Unethical Aspects of Homeopathic Dentistry

Unethical aspects of in brief • Provides a summary of the ‘science’ of

homeopathy. opinion homeopathic dentistry • Examines the claims made by several homeopathic organisations regarding dental treatment. D. Shaw1 • Provides an ethical analysis of claims made on behalf of dental homeopaths.

In the last year there has been a great deal of public debate about homeopathy, the system of alternative medicine whose main principles are that like cures like and that potency increases relative to dilution. The House of Commons Select Committee on Science and Technology concluded in November 2009 that there is no evidence base for homeopathy, and agreed with some academic commentators that homeopathy should not be funded by the NHS.1,2 While homeopathic doctors and hospitals are quite commonplace, some might be surprised to learn that there are also many homeopathic dentists practising in the UK. This paper examines the statements made by several organisations on behalf of homeopathic dentistry and suggests that they are not entirely ethical and may be in breach of various professional guidelines.

The ‘science’ of homeopathy would be somewhat unusual for a sub- In terms of dentistry, the only British Homeopathy is sometimes mistakenly stance to cause an illness outside home- organisation is the British Homeopathic believed to be simply another form of opathy but to cure it within homeopathy. Dental Association (BHDA), which aims complementary medicine similar to herb- The explanation for this strange princi- ‘to promote the use of homeopathy within alism, acupuncture or chiropractic. In fact, ple is provided by the second principle: the dental profession and to advance the homeopathy is even less mainstream than it is because the homeopathic remedy is professional understanding of the subject.’7 these alternative approaches. We shall see extremely dilute that it is able to cure a (The BHDA recommends that patients in the course of this paper that there is no condition it would normally cause, as it should try to find dentists who have com- high-quality evidence that homeopathy is ‘triggers the body’s natural system of heal- pleted training run by the FoH.) effective, but a more basic problem with ing’. This is also extremely counterintuitive, homeopathy is that its basic principles and the Society of Homeopaths admits that British Homeopathic Association have no basis in logic or science. ‘Scientifically it can not yet be explained What does each of these organisations The main principles of homeopathy precisely how homeopathy works.’3 As we have to say about homeopathic dentistry? are that like cures like and that potency shall see, it is far from clear that homeopa- The Society of Homeopaths says nothing increases relative to dilution. The Society thy works at all. specific, which is unsurprising as it exists of Homeopaths explains the first of these only to register dentists and provide a principles as follows: ‘a substance that Homeopathic Organisations Code. The BHA website has a link to a two- would cause symptoms in a healthy per- A number of organisations represent page document explaining dental home- son is used to cure those same symptoms homeopaths in the UK. The most prominent opathy, which states that ‘patients find in illness. For example, one remedy which is the British Homeopathic Association that a number of dental conditions respond might be used in a person suffering from (BHA), which ‘exists to promote home- well to homeopathic treatment, including insomnia is coffea, a remedy made from opathy practised by doctors and other pain, swelling, bruising, dental anxiety, coffee.’3 In other words, homeopathic cof- healthcare professionals’ and lobbies for nausea, tooth sensitivity, jaw cramping, fee cures rather than causes insomnia. This the provision of homeopathy on the NHS.4 teething in babies, neuralgia, toothache, is obviously rather counterintuitive, as it In addition, there is the aforementioned bleeding, infection, ulcers and cold sores.’8 Society of Homeopaths (SoH), which pro- While this list is long, this is actually quite vides registration for professional homeo- a circumspect claim: it is not stated that 1Lecturer in Ethics, Dental School, Faculty of Medicine, paths and has its own Code of Ethics and ‘evidence shows that homeopathic den- University of Glasgow, 378 Sauchiehall Street, Glasgow, 5 G2 3JZ Practice. There is also a third organisation, tistry works’, but that ‘patients find’ that it Correspondence to: Dr David Shaw the Faculty of Homeopaths (FoH), which works – and any such finding could be due Email: [email protected] promotes ‘academic and scientific devel- to a placebo effect. In the past, the BHA Refereed Paper opment of homeopathy and ensures the has made stronger claims about homeopa- Accepted 7 October 2010 DOI: 10.1038/sj.bdj.2010.1032 highest standards in the education, train- thy, but has learned from experience that ©British Dental Journal 2010; 209: 493–496 ing and practice of homeopathy.’ 6 such claims are often challenged. The BHA british dental journal VOLUME 209 NO. 10 NOV 27 2010 493

website also provides a list of homeopathic describe substances with a recognised ranging from 3C to 30C (diluted) to 200C. dentists and refers patients to the BHDA pharmacological content and effect, while A 2C dilution takes the original substance for further information. homeopathic remedies normally have nei- and dilutes it to one part in 100, and then In addition to the aforementioned docu- ther. For toothache, he recommends bel- repeats the dilution again, so that there ment, the BHA website also features two ladonna and pulsatilla. For abscesses, 30C is now one part in 10,000 of the original articles on dental homeopathy. One is from belladonna is also a good choice, but for substance. 3C therefore equals one part per 2001, and claims that ‘Several clinical tri- ‘chronic (recurring) abscesses then Hepar million. At 12C, no molecules of the origi- als and observational studies have dem- sulph should help, in the 6C potency if nal substance remain; by comparison, the onstrated the therapeutic effects of Arnica the abscesses are pus-filled, although you US water supply is allowed to have arsenic in the reduction of post-extraction com- should always visit a dentist if the condi- present at up to 4C.12 As already mentioned, plications’, but it has since been shown tion is severe.’ The fact that the abscesses homeopaths claim that the potency of such that this evidence was nothing of the sort, might be recurring because of the lack of medications increases with dilution, even and the trials were poorly designed.9 Given efficacy of extremely dilute nightshade is beyond the point at which no molecules that the science has moved on, it is some- not mentioned. The author also mentions are left, and that the water ‘remembers’ the what unethical of the BHA to have such arsenicum album for gum disease (with- substance that it has diluted. an outdated and misleading claim on their out specifying whether he means gingivitis Of course, the fact that dentists are treat- website. The same article also states that or periodontitis), arnica for broken teeth ing patients with ‘substances’ that have ‘Homeopathy when used in the dental set- and extractions, and nitricum acidum for none of their original molecules present ting is a safe and effective form of treat- ulcers. The article ends with an endorse- should be considered along with the fact ment which is often requested and sought ment of non-fluoride toothpaste, and the that, even were there molecules remain- by the general public.’ Homeopathic treat- suggestion that ‘some people believe the ing, there is no good evidence that any of ment may not directly harm the patient, peppermint in conventional toothpastes these treatments actually work. Is training but if it fails and she must then seek con- antidotes homeopathic medicines’. Advising dentists to treat patients with these ‘rem- ventional treatment to stop her pain or people to use toothpaste without fluoride edies’ really maintaining the best stand- bleeding, then she has been harmed and is bad enough, but suggesting that normal ards of treatment, as the Faculty claims? the treatment was not truly safe. We must toothpaste interferes with homeopathic Apart from anything else, it is mislead- also ask what is meant by ‘effective’ in remedies is an assertion for which there is ing patients to claim that they are being this context; placebos can be effective, no evidence whatsoever. Such suggestions treated with a substance when none of and so too can homeopathic remedies if risk harm to people’s oral health and are its molecules are actually present. (This this is all that is meant by the word, but deeply unethical. strange feature of homeopathy explains the minimum standard for evidence-based why it is possible to obtain homeopathic medicine (and dentistry) is more effective Faculty of Homeopathy plutonium.) Note also that all the ‘treat- than placebo – and it is far from clear that Considering that it seeks to maintain the ments’ in the BHA section of this paper this is true of homeopathy. highest standards of practice in home- were of similar extreme dilutions. A much more recent publication on opathy, it is somewhat surprising that the the BHA website explains common Faculty has no ethical code or practice British Homeopathic Dental Association dental ailments and potential homeo- guidelines on its website. What it does have pathic remedies.10 Its author states that is a copy of its Dental Guidelines for 2010, The BHDA’s website is reminiscent of the ‘Homeopathically-trained dentists are which recommend dental homeopathy for BHA’s several years ago. In contrast to the much more than drillers, fillers and bill- ‘common core applications; acute antici- more modest claims made by the BHA, the ers. We can even hope to improve the patory anxiety; acute dental fear both in SoH and the FoH, the BHDA makes very overall health of the patient and not just adults and children; post-operative pain; strong claims for dental homeopathy. The the dental condition presented to us.’ One post extraction/trauma; haemorrhage; homepage of the BHDA website welcomes would have thought that the same is also toothache; pericoronitis; teething; dental visitors with a question, which is answered true of the vast majority of convention- abscess; dry socket; [and] dental collapse.’11 with another question: ally trained dentists. He also recommends What should these conditions be treated ‘Why should you visit a Homeopathic that ‘You should always go to a dentist with? To take two examples from this dentist? if the pain is severe and preferably one list, the guidelines state that haemorrhage Do you think that your present dentist is who can also prescribe or recommend should be treated with china officinalis, really kind and caring? homeopathy’, the implication being that and a dental abscess should be treated with Homeopathy is a very caring discipline. a homeopathic dentist will be better able hepar sulphurus calcareum. The former is a Try a member of the BHDA, and experi- to treat the pain. The author goes on to Peruvian tree bark, and the latter is oyster ence a really kind, considerate, holistic and explain the top five reasons people visit shell and sulphur. But of course, given that caring approach to dental treatment.’13 the dentist, and suggests homeopathic these are homeopathic remedies, these sub- The obvious implication is that your ‘medicines’ for each one. The use of this stances will be very dilute. The FoH guide- current dentist is not really kind, caring word instead of ‘remedies’ is not unprob- line does not suggest a particular dilution, and considerate. Homeopathy may well lematic, as ‘medicines’ is usually used to but hepar is available online in dilutions be a caring discipline, but it is rather

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disrespectful to the profession to suggest that can cure the herpes simplex virus, the (GDC’s) Standards for Dental Professionals, that non-homeopathic dentists are some- cause of cold sores; while conventional which state that dentists must ‘provide a how inferior in terms of the care that they medicine can treat sores and make them good standard of care based on available provide. Ben Goldacre has pointed out that disappear, there is always a risk that they up-to-date evidence and reliable guidance… ‘a routine feature of homeopaths’ market- will return. Offering patients the hope of [and] justify the trust that your patients, ing practices is to denigrate mainstream a cure when none is available is extremely the public and your colleagues have in you medicine’,14 and this seems to be another unethical. (It is unclear what the ‘many by always acting honestly and fairly.’19 We example. Another page of the BHDA’s more’ cures offered by the sixth reason are have seen that the websites of the BHA, website offers six reasons to visit a homeo- supposed to be.) The websites of the BHA FoH and BHDA are not entirely honest, pathic dentist: and the FoH are also guilty of misleading and as already mentioned, the evidence 1. ‘Because they treat patients the public to some extent with their claims, indicates that homeopathy is not effec- holistically even if they do not make claims of cure. tive. Furthermore, for the placebo effect 2. Homeopathic remedies are effective to occur, patients must believe that they and have no unpleasant side effects Respecting the guidelines? are receiving treatment that is better than 3. There are remedies which stop Quite apart from the fact that some of the placebo – in other words, they must be swelling and pain after injections and claims on the BHDA’s website are mislead- deceived even in order to obtain the pal- extractions ing and unethical, they may also fall foul try benefit that homeopathy might offer.20 4. There are remedies which reduce the of the rules set out by both the Society The principle of respect for autonomy and pain and swelling of dental abscesses of Homeopaths (SoH) and the Advertising the requirements of valid consent mandate 5. There are remedies which alleviate Standards Authority (ASA). Section 48 of honesty and transparency when dealing toothache the Code of Practice and Ethics of the SoH with patients, but a small element of decep- 6. There are remedies which which [sic] lists nine principles that must be adhered tion is essential for homeopathy to work cure ulcers and cold sores and many to in advertising; the first three are: at all. In this sense, ethical homeopathic more [sic].’15 • ‘Advertising shall not contain claims of practice is virtually impossible, although superiority. prescribing simple placebos ethically may It is not clear why the first is really a • No advertising may be used which be possible in some situations.21 reason to visit a homeopathic dentist, as expressly or implicitly claims to cure many mainstream dentists adopt a holistic named diseases. Conclusion approach. But the main problem is the sec- • Advertising shall not be false, This paper has pointed out some problems ond claim. As stated above, it is misleading fraudulent, misleading, deceptive, with homeopathic ‘science’, highlighted to claim that homeopathic remedies are extravagant or sensational.’17 misleading and unethical aspects of the ‘effective’; homeopaths claim that there is websites of the BHA, the FoH and the in fact a great deal of evidence that home- As we have already seen, the BHDA’s BHDA, and suggested that the latter may opathy is more effective than placebo, but website certainly claims by implication be in breach of the codes of the Society all of this ‘evidence’ is flawed in one way that homeopathic dentists are more car- of Homeopaths and the Advertising or another, often through failure to prop- ing and holistic than mainstream dentists, Standards Authority. It appears possible erly randomise or blind trials.14 which seems to be an assertion of supe- that any homeopathic dentist is engaging Where is the evidence that homeopathic riority. Cold sores are not technically a in unethical practice to some extent and remedies can stop swelling and pain, alle- named disease, but the BHDA’s claim that may be in breach of GDC guidelines. One viate toothache, and cure ulcers and cold homeopathy can cure them would seem to of the principles of the SoH (section 11 of sores? (Note that the swelling and pain be in contravention of at least the spirit the Code of Ethics and Practice) states that claims are also made by the BHA and FoH of this principle. The SoH code also states ‘Homeopaths report research findings and websites.) No references are provided, pre- that the Advertising Standards Authority’s clinical experience methodically, honestly sumably for the simple reason that there Code of Practice must be adhered to; one and without distortion. All speculative is no such evidence. Such remedies may of its principles states that ‘No market- theories will be stated as such and clearly perhaps have a placebo effect that reduces ing communication should mislead, or be distinguished.’ 17 Any implication that swelling and pain (and patients might get likely to mislead, by inaccuracy, ambigu- homeopathy is effective beyond a placebo better naturally without even a placebo ity, exaggeration, omission or otherwise.’18 effect is speculative, but the various home- effect), but that is not the same as ‘stop- The BHDA’s website is clearly promoting opathy documents mentioned in this paper ping’ symptoms, which implies a direct homeopathic dentistry through ambiguity, do not clearly indicate that this is the case. physical effect. and as such may also fall foul of the ASA’s Many patients actively seek homeopathic The World Health Organisation recently rules. A similar case could be made regard- treatment, but any information they are warned against using homeopathy to treat ing the BHA and FoH websites, but they provided with should be honest and impar- serious diseases;16 while dental abscesses make substantially weaker claims. tial; many of the claims currently being are not as serious as malaria or HIV, they Finally, it appears possible that homeo- made by some homeopathic organisations can lead to complications if not treated pathic dentists in general are also in con- are unethical and damaging to the profes- properly. Furthermore, there exists no drug travention of the General Dental Council’s sion of dentistry. british dental journal VOLUME 209 NO. 10 NOV 27 2010 495

1. O’Dowd A. Giving homeopathy on the NHS is how_we_can_help/advice_sheets/Dental_care.pdf. should you visit a homeopathic dentist? unethical and unreliable, MPs are told. Br Med J Accessed 22 October 2010. http://www.bhda.co.uk/why.php. Accessed 2009; 339: b5080. 9. Darby P. Dental homeopathy – an accidental intro- 22 October 2010. 2. Shaw D. Homeopathy is where the harm is. J Med duction. http://www.britishhomeopathic.org/export/ 16. Mastha O. WHO warns against using homoeopathy Ethics 2010; 36: 130–131. sites/bha_site/hh_article_bank/conditions_a_to_e/ to treat serious diseases. Br Med J 2009; 3. Society of Homeopaths. What is homeopathy? http:// spring_2001.3_dental_homeopathy.pdf. Accessed 339: b3447. www.homeopathy-soh.org/about-homeopathy/ 22 October 2010. 17. Society of Homeopaths. Code of Ethics and what-is-homeopathy/. Accessed 22 October 2010. 10. Wander P. Introduction to homeopathy series: Top 5 Practice. http://www.homeopathy-soh.org/about- 4. British Homeopathic Association. About us. http:// reasons we visit the dentist. http://www.britishhome- the-society/documents/CodeofEthicsApr04.pdf. www.britishhomeopathic.org/about_us/. Accessed opathic.org/export/sites/bha_site/hh_article_bank/ Accessed 22 October 2010. 22 October 2010. conditions_a_to_e/Jan10_Homeopathic_dentistry. 18. Advertising Standards Authority Committee of 5. Society of Homeopaths. About the society. Code pdf. Accessed 22 October 2010. Advertising Practice. The CAP code. 11th ed. http:// of Ethics and Practice. http://www.homeopathy- 11. Faculty of Homeopathy. Dental Guidelines 2010. cap.org.uk/The-Codes/~/media/Files/CAP/Codes/ soh.org/about-the-society/code-of-ethics.aspx. http://www.facultyofhomeopathy.org/export/ CAPCode.ashx. Accessed 22 October 2010. Accessed 22 October 2010. sites/faculty_site/exams/guidelines/Dental_guide- 19. General Dental Council. Standards for den- 6. Faculty of Homeopathy. About us. http://www. lines_2010.pdf. Accessed 22 October 2010. tal professionals. http://www.gdc-uk.org/ facultyofhomeopathy.org/about_us/. Accessed 22 12. Environmental Protection Agency. Arsenic in drink- NR/rdonlyres/FFD61DA5-A09E-4B38-8FFB- October 2010. ing water. http://water.epa.gov/lawsregs/rulesregs/ BA342E9F0AF4/16687/147158_Standards_Profs2. 7. British Homeopathic Dental Association. About us. sdwa/arsenic/index.cfm. Accessed 22 October 2010. pdf. Accessed 22 October 2010. http://www.bhda.co.uk/aboutbhda.php. Accessed 22 13. British Homeopathic Dental Association. Homepage. 20. Ernst E. Harmless homeopathy? Int J Clin Rheumatol October 2010. http://www.bhda.co.uk/. Accessed 22 October 2010. 2009; 4: 7–10. 8. British Homeopathic Association. Homeopathy 14. Goldacre B. Benefits and risks of homeopathy. 21. Shaw D. Prescribing placebos ethically: the appeal and dental care: your guide to treatment. http:// Lancet 2007; 370: 1672–1673. of negatively informed consent. J Med Ethics 2009; www.britishhomeopathic.org/export/sites/bha_site/ 15. British Homeopathic Dental Association. Why 35: 97–99.

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