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Wednesday, June 15, 2011

News photo
Open wide: A dentist looms over a patient.

A dentist need not be a masked demon


Special to The Japan Times

HONG KONG — Of all the painful events of daily life, visiting a dentist is often the worst. Grown, otherwise strong and brave men have nightmares in which the dentist hovers over them, like a white-clothed and masked devil bringing pain and destruction. For some it is the sight of the needle that can induce a faint; for others it is the wretched whining of the drill, worse than fingernails on a school board because it presages pain to come; for others it is the sharp probing of very personal space while helpless, which may mutate to torture if they dare to move.

News photo
Toothy grin: This dental training skull has more teeth than a human mouth, and is used to indicate connections between the teeth and nerve centers. KEVIN RAFFERTY PHOTOS

The trauma of teeth usually starts at a tender age, before the toddling stage with sleepless nights accompanying the eruption of milk teeth. For most people it continues at regular intervals with the loss of those baby teeth, the coming of new teeth that don't properly fit the growing adolescent skull, wisdom teeth that play headaches games, the decay and toll of aging, not to speak of accidents in cars, on the playing field and on the battlefield of life.

Now a distinguished group of Japanese dentists has presented a radical piece of research that says it doesn't have to be this way. Much of the trauma and the pain can be avoided with better dental skills and regular checkups. "Your dentist should be one of your best friends, who will see that your teeth last for a lifetime and with a minimum of painful drilling," says Mikako Hayashi, who plays the part of the masked demon in the photo posted with this article.

From patients' disadvantaged prone position in the chair, this is welcome news — if they can believe it.

That's the big question. The radical work is a "Guideline" — a technical instruction on best treatment practices. But it advocates a new way of thinking about the care of teeth. For general dentists, it means they have to make potentially revolutionary changes to their traditional treatment methods, which have been summed up in three rhyming words — "drill, fill and bill."

For governments, the new policy prescription is potentially most radical and challenging of all: But do budget-strapped governments have the imagination to institute far-reaching reforms in everything from training of dentists to public health insurance?

Supporters of reform have one important weapon in Japan: Spending on social security has started to rise unsustainably with the rapidly aging population. With about 23 percent of Japanese aged over 65, there is a yawning gap between social outlays and receipts.

"Potentially, we are talking of savings of billions of yen a year on government spending on dental health services — as well as healthier teeth and lives, and patients who no longer have to fear visiting the dentist," says Yasuko Momoi, professor of operative dentistry at Tsurumi University School of Dental Medicine, who has chaired the group that has published the report for the Japanese Society of Conservative Dentistry.

The report is called prosaically, "Guideline for treating caries following a minimal intervention policy, an evidence and consensus based study," and in both the original Japanese and the English version, which has yet to be published, it is full of technical terms dealing with "proximal caries," "decalcified tooth lesions," "carious dentin," "pulp exposure," "reversible pulpitis," and the evil procedures and implements for dealing with them such as "stepwise excavation," "spoon excavators," "round burs," "polycarboxylate cement," "resin composite restorations."

Unless you are a dedicated dentist, you will probably quickly fall asleep trying to follow the details of ways of treating cavities in a step-by-step process that uses the rule of minimal intervention, that is, trying to do the least harm to the vital structure of the teeth with every step of the treatment. But if you read the report in its widest concept, the nine dentists and librarian who wrote it are calling for thoroughgoing reforms of established practices, which will extend back to dental training as well as government health care support, and billing and payment systems. In the case of Japan, there is much work to be done.

Dentistry is very much the, I hesitate to say Cinderella, more like an ugly younger sister of the medical world, that often gets forgotten. In the U.K., large numbers of dentists have abandoned the public-funded National Health Service, and some medical specialists say that realistically the best that can be done is try to keep public dental insurance treatment for children and for the very poor. In the U.S., where the private sector is regarded as sacred and government health insurance is a dastardly socialist plot, the very rich have movie star teeth, for which they pay thousands of dollars, and the very poor suffer bad teeth and tooth loss.

In Japan, the government has bravely shown the rest of the world the way by hoisting a flag declaring the slogan "80-20," meaning that at the age of 80 the average Japanese person will have 20 of his or her 28 natural teeth remaining (not counting the four wisdom teeth). But dentistry in Japan is riddled with inconsistencies, failings in the educational system, politics and widespread distrust.

Dentistry, apart from the bad rap it gets from the pain that often accompanies dental visits, has none of the glamor of general medicine. A tooth is only a tooth, and rarely a pretty sight when extracted. It is hard to see a "Dr. House," "Gray's Anatomy," "ER" or other TV shows being constructed round a dental hospital or clinic. Teeth and gums are hardly the same stuff as hearts and lungs and stomachs and rarely produce the immediate drama of life and death.

But it is a leap too far to dismiss dentistry as unimportant or to believe that whereas general medicine and need for treatment of the ailments of the body as a whole are vital matters that must be covered by government health insurance, teeth can be ignored until they cry out for attention, unless you are rich enough to pamper them.

Mikako Hayashi, an associate professor of restorative dentistry and endodontology at Osaka University Graduate School of Dentistry, and comanager and leading clinician of the university dental clinics, asserts that dental health deserves quality attention by governments. She says that teeth are the leading indicators of general health: If you have good teeth and gums, you are ready to challenge the world; if you have problems in your mouth, they may indicate bad health.

"Good teeth and good quality dental treatment are very much related to high quality of life. There is an English expression 'down in the mouth,' " Hayashi says, "which suggests that if you have a problem with your mouth, it reflects on your whole well-being and state of health. It is a good reason for regular visits to get good dental treatment to ensure that your teeth and gums are healthy, and you can face the world with a smile."

There is also another English expression, "to grit your teeth" used when facing an unpleasant situation, meaning nevertheless to try your darnedest in the face of the difficulties, with a variant expression, "through gritted teeth." All these expressions testify that teeth have greater importance than being an efficient means of chewing and biting, and the opening shot determining a physical attraction or not.

In the depressing research of the mouth, professor Deborah Greenspan of the University of California San Francisco and her husband, professor John Greenspan, also of UCSF, pioneered the role of dentistry in the fight against AIDS. Deborah Greenspan, an oral medicine specialist, investigated the relation of oral lesions to the presence and progression of AIDS, and with the help of scientists identified hairy leukoplakia, which became a diagnostic marker of AIDS. John Greenspan, an oral pathologist, linked lymphoma to the immunodeficiency of patients with Pneumocytosis and Kaposi's sarcoma.

Looking more positively, as professor Jonathan Knowles of University College London's Eastman Dental Institute noted, the area of the mouth and head in which dentists specialize is rich in tissues, cells and cultures that its advances can be important in general medicine, too.

The guideline produced by Momoi and her committee acknowledges great advances made in dentistry over the last 20 years. Japan has been in the forefront of some of the most important work through research at government universities, and in the labs of big medical and dental companies, especially in recognizing the structure of teeth and causes of decay — the achievements of university research — and the advanced materials to restore decayed or damaged teeth — the contribution of big companies such as GC, Kuraray and Shofu.

Worldwide there is increasing recognition that treatment of dental decay — or caries, as dentists call it — is best done by minimal intervention. The achievement of the work of Momoi and her colleagues is that their guideline is not a theoretical paper, but is rooted in hard evidence gleaned from searches of databases in Japanese and English, plus the more than 250 years of combined clinical experience of the members of the committee, all this honed by more than 100 hours of group debate to reach a consensus on the vital points.

Momoi pays tribute to "the insistence by Mikako Hayashi that if we wanted to be serious, we had to do a study that was evidence-based." Hayashi spent 18 months conducting research at Manchester University in the U.K., where she also contributed to the Cochrane Collaboration, which creates systematic medical reviews to assess the best treatment for diseases.

She has kept abreast of international developments through her research, particularly into the characteristics of dentin, the main component of teeth, to try to strengthen it to preserve healthier teeth longer. She is also investigating ways of assessing the risks of caries and preventing it. She is a member of the International Association for Dental Research and attends conferences of the European Organization for Caries Research and similar bodies. Momoi praises Hayashi's clinical skills as "the best conservative dentist in Japan."

The guideline produced by Momoi and her committee seeks to answer the most common clinical questions that dentists encounter, and it takes them step by step through the procedures in each case with recommendations graded by the degree of certainty and consensus by the experts. The committee worked hard to gain consensus and learn through the discussion process, say Momoi and Hayashi. The emphasis is practical patient-centered care that reduces pain and cuts expensive procedures.

Professor Nairn Wilson, dean of the London Dental Institute, the largest dental university in Europe, and who is one of the world's most renowned dentists as clinician, researcher, and adviser and examiner to dental schools from Hong Kong and Brunei to Qatar and Turkey, praises the Japanese guideline as "an authoritative, challenging and meticulous piece of work."

He adds that "good guidelines of the type that the Japanese group has produced are classed as primary research in U.K. Research Exercise Assessments."

He advises that the next steps — to gain widespread acceptance of the guideline — may be tough since "authors of guidelines invariably find themselves at odds with custom and practice and, as a result, the establishment. Rather than recognizing and valuing guidelines, the establishment can, at least initially, react negatively. They take a 'don't confuse me with the facts mentality.' However, over time they must come to accept them since the best evidence will come to the fore. Accepting and applying guidelines can feel like taking an unpleasant medicine — it isn't nice, but deep down you know it will do good."

As part of his "gambatte" advice, Wilson adds that "guidelines often have much more impact and result in many more improvements in patient care than most forms of primary research."

This sound advice warns of battles ahead. The first is to combat denial. I asked the Japan Dental Association (JDA), whose members include 72 percent of Japan's almost 100,000 dentists, for general comments on the guideline and its usefulness. JDA knows about the guideline because its has been published on government Web sites and the Society of Conservative Dentistry is one of the specialized organizations under the Japanese Association for Dental Science, part of JDA's massive umbrella. But after more than a month to study nine straightforward questions, the staff of the JDA said they could not reply unless they knew what the article was going to say, a small Catch-22 situation.

Recent advances in dentistry include recognition that teeth, if properly treated, regularly cleaned and cared for with a healthy diet, have self-healing properties, so that drilling and filling of teeth showing signs of decay should be a last, rather than a first, resort.

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