Dentists’ Charity: No Good Deed Goes Unpunished

b.johnson,dunwoody, you seem to be quite frustrated reading your comments. when’s the last time you went for a complete dental check up? are you retired? do you have health and dental insurance? are you one of the million unemployed people in america that were unfortunately laidoff? you sound like you are entitled to have whatever you want!! do you know what its like to have your own business in today’s economy? write to your local senator and complain to him how frustrated you are!

Why Howard?

Charitable services are something that we as practitioners provide almost daily. How many of us have provided care in our office to someone who was down and out and just written it off? How many have done charitable work at a clinic in the community for those who could not afford private care? How many accept some form of insurance that does not legitimately pay the cost of services rendered? The mistake of this practice was in the way that the community was informed of the charitable donation. Patients and community know very well that most health care professionals are called upon to help the less fortunate, but they really don’t wish to have it appear as a news release. I believe it works best to have the front desk staff to inform patients that call during the time of the charitable giving that the office is closed because the doctors and staff are providing dental services for the needy. When patients are rescheduled to clear the office for the day, each one should be told that the reason is that the office is providing charitable service for the community on that day. Don’t worry, the word will get out. When one of the rescheduled patients shows up for their next appointment, they will usually ask about the reason that they were rescheduled. It is a perfect opportunity to describe the warm and fuzzy feeling that helping those in need provides. The internal communication with patients of record is the best way to make this type of charitable giving known to the community. They will refer friends and family when they believe that the desire to help is genuine and not a marketing ploy. My congratulations to this generous group of colleagues. Keep up the good work.

NYCOF wants references. Perhaps we should begin with a vert recent papers by J.V. Kumar which NYCOF has claimed shows fluoride ineffective.

On the web NYCOF has widely represented that Kumar’s paper shows no effect of fluoridation on cavities. Readers can find the source of this misinformation by Googling for the original so-called press release titled “JADA Study Proves Fluoridation is Money down the Drain.”

J.V. Kumar’s study in the July 2009 Journal of the Am. Dental Association study shows that teeth which developed fluorosis as a result of ingesting fluoride were are resistant to cavities. Kumar’s study is important as yet another testament to water fluoridation’s effectiveness and also as further evidence of the importance of the systemic effect of ingested fluoride which comes with water fluoridation.

The data used in the Kumar paper comes from the National Institute of Dental Research survey published by Brunelle, Carlos and Heller in 1990. These authors found that, averaged across the United States, fluoridation reduced caries by 18 to 25%. In the Pacific Northwest, where few communities were then fluoridated and the “halo effect” is not operative, caries were reduced by a whopping 60%. (Table 9, Brunelle and Carlos, J Dent Res, Feb 1990) These findings were based on a very large data set with verified examiners. I am unaware of any substantial technical criticism of the paper.

In the early 90′s well known antifluoridation activist, John Yiamouyiannis, separately analyzed these data and concluded that fluoridation did not prevent caries. However, Yiamouyiannis erred by only considering the prevalence of cavities and ignoring the information in the data on caries severity. NYCOF’s claim that Kumar’s papers shows no effect on cavities, i.e. is “Money Down the Drain, simply restates Yiamouyiannis’s error.

Suppose a vaccine for a hypothetical viral disease prevented all deaths but had no effect on whether or not a person would acquire the viral disease. Clearly for many severe illnesses this would be a wonderful result. If NYCOF and Yiamouyiannis were to apply their severity-blind methodology to such a vaccine they presumably would advise against the its use because the same number of people “got” the virus whether vaccinated or not. The foolishness is transparently obvious.

Readers are invited to read the Kumar paper for themselves: Am Dent Assoc. 2009 Jul;140(7):855-62. The association between enamel fluorosis and dental caries in U.S. schoolchildren. Iida H, Kumar JV. http://jada.ada.org/cgi/content/abstract/140/7/855

Water fluoridation remains one of modern medical sciences most important public health interventions. Additional references are easily supplied. For example, one contemporary study shows that water fluoridation (in Louisiana) prevents about 75% of child hood operations under general anesthesia for cavities and saves 50% of the childhood dental budget for poor children. (Morbidity and Mortality Weekly
Report; 48(34);753-757 Sept 03, 1999)

So there are two references, perhaps NYCOF would prefer 50.

The sad matter is that specious arguments such as this are politically effective in creating opposition to water fluoridation. Hopefully the truth will eventually prevail.

Picker22

By the way, the Louisiana MMWR paper Picker22 refers to is neither a peer-reviewed study nor published in any medical or dental journals. The MMWR is created by the CDC who employs people to promote fluoridation – not study it.

From Picker’s source:

The findings in this report are subject to at least four limitations. First, although the analysis showed an association between lower caries-related costs and residence in one of the five F parishes, the analysis did not measure the length or magnitude of the children’s exposure to fluoride. Some children classified as residing in NF parishes once may have resided in F parishes and vice versa. It also did not verify that the water systems serving the five F parishes maintained fluoride concentration at the optimal level. However, misclassification of exposure status would be more likely to reduce the observed effect of fluoridation. Second, if access to dental care were better in NF than in F parishes, children with decay who resided in F parishes would be less likely to seek restorative care, resulting in an underestimate of treatment costs in F parishes and an overstatement of water fluoridation’s benefits.

Five points to respond to issues NYCOF raises

1. The Louisiana Medicaid paper is deemed fraudulent.

The editorial policies of MMWR are sufficiently rigorous and unbiased to qualify for indexing in the PubMed database. The quote you included from the publication was an Editorial Comment and is testimony to the scholarly and arms length editorial policies of the CDC publication. The lead author of the article was at Louisiana State University, not the CDC.

Of equal importance is the fact that water fluoridation’s dramatic impact on rampant caries in deciduous teeth has been confirmed by other studies. [ABCDN] Another Medicaid study from Louisiana published in a prestigious public dental health journal had very similar findings. [D]

2. Fluoride’s topical effect is a reason to not fluoridate.

The claim that fluoride’s effectiveness is principally topical has little implication for public water fluoridation policy because:

a. Water fluoridation is a proven public health intervention regardless of the scientific explanation of its effectiveness. There are no other cost effective options in the US.

b. Brushing with fluoride toothpaste is in fact both a topical and systemic application of fluoride. Some toothpaste is always swallowed. Thorough rinsing decreases effectiveness and effectiveness of tooth brushing correlates with plasma (i.e. swallowed) fluoride. Rinsing with a fluoride toothpaste slurry after brushing increases cavity prevention. [G]

c. Some of the known benefits of water fluoridation are possible only when fluoride is present during tooth development. [HIJKLM]

d. While the systemic effect may be more important, there is good evidence to support the importance of systemic effects. Fluoridated water consumed in childhood confirms a lifetime benefit. [M] The very quote you selected uses the phrase “mostly topical.” In truth this means 51% or more. Kumar’s recent article shows the systemic effect in action: fluorosis, obviously a systemic effect, protects teeth from cavities.

3. There are a lot of cavities in Detroit

Isolated factoids contain no useful information. Only studies designed to measure water fluoridation’s effectiveness are germane.

4. Fluoridation doesn’t prevent Early Childhood Caries

To my knowledge, no dental health expert believes water fluoridation prevents this disease. It is caused by poor parenting; children falling asleep sipping high sugar content fluids. Your listing it as a reason to oppose water fluoridation is typical of much of anti-fluoridation propaganda. You say something that is true and sounds convincing to the naive person, yet is totally unrelated to the debate.

5. A study showed Rural and Urban cavity rates equal.

From the Brunelle and Carlos study we know that simply measuring the presence of cavities does not demonstrate water fluoridation’s effect. This is precisely the mistake you and Yiamouyiannis made when you state that caries is shown to be ineffective by the first National Health and Nutrition Exam Survey data. Decayed, Missing, Filled Surfaces (DMFS) is a more sensitive and accurate measurement of the effect.

6. The Australian Study. . .Your conclusions are at odds with the authors who recommend that bottled water mandatorily contain fluoride so that the rural younger children are protected (the same teeth as were shown to be protected in the Louisiana studies).

————

The simple fact is that amongst professional public health and dental communities there is overwhelming agreement as to the propriety and effectiveness of water fluoridation. This is a transparent and irrefutable truth.

Large scale new implementation recently undertaken in California and Great Britain will bring many millions of additional people fluoridated water’s health benefits. While those who oppose water fluoridation are often politically effective at the local level, after 60 years it is clear that opponents have lost the intellectual scientific battle in the scientific forums most appropriate to these matters.

It is tragic that water fluoridation as debated by amateurs (as I consider both myself and NYCOF) is determining public water policy. Whenever the weight of good scientific evidence indicates that water fluoridation is a bad idea, public health professionals will acknowledge this and the practice will be abandoned.

Selective literature citations, and scientific non sequitur (i.e. cavity rates in Detroit) will often win politically with the general public, but until the antifluoridation beliefs succeed in forums of legitimate scientific debate, water fluoridation should and will continue.

Incidentally . . here is an international paper from Japan [F] which to quote: “The findings of this study conducted in 1987 in Japan parallel those reported by Dean et al. in the early 1940s”

Picker22

[A] J Public Health Dent. 1984 Spring;44(2):61-6. Caries patterns in Head Start children in a fluoridated community. Johnsen DC, Schultz DW, Schubot DB, Easley MW.

[B] Community Dent Oral Epidemiol. 1981 Jun;9 (3):112-6. Effect of fluoridation on the cost of dental treatment among urban Scottish schoolchildren. Downer MC, Blinkhorn AS, Attwood D.

[C] Community Dent Oral Epidemiol. 1988 Dec;16(6):341-4. Cost appraisal of a fluoride tablet programme to Manchester primary schoolchildren. O’Rourke CA, Attrill M, Holloway PJ.

[D] J Public Health Dent. 2000 Winter;60(1):21-7. Dental services, costs, and factors associated with hospitalization for Medicaid-eligible children, Louisiana 1996-97. Griffin SO, Gooch BF, Beltran E, Sutherland JN, Barsley R.

[E] Community Dent Oral Epidemiol. 1981 Jun;9(3):112-6. Effect of fluoridation on the cost of dental treatment among urban Scottish schoolchildren. Downer MC, Blinkhorn AS, Attwood D

[F] J Public Health Dent. 2000 Summer;60(3):147-53. The prevalence of dental caries and fluorosis in Japanese communities with up to 1.4 ppm of naturally occurring fluoride. Tsutsui A, Yagi M, Horowitz AM

[G] Swed Dent J Suppl. 1995;110:1-44. Toothpaste technique. Studies on fluoride delivery and caries prevention. Sjogren K.

[H] Aust Dent J. 1997 Apr;42(2):92-102. Prior fluoridation in childhood affects dental caries and tooth wear in a south east Queensland opulation. Teo C, Young WG, Daley TJ, Sauer H.

[I] Br Dent J. 2004 Oct 9;197(7):413-6; discussion 399. Epidemiological studies of tooth wear and dental erosion in 14-year-old children in North West England. Part 1: The relationship with water fluoridation and social deprivation. Bardsley PF, Taylor S, Milosevic A.

[J] Br Dent J. 1994 May 7;176(9):346-8. Comparison of the effect of fluoride and non-fluoride toothpaste on tooth wear in vitro and the influence of enamel fluoride concentration and hardness of enamel. Bartlett DW, Smith BG, Wilson RF.

[K] J Dent Res. 1990 Feb;69 Spec No:751-5; discussion 820-3. Fluoride in caries prevention: is the effect pre- or post-eruptive? Groeneveld A, Van Eck AA, Backer Dirks O.

[L] Community Dent Oral Epidemiol. 2004 Dec;32(6):435-46. Relative effects of pre- and post-eruption water fluoride on caries experience by surface type of permanent first molars. Singh KA, Spencer AJ.

[M] Community Dent Oral Epidemiol. 1992 Apr;20(2):81-3. Caries experience in subjects 18-22 years of age after 13 years’ discontinued water fluoridation in Okinawa. Kobayashi S, Kawasaki K, Takagi O, Nakamura M, Fujii N, Shinzato M, Maki Y, Takaesu Y.

[N] Texas Department of Health (2000). Water fluoridation costs in Texas: Texas Health Steps (EPSTD-Medicaid). http://www.dshs.state.tx.us/dental/pdf/fluoridation.pdf (accessed July 24, 2008).

Sad for NYCOF, you have never seen children with tooth decay and the inability to see a dentist on a regular basis. Every little bit does help. Walk the streets of the homeless to see the oral health care. Low income familys tend to present their children with soda, sports drinks and candy due to the low cost of these products.
I see children with tooth pain. A toothbrush is a luxuary to the homeless.
Karma NYCOF. I wish you well.

Forgot about this thread. Thought it was over. Will answer Picker when time is available. Actually, I “see” children in dental pain almost every day via news reports AND in fluoridated areas. No American child is fluoride-deficient. Studies show they are fluoride-overdosed and dentist deficient. At least two children and one adult (that made the newspapers) died from the consequences of untreated tooth decay.

No human ever got tooth decay from lack of fluoride because the condition does not exist. You might think fluoride is an essential nutrient; but science says it is not.

Talk about Karma

Organized dentistry is at the forefront of PREVENTING more dental health practitioners from easing the oral health burden facing too many Americans. By protecting your monopoly instead of allowing dental therapists to work in the US, dentists have more to do with keeping low income people in dental pain than I do.

Denturists would like to work directly with the public. Organized dentistry fights that. Hygienists would like to work directly with the public. Organized dentistry fights that too.

What the Louisiana Dental Association was the most egregious. They created a law that disallows a willing dentist from bringing treatment to children in schools who otherwise won’t get any care

Organized dentistry’s battle to keep the tooth-whitening business out of malls is a clear example of greed coupled with too much power.

Any services for child or adult is a gods send to me because I am one of the uninsured, thank you dentist makeing a difference! But, please don’t think so little of me that you compare me with an inanimet object. I am not a car or you’r lively hood. Can you imagine if someone told you they couldn’t give you poor mother or child preventitive care because she didn’t have enough money to care about? If you were a doctor who had been in a bad crash with other people but you yourself werent hurt that bad, that you would knowingly let someone die because they couldn’t pay you? Cops protect our lives with theres and so do firemen they only get 29,000. a year, teachers that are trying to educate your children for the worlds better future are tortured by your little angels and only get 10-12,000. dosent anyone think its time to help the people that daily put themselves in harms way and sometimes die for you and yours. These are the people and children of the people that you are trying to convince they “owe” you. Mabey some of these ungiving dentists should have oral surgury in an office that resembels a third world country and see if they still think anyone “owes” them. Just remember where the grant money came from that you borrowed to achieve this illustrius carreer. It came from the backs of people that work alot harded than you.