. The patient could have been taking other medicines or supplements and failed to inform his doctor, or drinking a lot of alcohol, or something else could have caused the problem. Even if true, Stephen Barrett could have included in the same newsletter a report of a side effect from a drug, and there are plenty of those to choose from.  Saw palmetto has been used for decades and this is the first case report of pancreatitis associated with it. Yet, Stephen Barrett believed it was important enough to mention it in his newsletter. This clearly indicates that Quackwatch looks out for negative outcomes on supplements as opposed to balancing the newsletter with a positive outcome on herbal research or mentioning negative studies or side effects from drugs. An unbiased scientist is balanced. It is my opinion that Stephen Barrett, M.D. is significantly biased and cannot be considered a true scientist.  
   A saw palmetto study with 225 men did not reveal any significant side effects from saw palmetto supplements when given for one year. See saw palmetto for details. Yet, as of August 2008, Stephen Barrett, M.D., of Quackwatch, has not yet mentioned this study in his newsletter. 

Is Stephen Barrett, M.D. a Quack? 
According to the Quackwatch website, Stephen Barrett, M.D. says this about quackery: Dictionaries define quack as "a pretender to medical skill; a charlatan" and "one who talks pretentiously without sound knowledge of the subject discussed."

Stephen Barrett, M.D. does not have a degree in nutrition science. He has been trained in psychiatry but has not practiced psychiatry for many, many years and has, to the best of my understanding, never practiced nutritional medicine. In my opinion, Stephen Barrett, M.D., when it comes to the field of medicinal use of nutritional supplements, can be easily defined as a Quack since he pretends to "have skills or knowledge in supplements and talks pretentiously" without actually having clinical expertise or sound knowledge of herbal and nutritional medicine. 
     A person can't be an expert at a topic if they have not had hands-on experience. Would you feel comfortable having heart surgery by a doctor who has read all the medical books on how to surgically replace a heart valve but has never performed an actual surgical procedure in an operating room? Would you feel comfortable relying on nutritional advice from a retired psychiatrist, Stephen Barrett, M.D. of Quackwatch, even though he has not had hands-on experience using supplements with patients and does not have a degree in nutrition science?
 

  On a positive note, he often does a good job when it comes to researching credentials of individuals in the nutritional industry or researching the legitimacy or marketing practices of certain supplement companies. He has uncovered or brought to light several cases of companies that have shady or fraudulent practices. I suggest he stay on this course (which is his forte) rather than giving his uneducated opinion on nutritional medicine or supplement research. I also hope he becomes more balanced in his reviews and makes the effort to also mention positive outcomes regarding supplement research, and not just negative outcomes. 

Stephen Barrett, M.D. and Quackwatch lose legal battle and ordered to pay defendant's attorneys' fees
December 2007 - After a 6-year legal battle, a California judge ordered Stephen Barrett, M.D. to pay the legal fees of a defendant who, although she has posted negative statements about him, was not held accountable due to a technicality. In an effort to protect Web hosting companies from what is posted on their clients' Web sites, the US Congress put into legislation language that the courts have interpreted as protecting individuals from suits if they don't originate the alleged libels. 

Emails
I am a PhD currently in the military (Navy) and just wanted to let you know that I read your online editorial regarding quackwatch. I couldn't agree with you more regarding the ignorance and pretentiousness of Stephen Barrett regarding alternative medicine, and nutritional supplements in particular. I wish you the best in your practice. 
   A. Thank you. Dr. Stephen Barrett appears to have an unreasonably strong dislike, almost a hatred, of natural supplements, and one wonders what motivates a person to have such feelings and to be so biased. We understand that there is a certain amount of fraud and consumer misleading in the natural healing field, but there is also such fraud in the drug industry and Stephen Barrett hardly says anything negative about the pharmaceutical industry.

I finally found someone else who feels that Stephen Barrett is a quack in his own right. 

Dear Sir, I am writing regarding the hypocrisy that is being perpetrated by those who hold themselves out to be all knowing in fields with which they have no clinical experience or practice. It is more than obvious that this retired Dr. Stephen Barrett of Quackwatch has close ties to the government, the pharmaceutical industry, and otherwise the monopoly that exists in this country that chooses to deceive the American populace in the interest of furthering their own graft, greed and corruption. I commend you on your work and am a long time follower. I want to say in closing it is doctors like you that help me maintain my faith in medicine. As for the rest maybe in time they will open their eyes and minds once their pocketbooks are filled with money.

Thank you for you review of Quackwatch and Mr. Stephen Barrett. Most of the questions you have posted I have wondered as well. Further, I have been unable to verify the claim that Stephen Barrett himself is a quack, but have found several articles, such as this http://www.foundationforhealthchoice.com/victory_barett.html, that do make such a claim. I am somewhat defensive toward anyone who seems to take the position that all "alternative medicines" are scams after my wife barely survived the abuse of the AMA's "traditional medicine" and was healed with the help of natural supplements. I also find it funny that modern medicine has managed to steal the label of "traditional" for themselves and pinned "alternative" on that which, at least in some cases, dates back to biblical times.

Q. First of all I would like to commend you on your open minded approach to nutrition and alternate health care. There is a lot of good in people that choose to look at things as open mindedly as humanly possible. I am a nursing student in Virginia and am doing some independent research on reflexology. A friend of mine gave me Dr. Stephen Barrett's web site as a source for some writing against this subject. When I "googled" QuackWatch, Google also found your site in the search. I am not writing to "land blast" you or to tear down what you said about Dr. Stephen Barrett. I have no connection with Dr. Stephen Barrett or you. In fact, I had not heard of either one of you until this very day. I would instead like to point out on a comment you made in your article. You said and I quote: "But the difference between me and Dr. Stephen Barrett is that I don't have a website that primarily focuses on bashing other people or bashing a particular and important aspect of the health industry, such as the nutritional field which holds enormous promise in health and medicine and has long been ignored, and its potential barely tapped." The part of this that I wish to challenge you on is the statement about the difference between you and Dr. Stephen Barrett. I wish to say only that you do in fact have a website primarily to bash someone, Dr. Stephen Barrett. I also agree that someone needs to start some reviews and critiques on the pharmaceutical industries. Maybe, since you seem to see it so clearly, you should start a website researching the poor practices of our government and the pharmaceutical companies. 
   A. Thank you for your email. There are more than 1600 pages on my website and only one of them has to do with Stephen Barrett and Quackwatch. Perhaps you did not realize this or did not have the time to look at the index on the home page. My website was not created with the intent to bash other people, but to provide nutritional research information by a medical doctor. The majority of the pages on Quackwatch have to do with criticizing someone in the health field or a particular form on natural health. Granted, I do not dispute many of the charges that Quackwatch makes regarding the lack of research to support certain forms of natural medicine. I also tend to agree with his evaluation of certain bogus healing or diagnostic methods. I have a major issue with his interpretation of supplement research.  Stephen Barrett fails to balance criticisms with positive research on nutritional medicine. Subscribe to the Quackwatch newsletter and you will realize after a few issues that little or nothing is ever mentioned about the benefits of supplements or nutritional approaches to disease prevention or treatment. He likes to choose and review studies that show no benefit from supplements, and by virtue of excluding positive outcomes from his website or newsletter, one gets the impression that supplements don't really work. This, in my opinion, is a disservice to the public.
   

My website constantly gets feedback from readers thanking me about providing honest and up to date nutritional  information. This type of information from a medical doctor with a nutrition background is not readily prevalent. Most doctors in this country are not aware that safe and effective nutritional options are available to treat or prevent a number of diseases. What is sad about the Quackwatch web site is that Stephen Barrett hardly mentions the benefits of natural approaches. As such, the public should be aware that, in my opinion, this doctor's viewpoints on natural medicine are not fair, nor are they balanced. Many people stumble upon the Quackwatch website and think that what is written there is from a doctor who is knowledgeable about the field of clinical nutrition and nutritional medicine. In my opinion he does not have adequate knowledge or experience in this area and the public should be aware of this fact. 
  

​​ I would like to have a review site on the pharmaceutical industry,  but I hardly have enough time to keep up with the advancing field of nutritional medicine. The pharmaceutical industry has created and marketed great products (vaccines, antibiotics, anesthetics for surgery, etc.) that have helped countless people. But, they have also promoted products that have hurt people (Vioxx) and pushed products that are expensive and full of side effects where natural alternatives exist (statin drugs versus natural alternatives). 
   I challenge anyone to provide me with strong evidence that Dr. Stephen Barrett is experienced in the clinical practice of nutritional medicine. If he does not have such experience, he should not pretend that he is an expert on this topic or that his views are superior to those he bashes.

Q. As a subscriber to Dr. Sahelian's newsletters, I was intrigued when I came across his name, vis-a-vis the Sahelian - Barrett correspondence. I was doing some trawling of the net regarding Krill ( no pun intended) when I chanced upon their interchange of disparate opinions. Newton's 3rd law of motion states that "for every force there is an equal and opposite force." Dr.Sahelian or Dr.Barrett? As Shakespeare said, "Aye, there's the rub." After reading all the correspondence, I feel that in boxing terms, it's a "technical knock-out" for Dr. Sahelian. Dr. Sahelien is a supposed guardian of medical ethics. Dr. Barrett is also a supposed guardian of medical ethics. This poses that perennially fascinating question of. "Quis custodiet ipsos custodes?" During the course of my trawl, I came across the following observation by one of the contributors to the Sahelian - Barrett debate. I think the contributor's comment is well-worth recording. "I also find it funny that modern medicine has managed to steal the label of "traditional" for themselves and pinned "alternative" on that which, at least in some cases, dates back to biblical times." I think that's a very profound statement. 
   A. Quis custodiet ipsos custodes? is attributed to the Roman poet Juvenal. It is translated as "Who guards the guards?" or "Who watches the watchmen?" I think it is time someone knowledgeable in the nutritional field watched Quackwatch.

My wife has been going to a MD who subscribes to the Nutri-Spec Testing method for proper nutrition. I am unable to find good information on its validity. She has been on the system for about 8 months and her "numbers" have not changed. I am skeptical that a urine and saliva test in the office can adequately determine what one is lacking in nutrition. And of course, they sell their own vitamins. Would appreciate any feedback.

I was wondering if u know anything about metabolic typing and whether or not u give credence to this type of evaluation. I'm working with a chiropractor who seems to know very much about health and nutrition and recommends the Nutri-Spec protocols. Upon reading an article by Stephen Barrett, M.D. criticizing the Nutri-Spec diet and calling it pseudoscience. I was wondering if u could clarify some things regarding the aforementioned practices, assuming you're familiar with them, i.e., metabolic typing and the follow up treatments. I read some things about Stephen Barrett and am taking them with a grain of salt. it's very hard to find out what regimen is right considering all the info that's out there. so many "so called experts" are extolling this or that treatment as the answer to one's health issues. I really don't know who to listen to and what path to go down!? is there not a data base from which I can find the correct info from real scientific experts that aren't biased to their findings, i.e., not affiliated with any one company. you know peer reviewed journals!? I would greatly appreciate your comments, because I'm sick of wasting money on quacks who say their way is the right way. thanks doc.
   On the issue of Nutri-Spec testing, I agree with the review by Stephen Barrett, M.D. on the Quackwatch website (as of Feb 2008). In my opinion, the Nutri-Spec testing is not a reliable way to determine what supplements a person needs. 

I am a chiropractor and massage practitioner and wanted to take a moment to thank you for your excellent summary of the "work" of Stephen Barrett, MD.  My profession has a lot to offer, but we also need to accept the critical thinking that is required to improve our abilities to serve the public. That being said, I am also suspicious of anyone whose claim to fame is attempting to destroy others while ignoring his own profession. Your web site is just about the best I have seen in terms of comprehensive information on the nutritional issues that the public faces on a daily basis. I, too, am suspicious of Nutri-Spec testing.

Q. Thank you for your information about the Quackwatch website. I was dismayed when I stumbled into his site and read his quack designation for muscle testing. I was diagnosed with collagenous colitis and bacterial overgrowth. The medical doctors were able to give me this diagnosis but said it had no known cause or cure. I went to a kinesiologist and an acupuncturist - both used muscle testing. They gave me supplements (and acupuncture) and directed me to information about what I could and could not eat. I'd been hopelessly ill for four months and had lost 20 pound, was weak and directionless. As soon as I started on the supplements and remedies I started improving and in four weeks I see few signs of my illness. 
   A. I actually agree with Stephen Barrett, M.D. and the information on the Quackwatch page regarding applied kinesiology. Quackwatch website describes it as "Applied kinesiology proponents claim that nutritional deficiencies, allergies, and other adverse reactions to foods or nutrients can be detected by having the patient chew or suck on these items or by placing them on the tongue so that the patient salivates. Some practitioners advise that the test material merely be held in the patient's hand or placed on another part of the body." Stephen Barrett, M.D., concludes, "The concepts of applied kinesiology do not conform to scientific facts about the causes or treatment of disease. Controlled studies have found no difference between the results with test substances and with placebos. Differences from one test to another may be due to suggestibility, distraction, variations in the amount of force or leverage involved, and/or muscle fatigue."
   I agree. Although I do not doubt the supplements and acupuncture treatment helped you, I seriously doubt it had anything to do with the applied kinesiology muscle testing. 

Q. I am a 30 year old police officer who was injured at work by a Taser. It threw my back out. I have since gotten sick and have been sick for 2 years. I have dizziness, shortness of breath, weakness, fatigue, weight loss etc. I also found my sugars were unstable, and my hormones such a cortisol, testosterone, and DHEA, were completely low. My adrenals were in a severe state of fatigue and under producing. I have been seeing a chiropractor that uses a combination of muscle testing, holistic medicine with supplements, and adjustments. I was wondering if you had an opinion on muscle testing and this type of practice. I have heard a lot of positive things from people, and they say it helped them. I have seen reports saying muscle testing is not reliable. I have also seen reports showing them being very accurate. I don’t believe anything from Quackwatch because they have a typical negative Mainstream view point. 
   A. I do not find muscle testing to be a reliable form of diagnosis, but I am a proponent of natural healing and supplements. The Quackwatch website has some reliable information and also some very biased opinions and interpretation of studies. However, no one is fully objective, including me.

Q. The following article supports your argument: "There are more people who die and are injured from Tylenol use each year than there probably have been in the last decade or more of supplement use." Comment Regarding Statistics: At the under-reported estimate of 100,000 people who die each year as a direct result of prescription drugs, in comparison to the total number of 10 people reported to have died as a result of a nutritional product in the 23 years from 1983-2007; the resulting comparison equals a minimum 2,300,000 deaths from drugs versus 10 deaths from vitamins over the same period.
   VITAMINS VERSUS DRUGS SAFETY AND EFFECTIVENESS by Dr. Andrew W. Saul. “More than 1.5 million Americans are injured every year by drug errors in hospitals, nursing homes and doctor's offices, a count that doesn't even estimate patients' own medication mix-ups. On average, a hospitalized patient is subject to at least one medication error per day. More than 100,000 patients annually die, just in the USA, from drugs properly prescribed and taken as directed. On the other hand, a review of poison control center reports reveals that vitamins have been connected with the deaths of a total of ten people in the United States over the last twenty-three years."
   A. Thanks for sending this. The medical profession, the media, and the FDA make a big deal anytime there are adverse events associated with supplement use but fail to put it in perspective in regard to prescription medication dangers.

I recently came across you from a web page of yours about QuackWatch and glad to see you are putting Dr. Barret in his place.

Let me say that I am very sorry that Dr. Sahelian has been attacked by the doctor from Quack Watch. As Dr. Sahelian aptly pointed out while there is a need for an individual or group to watch out for those who prey upon the gullible and take advantage or market stuff that is of little benefit or inferior quality, there are also those who are easily threatened by people with knowledge and good intentions truly who want to help people avoid the adverse effects of drugs that are often dangerous and or of little benefit. I recently read a very positive statement by a Dr. Minocha sp? who spoke very highly of Dr. Sahelian’s book Mind Booster and of his work in general. Thank goodness that there are allopathic doctors who are willing to go on record in support of people like Dr. Sahelian. Thank you for your research and your continued efforts to explore the many benefits of alternative and complimentary medicine. Allopathic medicine has its value, but we can’t afford to ignore the myriad of natural and often far safer solutions and substances that are available to us.

I appreciate the bit you had on Dr. Stephen M. Barrett. I wasn't feeling too great and reading an article he wrote that mentioned herbs in relation to "Pro Quackery legislation" and generally saying they are not based on science, in a search for an herbalist in my area sort of dashed my hopes about the possibility of an herbal / alternative medicine for my A.D.D. and anxiety (so far 0/3 for medications to treat both or one without significant side effects). I guess I get swayed too easily in arenas I'm uninformed / inexperienced with and my A.D.D. and anxiety sure don't help me being able to stay focused, so reading in-depth about herbs at this time with school (more anxiety, less energy / time) will probably prove to be difficult but I am going to keep looking into it. It's sad that in this search: "do health insurance companies include herbalists?" His article came up near the top on google--perhaps I need to fine tune my searching skills. I was quite sure they are not really covered by insurance companies, but either way, I think they're worth looking into. I'm just not working so money is tight. 

I just wanted to state that I appreciate what you've written about Stephen Barrett and his quackwatch website. I happen to know personally that he does not do his research. I am the formulator for NutriPlex Formulas and ended up on his dubious website when he erroneously and without reason to publish, stated that a certain 
person writes a newsletter for NutriPlex and that person is in essence a quack. Barrett never called us or performed any due diligence regarding this libel. I applaud you for standing up to him. His website, while sometimes helpful, is mostly a witch hunt and always, as you indicated, without fairness in regard to the damage done by modern medical modalities and prescription drug iatrogenic results.

The rebuttal to Quackwatch.org is well justified. I myself have used supplements (with breaks) like Omega-3 and other herbal products and seen the difference in my functioning. Although not all supplements have helped me, many did, and I stick to the one's that did especially those that have scientific studies mentioned on your site. And moreover, the products you have formulated don't contain high doses of herbs, vitamins like other companies sell which I have used in the past and suffered from insomnia, overstimulation. I have taken Antidepressants prescribed by my doctor and although they were needed by me initially they did cause a number of disturbing side effects in the long term which are hardly even known by doctors themselves and hidden by Pharma companies. I think Stephen Barret is not likely to focus his attention as much of the dark side of these drugs. Today , fortunately the Dose of my Drug has been minimized under the supervision of my doctor, and in addition taking Omega-3 and 2 other supplements which have kept me more healthy than before.

I read with great interest your web rebuttal of Dr Barrett’s quackery site. I must say it was very neutral in approach, bearing in mind the whole subject being a criticism of Dr Stephen Barrett. The conclusion that he is indeed a quack in definition, I must agree, as his MD is in psychiatry, a subjective discipline at best. I also agree with the criticism of pharmaceutical companies promoting the use of dangerous drugs. They have even managed to squirm their way out of being sued for making wrongful claims. They don’t need a web site to promote their billion dollar scams, they just need corrupt or misinformed governments to dupe a very naïve public. Maybe this information should be made public?

I am a PhD from Tokyo, Japan and delighted to discover that someone is making cogent critiques of Stephen Barrett's biased writings. His approach, as you correctly said, is hardly scientific. His comments on various treatments such as Chinese medicine show not a careful probing evaluation based on accurate data but rather ignorance. One example is his constant attack on Andrew Weil, an attack that seems motivated more by jealousy than anything else. Can correct breathing done regularly be helpful? I certainly think so. Can it cure cancer? Of course, not and I do not know any sane person who makes that claim yet that is how Barrett ridicules breathing practices. Let me hasten to add that I have no medical qualifications but am a careful researcher in art history, so I know what careful research is. I know but apparently Barrett does not. Thank you for your criticisms and I do hope they reach a wide audience. 

I just came across your response to Quackwatch and feel a certain relief that another M.D. is confronting his “research.” I have three general questions: I would like to know the efficacy of hair testing to determine heavy metal levels in the body. The validity of urine pH levels to determine acidity in the body (general question) as associated with a pH balancing product by Vaxa International (product question if possible). Is there any harm in using a pH balancing product even if there is no pre-testing. The question comes from a discussion in a little remedy store in Key Largo, FL where we are staying. When we researched online prior to buying the products and getting the hair test, Quackwatch came up “naturally” calling it all nonsense.
    

Hair testing can show certain heavy metal levels, but it is not common for people to have such problems and most symptoms and illnesses people have are not due to heavy metal toxicity. Unless a person has kidney disease there is no need to manipulate pH levels of the blood or urine, the kidneys do it quite well and most such products are not of benefit for the majority of users.

Thank you for what appears to be a lifetime of dedication to alternative healing practices. I also appreciate your exposing Stephen Barrett, M.D. for poor research and questionable often negative conclusions. As a lifelong healer and retired medical researcher, today I discovered a very well written authoritative article on Quack Watch that was exactly correct until he cited a fluffy poorly conducted study and came to a dead wrong conclusion. I immediately read over a few of his other articles and all exhibited the same succinct authority figure dead on accurately describing situations followed by one or more poorly done studies to justify his barbed incorrect opinion. I looked into his background then winced when I saw he is a retired teaching psychiatrist. Traditional medicine makes people well. We take pills or have surgery, recover and get on with our lives. Psychiatrists almost never get anyone well and rarely do they ever have a patient get off drugs. Psychiatry fixes brains by electrocuting them and pouring psychotropic chemicals into them that block our ability to feel, experience, think and control our emotions. In other words, this group serves as the street dealers for psychotropic pharmacy companies with the worst healing record in medicine. Like witch doctors of old when their efforts fail they charge more and add more drugs. If failure continues they blame the patient because they just don’t have a clue what is really going on or how to make repair. If we could stop the pharmaceutical companies from public advertising and bribing physicians to promote their products then replace FDA approval processes with non-financially motivated peer reviewed studies, I suspect most Psychiatrists would have little to prescribe to patients because most psychotropic drugs would never get approved. How could someone who teaches this nonsense be considered an authority figure in any sense of the word?
    

I partially agree with some of the things you mention. There are a number of psychiatric medications that are quite useful in treating psychiatric conditions such as schizophrenia and there are a number of competent mental health professionals. I do see your point, though, that we are overmedicating patients and not using alternative dietary supplements or other methods that could be just as, or more, beneficial with fewer side effects. Questions have been raised as to whether prescription antidepressants such as Prozac, Zoloft, or Paxil are any more effective than placebo pills. And certainly, we are overmedicating children who are diagnosed with mood disorders or ADHD.

We are thinking of choosing Dr. Ray Sahelian for a project regarding a chapter in a professional book on nutritional medicine. This was not a whim but a long thought decision based on his remarkable knowledge and insight in the field of nutritional medicine and also on the type of person he is, as judged by the way he deals with various issues (one that I read about is his reply to some remarks made by S. Barrett, MD some time ago - a reply that was highly professional and in line with the accepted standards of good manners).

I read your article about Quackwatch and I had the same impression that his reviews are very slanted as to what big Pharma or the FDA opinion, which for the most part is not in the best interest of patients. You mentioned you agreed with Dr. Barrett about Hulda Clark's book being pitiful.

I just wanted to thank you for being outspoken about Stephen Barrett and the wealth of information listed on your page about this matter. It was extremely helpful, and I believe his serving the AMA and Pharmaceutical companies by slandering other people is despicable. I continually read your website because of your personality and effort to be as objective as possible.

I recently read the article written by Dr. Barnett regarding Standard Process. I am new to this product and wondered if you have done any research about Standard Process. My new chiropractor suggested I use it because my bones are too weak. I haven't taken the product long enough to see any side effects or progress. I'd like to give my doctor the benefit of the doubt that he's looking out for my best interest. I thank you in advance for your time and response.
   As a general rule, I prefer not to comment on products I have not formulated or comment on other companies.

I found your post very interesting. I also find the same kind of bias in Dr. Dean Edell. The hard fact is that Dr. Barrett's entire industry has thrived on the use of psychotropic drugs so it’s no surprise he has little criticism for big pharma, they have, after all, been his life's blood. I grew up a Seventh-Day-Adventist, I no longer practice that, but I know that they have been amazing combining sound nutrition and the use of herbs and supplements with state of the art western medical techniques.

Do You have experience with MMS drops and also Hulda Clark Zappers for treating micro-organisms in the body - like Protozoa, Nematodes, Larvae, Parasites, worms, Lyme disease? What do you do for these?
   I am not familiar with MMS drops. As to the zapper, I think the promises and claims are far ahead of any clinical studies or proof and this smells like a scam to me. I try to keep an open mind, but sometimes claims of cures are made that stretch the imagination.

After reading Stephen Barrett’s comments on Juice Plus, I came across your website and informative comments. I would like to know your opinion of Juice Plus since Dr. Barrett has condemned it. I have been on this supplement for 4 months and found that for a fact my cholesterol has improved ,and my gums have improved more in 3 months than have ever before. I have done nothing different other than take juice Plus on a daily basis. But I worry about promoting this to other people (grandsons, etc.)
   I have no way of knowing the quality control of the production of this product, but I don't see any harm in regularly (but not daily) consuming a product that is a concentrate or extract of fruits and vegetables. I prefer fresh organic juicing of fruits and vegetables. Some MLM products may have many benefits but they could also be an expensive way to supplement and other less expensive options could be available.

I'm a student at Parker University (formerly Parker College of Chiropractic). I enjoyed your rebuttal of Dr. Barrett's website, and I have a few comments of my own. His claim that chiropractic care is based on 'nerve interference' is only partly true, and his representation of the matter is woefully incomplete. We know that a joint that needs adjusting is firing nociceptive impulses and the lack of normal joint position/motion is inhibiting the type 1,2 & 3mechanoreceptors. The adjustment afferentates the brain, and by putting motion into the joint, causes firing of the mechanoreceptors, inhibiting nociception at a particular spinal level. This inhibits total sympathetic activity, bringing the patient into a more balanced state with regard to sympathetic and parasympathetic activity. An actual 'pinched' nerve is only thought to be involved in up to 3% of cases. Second, his claims about cervical adjustments are completely false. With the previous paragraph in mind, and knowing that the highest concentration of mechanoreceptors in the spine are located in the cervical region, it follows that a dysfunction in said region could have serious effects, and that correcting these problems can provide significant relief of a number of different symptoms. What may be harder to accept, coming from a different philosophical background, is that the restoration of the nervous system's ability to communicate with a particular region of the body allows the normal physiological processes to occur. Said another way, if the communication to and from a particular region is interrupted, how is the nervous system to direct or fine tune function in response to stimuli?

I wanted to let you know of a website called canlyme dot com/quackwatch.html that has more information about his legal history.

I did the research on Dr. Barrett’s Quackwatch legitimacy and got across your site and review, which is very informative. I believe in nutrients and supplements and was very upset what I read on Quackwatch. I’m glad to find that you and people who replied to your review have a positive view on importance of supplements. 

Stephen Barrett, MD Quack Watch is holding out he is the author of 30 peer-reviewed articles. I have attached a bibliography he gave me when challenged. Only 2 out of 43 are published under today’s standards as posted by the National Institute of Health PubMed. Some papers have no authors listed on the papers, etc. There is a total of six of 43 listed on PubMed. Four are single author articles which are no longer allowed for listing due to objectively concerns.”

Although there are many deserved listings on quackwatch, just because an individual or an organization is on quackwatch does not by definition make them a quack, as there may be other agendas at play.

HISTORY OF FOCAL INFECTION

The focal infection theory has been around for over one hundred years. For the most part, a biased and flawed analysis by the dental profession incorrectly discredited the validity of the principles of focal infection. The American Academy of Endodontists originally cited three reasons why the original research by Price and Rosenow should be discredited. 

• ​​ Very large quantities of bacteria were used to test for focal infection.

Both Price and Rosneow recognized this criticism and repeated the experiments with much lower doses of bacteria with the same results. 

Rosenow stated in 1921,” The number of bacteria injected was relatively large and this has been objected to. I believed it worthwhile therefore to continue the studies in a larger more varied series…and to study the effects of the injection of smaller doses of bacteria” 

[Rosenow, E.C., Focal Infection and Elective Localization of Bacteria in Appendicitis, Ulcer of the Stomach, and Pancreatitis. Surg., Gynec., and Obst. 33:19-26, 1921][ Rosenow, E.C., Studies on Elective Localization. Focal Infection With Special Emphasis To Oral Sepsis. Jour. Dental Res. 1:205-267, 1919]

• Lacked many aspects of modern scientific research including absence of proper control groups.

(See appendix G for bio of Weston Price, DDS)

Control groups were not known or used during the time of this research. That does not necessarily make the experimental observations and results invalid. 

An interesting article appeared in the British Medical Journal titled: Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized controlled trials. 

The point being do you really need to do a double blind, randomized, placebo-controlled experiment to determine which is safer, wearing a parachute or not wearing a parachute, when jumping out of an airplane? No. Controlled experiments are good. But some of the older experiments and research performed without the current control protocol are valid as well. 

• The bacteria on the root canal teeth were the result of contamination during extraction and not from the root canal tooth itself. (The AAE has since removed this as a reason to discredit focal infection)

This false conclusion is cited by Grossman ​​ (See Appendix H for ​​ articles by Easlick and by Grossman that are the first two reference articles cited on the AAE Root Canal Safety Page) in an attempt to invalidate focal infection and is based on the results of a study by Fish and MacLean of just four teeth that had the gum tissue sterilized before extraction in an attempt to prevent bacterial contamination during extraction. 

These researchers failed to culture bacteria around the root apex and incorrectly concluded that root canal teeth were sterile, and any bacteria were the result of contamination during extraction. Current research shows that even with modern culturing techniques, many of these bacteria are difficult or impossible to culture, that it is impossible to sterilize an infected tooth and all root canal teeth will still contain bacteria after completion invalidating Grossman’s conclusions.

Grossman’s original writing on this subject:

“Cultures made from extracted teeth do not therefore reflect the true bacteriologic status, whether it be of vital or of pulpless teeth, unless, as shown by Fish and MacLean, the gingival tissue is first cauterized. Since pulpless teeth fell into some disrepute chiefly because of bacteriological studied made in the last fifteen or twenty ears, and since the findings were generally based on bacteriological examinations made after extraction, past interpretations can no longer be held valid in the light of recent knowledge.”…

• “We must look to recent and future studies, rather than those of the past, to determine the real status of the pulpless tooth

 ​​ ​​​​ [From: Root Canal Therapy ​​ First Edition, 1940. ​​ Reprinted in: ​​ Journal of Endodontics ​​ Special Issue, January 1982, Volume 8]

Grossman was wrong. These “future studies “definitively show that it is NOT contamination during extraction as Grossman’s concludes, is in fact infection in the root canal tooth itself as well as any affected surrounding jaw bone. Grossman’s conclusions are based on outdated science. Interestingly, this outdated article is the second reference cited by the AAE in the attempt to debunk focal infection. 

The AAE states on their Root Canal safety web page that “Dr. Price recommended tooth extraction – the most traumatic dental procedure – over endodontic treatment.”….”

On the contrary that is not what Dr. Price recommended at all. ​​ Although Dr. Price found fault in the root canal procedure and advocated for improvement, this is what he actually said:

“Don’t jump to the conclusion that all root filled teeth should be extracted….I am not ready to draw the line so rigidly as to state that all root filled teeth should be extracted for every patient or for all patients in any given time …”

Things have not changed much since Price’s time because I was also wrongly accused of recommending extraction of all root canal teeth and promoting miracle cures, when nothing could be further from the truth. When I was ​​ in practice I turned away more people than I treated because A., I did not see evidence of pathology warranting tooth extraction and B. because the patient believed that their root canal tooth was definitively causing their particular disease, and that root canal extraction would cure them; a prognosis that I could not realistically make based upon available data. ​​ (See Appendix F for patient letters of support and description of my treatment)

The argument against the focal infection theory was mainly carried out by just a handful doctors. ​​ Doctor Percy Howe based his opposition on a single study he conducted injecting rabbits with normal streptococci bacteria obtained from the mouth, not bacteria from an infection site or a root canal treated tooth where none of the animals became sick or died. ​​ 

John Buckley was unable to see how root canal teeth that showed evidence of bone repair around the tip of the root could still be infected. He further questioned the validity of focal infection when root canal teeth were extracted, and the patient did not recover from their specific disease. 

Reinmann and Havens in 1940 declared most studies of infection of root canal teeth invalid because of possible contamination. Current research proves otherwise. All root canal teeth are indeed infected. They also claimed that abnormal areas in the bone around the ends of root canal teeth may not be caused by infection. ​​ This is also incorrect. They are always caused by infection and in most cases will remain infected after root canal completion. 

Hughes in 1994 stated that focal infection has been proved ineffective, yet no supporting documentation was ever cited. He fails to cite any of the work of Rosenow published after 1923. Rosenow continued to publish until 1958 with some of these later publications addressing the original criticism of his earlier work and confirming the validity of focal infection. 

Hughes stated that, “the true incidence of focal sepsis in patients with inflammatory arthritis was never compared with that of normal controls during Rosenow’s time, implying that Rosenow’s work was flawed and deficient. However, Rosenow did make comparisons with normal controls when appropriate. 

Hughes stated that researches attempted to repeat the work of Rosenow but failed to confirm Rosenow’s ​​ findings but conceded that these researchers rarely followed the stringent bacterial specific culture conditions used by Rosenow and 20 other researchers that confirmed Rosenow’s findings. ​​ It is important to note that these bacteria are extremely difficult to culture even with todays’ techniques, and researchers are finding many species of bacteria in and around root canal teeth not by culturing, but by DNA testing. So, Hughes position statements are based on inaccurate data and conclusions should not be used in the argument against focal infection. 

On the other hand, many leading physicians of that time supported focal infection theory including Charles Mayo, M.D., one of the founders of the world-renowned Mayo Clinic who stated in an article published in Mouth Health Quarterly June 1935:

​​ 

“I have looked on the mouth as a particularly likely place for foci of systemic infection to be found, and I have been a campaigner for removal of devitalized teeth, and of teeth about the roots of which abscesses have formed. This effort has led me to plead for closer co-operation between physician and dentist in the practice—of preventive dentistry. I am not thinking only of the prevention of dental decay or pyorrhea—but of injury to the joints, the muscles and the viscera rising from disease in or about the teeth. I have always felt that the practice of medicine includes dentistry; that dentistry is the practice of a special branch of medicine as ophthalmology, or any of the other specialties of medicine. Those who practice preventive dentistry practice preventive medicine.” Dr. Mayo goes on to suggest that while it may be too much to expect all dentists to be Doctor of Medicine, all dentists should know much more about medicine, and physicians and surgeons should know much more about dentistry!

Countless additional scientific papers and books demonstrated the link between oral infections and systemic disease. Dr. Martin Fisher. Professor at the university of Cincinnati medical school wrote an entire book on this subject titled Death and Dentistry.”

“I stand, then, for a general recognition of our true status in the professional world. Our work, - the practice of Dental Surgery – is surely as much a branch of general medicine and surgery as Ophthalmic Surgery or Aural Surgery or Gynecology….it surely seems necessary that we should understand our general pathology; and to do that we must understand our anatomy, physiology, histology, bacteriology, surgery and medicine to really know the body in health and disease….

…I am personally of the opinion that we shall never gain the cooperation of the medical profession without taking a full medical course and practice dental surgery as a branch of general surgery and preventive medicine”.

[The Renaissance in dental practice ​​ E. Melville Quinby, M.R.C.S., L.R.C.P., D.M.D. ​​ Boston Mass. 1916]

THE HUMAN MOUTH IN ITS RELATION TO PREVENTIVE MEDICINE AND PUBLIC HEALTH

By W.G. Ebersole, M.D., D.D.S., Sec’y-Treas., National Mouth Hygiene Ass’n. ​​ Read before the new Jersey State Dental Society at Asbury Park, N.J., July, 1913

“The most important organ in the body from a standpoint of preventive medicine is the human mouth. Notwithstanding this fact, no other organ in the body is so little considered by the members of the medical and dental professions and by the laity.”

“The mouth is the principal harbinger and most extensive breeding place for pathogenic microorganisms and is the path through which most of these organisms enter the human system.…

…we would ask if we have not overlooked or neglected in our search for sources of infection the greatest producer and at the same time the widest disseminator of disease-producing germs.…

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.”

The role of oral sepsis as a cause of systemic disease was championed by William Hunter, M.D. , a prominent British physician and professor of medicine at McGill University, in a publication and a 1910 ​​ talk at McGill University, Montreal. Dr. Hunter spoke of dental restorations “built in, on, and around diseased teeth which form a veritable mausoleum of gold over a mass of sepsis to which there is no parallel in the whole realm of medicine.” 

Dr. Hunter wrote:

“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 an attempt to debunk Dr. Hunter’s views, the AAE, in their Fall/Winter 1994 newsletter states that Dr. Hunter was only referring to infection found around and under poorly fabricated dental restorations, not pulpless (root canal) teeth. ​​ 

It appears that the AAE is quoting the article by Easlick , their first reference article cited on the AAE Root Canal Safety webpage titled, An Evaluation of the Effects of Dental Foci of Infection on Health. [JADA 42:615-686, 694-697, June 1951.] where Easlick writes,

​​ “In 1910 an English physician, William Hunter, indicted American dentistry for the systemic pathology engendered by gold crowns and septic bridgework.”

However, that is not what Dr. Hunter actually said. Dr. Hunter was referring to oral sepsis from ALL sources such as periodontal disease, infected teeth, and chronically infected root canal teeth, not just poorly fitting dental restorations as Easlick and the AAE claim. ​​ Dr. Hunter, in a publication and a 1910 talk at McGill University, Montreal. Dr. Hunter spoke of dental restorations “built in, on, and around diseased teeth which form a veritable mausoleum of gold over a mass of sepsis to which there is no parallel in the whole realm of medicine.” * 

[*The Oral-Systemic Disease Connection. An Update for the Practicing Dentist. Michael L. Barnett, DDS. JADA, Vol. 137 http;//jada.ada.org. Oct. 2006]

Dr. Hunter wrote:

"No one has probably more reason than I have had to admire the sheer ingenuity and mechanical skill constantly displayed by the dental surgeon. And no one has had more reason to appreciate the ghastly tragedies of oral sepsis, which his misplaced ingenuity so often carries in its train. Gold fillings, gold caps, gold bridges, gold crowns, fixed dentures, built in, on, and around diseased teeth, form a veritable mausoleum of gold over a mass of sepsis to which there is no parallel in the whole realm of medicine or surgery. The whole constitutes a perfect gold trap of sepsis of which the patient is proud, and which no persuasion will induce him to part with; for has it not cost him much money, and has he not been proud to have his black roots elegantly covered with beaten gold, although no ingenuity in the world can incorporate the gold edge of the cap or crown with the underlying surfaces of the root beneath the edges of the gums? There is no rank of society free from the fatal effects on health of this surgical malpractice."

12. Hunter W. The role of sepsis and of antisepsis in medicine. Lancet (London) 1911; 1:79-86. 

13. Hunter W. The role of sepsis and of antisepsis in medicine. Dent Cosmos 1918; 60:585-602. 

In 1912 ML Rhein ​​ was one of the first to respond intelligently to William Hunter's vicious attack on American dentistry.

In doing so, Rhein directed the blame for the lack of concern for oral sepsis to the physicians. 

"It has been unfortunate that the insidious nature of this grave evil has been ignored by medical men for so many years. This apparent indifference of the physician to oral sepsis has unquestionably had an important bearing on the reckless indifference shown by so many dentists to the presence of septic foci in the alveolus." 

Additionally, he cited the low fees and the complaints of the dentists that they "cannot get paid for the time needed to remove pulps properly and to seal root canals aseptically," as causes for indifference on the part of the dentist. 

[Rhein ML. Oral sepsis. Dent Cosmos 1912; 54:529-534] 

 The repercussions with admitting that the premise of the original research on focal infection was indeed correct would be staggering. Suddenly dentists performing sub-par root canals could be sued if their patient had a heart attack that was triggered by a chronic root canal infection. Dentists would also be liable for failure to inform patients that their root canal tooth will always be infected and may cause or contribute to systemic diseases such as heart disease. ​​ And medical insurance companies might be forced to include dental care under medical insurance plans. 

As you can see, the opinion on the validity of the focal infection theory from 1900-1950 was as divided then as it is now. ​​ We can scrutinize the old research ad nauseum, but the truth is we will never know who was right and who was wrong over 100 years ago. So, simplicity let’s just ignore all of the old research, throw it out the window, and focus on the new research presented in this article. 

The AAE continues to assert:

​​ “Decades of research contradict the beliefs of “focal infection” proponents; there is no valid, scientific evidence linking endodontically treated teeth and systemic disease. Yet some patients still her about this long-dispelled theory.”

I don’t think so. There is too much evidence to the contrary. I believe the AAE knows it and are deliberately misleading the public. And I believe websites such as quackwatch know it as well.

“I stand, then, for a general recognition of our true status in the professional world. Our work, - the practice of Dental Surgery – is surely as much a branch of general medicine and surgery as Ophthalmic Surgery or Aural Surgery or Gynecology….it surely seems necessary that we should understand our general pathology; and to do that we must understand our anatomy, physiology, histology, bacteriology, surgery and medicine to really know the body in health and disease….

…I am personally of the opinion that we shall never gain the cooperation of the medical profession without taking a full medical course and practice dental surgery as a branch of general surgery and preventive medicine.”

[The Renaissance in dental practice ​​ E. Melville Quinby, M.R.C.S., L.R.C.P., D.M.D. ​​ Boston Mass. 1916]

THE HUMAN MOUTH IN ITS RELATION TO PREVENTIVE MEDICINE AND PUBLIC HEALTH

By W.G. Ebersole, M.D., D.D.S., Sec’y-Treas., National Mouth Hygiene Ass’n. ​​ Read before the new Jersey State Dental Society at Asbury Park, N.J., July, 1913

“The most important organ in the body from a standpoint of preventive medicine is the human mouth. Notwithstanding this fact, no other organ in the body is so little considered by the members of the medical and dental professions and by the laity.”

“The mouth is the principal harbinger and most extensive breeding place for pathogenic microorganisms ​​ and is the path through which most of these organisms enter the human system.”…

“…we would ask if we have not overlooked or neglected in our search for sources of infection the greatest producer and at the same time the widest disseminator of disease-producing germs.”…

Using First Principles Analysis to Get to the Truth.

“The discovery of truth is prevented more effectively, not by the false appearance things present and which mislead into error, not directly by weakness of the reasoning powers, but by preconceived opinion, by prejudice.” – Arthur Schopenhauer

How do we decide what is correct and what is false in medicine and dentistry? In other words, how do we decide who or what to believe when it comes to healthcare? With so many opposing points of view on the same health topic how do we know which one to believe?

If you are more inclined to prefer a more natural approach to medicine does that mean discarding everything that allopathic medicine has to offer? Conversely, if one chooses to follow a predominately mainstream medicine approach, then should all natural alternatives be discarded as useless? Naturally, the answer is, ‘of course not.’ There are good and bad in both camps. But how do you distinguish the good from the bad – the correct from incorrect?

How to protect your health by using ‘first principles’

You do this by first distilling any conclusion down to the fundamental principles upon which the conclusion is based and reason up from there.

When either accepting or challenging current belief systems, it is imperative that all reasoning and conclusions be drawn from the level of established science, and not on assumptions, preconceived prejudices, or analogy. This is the concept of first principles. Fundamental truths upon which any hypothesis or theory is based must conform to both rational consistency and empirical observation. Any deviation from these principles will often lead to false conclusions.

If any of the parameters upon which a theory is based fails to conform to both rational consistency and empirical observation, then this theory must be discarded as incorrect.

So, what does that mean? It means that all conclusions must be first based on rational consistency of what can be possible as defined by the accepted laws of physics, chemistry and biology. That doesn’t mean that it is possible, only that it can be possible. Is it rational? Can it happen? If so, then the first condition of establishing correctness is satisfied. If not, then we can immediately dismiss it as incorrect.

Finding the truth with the help of dinosaurs

Let’s say there is a claim that dinosaurs are currently living on the moon. Does this satisfy rational consistency? The answer is obvious, no.

First of all, dinosaurs are extinct. In addition, we know that the moon has no air, so supporting a living creature dependent on respiration such as a dinosaur would be impossible. We can stop right there because this claim does not meet the requirement of rational consistency. We do not need any further evidence.

But, what if someone claimed that there are huge cities built on the moon with thousands of people living there. Could this be true? Well, of course that is highly unlikely, but it could be true. We do have the technology to do this. Although highly unlikely, it could be possible.

So how do we find out if this is true or not? We look for empirical evidence. We make observations. There are telescopes that can examine the surface of the moon facing us. There are spacecraft orbiting the moon with cameras that can easily spot a city on the moon. We can directly look and see if there are cities on the moon or not. If there are none, then the claim is false.

So, first principles accept that statements made about reality must conform to the properties of reality which are:

1. Rational consistency: If it is rational it might be true. It does not mean that it is true, only that it could be.

2. Empirical evidence: If both empirically valid and rationally consistent, then it is true.

Applying first principles to a root canal procedure and risk analysis

So how do we apply this to our analysis of the risks involved with poorly performed root canal teeth? 

Currently accepted beliefs and accepted truths, such as the American Association of Endodontists (Dentists who specialize in performing root canals) assertion that root canal teeth cannot cause or contribute to systemic disease and do not leak bacteria and toxins systemically, must be distilled to the first principles upon which this claim is based.

We first must define all of the properties of root canal teeth. Then, we can ask the question on how these objective properties of root canal teeth relate to known biological and physical principles. We continue the analysis from the ground up until we reach a logical conclusion. Then, we test this conclusion with direct observation.

Let’s look at the role of root canal teeth and heart disease. It has been established that a main driving factor in cardiovascular disease and heart attack is inflammation and the resulting damage to the lining of the coronary artery (endothelium). We know that infection and bacterial toxins are one source of this inflammation and endothelial damage. But, how does a root canal contribute to cardiovascular disease?

It is established that all root canals remain infected and become more infected over time. The American Dental Association has acknowledged this. It is also true that these bacteria produce potent exotoxins. Dr. Boyd Haley has demonstrated the presence of potent toxins leaching directly out from the root canal tooth root.

The untold truth 

The American Association of Endodontists states that toxins are not released from root canal teeth. It claims that both bacteria and toxins that are inside the tooth remain “entombed” within the tooth and that they do not travel systemically to other sites in the body. And if bacteria do make their way out of a root canal tooth this organization further asserts that the infection will remain local and not travel to distant sites in the body.

Are these statements both rationally consistent and supported by empirical evidence?

Bacteria within root canal teeth produce many varieties of small molecule toxins. Can these toxins escape from inside the tooth? As mentioned above, Dr. Haley has tested root canal teeth for toxin release and found that root canal teeth do indeed release very potent toxins. These molecules are very small and make their way out of the tooth root.

In addition, biopsies have shown that a large percentage of root canal teeth do not have a complete seal within the canal. Remember, these toxins are very, very small molecules. They can easily diffuse out through the root surface and also out the apex of the tooth root. They cannot be “entombed” inside the tooth.

If it doesn’t make rational sense, and contradicts observation, it must be false

The statement by the American Association of Endodontists does not satisfy rational consistency or empirical evidence. So, it must be false.

The truth is that bacterial toxins do leach out of root canal teeth. Small molecules cannot be contained inside an imperfectly sealed root canal or porous root surface. This is not rationally consistent. Empirical evidence from the research of Dr. Haley has confirmed the release of these toxins. Once they are released there is nothing to stop them from traveling to other sites in the body.

Now what about the bacteria themselves? Remember the ADA claims that the bacteria remain “entombed” within a completed root canal. Is this true?

Virtually 100% of the bone around the bottom of the tooth socket after extraction of a root canal tooth was shown to be infected with bacteria. I can’t remember a single case where I obtained a negative bacterial culture from the bone surrounding a root canal–treated tooth. 

The American Association of Endodontists says that even if bacteria leak out of a root canal tooth they will remain in the tissues immediately adjacent to the tooth and will not travel to distant sites of the body. They further state that the immune system will destroy any bacteria that get into the bloodstream before it can be seeded to another body part.

Both statements are incorrect. It has been established that pathogenic bacteria within root canal teeth can “disarm” the immune system through a variety of mechanisms and may not be destroyed. It has also been proven through DNA analysis that the same bacteria from root canal teeth are found in the plaques of coronary arteries and in the blood clots that have caused a heart attack. These bacteria traveled from a root canal tooth to the coronary arteries of the heart.

SUMMARY

Here is what we know about poorly performed root canal teeth:

1. Most, if not all root canal teeth remain infected and can become more infected over time.

2. Pathogenic bacteria inside the root canal-treated tooth produce potent exotoxins that can leak out of the tooth and travel systemically.

3. Bacteria inside the root canal tooth leak out of the tooth into the adjacent bone and contribute to persistent apical periodontitis. 

4. This chronic apical periodontitis can be a source of increased inflammation in a subset of root canal treated teeth. 

5. The immune system does not always eliminate these pathogenic bacteria.

6. Bacteria from infected teeth have been found in distant sites of the body such as coronary artery plaque, pericardial fluid in coronary diseases patients, and in ruptured cerebral aneurysms. This has been positively confirmed by documenting the presence of the DNA unique to root canal pathogens at these sites.

More and more studies are confirming the role of chronic infection and inflammation as risk factors for numerous systemic diseases. 

Understanding this, it makes sense to reduce or eliminate possible sources of infection and to lower inflammation wherever possible.

Since poorly performed root canals can be a source of chronic infection and increased inflammation, these teeth might well be risk factor for systemic diseases. 

Although so far nothing can completely eliminate bacteria from an infected tooth, new technologies in root canal treatment such as photon-initiated photoacoustic streaming can significantly improve the cleaning and disinfection of the root canal system leading to better healing of apical periodontitis, a reduction in inflammation, and therefore a reduction or elimination of systemic risk.

I believe that the dental profession should aggressively embrace the role of oral health on overall general health and set new standards for root canal treatment and measures of root canal success. The bar for minimal acceptable treatment parameters should be set higher. 

We are all human. And because we are human, we are imperfect.

We need to fight the temptation to shape the facts to fit our belief system, and instead shape our belief system to fit the facts. 

That is easier said than done.

“Preconceived notions are the locks on the door to wisdom.” (Mary Browne)

• Toxic Tooth Preface.

• It’s Time to Break Down the Wall Between Dentistry and Medicine. By Bruce Donoff MD, DDS (Stat news 2017)

• Dental Caries and Head and Neck Cancer ​​ (JAMA, 2013)

• AAE Newsletters

• Jerry Bouquot, DDS, MSD Biographical Profile

• Patient Letters to the NYS Dental Board

• Weston Price Bio

• Articles by Easlick and Grossman that are referenced by the AAE ​​ that they say debunks Focal Infection Theory. Current peer reviewed research shows that these articles are filled with false assumptions and outdated information.

• Article about Dr. Oz article in response to his critics.

• Article: Yes, Licensing Boards Are Cartels. The Case For Why Congress Should Get Involved. ​​ By Eric Boehm. Sept. 2017).

• Article: The Truth About Dentistry. It’s Much Less Scientific-And More Prone to Gratuitous Procedures-Than You may Think. By Ferris Jabr. The Atlantic. May, 2019).

• Article: Root Canal Safety. By Dr. Marcus Johnson. This article is endorsed by the AAE.

• More on Stephen Barrett, Jackson Leeds and others.