Thursday, May 12, 2016

Treatment Scores Saved Me from Having to Get Four Cavities Drilled and Filled

I like my dentist and have been going to him for many years. Last year, He used the DIAGNOdent laser diagnostic device and said I needed to have four cavities filled. The DIAGNOdent laser showed a cavity in each of my four wisdom teeth.

This was troubling, since I brush and floss, and have almost never had a cavity as an adult, but now had four of them!

2015 DIAGNOdent Readings

My 2015 DIAGNOdent laser readings in the four affected teeth were:

  • 17
  • 17
  • 15
  • 15

I left the dentist dismayed and shocked. This technology, the DIAGNOdent, had discovered four cavities in my teeth. The last thing I wanted to do was have four teeth drilled and filled! That’s painful! Suffering in the dentist’s chair has never been easy.

I decided to create a list of treatments for a cavity, and then figure out the Treatment Score for each one of those treatments.

The first thing I learned was that the DIAGNOdent can find “microcavities” not “actual cavities.” A typical “cavity” diagnosed by vision or x-ray goes all the way through the enamel and into the dentin of the tooth.

The DIAGNOdent laser is able to diagnose cavities that are “pits in the enamel,” but do not go through the enamel. Thus, they are called “microcavities.” They are also called “superficial cavities,” “surface caries,” “superficial caries,” “initial caries,” and “incipient carious lesions,” depending on how much of a stickler you want to be.

All these different terms are important, because their existence means that you have to search PubMed and other databases using all these different terms. The main point is that a microcavity affects the outer layer of the tooth, the enamel, only. DIAGNOdent readings can go from 0 to 99. I called KaVo Dental, because they make the DIAGNOdent to ask what a reading of 99 meant. They said it would mean that the cavity definitely goes all the way through the enamel into the dentin, but that your dentist should find and fix your cavities before they ever get that far.


DIAGNOdent Readings

On the KaVo Dental website I found this explanation for the DIAGNOdent readings:

0-10 means you have “Healthy Tooth Structure”
11-20 means you have “Outer Half Enamel Caries”
21-30 means you have “Inner Half Enamel Caries”
30+ readings mean you have “Dentin Caries”

(Source: http://www.kavousa.com/US/Customer/Document-Library.aspx Accessed May 12th, 2016.)

From reading medical articles, I became satisfied that the DIAGNOdent laser was a more sensitive method to detect microcavities than visual examination or x-rays.

Great! Catch cavities early, drill and fill them, and all will be wonderful! Right? Not so fast. Science-based medicine means going to the medical literature and seeing what it says.

After some more reading, I found out there are potential significant side effects to drilling and filling. Several articles theorized that when you drill through the enamel into the dentin to fill a cavity you increase the risk for tooth demise, because now you have a hole going all the way through the enamel and into the dentin of the tooth. That potentially opens up the inside of the tooth for bacterial contamination. Allegedly, every filling in your teeth, even if they are very superficial, put you at risk for more tooth deterioration, because the edges of the filling can be future spots for decay. As many people learn, fillings in your teeth do not necessarily last forever.

What did I want to achieve? What was the important outcome for me? After even more reading, I decided that what was important to me was the long-term survival of my teeth. The survival of the tooth was the most objective and significant outcome measure that I could find.

So, I wanted studies that focused on the long-term survival of the teeth. I wanted to be sure that whatever I did, that over the years, it increased the survival of my teeth instead of decreased the survival of my teeth. Many studies in medicine don’t go on for a lifetime, because that would be too expensive. So, I decided to look for five-year studies.

I want to keep my teeth in my mouth forever if possible. I want them all to survive my entire life span, but I was willing to start with five years.


Treatment List

I came up with a partial list of treatments for microcavities:

1. sugar reduction
2. acid reduction
3. watchful waiting
4. drilling and filling
5. ozone
6. fluoride toothpaste
7. fluoride rinse
8. fluoride varnish
9. fluoride gel


Treatment Scores

What Treatment Scores did I come up with?


All I found was “no data” = ND.

What I wanted to find was great studies for all of these treatments at the five-year mark. Instead, I was lucky if I could find a six-month or 18-month study that was tangentially related. I spent at least 20 hours on this project. It actually became a nightmare. Over and over again, I realized that for what I really wanted to know, all I could find was “missing data” or “no data.”

This is why we need Treatment Scores. We need to quantify what we know and what we don’t know. In addition, we can reduce the time spent searching the medical literature from 20 hours to 2 minutes.

What we don’t know is staggering. For example, Cochrane Reviews are one of the most respected sources of review articles. Yet, a statistician wrote this:

“…I'll like Cochrane when it answers 10% of the questions I get." - Jon Brassey, BSc
(http://evidencelive.org/speaker/jon-brassey/ Accessed 8/24/2015)

Jon Brassey, BSc hits the nail on the head. The problem with the medical literature as it exists today is that it doesn’t answer most of our clinical questions. In reality, we only know a lot about the “tip of the treatment iceberg.” All the rest of the treatments are “under the water.” We know very little about their treatment effects.

All I wanted to know was what the medical literature said about treatments for microcavities after five years of follow-up. What I got was the big squadouche, zip, nada, nothing, “no hard data situation.”

All these problems are why we invented Treatment Scores. We need to quantify medical treatments to find out what we know and what we don’t know. We need to start doing research to fill in the blanks. It’s my belief, that every practicing physician should be involved in clinical research. Believe it or not (I write sarcastically) it’s actually important that physicians, dentists, nurses, pharmacists, and everybody else know what they know and what they don’t know.


What did I do?

So, what did I do? Since I had no five-year facts, only impressions, I ended up treating my microcavities with fluoride toothpaste. How did that turn out for me?


2016 DIAGNOdent Readings

When I went back in 2016, the DIAGNOdent readings were as follows:

17
17
15
15

The DIAGNOdent readings were exactly the same! The dentist remarked that now he leaves such microcavities alone unless the reading is over 40.

The conventional wisdom, possibly the standard of care, and the medical literature have been changing over time. Fortunately, my dentist acknowledges change.

I like the DIAGNOdent laser technology. I like the idea of finding cavities early and either following them, or treating them, depending on what seems to be the best thing to do using science-based medicine and shared decision-making with the dentist.

The DIAGNOdent is an early warning system that you need to take better care of your teeth.

Early diagnosis of microcavities, when you thought everything was perfectly fine, certainly motivates you to learn and actually do something, whether that something is “watchful waiting” or something else from your treatment list.


What am I going to do now?

This next year I’m going to watch my diet more carefully. I have Coca-Cola®, Mountain Dew®, orange juice, and sports drinks in my refrigerator. These drinks are all acidic and sugary. When I drink them, I’m going to dilute them with water and ice to try to reduce the pH level. I don’t want concentrated acid washing across my teeth anymore. I should consider quitting them altogether.

I also drink black coffee which is supposed to be acidic.

I actually bought some pH paper and tested several of the things in my refrigerator. Remember that a pH of 7 is neutral, and anything less than 7 is acidic.

Energy drink 1, pH = 2.0
Iced tea with lemon, pH = 4
Caffeine free diet cola, pH = 4
Orange juice, pH = 4.0
Energy drink 2, pH = 5.5
Iced Tea in a bottle, pH = 6
Milk, pH = 7
Coffee, pH = 7 (surprise?)
Water, pH = 7

My testing was very crude and may not be accurate at all. You should look up the pH of things you drink on the Internet as there are some very good studies out there on the pH of various drinks. My coffee tested at pH equals 7, which I am suspicious about. I do make my coffee very weak, and perhaps I accidentally bought a brand of coffee that has a very low acid level.


Treatments

To summarize my treatment regimen for the next year I’m going to try to:

  • reduce sugar intake
  • reduce acid intake
  • continue to use fluoride toothpaste

I do not consider my treatment plan for next year scientific. I’m going to go back and try to create Treatment Scores for shorter time periods and with different outcome measures. I will probably try to look at “cavity resolution,” meaning that the cavity disappears, and I will look for short term studies of six months or a year, because long-term studies don’t seem to exist. I will also try to find more information about the side effects. At first glance, hard data on the side effects seems to be lacking for the long-term. What are the side effects of fluoride intake? How many randomized controlled studies will I be able to find at one year of follow-up? Or at five years of follow-up? These are important clinical questions that need to be answered. If I don’t quantify fluoride as a treatment, how will I know how beneficial or dangerous it might be?

The future of medicine will be Treatment Scores. Once the data has been organized in “Treatment Score fashion," automatic algorithms can be used to keep trying to improve the Treatment Score, or update the Treatment Score. Eventually, we will all understand treatments much better.

Am I doing the right things? Will I save my teeth or lose my teeth? Have I missed anything? Until treatment quantification is perfected with Treatment Scores I will always have nagging doubts. At least for one year, science-based medicine and Treatment Scores have saved me from undergoing drilling and filling of four microcavities.

The sad fact is that what we really need to know about medical treatments we often don’t know. It’s time to use health information technology for something that benefits both patients and doctors. We need to use health IT for Treatment Scores.

What will my DIAGNOdent readings be next year? (See the disclaimers below.)

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