Dental Malpractice: The myth of holistic dentistry, biological dentistry, cavitations, and neuralgia inducing cavitational osteonecrosis (NICO).
In these days of alternative approaches to traditional medicine and dentistry, the concept of holistic or naturopathic dentistry has arisen. Patients concerned about the idea of heavy metal toxicity are often drawn to practitioners who advocate the removal of traditional amalgam fillings. The American Dental Association (ADA) has published a pamphlet entitled Principles of Ethics and Code of Professional Conduct. The code mandates “5.A REPRESENTATION OF CARE. Dentists shall not represent the care being rendered to their patients in a false or misleading manor.” In the included advisory opinions, the ADA has noted “based on current scientific data, the ADA has determined that the removal of amalgam restorations from non-allergic patients for the alleged purpose of removing toxic substances from the bodies, when such treatment is performed solely at the recommendation of the dentist, is improper and unethical.” The code goes on to state “5.A.2 UNSUBSTANTIATED REPRESENTATIONS. A dentist who represents a dental treatment or diagnostic techniques recommended or performed by the dentist has the capacity to diagnose, cure, or alleviate diseases, infections, or other conditions, when such representations are not based upon accepted scientific knowledge or research, is acting unethically.”
Holistic dentists also refer to themselves as biologic dentists. The ADA does not recognize either holistic dentistry or biological dentistry as an appropriate specialty. In fact, the Code of Ethics and the Code of Professional Responsibility maintains that advertising specialty certification not approved by the ADA is in and of itself unethical.
We recently represented a patient suffering from Multiple Sclerosis, who was seeking holistic alternatives to attempt to alleviate her symptoms and/or progression of her MS. She was drawn to the website of a holistic dentist for the purpose of removing amalgam fillings. She presented with no pain or other symptoms. Thirty years prior she had undergone extractions, without difficulty, of all four of her wisdom teeth. This so-called holistic treater convinced her that those extraction sites had what he referred to as cavitations. He discussed the concept of NICO (neuralgia inducing cavitational osteonecrosis). He recommended surgical removal of the cavitations together with treatment of ozone injections, without radiographic proof of the existence of these so called cavitations and in the absence of pain or other pathology. Clinical examination performed by the dentist was normal. The patient underwent surgical exploration of all four extraction sites with a curette and electric drill. As a result, this dentist caused bilateral damage to her inferior alveolar nerves. The inferior alveolar nerve (IAN) stems from the third branch of the facial nerve, on each side of the face, and proceeds along the base of the jaw, partly through a bony canal, to the midline of the chin. As a consequence of the damage, she sustained bilateral anesthesia of her lip, cheeks, teeth, and gums, with devastating impact on her life.
The concept of NICO, neuralgia inducing cavitational osteonecrosis, is outside the mainstream of oral surgery and dentistry. Cavitations are generally poor healing areas that harbor microorganisms. In the case of this patient, there was no evidence of that. She presented with no pain or swelling. The treatment with ozone injections into the surgical sites was also well outside the mainstream of dentistry. Paresthesia, or numbness of the right and left IAN, should be at the top of complications and risks of surgery in those areas.
The asymptomatic patient who presents to a holistic or biological dentist and receives a recommendation of surgical intervention to treat cavitations or NICO should clearly seek a second opinion from a qualified board certified oral and maxillofacial surgeon before exposing him or herself to a what can be a life altering injury.
Dental consumers should be leery of unsubstantiated treatment options and treatment claims spelled out on a practitioner’s website. With the exceptions of those dental specialties that require hospital privileges, such as oral and maxillofacial surgery, the great majority of dental practices are not subject to peer review. In Connectict, the Dental Practice Act (Section 20-103a, Connecticut General Statutes) essentially allows a dental practitioner to perform any type of treatment where such individual has obtained the requisite training or experience, without the need for specialty certification. In those dental practices, such as oral surgery that require hospital privileges, hospitals have morbidity and mortality committees that conduct peer review of any adverse consequences suffered by the patient. Credentialing committees limit what practitioners are permitted to do in the hospital setting. By contrast, in the dental office, there is no one looking over the dentist’s shoulder questioning the practitioner’s training or experience and ability to provide certain treatments.
An excellent article appears on the website Quackwatch.org written by Dr. Stephen Barrett entitled “Cavitational Osteopathosis, Bouquot, NICO and ‘Biological Dentistry’.” Dr. Barrett notes “believers in ‘biological dentistry’ have taken the treatment one step further. They claim that root canal treated teeth cause NICO, as well as a host of other chronic systemic diseases. They recommend removing all root canal treated teeth…” Dr. Barrett sites to a position statement published in 2012 by the American Association of Endodontists indicating that that association could not condone surgical interventions intending to treat suspected NICO lesions, until an orofacial pain specialist confirmed the diagnosis. That position statement goes on to state, “In addition, the practice of recommending the extraction of endodontically treated teeth for the prevention of NICO, or any other disease, is unethical and should be reported immediately to the appropriate state board of dentistry.” Dr. Barrett notes that there have been a number of dental malpractice lawsuits for NICO related misconduct, suing dentists who diagnosed nonexistent cavitations. “Some of the plaintiffs also had teeth and/or amalgam fillings removed unnecessarily, and some required extensive medical and surgical treatment to repair jaw damage and disfigurement caused by the NICO surgery. Some of the patient wound up with chronic pain.”
Dr. Barrett also notes that because most insurance companies do not cover procedures related to “cavitational osteonecrosis,” many practitioners who diagnosis NICO misstate or miscode the procedures in order to obtain insurance payments, which is in and of itself fraud. Dr. Barrett provides the following advice to consumers of dental services: “If you find yourself in the office of a dentist who tells you that a systemic disease or pains far from the mouth are due to infected jaw-bone cavities, run fast and find another dentist!” (www.quackwatch.org\related\cavitation)