THE AMERICAN COUNCIL ON SCIENCE AND HEALTH PRESENTS

Dr. Elizabeth Whelan, President ACSH, 1995 Broadway 2nd Floor, New York, NY 10023 A PRIMER ON DENTAL CARE: QUALITY AND

Prepared for The American Council on Science and Health

By John E. Dodes, D.D.S.

Art Director: Jennifer Lee

SEPTEMBER 2006

AMERICAN COUNCIL ON SCIENCE AND HEALTH 1995 Broadway, 2nd Floor, New York, NY 10023-5860 Phone: (212) 362-7044 • Fax: (212) 362-4919 URLs: http://acsh.org • http://HealthFactsAndFears.com E-mail: [email protected] TABLE OF CONTENTS

Genuine Credentials------01

Dubious Credentials------01

The Relation of to Systemic Disease------02

Smoking------02

Tooth Whitening------02

Implants------03

Bonding------03

The Dental Exam and X-Rays------03

Fluoridation------04

Dental Insurance------04

Dubious Dental Care------05

Inappropriate TMJ Therapy------05 Biologic and NICO------06 Silver Amalgam Toxicity------06 ------07 Promotion of Dubious Dentistry------08

Recommendations------09

References------10

ACSH accepts unrestricted grants on the condition that it is solely responsible for the conduct of its research and the dissemination of its work to the public. The organization does not perform proprietary research, nor does it accept support from individual corporations for specific research projects. All contributions to ACSH—a publicly funded organization under Section 501(c)(3) of the Internal Revenue Code—are tax deductible.

Copyright © 2006 by American Council on Science and Health, Inc. This book may not be reproduced in whole or in part, by mimeograph or any other means, without permission. 1 Y R E K

Endodontics: Diagnosis and treatment of diseases of C xperts on dental health fraud suspect that over a A

billion dollars a year is spent on dubious, the root pulp and related structures (). U unnecessary, and poor-quality dentistry. Oral and Maxillofacial Surgery: Tooth extractions; Q E D diagnosis and surgical treatment of diseases, N

Dental diseases are among the most common ailments injuries, and defects of the mouth, jaw, and face. A in the United States, accounting for over $70 billion in Oral Pathology: Diagnosis of tumors, other diseases Y T

1 I bills. The majority of dentists work in the privacy of and injuries of the head and neck. L their own office where they usually are not subject to : Dental care of infants and chil- A U

review by knowledgeable colleagues. This situation, dren. Q :

plus the fact that the harm done by poor dental care : Diagnosis and correction of tooth align- E may not become apparent for many years, makes it ment and facial deformities. R A

difficult for consumers to evaluate the quality or the Periodontics: Diagnosis and treatment of diseases of C necessity of the treatment they receive. the gums and related structures. L A

Prosthodontics: Diagnosis and treatment involving the T replacement of missing teeth. N Experts on dental health fraud suspect that over a bil- E lion dollars a year is spent on dubious dentistry. The Public Health Dentistry: Prevention and control of D

February 1997 issue of Reader’s Digest contained an dental disease and promotion of community den- N article, “How Honest Are Dentists?” that illustrated tal health. O R the vast potential for unnecessary over-treatment by Oral and Maxillofacial Radiology. E M

unscrupulous dentists. The author, William I

Ecenbarger, went to 50 dentists in 28 states and asked Several other groups of dentists are trying to be recog- R what dental treatment he needed to have done. He nized as official specialties but have not achieved P A brought a recent full set of x-rays and told the dentists recognition yet. he was satisfied with the way his teeth looked. He had previously been examined by an expert panel of den- tists (I was a member of the panel) and told he had 2 teeth that needed repair. Many of the dentists he saw Dubious Credentials told him he needed numerous crowns, the dentist in Some dentists who have not completed train- New York City recommended 21 crowns and veneers ing but who limit their practice or emphasize an aspect on the lower 6 front teeth at a cost of $29,850. Only 21 of their practice refer to themselves as specialists. dentists performed an oral cancer screening and only Many such dentists practice in a scientific manner and 14 did the recommended periodontal screening. In do high-quality work. However, some claim to be spe- addition, a number of the dentists missed the 2 teeth cialists in fields that are either unrecognized, unscien- that needed treatment and recommended other work. tific, or both. These include “,” “TMJ disorders,” “holistic dentistry,” “bonding,” ACSH believes that unnecessary and unscientific den- “implants,” and “amalgam detoxification.” A few den- tistry poses a substantial risk for the American public. tists base their claim of being a specialist on atten- This report identifies the main problem areas and sug- dance at a weekend seminar. gests what can be done about them. Consumers should also be wary of three other types of credentials: 1) nutrition “degrees” from unaccredited Genuine Credentials correspondence schools, 2) “professional member” certificates from organizations with no scientific There are over 110,00 dental offices in the U.S.A.1 standing, and 3) certificates of attendance distributed Dentists have either a D.D.S. (doctor of dental sur- at “continuing education” courses. Although the great gery) degree or the equivalent D.M.D. (doctor of med- majority of continuing education courses are valid, ical dentistry) degree. The American Dental unscientific theories and unethical practices are taught Association (ADA) recognizes 9 specialties. To be at some of them. called a specialist, a dentist must undergo at least 2 years of advanced training accredited bv the ADA Council on Dental Education in one of these disci- plines: 2 Y R E K C A

The Relation of Periodontal Smoking U Disease to Systemic Disease Q Smoking has obviously been shown to be a major D

causative factor for lung cancer and cardiovascular N In the 2000 Surgeon General’s Report on Oral Health A

disease. It is also strongly associated with the develop- Y in America, it was noted that “the concept of oral T

ment and exacerbation of periodontal disease. I

health as secondary and separate from general health L Smoking will cause far greater loss of bone around the is deeply ingrained in American consciousness and A teeth of patients with periodontal disease, and smok- U

hence may be pivotal and most difficult to over- Q

2 ing makes the prognosis for successful treatment far :

come.” Yet recent news stories have discussed the E worse. Chewing tobacco is also a major cause of oral connection between gum disease and both low birth- R cancer and should be strongly discouraged in athletes A

weight babies and a higher risk of cardiovascular dis- C 3 who are often role models for young people [Editor’s ease. L

note: As ACSH has noted elsewhere, though, switching A T

to smokeless tobacco can yield a net reduction in over- N There is very strong research showing a correlation all cancer risk for those smokers who are otherwise E between periodontal disease and serious general health D unable to quit cigarettes]. problems. But, so far, scientists have not established a N clear “cause and effect” relationship. We do know that O R periodontal disease causes inflammation. The amount E M of inflammation can be measured with a blood test for I certain chemicals such as C-reactive protein and tumor R necrosis factor-alpha. It has been shown that these and It seems that Americans are almost pathologically con- P other chemicals that are indicative of inflammation are cerned with how white they can get their teeth. The A much higher in patients with periodontal disease.4 normal color of teeth is yellow-white. Almost all bleaching products contain hydrogen peroxide in dif- There is strong evidence of a connection between peri- ferent concentrations. The more concentrated the per- odontal disease and diabetes.5 Patients with diabetes oxide, the less time it has to be in contact with the have more severe periodontal problems and patients teeth. One hour bleaching employs very concentrated with periodontal disease have more severe diabetes.6 peroxide, around 38%. At this strength, it can burn the There are also several studies in which successful peri- gums severely, so the dentist has to spend a great deal odontal therapy in diabetic patients resulted in better of time placing a protective membrane over the gums glycemic control. before the peroxide is applied. Because of this, the cost is high — between $350 and $1500. You can also At this time it appears that periodontal disease is also have custom trays made. These are clear plastic and fit an important risk factor in the development of both snugly over the teeth. The patient is given 15% to 20% cardiovascular disease and strokes.7 Other established peroxide to put into the trays and they are then placed health risks are: smoking, family history, high blood over the teeth. This technique takes about an hour a pressure, obesity, diabetes, and physical inactivity. day for a week and the trays can also be worn while asleep. There are also over-the-counter whitening Unfortunately, we do not know if treating periodontal products such as white-strips. These have a much disease successfully will lower a patient’s risk of these lower concentration of peroxide and therefore need to serious diseases. But it is a safe bet that preventing be worn for far longer, but they do work and are much periodontal disease from occurring at all will lower the less expensive. risk of developing inflammatory chemicals that are risk factors for systemic problems. All whitening products can cause the teeth to become temporarily sensitive to hot and cold. If this happens simply lessen the time that the peroxide is on the teeth. Overuse of any tooth-whitening product can weaken the enamel so it’s very important to carefully follow the dentist’s or manufacturer’s instructions. 3 Y R E K

patients to change both the shape and color of their C Implants teeth without having crowns (caps) made. A U

Dental implants have a checkered history. Many years Q D

ago they were marketed without proper testing and N had a very high failure rate. The newer implants that The Dental Exam and X-Rays A have been used for approximately 25 years have a suc- Y T I

cess rate of well over 90%. They are usually made of The dental exam has been an area often undervalued L titanium and are shaped somewhat like the root of a by the public and neglected by some dentists. Many A U

tooth. When they are properly done, a patient can patients have become accustomed to paying very little Q :

expect them to last a very long time. for a cursory yearly dental exam. E R A

Unfortunately there are dentists doing implants who The examination is a vital part of a dental visit. It pro- C are not properly trained. There is no recognized spe- vides the information the dentist must have to develop L A cialty in implantology, although the American Dental a diagnosis and a plan of treatment. The dentist looks T N

Association has been petitioned to establish one. It is carefully at the patient’s face, bones, teeth, gums, E doubtful whether the ADA will do so, since so many cheeks, tongue, palate, and floor of the mouth. With D different groups are doing implants, including general the fingers, the dentist feels the tissues, particularly N dentists, oral surgeons, and periodontists. any swollen, irritated areas, and tests the teeth for O R

movement or looseness. A sharp explorer (the curved E M

As a general rule, it is probably safer to have the sur- instrument many patients call a “pick”) is used to I gical part of the implant procedure done by someone check for cavities and defective fillings or crowns. A R who has great experience doing surgery in the mouth, calibrated periodontal probe shows if the gums are P A such as an oral surgeon or a periodontist. They are best tightly attached to the teeth or if there are periodontal equipped for unexpected problems such as bleeding. problems such as bone loss or pockets around the Usually a general dentist or prosthodontist then con- teeth. Special biting instruments are useful in diagnos- structs the replacement teeth, which will attach to the ing cracked teeth. And some dentists have tiny closed- implants. circuit cameras that can project a magnified image of your teeth on a color TV set. It is recommended that a patient needing implants seek out dentists with experience and ask how many X-rays are absolutely essential for a proper exam. A implants the dentist has done, what type of implants full set of x-rays (14 to 18 separate films) should be will be used, what the total cost will be (usually taken every 5 to 7 years and bite-wing x-rays (2 or 4 around $3000 to $4000 per implant), and how long the separate films) should be taken every year or year and procedure will take. a half. Some dentists use an x-ray machine that moves around your head and takes a picture of the entire mouth. These are called panorex x-rays and are very useful for orthodontists and oral surgeons but are not Bonding very good at detecting decay or periodontal problems. Bonding is a technique for attaching a number of dif- Digital x-rays use a sensor rather than film, and the ferent materials to the tooth. It is a safe and useful image is sent to a computer screen. Digital x-rays give technique for repairing broken, chipped, or discolored excellent results and require far less radiation than reg- front teeth. However, it does have limitations. The ular x-rays. But patients should still have a lead apron teeth should not have periodontal disease and bonding placed on them. cannot correct severe orthodontic problems. Perhaps the most overlooked aspect of the dental exam Bonding is accomplished by using an acid to etch the is the search for abnormal tissue that might be cancer- tooth, after which a type of acrylic plastic is placed on ous. Cancer of the mouth and throat is a major cause the tooth. Almost all dentists now use a light to make of cancer-related death in the U.S., exceeding the the plastic set. This allows dentists to shape and color annual death rates for cervical cancer and malignant the restoration and is a major cosmetic breakthrough. melanoma. Thin porcelain “laminates” can be attached to the teeth using a bonded plastic “glue.” This often allows 4 Y R E

There is a new way to easily evaluate any areas that K C

the dentist suspects may be cancerous. It is known as In the United States, 62.2% of the population has A a “brush biopsy” because the dentist uses a tiny stiff- access to properly fluoridated water. More than 360 U bristle brush to scrape some cells off the questionable million people worldwide, spread throughout over 60 Q 12 D area. Those cells are rubbed onto a glass slide and countries, also drink fluoridated water. Dr. C. Everett N mailed to a company that uses a computer to select Kopp, the former Surgeon General of the United A Y

those slides that need to be looked at by a pathologist. States stated, “Fluoridation is the single most impor- T I

If the cells are abnormal, a fax is sent to the dentist tant commitment that a community can make to the L within a few days and the patient is referred for further oral health of its citizens.” A U evaluation. In recent studies, this computer-assisted Q 8 : analysis detected nearly 100% of confirmed cancers. Fluoridation should be encouraged in those communi- E Since the patient needs no anesthesia for this test and ties that are still not fluoridated. R A it is quite inexpensive, dentists now have a wonderful C new technique for early detection of oral cancer. L A T

Dental Insurance N In order to avoid misdiagnosis and improper dentistry, E a thorough and meticulous exam is critically impor- D

By the mid-1990s, over 40% of Americans over 2 N tant. years old were covered, to some degree, by private O

dental insurance.13 Yet insurance has had only a limit- R E

ed effect on the oral health of the US population. M I

Fluoridation There are many reasons, including: the working poor R and unemployed, who usually have greater dental P Recent surveys report that more than 94% of adults needs, are usually uninsured; many dentist do not par- A have had decayed teeth and 22.5% had root surface ticipate in Medicaid, which provides only limited den- decay.9 Decay is the most common disease of all tal coverage, because of low reimbursement; most humanity. Fluoride is one on the most common ele- dental insurance plans have annual limits that are too ments on earth and is an essential nutrient. low for comprehensive treatment; low quality, assem- bly line type practices are often major providers for In growing children, fluoride will strengthen the hard those with insurance and quality assurance is more structures of the teeth, both enamel and dentin. In myth than reality; fee-for-service is a powerful incen- adults, fluoride will only be absorbed by the enamel tive to maximize production leading to over-treatment; surface, giving the teeth temporary but substantial capitation plans often under-treat their patients.14 resistance to decay. A review of dental insurance plans concluded that Fluoride that is delivered through community water “any and all of the (insurance) programs can perform systems at 1 part per million (ppm) has a large margin effectively, but only if the basic principles of quality of safety. “Numerous studies done before and after assurance and cost containment are effectively supplemental fluoridation have shown no changes in applied. The problem is not to pour more money into death rates from cancer, heart disease, intracranial health care, but how to reduce the incredible amount lesions, nephritis, cirrhosis, or any other cause. In of excess and substandard treatment and outright addition, the normal disease and death rates of more fraud. Money saved by reasonable and sensible than 7 million Americans who have lived for genera- administration can then be reallocated to improve pop- tions where the natural fluoride concentration was 2 to ulation coverage and benefits so that no one — no one 10 mg/L (1 mg/L being the recommended dose) is — in the United States need be denied access to good compelling evidence of fluoridation’s safety.”9 10 As health care.”14 Consumers Union has concluded:

The simple truth is that there’s no “scientific con- troversy” over the safety of fluoridation. The practice is safe, economical, and beneficial. The survival of this fake controversy represents one of the major triumphs of quackery over science in our generation.11 5 Y R E

teeth while sleeping. Similar appliances (bite splints) K

Dubious Dental Care may be prescribed to relieve muscle strain in patients C A

with TMD. Night guards and bite splints do not cause U This section discusses a number of areas of dental teeth to become misaligned. Q practice that involve considerable controversy. “TMJ D therapy” is a “no-man’s-land” in which some practi- N

Plastic appliances are sometimes misprescribed when A tioners act responsibly while others make extravagant a patient’s joint makes a clicking or grinding noise, Y claims and prescribe expensive treatment that is inef- T even when there are no other symptoms. Research I fective. “Biologic dentistry” is a hodgepodge of unsci- L

shows that joint sounds without pain or restricted or A entific theories and treatments based on discredited irregular jaw movement do not indicate any disease U science. And the allegations against silver-amalgam Q process and that no treatment should be undertaken in : fillings are caused by greed and gullibility. 16 E

these circumstances. R A

Inappropriate TMJ Therapy C

Some dentists use electronic instruments to diagnose L

and treat TMJ disorders. The diagnostic procedures A A confusing muddle of diseases and conditions has T

include: surface electromyography (EMG), jaw track- N been lumped under the term “TMJ” disorders. The E

ing, silent period durations, thermography, sonogra- D most common symptom of “TMJ” is chronic facial

phy, and Doppler ultrasound. Use of these procedures N pain (pain lasting more than 3 months), often accom- for diagnosing TMJ is not supported by scientific evi- O

panied by difficulty in fully opening the mouth. R dence. Similarly, treatment with ultrasound or TENS “TMJ” is actually the abbreviation for “temporo- E

(transcutaneous electrical nerve stimulation, in which M mandibular joint,” the hinge joint that connects the I

a low voltage, low amperage current is applied to R lower jaw to the skull. Since the joint itself may not be painful body areas) has not been proven effective.17 18 P

the source of the symptoms, the term “temporo- A mandibular disorders” (TMD) is more accurate. Some dentists obtain TMJ x-ray films as part of their routine dental examination. These films should be TMJ disorders have been described as dentistry’s obtained only when there is a history of trauma or pro- “hottest” area of unorthodoxy and out-and-out quack- gressive worsening of symptoms, but not as a routine ery.15 Pains in the face, head, neck, and even remote screening procedure.19 parts of the body have been erroneously diagnosed as TMJ problems. Some practitioners also claim that a There are also physicians who refer patients with “bad bite” causes ailments ranging from menstrual facial pain to unscientific “TMJ specialists.” Still cramps, impotence, and scoliosis to a host of systemic worse is the collusion of self-styled “TMJ experts” diseases. with attorneys. Some dentists solicit personal injury attorneys by offering to certify accident victims as The correction of a “bad bite” can involve irreversible having accident-related TMJ injuries — including treatments such as grinding down the teeth or building “mandibular whiplash,” a diagnosis not recognized by them up with dental restorations. The most widespread the scientific community. Attorneys have even been unscientific treatment involves placing a plastic appli- invited to free medico-legal seminars with a brochure ance between the teeth. These devices, called stating that a patient “was awarded a settlement of mandibular orthopedic repositioning appliances over $100,000 for TMJ injuries alone...based (MORAs), typically cover only some of the teeth and on...emotional and physical distress resulting from the are worn continuously for many months or even years. TMJ injury.” Ultimately, the insured public has to pay When worn too much, MORAs can cause the patient’s for such abuse with higher premiums. teeth to move so far out of proper position that ortho- dontics or facial reconstructive surgery is needed to There is considerable evidence that for patients with correct the deformity. TMJ expert Charles S. Greene, real TMJ problems, safe, simple, inexpensive treat- D.D.S., of Northwestern University Dental School, ments (such as warm moist compresses, cold com- cautions that plastic appliances should be used only presses, ibuprofen, simple jaw exercises, and a soft when necessary, for limited periods of time, and never diet) will produce similar high rates of improvement while eating. as do unsafe, complex, irreversible, expensive treat- ments.20 MORAs are different from “night guards,” which cover all the teeth and are used to prevent abnormal Dr. Joseph Marbach, the late former director of both wearing down of the enamel in people who grind their 6 Y R E

the Facial Pain Clinic at the Harvard School of Dental According to an article in Milwaukee Magazine, a K

Medicine and of pain research at Columbia group of local patients filed suit against several practi- C A

University’s School of Public Health, warned against tioners who diagnosed them with NICO, resulting in U surgery as a treatment for TMJ disorders. Some proce- unnecessary tooth extractions and invasive and Q dures remove the disc between the skull and the lower destructive jaw surgeries.24 D N

jaw; others surgically reshape the joint or even replace A the entire joint with an artificial one. Surgery should Patients who are diagnosed with NICO should get sec- Y T be considered for tumors, “frozen jaws,” or other ond opinions, preferably from a local dental school. I L definitively diagnosable problems that can only be And patients should refuse to have asymptomatic root- A resolved through surgery. Patients should always ask canal-treated teeth extracted because of this very ques- U Q how likely it is that the surgery will make the symp- tionable diagnosis. Insurance carriers should refuse : E

toms worse or cause other complications. Since sur- reimbursement for NICO-related treatments and for R gery is irreversible, other alternatives should be the use of the Cavitat diagnostic device. Aetna has A C

exhausted first. If surgery is recommended, it is pru- already taken this step. L dent to obtain a second opinion. A consultation with a A T member of the oral surgery department of a dental Silver Amalgam Toxicity N E

school would be ideal. D

“Silver” fillings, usually called “amalgams,” are made N

Biologic Dentistry and NICO by mixing an alloy of silver, tin, copper, and zinc with O R

mercury in about a 50/50 ratio. Although the vast E

Recently, a lawsuit alleging malpractice, conspiracy to majority of dentists recognize that silver fillings are M I

commit fraud, and intentional misrepresentation was safe, some dentists and “holistic” physicians blame a R filled against a number of dentists, an osteopath, and large number of diseases — such as multiple sclerosis, P the manufacturer of a unproven diagnostic device immune deficiency diseases, and emotional conditions A called the Cavitat.21 The lawsuit alleges that this group — on the minuscule amounts of mercury that may leak caused a patient to have a number of teeth unnecessar- out of fillings. ily extracted to treat a disease called neuralgia-induced cavitational osteonecrosis (NICO), which the lawsuit Anti-amalgam dentists often use a mercury vapor claims does not even exist. detector to convince patients that they need “detoxifi- cation.” To use this device, the dentist has the patient NICO has been defined as a syndrome of chronic chew vigorously for up to ten minutes, which may facial pain caused by loss of blood supply within the cause a tiny amount of mercury to be released from the jaw, resulting in bone cavity formation. Promoters of surface of the filling. Although this exposure lasts for NICO state that it is similar to a recognized condition just a few seconds and most of the mercury will be called avascular osteonecrosis (AO).22 AO can occur exhaled rather than absorbed by the body, the in bones that do not have a lot of collateral blood ves- machines give a falsely high readout, which the anti- sels, such as the hip, but the human mouth is inundat- amalgamists interpret as dangerous.25 The most com- ed with blood vessels and, because of this, most monly used device, the Jerome mercury tester, is an experts do not believe that AO can occur in the jaw industrial probe that multiplies the amount of mercury bones. it detects by a factor of 8,000. This gives a reading for a cubic meter of air, a volume far larger than the Pain and conditions in other parts of the body far from human mouth. The proper way to determine mercury the jaws have also been blamed on NICO jaw cavities. exposure is to measure blood or urine levels. Scientific Treatment normally consists of extracting all teeth that research has shown that the amount of mercury have root canal therapy and surgical exploration of the absorbed from fillings is insignificant. jawbone and packing of the surgical defects with antibiotic gauze or injecting the “cavitations” with Anti-amalgamists also may use a voltmeter to measure antibiotics for up to 9 weeks. There is no scientific evi- supposed differences in the electrical conductivity of dence to support these claims.23 the teeth. One such device — the “Amalgameter” — was investigated by the FDA because literature Post-graduate seminars sponsored by an association of accompanying it recommended using the device to “biologic dentists” have persuaded a number of den- determine the order in which silver fillings should be tists and some physicians to diagnose NICO in removed. The FDA wrote the company: “there is no patients with numerous different symptoms. scientific basis for the removal of dental amalgams for 7 Y R E

the purpose of replacing them with other materials as The Academy of General Dentistry estimated that at K described in your leaflet...We consider your device as least 5% of dentists were “holistic.”30 In addition to C A

being directly associated with...a process that may financial abuse, “holistic” dentistry can lead to misdi- U have adverse health consequences when used for the agnosis and/or incorrect treatment for serious and Q purposes for which it is intended.”26 Although the den- potentially life-threatening disease. D N tist who manufactured this product has stopped pro- A duction, these and similar gadgets are still in use. Holistic dentists promote a wide variety of food and Y T diet fads that can be quite lucrative. An article in a I L

There is overwhelming evidence that mercury-amal- dental trade journal asked: “Are you interested in dou- A gam fillings are safe.27 Although billions of amalgam bling your net practice income? We almost did it last U Q fillings have been used successfully, fewer than fifty year...we used nutritional counseling as the vehicle.”31 : E cases of allergy have been reported in the scientific lit- Discredited diagnostic methods such as hair analysis, R erature since 1905.28 Yet anti-amalgam dentists often lingual ascorbic acid testing, testing for food allergies, A C

recommend that amalgams be replaced with plastic, pendulum divining, and other bizarre, occult practices L A

gold, or porcelain fillings — a very profitable recom- are often employed to convince patients to purchase T mendation but one that can lead to serious complica- expensive supplements, vitamins and herbal prepara- N 32 E tions. A number of patients have needed root canal tions. D therapy and even lost teeth after the unnecessary N removal of amalgam fillings. One of the most wide-spread unscientific diagnostic O R

techniques is called (AK). AK E

Because anti-amalgam advocates have not been able proponents believe that every organ dysfunction is M I

to win in the court of science, they are trying to win in accompanied by a specific muscle weakness and that R the political arena by attempting to have gullible leg- by testing the muscles the improperly functioning or P islators pass laws making it a crime for dentists not to diseased organ system can be detected. Its practition- A inform patients that silver fillings contain “poisonous ers, many of whom are chiropractors, also claim that mercury.” A recent scientific review of the amalgam nutritional deficiencies, allergies, and other adverse controversy concluded that “the evidence supporting reactions to food substances can be detected by plac- the safety of amalgam restorations is compelling.”27 ing the food in the patient’s mouth. “Good” substances will make certain muscles stronger and “bad” sub- Holistic Dentistry stances will cause muscle weakness. Dentists who share these beliefs typically test muscle strength by The word “holistic” once meant treatment of the asking patients to hold an arm parallel to the floor and whole person with due attention to emotional factors, then pushing down on the arm before and after vita- lifestyle, and prevention. But today some dentists have mins, food substances, or a plastic bite appliance is put subverted this definition to include many pseudoscien- in the patient’s mouth (with the amount of pressure tific and outright fraudulent methods. Many holistic applied by the dentist an easily misjudged or even dentists seem more interested in medical than in den- deliberately varied factor). Treatment could be any- tal procedures and make health claims that are clearly thing from a simple vitamin to an expensive full beyond the scope of dental practice.29 mouth reconstruction.

Prevention is an important goal of health care, espe- Although the theories of AK are so bizarre that testing cially in dentistry, since dentists understand how to them might seem a waste of resources, several inves- prevent or control most major dental diseases. But pre- tigators have subjected AK to controlled tests. One vention is an area easily abused by quacks. “Holistic” study found no difference in muscle response from dentists typically claim that disease can be prevented one substance fo another,33 while other studies found by maintaining “optimum” health, or “wellness.” In no difference between the results with test substances the dental office these schemes usually involve the and with .34 35 purchase of expensive nutritional supplements, plastic bite-altering appliances or invasive and unnecessary The bones of the adult skull are fused yet there are dentistry such as having all the teeth crowned to dentists who claim that these bones can be manipulat- “increase” athletic performance. “Wellness” is some- ed. This is called “cranial ,” and its propo- thing that quacks get paid for when there is nothing nents claim they can cure or prevent a wide variety of wrong with the patient. health problems ranging from headache and visual problems to an “imbalance” in leg lengths. The manip- 8 Y R E

ulation is accomplished by pushing hard on the face Many dentists actually believe in the unproven tech- K and skull.36 The only demonstrable results of this ther- niques they promote. The instruction of dental stu- C A

apy are loss of money and extensive facial bruising. dents may be partially to blame. The scientific U

method, scientific reasoning, and statistics are not Q is based on the notion that stimulating emphasized in dental education. Some dental schools D N

various points on or just beneath the skin can balance are largely authoritarian — with an emphasis on mem- A the “life force” and enable the body to recover from orizing facts rather than understanding their scientific Y T disease. is acupuncture of the and basis. Enid Neidle, Ph.D., former director of scientific I L is based on the notion that the entire body is represent- affairs for the American Dental Association, wrote that A ed on the surface of the ear. Proponents claim that it is these factors leave many students “susceptible to the U Q effective against facial pain and ailments throughout experiences of others,” willing to accept the views of : E the body. It is accomplished by twirling needles or a perceived authority figure without demanding to R administering small electrical charges at points on the know the science supporting those views. A C

ear that supposedly correspond to the afflicted area or L A

organ system. There are no properly controlled scien- On the post-graduate level, quality control in continu- T tific studies to support auriculotherapy. ing education courses is often lacking. Today, states N E

often require many hours of such courses in order to D

Reflexology, also known as “zone therapy,” is based renew a dental license. Although most are valid, cours- N on the theory that pressing on the hands or feet can es on unproven and disproven topics are more com- O

38 R

help relieve pain and remove the underlying cause of mon than they should be. E

disease in areas far from the hands and feet. M When a prestigious dental school or reputable profes- I

Proponents claim: 1) the body is divided into ten zones R which begin or end in the hands or the feet; 2) each sional group sponsors a course eligible for official P organ or part of the body is represented on the surface continuing education credit, it is easy to mistakenly A of the hands and feet; 3) the practitioner can diagnose conclude that the information will be valid. ADA offi- abnormalities by feeling the feet; and 4) massaging or cials have set up criteria for sponsors of CE courses pressing each area can stimulate the flow of “,” but leave it up to the sponsors to vet the lectures. The blood, nutrients, and nerve impulses to the correspon- Greater New York Dental Meeting, which is one of the ding body zone.37 There is no scientific evidence to largest in the world, allowed a lecture at the 2005 con- support these claims. is also claimed to vention by a group that promotes the NICO diagnosis reduce stress. Since foot massage can be relaxing, this and the false doctrine that amalgam is poisonous and claim may have some validity. However, there is no another lecture by an affiliated group on “Bi-Digital reason to pay high fees to have this service performed O-ring diagnosis,” which is an unscientific method of in a dental office. “determining internal-organ ‘representation areas’ on the human tongue.”39 The chairman of the dental Promotion of Dubious Dentistry meeting replied that “we feel we have fulfilled our role in responsibly developing a well-balanced program Quackery, which has been defined as the promotion of for the dental profession to enjoy...[It] should not be construed as indicating endorsement or approval by false or unproven methods for profit, has a long and 40 sad history, but up to thirty years ago was rare in den- the Greater New York Dental Meeting.” tistry. A number of factors have contributed not only to an increase in dental quackery but also to the misdiag- Unfortunately, this kind of reasoning is all too com- nosis and over-treatment of dental patients. These mon among those with the power to control these include increased competition, advertising, higher cost potentially dangerous lectures. for education and for opening a practice, lower inci- dence of tooth decay due to fluoridation and better oral The media often promote quackery and experimental hygiene, diminished dental education in the methods methods by not investigating thoroughly. Many sci- of science, and the failure of organized dentistry to ence reporters do not have the educational background develop guidelines and policies for maintaining high necessary to evaluate health topics. In one case, on quality dental care. Some dentists with an entrepre- CBS’s 60 Minutes, anti-amalgam advocates were neurial talent seem willing to embrace virtually any allowed to terrorize the public with false allegations of dubious practice that has profit-making potential. the toxic effects of amalgam fillings. This led count- less patients to seek unnecessary and risky replace- ment of their fillings. 9 Y R E

Stephen Barrett, M.D., a leading expert on quackery, Overtreatment should be roundly condemned by K C

has labeled that 60 Minutes segment “the most irre- organized dentistry. A sponsible program ever aired on a health topic.” The U program featured a woman who said that her severe To state dental boards: Q D

symptoms of multiple sclerosis had disappeared the N day after her amalgam fillings were removed. This is • The false diagnosis of silver-amalgam toxicity A impossible, since drilling out the fillings causes a tem- and/or NICO has such potential for harm and Y T I porary increase in the amount of mercury in the body, shows such poor judgment on the part of the L not an overnight decrease, and mercury has nothing to practitioner that ACSH believes dentists who A 27 U do with causing MS. engage in these practices should have their licens- Q :

es revoked. E

On the other hand, NBC-TV’s Dateline did a story on R A

amalgam fillings that was accurate and very critical of To legislators: C the 60 Minutes segment. And Inside Edition used a L A hidden camera to show how a dentist tried to persuade • Funding for state consumer protection and profes- T N

the unnecessary removal and replacement of amalgam sional regulatory agencies should be increased. E fillings in the reporter’s mouth. • State laws should be strengthened so that dentists D

performing dubious dental procedures can be dis- N ciplined more quickly. O R

• State boards should be required to make discipli- E

Recommendations M

nary actions public. I

• Insurance companies should not be forced to pay R Public protection against unscientific and unnecessary P for inappropriate TMJ therapy or any other type dentistry is needed. Here are some recommendations: A of unscientific treatment. To consumers: To dental organizations: • Remember that dentists are neither trained nor • The American Dental Association should issue licensed to treat problems outside of the mouth guidelines categorizing dental techniques as: 1) and jaws. generally safe and effective, 2) experimental but • If a dentist tells you that silver-amalgam fillings based on sound scientific principles, or 3) are poisonous, find another dentist! unsound or disproven. • Don’t hesitate to get a second opinion when exten- • Dental malpractice insurers should withhold cover- sive dental work is proposed or unorthodox pro- age for claims arising from procedures classified cedures are suggested. as unsound or disproven. • Don’t let the dentist confuse elective cosmetic pro- • Third party insurers should not pay for unsound or cedures with dentistry required to treat disease. disproven procedures and should closely monitor • If you suspect that you have been a victim of den- claims based on experimental treatments. tal quackery or mistreatment, contact your local • Steps should be taken to stop the spread of misin- dental society and your state attorney general. formation to dentists through accredited courses. This can be accomplished by setting and enforc- To dental educators: ing standards for the sponsors of courses and lec- turers. Unproven hypotheses and conjectures • The best defense against quackery is an under- must be distinguished from factual information. standing of how scientific knowledge is devel- The standards that exist today do not weed out oped and verified. Dental education should questionable topics and speakers. include instruction on the and the detection of quackery. Courses on consumer Some educators are concerned that overly rigid stan- health should also be included in everyone’s edu- dards can stifle the development of important new cation. ideas. However, these recommendations will not stifle • Teaching ethics needs to start with the way patients scientific progress, since dentists can still take such are treated in dental schools. All too often they courses but will simply receive no credit for them. are thought of by both teachers and students as a means to a diploma and nothing more. 10 Y R E K

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28. American Dental Association. When your patients ask A Encyclopedia of Water, John Wiley and Sons, 2005. about mercury in amalgam. J Amer Dent Assoc. 10. World Health Organization. Fluorides and Human 120:395-398, 1990. Health. Monograph 59, Geneva. World Health 29. Greene CS. Holistic Dentistry — where does the holis- Organization, 1970. tic end and the quackery begin? J Amer Dent Assoc. 11. Anon. Fluoridation: a two-part report. Consumer 102:25-28, 1981. Reports, Jul-Aug, 1978. 30. Remba Z. Beyond Dentistry: How far is too far? Acad 12. American Dental Association. Fluoridation Facts. Gen Dent Impact. 12(8):1, 6-7, 1984. Chicago: Council on Access, Prevention and 31. Jacoby HP. Nutrition Counseling Boosted our Practice. Interprofessional Relations, 1999. Dent Econ, pp. 19-20, Sept. 1985. 13. American Dental Association. Key Dental Facts. 32. Jarvis WT and Kravitz E. Food, Fads, and Fallacies. In Chicago, May 1994. Pollack RL, Kravitz E, eds. Nutrition in Oral Health 14. Friedman JW, Schissel MJ, Dodes JE. Rethinking and Disease. Philadelphia: Lea & Febiger, 1985. Dental Insurance. J Public Health Dent. 55:131-132, 33. Triano JJ. Muscle strength testing as a diagnostic screen 1995. for supplemental nutritional therapy. J Manipulative 15. Berry JH. Questionable Care: What can be done about Phys Therapy. 5:179-182, 1982. dental quackery? J Amer Dent Assoc. 115:679-685, 34. Friedman MH, Weisberg J. Applied Kinesiology — 1989. double-blind pilot study. J Pros Dent. 45:321-323, 16. Greene C and Laskin D. Long-term status of TMJ click- 1981. ing in patients with myofascial pain and dysfunction. J 35. Kenny JJ, Clemens R, Forsythe KD. Applied Amer Dent Assoc. 117:461-465, 1988. Kinesiology unreliable for assessing nutrient status. J 17. Mohl ND, et al. Devices for the diagnosis and treatment Amer Dietetic Assoc. 88:698-704, 1988. of temporomandibular disorders. J Pros Dent. 63:198- 36. Fryman VM. Cranial Osteopathy and its role in disor- 201, 332-335, 472-476, 1990. ders of the temporomandibular joint. In Gelb H ed. 18. Deyo RA, et al. A controlled trial of transcutaneous Symposium on temporomandibular joint dysfunction electrical nerve stimulation (TENS) and exercise for and treatment. Dental Clinics of North America. W.B. chronic low back pain. New Eng J Med. 322:1627-34, Saunders. 27:595-611, 1983. 1990. 37. Cornacchia H and Barrett S. Consumer Health — A 19. McNeill C, Mohl ND, Rugh JD, Tanaka TT. Guide to Intelligent Decisions. St. Louis: Times Temporomandibular disorders: diagnosis, management, Mirror/Mosby, 1989. education, and research. J Amer Dent Assoc. 120:253- 38. Neidle D. On the Brink — Will Dental Education Be 263, 1990. Ready for the Future? J Dent Educ. 54:564-566, 1990. 20. Greene C, Laskin D. Long-term evaluation of treatment 39. Raso J. The Dictionary of Metaphysical Healthcare. for myofascial pain-dysfunction syndrome: a compara- National Council Against Health Fraud, 1996. tive analysis. J Amer Dent Assoc. 107:235-238, 1983. 40. Seldin L. Personal communication, Nov. 2004. A CSH BOARD OF TRUSTEES

MFrederickcKenna Long Anderson, & Aldridge Esq. UJamesniversity E. ofEnstrom, California, Ph.D., Los Angeles M.P.H. PThomasamela B. Campbell Jackson and Jackson, Thomas M.P.H.C. Jackson Charitable CKennetholumbia UniversityM. Prager, Medical M.D. Center Fund Katherine L. Rhyne, Esq. ANigellbert EinsteinBark, M.D. College of Medicine UJackniversity Fisher, of California, M.D. San Diego King & Spalding LLP CElizabethommittee toMcCaughey, Reduce Infection Ph.D. Deaths Lee M. Silver, Ph.D. UElissaniversity P. Benedek,of Michigan M.D. Medical School NHon.ew York, Bruce NY S. Gelb Princeton University THenryhe Hoover I. Miller, Institution M.D. Thomas P. Stossel, M.D. TexasNorman A&M E. University Borlaug, Ph.D. UniversityDonald A. of Henderson,Pittsburgh Medical M.D., Center M.P.H. Harvard Medical School IRodneyndo-US Science W. Nichols & Technology Forum Elizabeth M. Whelan, Sc.D., M.P.H. YMichaelale University B. Bracken, School of Ph.D., Medicine M.P.H. American Council on Science and Health

ACSH FOUNDERS CIRCLE

UChristineniversity ofM. California, Bruhn, Ph.D.Davis IA.nstitute Alan forMoghissi, Regulatory Ph.D. Science MStephenemorial Sloan-KetteringS. Sternberg, CancerM.D. Center CRobertase Western J. White, Reserve M.D., University Ph.D.

ETaiwornst & K.Young Danmola, C.P.A. GJohnrove CityMoore, College, Ph.D., President M.B.A Emeritus KLorraineetchum Thelian

UThomasniversity R.of DeGregori,Houston Ph.D. LAlbertyons Lavey G. Nickel Nickel Swift, Inc. MKimberlyassachusetts M. Thompson,Institute of Technology Sc.D.

A CSH EXECUTIVE STAFF

Elizabeth M. Whelan, Sc.D., M.P.H., President

A CSH BOARD OF SCIENTIFIC AND POLICY ADVISORS

C.S.Ernest Mott L. Center Abel, Ph.D. ThomasRobert JeffersonL. Brent, UniversityM.D., Ph.D. / A. l. duPont Omaha,Michael NE D. Corbett, Ph.D. Philadelphia,George E. Ehrlich, PA M.D., M.B. Hospital for Children TGaryexas A&MR. Acuff, University Ph.D. JMortonohn Hopkins Corn, University Ph.D. WMichaelestern Health P. Elston, M.D., M.S. UniversityAllan Brett, of South M.D. Carolina UJulieniversity A. Albr of Nebraska,echt, Ph.D. Lincoln UNniversityancy Co oftugna, Delaware Dr.Ph., R.D., C.D.N. KWeyilliam West, N FL. Elwood, Ph.D. KKennethBinc G. Brown, Ph.D. GJameslendon E.College, Alcock, York Ph.D. University NH.ational Russell Beef Cross, Ph.D. BStepheneth Israel K. Deaconess Epstein, MedicalM.D., M.P.P.,Center FACEP Adel,Gale GAA. Buchanan, Ph.D. SanThomas Francisco, S. Allems, CA M.D., M.P.H. RollinsJames School W. Curran, of Public M.D., Health, M.P.H. Emory HarvardMyron E.School Essex, of PublicD.V.M., Health Ph.D. Bell,George Boyd M. & Burditt,Lloyd LLC J.D. University AmericanRichard G.Society Allison, for Nutritional Ph.D. Sciences PennsylvaniaTerry D. Etherton, State University Ph.D. Charles R. Curtis, Ph.D. TexasEdward A&M E. UniversityBurns, Ph.D. Ohio State University OhioJohn State B. Allred, University Ph.D. St.R. GregoryLouis University Evans, Center Ph.D., for M.P.H.the Study of Ilene R. Danse, M.D. UniversityFrancis F. of Busta, Minnesota Ph.D. Bolinas, CA Bioterrorism and Emerging Infections UniversityPhilip R. ofAlper, California, M.D. San Francisco Robert M. Devlin, Ph.D. William Evans, Ph.D. UniversityElwood F. of Caldwell, Minnesota Ph.D., M.B.A. University of Massachusetts University of Alabama UniversityKarl E. Anderson, of Texas Medical M.D. Branch, Galveston Seymour Diamond, M.D. Daniel F. Farkas, Ph.D., M.S., P.E. TexasZerle A&ML. Car Universitypenter, Ph.D. Diamond Headache Clinic Oregon State University HudsonDennis InstituteT. Avery Donald C. Dickson, M.S.E.E. Richard S. Fawcett, Ph.D. UniversityRobert G. of Cassens, Wisconsin, Ph.D. Madison Gilbert, AZ Huxley, IA Kaiser-PermanenteRonald P. Bachman, Medical M.D. Center Ralph Dittman, M.D., M.P.H. Owen R. Fennema, Ph.D. UniversityErcole L. ofCavalieri, Nebraska D.Sc.Medical Center Houston, TX University of Wisconsin, Madison InternationalRobert S. Baratz, Medical D.D.S.,Consultation Ph.D., Services M.D. John E. Dodes, D.D.S. Frederick L. Ferris, III, M.D. AlbanyRussell Medical N. A. Cecil,College M.D., Ph.D. National Council Against Health Fraud National Eye Institute Allentown,Stephen Barrett,PA M.D. Theron W. Downes, Ph.D. David N. Ferro, Ph.D. BartsRino andCerio, The M.D. London Hospital Institute of Pathology Michigan State University University of Massachusetts UniversityThomas G.of FloridaBaumgartner, Pharm.D., M.Ed. Madelon L. Finkel, Ph.D. HealthMorris Education E. Chafetz, Foundation M.D. UniversityMichael Pof. DoGeorgiayle, Ph.D. Weill Medical College of Cornell University LomaW. Lawrence Linda University Beeson, School Dr.P.H. of Public Kenneth D. Fisher, Ph.D. Health UniversityBruce M. ofChassy, Illinois, Ph.D.Urbana-Champaign UniversityAdam Drewnowski, of Washington Ph.D. Office of Disease Prevention and Health Sir Colin Berry, D.Sc., Ph.D., M.D. Leonard T. Flynn, Ph.D., M.B.A. Institute of Pathology, Royal London Hospital Milan,Martha MI A. Churchill, Esq. U.S.Michael Army A.Institute Dubick, of SurgicalPh.D. Research Morganville, NJ Barry L. Beyerstein, Ph.D. Simon Fraser University NewEmil York William Eye & Chynn, Ear Infirmary M.D., FACS., M.B.A. TorontoGreg Dubord, Center for M.D., Cognitive M.P.H. Therapy EmoryWilliam University H. Foege, M.D., M.P.H. Steven Black, M.D. Kaiser-Permanente Vaccine Study Center UniversityDean O. Cliver,of California, Ph.D. Davis Savannah,Edward R. GA Duffie, Jr., M.D. Doylestown,Ralph W. Fogleman, PA D.V.M. Blaine L. Blad, Ph.D. Kanosh, UT UniversityF. M. Clydesdale, of Massachusetts Ph.D. UniversityLeonard J.of Duhl,California, M.D. Berkeley UniversityChristopher of Maryland H. Foreman, Jr., Ph.D. Hinrich L. Bohn, Ph.D. University of Arizona VirginiaDonald Polytechnic G. Cochran, Institute Ph.D. and State DuncanDavid F.& Duncan,Associates Dr.P.H. UniversityF. J. Francis, of Massachusetts Ph.D. University Ben W. Bolch, Ph.D. Rhodes College AverillJames Park, R. Dunn, NY Ph.D. UniversityGlenn W. of Froning, Nebraska, Ph.D. Lincoln W. Ronnie Coffman, Ph.D. Joseph F. Borzelleca, Ph.D. Cornell University Medical College of Virginia InstituteRobert L.for DuP Behavioront, M.D.and Health Tucson,Vincent AZ A. Fulginiti, M.D. Bernard L. Cohen, D.Sc. Michael K. Botts, Esq. University of Pittsburgh Ankeny, IA UniversityHenry A. ofDymsza, Rhode Island Ph.D. ClaremontRobert S. GraduateGable, Ed.D.,University Ph.D., J.D. PublicJohn J.Health Cohrssen, Policy AdvisoryEsq. Board George A. Bray, M.D. Michael W. Easley, D.D.S., M.P.H. Shayne C. Gad, Ph.D., D.A.B.T., A.T.S. Pennington Biomedical Research Center International Health Management & Gad Consulting Services Gerald F. Combs, Jr., Ph.D. Research Associates Ronald W. Brecher, Ph.D., C.Chem., DABT USDA Grand Forks Human Nutrition Center GlobalTox International Consultants, Inc. ScottWilliam & White G. Gaines, Clinic Jr., M.D., M.P.H. ProfessionalCharles O. NuclearGallina, Associates Ph.D. McLeanGene M. Hospital/Harvard Heyman, Ph.D. Medical School TheJames Weinberg C. Lamb, Group IV, Ph.D., J.D., D.A.B.T. CantoxIan C. HealthMunro, Sciences F.A.T.S., International Ph.D., FRCPath

QRaymonduest Diagnostics Gambino, Incorporated M.D. SRichardavannah, M. GA Hoar, Ph.D. SLawrencean Antonio, E. TX Lamb, M.D. BHarriseth Israel M. MedicalNagler, Center/ M.D. Albert Einstein College of Medicine RRandyutgers R.University Gaugler, Ph.D. YTheodoreale University R. Holford,School of Ph.D.Medicine CWilliamollege Park, E. M. MD Lands, Ph.D. DurbanDaniel InstituteJ. Ncayiyana, of Technology M.D. J. Bernard L. Gee, M.D. Robert M. Hollingworth, Ph.D. Lillian Langseth, Dr.P.H. Yale University School of Medicine Michigan State University Lyda Associates, Inc. PPhilipurdue E.University Nelson, Ph.D. K. H. Ginzel, M.D. Edward S. Horton, M.D. University of Arkansas for Medical Science Joslin Diabetes Center/Harvard Medical School UniversityBrian A. Larkins,of Arizona Ph.D. DJoyceenver, A. CO Nettleton, D.Sc., R.D. William Paul Glezen, M.D. Joseph H. Hotchkiss, Ph.D. Baylor College of Medicine Cornell University NLarryational Laudan, Autonomous Ph.D. University of Mexico UJohnniversity S. Neuberger, of Kansas School Dr.P.H. of Medicine Jay A. Gold, M.D., J.D., M.P.H. Steve E. Hrudey, Ph.D. Medical College of Wisconsin University of Alberta LTomiberty B. Mutual Leamon, Insurance Ph.D. Company Cupertino,Gordon W. CA Newell, Ph.D., M.S., F.-A.T.S. Roger E. Gold, Ph.D. Susanne L. Huttner, Ph.D. Texas A&M University University of California, Berkeley EJaynvironmental H. Lehr, Ph.D.Education Enterprises, Inc. WesternThomas Kentucky J. Nicholson, University Ph.D., M.P.H. Reneé M. Goodrich, Ph.D. Lucien R. Jacobs, M.D. University of Florida University of California, Los Angeles UniversityBrian C. Lentle,of British M.D., Columbia FRCPC, DMRD YaleSteven University P. Novella, School M.D. of Medicine TheFrederick George K.Washington Goodwin, University M.D. Medical Center UniversityAlejandro of R. Toronto Jadad, M.D., D.Phil., F.R.C.P.C. 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Mondell, M.D. Laurence J. Kulp, Ph.D. Baltimore Headache Institute University of Washington GeorgetownJ. D. Robinson, University M.D. School of Medicine Dwight B. Heath, Ph.D. Brown University CaliforniaJohn W. CancerMorgan, Registry Dr.P.H. UniversitySandford ofF .MiamiKuvin, School M.D. of Medicine/ Hebrew DartmouthBill D. Roebuc Medicalk, Ph.D.,School D.A.B.T. Robert Heimer, Ph.D. Yale School of Public Health University of Jerusalem NewStephen York J.University Moss, D.D.S.,College ofM.S. Dentistry/ Health Education Enterprises, Inc. TheDavid United B. Roll, States Ph.D. Pharmacopeia AmericanRobert B. Enterprise Helms, Ph.D.Institute NorthCarolyn Carolina J. Lackey, State University Ph.D., R.D. UniversityBrooke T. of Mossman, Vermont College Ph.D. of Medicine MichiganDale R. RStateomsos, University Ph.D. RutgersZane R. University, Helsel, Ph.D. Cook College UniversityJ. Claybur ofn California,LaForce, Los Ph.D. Angeles TheAllison Children’s A. 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Tatini, of Minnesota Ph.D. RCarolochester Whitlock, Institute Ph.D., of Technology R.D. Wallace I. Sampson, M.D. S. Fred Singer, Ph.D. Stanford University School of Medicine Science & Environmental Policy Project UniversitySteve L. Taylor,of Nebraska, Ph.D. Lincoln Wilmington,Christopher NC F. Wilkinson, Ph.D. Harold H. Sandstead, M.D. Robert B. Sklaroff, M.D. University of Texas Medical Branch Elkins Park, PA TuftsJames University W. Tillotson, Ph.D., M.B.A. NationalMark L. Institute Willenbring, on Alcohol M.D., Abuse Ph.D. and Alcoholism Charles R. Santerre, Ph.D. Anne M. Smith, Ph.D., R.D., L.D. Purdue University Ohio State University HDimitriosarvard School Trichopoulos, of Public Health M.D. UCarlniversity K. Winter, of California, Ph.D. Davis Sally L. Satel, M.D. Gary C. Smith, Ph.D. American Enterprise Institute Colorado State University WMurrayinchendon, M. Tuckerman,MA Ph.D. RJamesochester J. InstituteWorman, of TechnologyPh.D. Lowell D. Satterlee, Ph.D. John N. Sofos, Ph.D. Vergas, MN Colorado State University URobertniversity P. of Upchurch, Arizona Ph.D. URussellniversity S. of Worrall, California, O.D. Berkeley Jeffrey W. Savell Roy F. Spalding, Ph.D. Texas A&M University University of Nebraska, Lincoln UMarkniversity J. Utell,of Rochester M.D. Medical Center UStevenniversity H. of Zeisel, North Carolina M.D., Ph.D. Marvin J. Schissel, D.D.S. Leonard T. Sperry, M.D., Ph.D. Roslyn Heights, NY Barry University UniversityShashi B. of Verma, Nebraska, Ph.D. Lincoln NutritionMichael Institute,B. Zemel, University Ph.D. of Tennessee Edgar J. Schoen, M.D. Robert A. Squire, D.V.M., Ph.D. Kaiser Permanente Medical Center Johns Hopkins University UniversityWillard J. of Visek, Illinois M.D.,College Ph.D. of Medicine UniversityEkhard E. of Ziegler, Iowa M.D. David Schottenfeld, M.D., M.Sc. Ronald T. Stanko, M.D. University of Michigan University of Pittsburgh Medical Center ULynnniversity Waishwell, of Medicine Ph.D., and DentistryC.H.E.S. of New Jersey, School of Public Health AmericanJoel M. Schwartz, Enterprise InstituteM.S. UniversityJames H. of Steele, Texas, HoustonD.V.M., M.P.H. GeorgeDonald Washington M. Watkin, University M.D., M.P.H., F.A.C.P. BrooklynDavid E. College Seidemann, Ph.D. PennsylvaniaRobert D. Steele, State University Ph.D. Miles Weinberger, M.D. University of Iowa Hospitals and Clinics UniversityPatrick J. of Shea, Nebraska, Ph.D. Lincoln UniversityJudith S. ofS tern,California, Sc.D., Davis R.D. John Weisburger, M.D., Ph.D. Michael B. Shermer, Ph.D. Ronald D. Stewart, O.C., M.D., FRCPC Institute for Cancer Prevention/ New York Medical Skeptic Magazine Dalhousie University College Sidney Shindell, M.D., LL.B. Martha Barnes Stone, Ph.D. Medical College of Wisconsin Colorado State University TheJanet ToxDoc S. Weiss, M.D.

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