Some news about a study linking brain tumors to dental x-rays has appeared on numerous major networks recently, and I’d like to address some of the issues that it brings up. First of all, I’d like to say as a practicing dentist for the past 30 years that I am extremely concerned about the health & safety of dental patients. I have always been very careful and hygienic over the years concerning radiating patients. I take my responsibility to protect the public and to foster & engender their overall health and safety, as well as promoting good dental and oral health very seriously. I personally plan to be the first dentist in San Francisco to develop and offer the use of a protective lead helmet to go along with our usual lead apron. It can’t hurt and if it helps protect my patients, I’m all for that. I want to emphasize that I welcome information that helps me protect the public, and that I am proactive in delivering radiation sparingly.
To illustrate this anecdotally, I have been known to fire dental assistants for taking intraoral radiographs using poor or careless aim, therefore rendering the x-rays less that perfectly readable. I can recall an instance where I looked an assistant in the eye and said “You are consistently radiating my patients without giving me the information that I need for good treatment! You’re fired” I mention this instance so you know I do not take my responsibilities in gathering the information that x-rays can afford me lightly.”
This study, however, was presented in such a way that it has caused concern in me, that it could alarm the public enough that they may refuse or delay x-rays that could disclose conditions which are best treated before they hurt. The neurosurgeon featured on CBS’s “This Morning” program on April 10th, Dr. David Langer’s use of the phrase “if you have symptoms, if you have pain in your teeth, and the dentist examines you and is concerned you have a cavity, you need an x-ray” is worrisome to me. One of the great values of routine x-rays is to detect problems so we can solve them while they are still minor and before they cause symptoms or pain of any kind. This is called preventive dentistry. If patients refuse x-rays until symptoms occur, this could be a national oral health disaster of a magnitude that staggers the imagination. It would be like moving preventive dentistry back 100 years. All the advances and strides that modern dentistry has achieved come from training the public to trust the dentist to find and avert problems while they are small, inexpensive, and easy to fix. “Visit your dentist twice a year” are words that have imbedded themselves in the American public to their great benefit. Americans now have the best, most well maintained teeth in the world because they let the dentist find problems while they are small. Just that one phrase alone from Dr. Langer on national news is the equivalent of “don’t check it until it hurts.” I can’t tell you how much that alarms me that the public may take those words to heart and suffer the consequences.
Having expressed my distress about the way this piece of research was presented, I ‘d like to go on and talk about the research itself. First of all, Meningiomas may be the most common type of brain tumor diagnosed, but they still are a rare occurrence in the population at large. I’d also like to point out that the early indications of ionizing radiation perhaps being the cause, came largely from instances where the radiation was a considerably higher dose than what modern dental x-rays deliver.
Next I’d like to say that the way the study was set up is questionable. A group of people who had been diagnosed with this tumor were asked to remember whether they had been x-rayed regularly at their dental offices in the past. One could also ask the same group if they’d had MRI’s, CAT scans, chest x-rays, or imbibed alcohol or smoked cigarettes. We can always target something in retrospect and “memories” may fill in the suggested blanks with questionable accuracy. The American Dental Association has issued a press release concerning this media presentation of the study. In part, this press release says “The ADA has reviewed the study and notes that the results rely on the individuals’ memories of having dental x-rays taken years earlier. Studies have shown that the ability to recall information is often imperfect. Therefore, the results of studies that use this design can be unreliable because they are affected by what scientists call “recall bias.” Also, the study acknowledges that some of the subjects received dental x-rays decades ago when radiation exposure was greater. Radiation rates were higher in the past due to the use of old x-ray technology and slower speed film. The ADA encourages further research in the interest of patient safety.”
Myself and all dentists that I know & associate with are educated about, concerned with, and proactive in dealing with radiation safety. We do follow the ADA recommendation to minimize radiation exposure. We all do use protective aprons, thyroid collars, fast speed films, modern machinery, and/or digital x-rays in efforts to care for and protect our patients. And as I mentioned earlier, I’ll be the first to develop and encourage a protective head cover.
I’d like to assure and protect the public’s trust in their highly trained and generally very ethical family dentist. Trust your dental practitioner and allow proper, necessary, and safe dental x-rays in order to receive the preventive vision that they afford your doctor. Don’t wait till it hurts.
Questionnaire:
Question: So in clarification, you feel that dentists are for the most part already taking careful precautions concerning radiation and your main fear is that patients won’t allow x-rays except for when something hurts and therefore catching things when they are small will go by the wayside.
Answer: Precisely. I fear that this will cause dentists to have to struggle even further to gain cooperation from the patient in proceeding with proper care. Already dentists are having to talk and convince and dance to get patients to prioritize good dental care. We compete with everything from Day Spa’s to big screen TV’s. If it doesn’t hurt why fix it when money could be spent elsewhere? Also, fear of receiving care, and the inconvenience of having to put up with dental procedures, as well as pay for them, keeps millions from the care they need. So other priorities for one’s time and money, fear of dental procedures, and the inconvenience of having to schedule care, all keep patients from oral health. One more fear or excuse is not what dentists nor the public needs. Catching conditions early with regular check up x-rays (bite-wings, etc.) is key to keeping costs low and care easy and simple.
Question: Do you have an example of delay in the taking of x-rays causing worsening dental conditions?
Answer: In my 30 years of practice, I have hundreds of examples. Three come to mind quickly and I’d be happy to recite them. The first one, is that of a young man who had seemingly good health and no symptoms. He was however, fearful of me even discovering that he might need care. He would literally come in saying “don’t find anything Doc, don’t find anything wrong with me!” He didn’t want me to look too closely because he didn’t want to face any procedures. He would delay and refuse dental x-rays to the point that when I insisted upon taking a full series of films, it was basically “too late” for his second molars. His wisdom teeth were impacted and moving forward at such an angle that they destroyed the roots of the teeth in front of them. Had I been allowed to pick up that condition on routine x-rays just a year or two prior, we could have taken action and saved the second molars from having to be removed.
In another instance, a woman in her 30’s, a young mother, kept delaying x-rays claiming that she may be pregnant or that she wanted to preserve her finances for other priorities, finally allowed routine bitewing x-rays. It was too late for two of her bicuspids. Internal pulpal resorbtion had hollowed them out and they were lost and they had to be removed. Internal resorbtion is when the nerve kind of goes ballistic and dissolves tooth structure from the inside. If she had allowed routine check up x-rays in the absence of symptoms we would have seen the pulp changing shape and been able to save those teeth.
And just a few days ago, a patient who hadn’t been in two years because she was distracted with family responsibilities, had decay that was at such a surprisingly advanced stage, that she will need root canal treatment to save several teeth. If I had had to rely on the x-rays from 2 years ago, I would not have caught the problem until pain began, and then it is possible the teeth would have become unrestorable or unsavable. If we catch decay early it can be solved with a simple and relatively easy and inexpensive filling. If decay is allowed to advance too far, it reaches the dental pulp or nerve and then abscess occurs and necessitates root canal treatment, which is the removal of the dental pulp, in order to save the tooth. Patients all want to avoid needing root canal treatment, but if they deny the dentist a way to detect decay in its early stages, more teeth will need this advanced treatment.
Question: Dr. Langer said something to the effect that he assumed “most dentists are intelligent” and therefore would not take x-rays until signs or symptoms appear. It sounds like you think that is an unintelligent way to practice dentistry.
Answer: I have great respect for neurosurgeons. That is a lot of education and prestige. It is a good time to say that dentists are a highly trained group of health professionals. We aren’t brain surgeons but we do intra-oral surgery every day on human tissues belonging to the awake and aware. We don’t work, as a rule, on the unconscious. We are the anesthesiologist, the surgeon, the psychologist, the technician, the pharmacist, and the entertainer as well as often the “in loco parentis”. And we do it all with a smile and repeat it again in the next 45 minutes. Entry to dental schools is highly competitive. Only the best and brightest get accepted. It is hard to get in…and even harder to get out. It isn’t respectful to refer to dentists ingratiatingly, nor to tell them how to do their jobs. Dr. Langer is not the only one. Another health commentator on ABC’s “Good Morning America,” Dr. Richard Besser, also recently told dentists to quit taking so many x-rays. Frankly, neither of these gentlemen know what they are talking about in telling dentists how to practice. The dental community should speak up as it is condescending and irresponsible of them to warn the public against the practices of the dental profession. They don’t know that we use x-rays to check the alveolar bone crest, the width of the periodontal ligament, periodontium in general, pulpal tissues, and to check for the presence of abscesses and cysts and tumors. Cavities are not the only thing we look for or treat. And we don’t need these fellows on TV to tell us what we already know and that is to prolong the interval of check up x-rays on the long standing patient who rarely has problems. We all figured that out years ago. I would never go on national TV and frighten people away from the tools that neurosurgeons need and use in order to rule in or rule out problems. We dentists are intelligent after all, and have the integrity to hold our patient’s well being as the utmost goal.
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