NTP Study Strengthens Evidence Showing Fluoridated Water is a Safe Way to Prevent Tooth Decay, But Critics Ignore the Study They Once Welcomed

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A study led by researchers at the federal government’s National Toxicology Program (NTP) has found no link between elevated levels of fluoride and cognitive harms. Released in February, the NTP study examined rats that consumed food and water with varying exposures of fluoride during their prenatal development through their adulthood. At these exposures, the researchers reported that they “observed no exposure-related differences in motor, sensory, or learning and memory performance” for any of the nine different tests they conducted.

Although fluoride critics often assert that fluoridation is harmful to the thyroid, the NTP study revealed that thyroid hormone levels were not altered by exposure to levels as high as 10 or 20 parts per million (PPM) of fluoride.

Critics’ Noteworthy Silence

When the NTP study was first announced, the Fluoride Action Network (FAN)—the leading anti-fluoride group in the U.S. — welcomed the news with a headline declaring that the study’s findings “could end fluoridation.” FAN cited the NTP’s “cutting edge scientific tools” and wrote that the NTP’s decision to conduct a study “puts a lie to [proponents’] claims” about fluoridation.

The American Fluoridation Society (AFS) noted that FAN has been distinctly quiet since the NTP study results were publicly released.

“Critics of community water fluoridation were thrilled when the NTP said they would conduct a thorough study of this issue,” said AFS President Johnny Johnson. “However, they have been as quiet as a church mouse since the NTP’s findings were made public. Once again, they choose to ignore the studies that don’t fit into their fear-based mindset.”

The NTP research studied rats that consumed water with three different concentrations of fluoride (0, 10 and 20 PPM) and two different fluoride levels in food: 20.5 PPM (a standard diet) and 3.24 PPM (low-fluoride diet). The only side effect found by the NTP study was inflammation of the prostate gland, which was observed only at a fluoride exposure that was far above the level of human exposure by drinking fluoridating water.

In addition to the NTP study, research published in 2015 by the Journal of Public Health found no link at all between fluoridation and IQ scores. This 2015 study was conducted in New Zealand, where fluoridation programs are common. The New Zealand study examined a large sample of people and examined IQ scores collected over a 31-year period.

Few public health topics have been researched as thoroughly as CWF. In fact, the database maintained by the U.S. National Library of Medicine contains more than 56,000 studies or research papers on fluoride. And the Library’s records include more than 6,400 studies that focus specifically on fluoridation.

Two other recent reports reinforce the safety of fluoridated water. In a report issued this March, Public Health England reviewed the evidence surrounding fluoridation and reached this conclusion: “The findings of this report agree with the view that water fluoridation is an effective and safe public health measure to reduce the frequency and severity of dental decay, and narrow differences in dental health between more and less deprived children and young people.”

In April, the Food Safety Authority of Ireland (FSAI) issued a report stating that “there is currently no scientific basis for concerns about the safety of children and adults” due to fluoride exposure from foods and drinks.

For more information, visit americanfluoridationsociety.org.

Management of Treatment Complications

By Sue Wilson, MBA, CPHRM, Patient Safety Risk Manager, The Doctors Company

Even when a patient is provided with care that meets the standard of care, complications may arise during, or as a result of, the treatment provided. It often is helpful to review this type of case to determine not only the root causes, but also how the complication was managed.

Case Study
A patient presented to a dentist for evaluation of tooth extraction and fitting of dentures. During the extraction, the patient complained of extreme pain and allegedly stated it felt as if the jaw had been broken.

The patient was discharged home and returned the following day complaining of pain, and presented with a swollen and bruised jaw.

A dental X-ray revealed a compound fracture of the left mandible. The dentist referred the patient to an oral surgeon, with a letter outlining the X-ray results and information about when the fracture may have occurred. The oral surgeon diagnosed a left displaced mandible fracture and admitted the patient to the hospital for surgical repair. The following day an open reduction internal fixation (ORIF) was performed and the patient was discharged a day later.

Subsequently, the patient developed complications and required several additional surgical procedures. The patient alleged the dentist was negligent in failing to properly document the extraction procedure, failed to maintain proper medical records, failed to take adequate pre-extraction X-rays, applied excessive force during the extraction that resulted in the fracture and failed to adequately assess the patient’s complaint by immediately obtaining an X-ray. The plaintiff’s expert dentist affidavit opined the dental care was below the standard of care and directly caused the subsequent injury and complications. Medical records from subsequent treating professionals revealed the patient continued to have pain, loss of jaw function and became anorexic as a result of inability to chew properly. The case was settled.

Documentation
It’s widely understood that health care records should contain a complete assessment of prior dental, medical, surgical and pharmaceutical history. However, there often is confusion about how to document complications or complaints. It’s important to objectively describe any complaint or complication arising during or following a procedure, as well as the assessment and actions taken in response to the complaint or complication. In this case, when the patient complained of pain, the dentist did not stop to determine the source or severity of pain and did not obtain an X-ray post treatment. Although the dentist stated in a letter to the oral surgeon he suspected the fracture occurred following extraction of a specific tooth that was ankylosed, he did not document the same in the patient’s record, nor did he document discussions with the patient following the procedure.

Recordkeeping
When a request is received for records and X-rays, a complete copy should be made and the originals retained in the office. In this situation, all original X-rays and medical records were given to the patient without keeping a copy, making it difficult to determine what was documented by the dentist and staff. When referring to another care provider, provide a copy of the medical records and X-ray films, but the original records and films should be kept and it should be documented that a copy was sent to the treating provider or given directly to the patient.

Communication
Maintaining communication with the patient and other treatment providers is essential. In a study of plaintiffs who were asked why they chose litigation against their health care provider, most responded they were seeking an apology and an explanation. It’s important to provide both to a patient who is potentially or actually injured. However, in many cases the cause of injury or complication is not known right away; therefore, it’s equally important not to assume blame, or to point to others as the cause of complication or injury.

Consult with Your Insurance Provider
When an adverse outcome resulting in potential or actual harm occurs, it should be discussed with your insurance company representative as soon as possible. In this case, the event was not reported until the patient requested her medical records and retained an attorney. At The Doctors Company, there are claim specialists and patient safety risk managers who can assist with communication, documentation, legal and regulatory questions and, if appropriate, compensation to the patient. Seek guidance from a patient safety risk manager or claim specialist before financial arrangements and agreements take place in connection with an undesired outcome, complication or injury.

Although zero injury is the goal, when an undesired outcome, actual injury or serious complication does occur, it often is how it is handled that determines the outcome for both the patient and the health care provider.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Reprinted with permission. ©2018 The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

FDC2018 Speaker Preview

21st Century Laser-assisted Dentistry

By Dr. Anthony Cardoza

Over the last 29 years, I have witnessed many technological advances in dentistry. Some of these advances have included computers throughout the office, digital X-rays, digital intra-oral photography, loupe and microscope magnification, and CAD/CAM technology, just to name a few. One of the most significant technological advances has been the evolution of the dental laser, and it’s this technology that’s really firing my passion for dentistry.

Lasers have been used in dentistry for several decades, but during the last five years they have become widely accepted and now tens of thousands of dentists in the U.S. and around the world have implemented lasers. Market acceptance of dental lasers is rapidly growing at a level where digital imaging was five to seven years ago.

In my practice we have several lasers for both hard- and soft-tissue applications, which are used for a wide range of procedures. It’s well-established that different procedures require different laser wavelengths. Wavelength is important because specific body tissues (chromophores) interact in different ways depending on the laser source. Therefore, it’s important to use the proper wavelength that is tissue-specific for the procedure.

The following are a few of the laser procedures performed in our office every day and the clinical advantages they offer our practice and, most importantly, our patients.

The near infrared diode laser has become my laser of choice for hygiene and soft tissue. It’s extremely effective for hygiene procedures such as laser bacterial reduction (LBR) and laser de-epitheliazation during scaling and root planing. Additionally, it’s excellent for soft-tissue surgical procedures such as frenectomy, gingivectomy, fibroma removal, and gingival retraction for crown and bridge impressions.

The most versatile laser I have is the erbium mid-infrared wavelength hard/soft-tissue laser. I use this laser several times a day for no-shot, no-drill cavity preps. My patients love being able to avoid having shots and post-op numbness. This laser gives me the ability to quickly and effectively remove decay, and often these restorations weren’t scheduled, but discovered during hygiene examinations. We can complete these procedures in one appointment and avoid the inconvenience of rescheduling the patient. With my erbium laser I can perform these procedures fast and often without anesthesia.

In addition, by lengthening the pulse duration, I also can perform many soft-tissue and bone procedures. Procedures like apicoectomy, gingivectomy, osseous recontouring and laser periodontal surgery are examples of treatments performed with the erbium laser.

Finally, lasers are now being used during endodontic treatment in the form of laser activated irrigation to greatly reduce bacteria and debris found in the canals without a net thermal elevation within the canal. Lasers also are now being used for snore reduction. The role of lasers in dentistry is continuing to increase as we see ongoing research in both lasers and their use in various applications in dentistry. The decision is no longer whether to add a laser to your practice, it’s just a matter of which laser will best fulfill your needs.

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Dr. Cardoza will be speaking at the 2018 Florida Dental Convention in Orlando in June. On Thursday, June 21, “Dispelling the ‘CSI Effect’ Myth” will be at 9 a.m., and “Dentistry’s Role in the Mass Disaster Scenario, Child Abuse and Intimate Partner Violence Recognition,” will be at 2 p.m. later that same day. On Friday, June 22, his workshop, “21st Century Laser-assisted Dentistry” will be at 9 a.m. with a repeat of the workshop at 2 p.m. To register, go to floridadentalconvention.com.