Having such research in a frequently read (and cited) journal like the JADA is problematic in many ways. Time and my attention span will not permit me to go into great depth into those issues, but I do want to present an outline of the article, how (while no doubt well-intentioned) bad science was constructed atop a foundation of worse science, why the JADA had no business publishing such nonsense, how our body of scientific knowledge was not advanced one iota by this piece, and why the American Dental Association sullies the concept of science based inquiry when it associates with pseudo- and pre-scientific woo.
This research, supported by the National Center for Complementary and Alternative Medicine (NCCAM), was authored by four Chiropractors, a PhD (all but one of whom are associated with the Palmer College of Chiropractic), two dentists, and an RN (the latter three associated with the University of Iowa College of Dentistry). Their stated goal was to “assess the feasibility of conducting a full-scale RCT to evaluate the effectiveness of AMCT (Activator Method Chiropractic Technique) for the treatment of patients with chronic myofascial TMD (Temporomandibular Disorder).” (Note: RCT = Randomized Controlled Trial) Their rationale was that since many TMDs “can become a chronic problem lasting several years, and patients receive little help from traditional forms of treatment”, perhaps complementary and alternative medicine (CAM) therapies should be considered.
Yes folks, you heard right! Three. Minute. Orthodontics. Why spend thousands of dollars and years of aggravation with braces, palatal expanders, retainers, cut cheeks, and social isolation when you can correct your overbite in three minutes?
How, you might ask? With all the scientific advances in orthodontic treatment in the past 100 years, with the improvement in imaging, diagnosis, and the amazing materials we have these days- how can we push the envelope even further in orthodontics?
Well, I’ll tell you.
According to the video you’re about to see, “Dental Acupuncture is a special branch of acupuncture. Asthetic Dental Acupuncture is a Super Specialty.” So, dear Prism readers, I hope you feel like a priviliged insider because you’re about to see a “Super Specialist” at work. You can’t get this anywhere else. I’ve been practicing dentistry for over 27 years, and I have studied with some of the finest and most prestigious clinical dentists in academia and in practice, and I have never had the good fortune to even touch the hem of a “Super Specialist’s” garment. So, I hope you’ll excuse my giddiness.
Anyway, many of you may remember the scene from the movie “There’s Something About Mary” in which the hitchhiker, played by comedian Harland Williams, talks about the next big thing – Seven Minute Abs. Watch.
Well, that same “outside the box” thinking has hit dentistry, thanks to a pair of Indian “Super Specialists.” The video below show a case report of an overbite allegedly being corrected by “asthetic acupuncture.” Warning: It’s a little graphic in a stabby, bleedy sort of way.
So there you have it.
Ok, joking aside. I realize that this is a fringe treatment in a far-off land, at least far off from where I’m composing this post. I also realize that this treatment isn’t widespread, nor is it likely to become so. It’s quackery, pure and simple. It’s about as far away from the standard of care as a dental procedure can get. It’s funny because even a non-dentist, nay, even any person with a modicum of science knowledge or common sense can see this is bunk and ludicrous and biologically implausible and every other hyperbolic refuting description one can think of. That being said, it is an excellent example of why we at The Prism do what we do. There are quacks like that out there. Not only in India, but everywhere. There are innocent and gullible individuals who fall prey to such quacks. Not only in India, but everywhere. The quacks need to be stopped and the laypeople need to be educated; it’s as simple as that. The public is harmed when charlatans like this are allowed to deceive the patients who entrust them for their care. Whether you’re an activist trying to shut this crap down, or an educated health care professional, or a concerned resident of Planet Earth, we all must resist woo in all its forms and wherever it rears its ugly head. Even if it seems harmless, the underlying deception and denial of reality hurts everyone.
Believe it or not, there are podcasts out there that are even better than the one Jason and I did a couple of weeks ago (#sarcasm). Among the many fine choices out there, RadioLab is consistently excellent and intriguing; it is invariably at the top of my listening queue. Recently, RadioLab did a show on a patient who survived rabies, which until recently was 100% fatal- a death sentence with no chance of commutation or reprieve from the Governor. The story itself is amazing, and you should stop reading here, take a brief intermission and go listen to it. I’ll be here when you get back.
OK, back? Pretty good, huh? Though I was transfixed during the entire episode, do you know what little tidbit of information stuck with me more than anything else? The off the cuff factoid that back in medieval times, one of the treatments for rabies was to pluck the feathers from around a rooster’s anus, then apply said anus to the animal bite, ostensibly to “suck out” the infection. Makes sense, eh? I mean, I’m no rooster anus aficionado, but I can imagine that it might resemble a suction cup sort of thing. These are some pretty weird dots to connect to be sure, but I guess that when faced with a potentially fatal disease, physicians back then tried anything and everything hoping to find that magical cure, even if by luck or trial and error. Without the scientific method, that’s pretty much all they had.
Why, I can hear you ask, whywould tincture of tush even continue as a recommended treatment after the first attempt or two? OK, I’ll give the doctor/barber/blacksmith the benefit of the doubt when thinking of it for the first time and giving it a go, but then after that? How could the doctor of yesteryear think this was a good idea? Did his success rate in treatment skyrocket after sphinctotherapy? How does one rationalize this?
Well, here’s how it went down, and the reason I’m bringing this up isn’t just because it’s a fun, quirky subject or that I have a thing about poultry and/or anuses. There are modern day applications of this same dysfunctional thought process, and the public must be made aware of these modern day purveyors of rooster anus therapies and their likes.
Suppose you’re this guy, the village doctor:
A frantic mother comes running into your office/stables with her 12 year old daughter in tow. The young girl has just been bitten by a mad dog and everyone knows what that means. Thinking quickly, you grab a rooster, pluck the feathers from around its anus (I’m sure there’s an insurance code for that), and apply buttsuction pressure to the wound stat. You then write a prescription to the mother like so:
After a week, you go and check up on the family; lo and behold! the girl is fine. No signs of rabies and the wound is healing well. When you get back to your office/stables, you look back over your notes and determine that your avian treatment protocol has roughly a 25% success rate. “That’s pretty good” you say. “If it weren’t for my quick thinking and medical acumen, they all would have died. This modern treatment of rabies is proof that we have truly made great advances in medical science. In my experience, rooster anus is the treatment of choice for rabies.”
So what is the reality here? Do sphincters possess medicative qualities? Was Yorick the doctor/barber/blacksmith on the right track?
No and no.
The reality is that while rabies is a horrible disease, it is only 100% (well, until recently at least) fatal once it has established a foothold in the host. Often, a person who is bitten by a wild animal doesn’t contract rabies at all. There are several possible explanations for this: 1. the animal didn’t have rabies to start with, 2. the bite didn’t break the skin, 3. the virus didn’t enter the bloodstream or other area where it could take up residence in the nerve tissue, or 4. the victim’s antibodies dispatched the viruses before they could cause harm.
There could be other explanations and scenarios, but you get the picture. While all rabies infections were 100% fatal, not all animal bites were. Dr. Yorick, of course, wasn’t aware of all the times a person was bit who subsequently remained healthy. His experimental group, as it were, consisted only of those who either had been bitten but not yet showed the signs of rabies or people with full-fledged rabies. The former group would naturally respond reasonably well to Rooster Anus Therapy®, not because of the rooster, but because that person stood a decent chance of remaining healthy anyway. Yorick naturally would take credit for the health of this subgroup. This fallacy in reasoning is called Post Hoc, Ergo Propter Hoc, which is similar to Affirming the Consequent. The logical structure goes something like this: P occured before Q. Q resulted, therefore P caused Q. Translated, this reads “If I put a rooster’s anus onto an animal bite, the patient will not contract rabies. The patient did not contract rabies. Therefore, rooster anus is effective and prevented the rabies.” This is where Yorick went wrong and relied only upon his experience, but you can’t blame the chap.
You can, however, blame the frauds, quacks, and ignorant practitioners of woo out there who peddle their own version of rooster anuses to a gullible and unsuspecting public. From homeopathy to acupuncture, to just about every kind of “complementary” or “integrative” therapies, they all work on the same Affirming the Consequent principle. You pressed, poked, stabbed, or shocked some alleged point on your body and your knee pain felt better? You swallowed a supplement and you slept better last night? You pressed a rooster anus to your squirrel bite and you didn’t get rabies? The delusional practitioner will think “In my experience, ________ has worked well.” This is very dangerous thinking.
Modern day alt-med thinking and medieval rooster thinking is pretty much the same thing.
Most health care practitioners worth their salt know this; however, a vast number of lay people, as well as many other health care providers either don’t know it or choose to ignore it because of some bias or agenda. Or perhaps they are outright charletans. However, it is the responsibility of every science minded individual to fight this type of thinking and challenge these dysfunctional practices wherever they occur.
Editor’s Note: Grant has been away playing in Glacier National Park, and Jason is away in Colorado taking part in the grueling Transrockies Run. While we’re away, we thought we’d post an article Grant (along with friend and colleague Dr. Steve Hendry) wrote a couple of years ago for the Science Based Medicine Blog. It’s just as relevant to the mission and purpose of The Prism as it is to SBM, so we thought it would be fitting to reprint it here. This version has been slightly modified from the original.
Form follows function, as the old saying goes. Nowhere in the human body is this adage more fitting than in the oral cavity. In less than two generations, the practice of dentistry has evolved from basic pain relief and function-based procedures (such as extractions and fillings), into today’s practices of complex cosmetic rehabilitation, orthopedic and orthodontic management of the teeth, jaws, and facial structures, replacing missing teeth with dental implants, and treatment of sleep apnea and temporomandibular joint (TMJ) disorders, to name but a few. With such rapid progress, it is to be expected that for every science based advance made in our field, there are just as many claims that are either dubious in their evidential support or outright pseudo-scientific or anti-scientific nonsense.
In this article, we’ll be taking a look at the roles that health care practitioners such as chiropractors, osteopathic physicians, and physical therapists, are attempting to play in the dental field. We will also see how well-meaning dentists have been trained in and apply their pseudo-scientific principles in their dental practices. In particular, we’ll be examining Cranial Osteopathy (also known as Craniosacral Therapy or Cranial Therapy) in the management of the dental patient, the purported benefits claimed by practitioners of cranial osteopathy, and the quality and quantity of evidence for this type of treatment in the scientific literature.
Basic Skull Anatomy
The human skull is made up of some eight cranial (head) bones and fourteen facial bones. These bones help protect the organs of vision, hearing, taste, equilibrium, and smell. Without them, our brains would continuously spill out onto the table, which would be embarrassing and maladaptive. They also provide attachment for muscles that move the head, control facial expressions and chew our food. At birth, the spaces between the cranial bones- called fontanelles – are relatively wide and elastic, allowing the infant to squeeze through the birth canal and later permitting brain growth in the first few years of life. In humans the lateral fontanelles close soon after birth, the posterior fontanelle generally closes several months later, and the anterior fontanelle may remain open for three years.
By early childhood, the cranial bones become tightly interlocked in a zig-zag, zipper like pattern (illustrated nicely here) that renders them immovable in a macroscopic sense, although each suture (called a synarthrosis if you want to impress your friends at parties) has a very slight amount of flexibility- 10-30 micrometers on average (1 micrometer = 1/1000th of a millimeter or approximately 4/100,000ths of an inch). These sutures fill the minuscule space between the cranial bones, essentially stitching them together with dense, strong connective tissue fibers called Sharpey’s fibers.
Here at the Prism, it is our thesis that one of the major issues with alternative medicine is their over-reliance on anecdotes (n = 1) as solid evidence for whatever treatment regimen or therapy they are promoting. To be sure, an anecdote in and of itself is not de facto invalid; for example, when a proven therapy works, we have a positive anecdote to attest to it. However, any self-respecting science based individual would not place any significant weight on a single anecdote, or even a small cluster of consistent anecdotes, without evaluating the context in which is it offered.
The philosophic heart of the anecdote-as-evidence issue is “The Problem of Induction,” elucidated most famously by David Hume in the 1700s. Called “the glory of science and the scandal of philosophy” by philosopher C.D. Broad, inductive reasoning is a useful method of acquiring knowledge; however, it is not without its issues.
(I’ll try to figure out how to embed one of these days…)
So you see that while it is useful (and often necessary) to apply to the general what is observed from the specific, the logic is not airtight. The premise “the future will resemble the past” is the cornerstone of the argument, and it can never be shown to be true (at least not without a time machine!).