MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

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I have repeatedly discussed the risks of chiropractic manipulation. Sadly, when doing so, we have to rely mostly on case reports (there is no monitoring system that would record such events, reliable incidence figures are therefore not available). This means every new case report is of considerable importance.

Korean neurosurgeons recently reported the case of a patient who had an infarction of the posterior inferior cerebellar artery (PICA) after a chiropractic cervical manipulation. A 39-year-old man visited the emergency room with signs of cerebellar dysfunction, presenting with a 6-hour history of vertigo and imbalance. Two weeks before, he had been treated by a chiropractor for intermittent neck pain. At the time of admission, brain computed tomography, magnetic resonance imaging, and angiography revealed an acute infarction in the left PICA territory and occlusion of the extracranial vertebral artery (VA; V1/2 junction) as a result of a dissection of the VA. Angiography revealed complete occlusion of the left PICA and arterial dissection was shown in the extracranial portion of the VA. The patient was treated with antiplatelet therapy. Three weeks later, he was discharged without any sequelae.

The authors concluded that the possibility of VA dissection should be considered at least once in patients presenting with cerebellar dysfunctions with a recent history of chiropractic cervical manipulation.

In the discussion section, the authors leave little doubt about the question of causality: damage to the V3 portion is the most common injury that may occur after chiropractic manipulation related to anatomical structures. The VA is located horizontally in a groove in the upper side of the atlas’ posterior arch. During abruptly forced neck rotation and stretching, the gap between the atlas and the atlanto-occipital membrane, which the VA penetrates, can be stretched, resulting in dissection. In our case, it appeared that the V1/2 junction had been dissected due to excessive lateral bending of the neck, thought to be caused by an impact to the left transverse foramen of the sixth cervical spine, through which the left VA passes. It is presumed that there was a mechanical injury to the vessel wall at the time of the procedure, which caused dissection and then the thrombus generated, and two weeks after small emboli caused the occlusion of PICA. Low-speed, high-amplitude manipulations that consist of a series of smooth, repetitive movements are configured in certain areas of the neck, and this does not often cause damage. However, a sudden thrust or high-speed, low-amplitude manipulation is often considered the cause of VA dissection. In particular, this type of manipulation can be theorized to result in a sudden, symmetrical rotation of the extended cervical vertebrae, leading to damage to the high cervical and proximal parts of the carotid artery and VA.

It is high time, I think, that chiropractors take such events seriously. At the very minimum, we need a system of monitoring such cases, so that – eventually – we will be able to define their frequency. In this context, it is obviously important to remember that there is precious little evidence to suggest that neck manipulations are effective for any condition. What inescapably follows is clear: until we have reliable incidence data, it is wise to avoid chiropractic neck manipulations altogether.

This is an unusual post: it is by an osteopath who sent it to me for publication but insists he does not want to be named because he is still working in the profession. I think he has an interesting story to tell and therefore agreed to publishing his article, even though its author has to remain anonymous.

I graduated with an honours degree in osteopathic medicine in 2000 and remain registered as an osteopath. I am writing to help others avoid the same errant thought patterns that I developed, when assessing osteopathy.

My venture into the world of osteopathy began, as I am aware many have, with the assurance that osteopathy is far better than physiotherapy. There is an established musculoskeletal pathway in this country provided by physiotherapists and to wish to practice a therapy other than this, one must be sure that it is superior to physiotherapy in many aspects: effectiveness, remuneration, job satisfaction etc. And this belief was drummed into me ad nauseam by virtually all the osteopaths that I encountered. Despite hearing this for over 20 years, I have yet to see any evidence that it is the case.

The manipulative therapy at the heart of osteopathy should be a focus of strong suspicion. It is obvious that the cracks and pops elicited from spinal and peripheral joints are nothing more than a placebo party-trick, but it is a key feature of the treatment taught and practised by osteopaths throughout the country. In fact, the evidence appears to contradict the structural/mechanical model that underlies osteopathy. Spinal alignment, muscular and postural imbalances are seemingly not predisposing or maintaining factors for many musculoskeletal conditions, despite what continues to be taught in osteopathic colleges. It is hugely underappreciated that most of the factors deemed by osteopaths to be significant to a patient’s symptoms are prevalent in asymptomatic people.

The reality facing osteopaths is that spinal and musculoskeletal pain in general is so little understood, that you can only be confident in your ability to ‘treat’ it with osteopathic manipulative therapy by ignoring the complexity and opacity of the problem. Chronic low back pain for example, is such an obscure entity that it seems the success of one practitioner over another has little or nothing to do with their technical knowledge or ability, and more, maybe, to do with interpersonal dynamics. This makes for a frustrating and somewhat embarrassing career, given that the technical side of much of the work is a charade. I saw no objective reason to believe that I could do significantly more good for a patient than could be done with some basic exercise and possibly a massage.

When I graduated, there was widespread debate over whether dysfunction of the lumbo-sacral joints or the sacro-iliac joints was the most significant factor in back pain. Some osteopaths focused on one area, others on the other. I didn’t however perceive a difference in results from either group of practitioners, or from me, when switching between the two models. In fact, if I made no attempt to differentiate between the two, still no change. This proved true across the board – little or no change in outcome from a wide variety of approaches to the same issue. This is the nature of osteopathy; it is mostly vacuous as a form of assessment and treatment.

A common remark amongst osteopaths is that if you see ten osteopaths, you will get ten different diagnoses. This has consistently been my experience with my own symptoms, those of friends and family, and clinical observation. Good luck developing your ‘skill’ in that environment. Inter-practitioner repeatability was virtually non-existent when assessing the position and function of most joints of the body, especially the spine. If it is not repeatable (and very little in osteopathy is), then it is not science.

Confirmation bias was a huge factor in my education. ‘Successes’ were celebrated and failures ignored. We enjoyed reports from patients of how much good we had done but had practically no training in how osteopathy relates to scientific evidence. We still don’t have a decent body of research as to how it fares as a therapy compared to other approaches, or how specifically osteopathic treatment outcomes differ from the natural progression of symptoms.

 

Osteopathy is so far removed from mainstream medicine that it has been possible to build and maintain it on a foundation of anecdotal evidence; born of a vague perception that it must be superior to large institutionalised medicine, which is inherently inept and corrupt. There is an awareness amongst osteopaths that the evidence for osteopathy is pretty much all anecdotal but there is a faith that it will be proven effective once tested properly. Never mind the fact that anecdotal evidence is the worst form of evidence and you should not follow a system of healthcare produced by it. It is worse than no evidence, because when heeded it can lead to believing falsehoods that seem true.  In osteopathy, the scientific method has largely been ignored for groupthink and indoctrination.

Osteopaths in private practice (which is most of them) encounter huge financial pressure to over-diagnose and over-treat. Most episodes of musculoskeletal pain should be viewed as a normal part of life. They are self-limiting and do not require any formal intervention. Unfortunately, people’s anxieties are perpetuated by osteopaths who pander to the worried-well, to maintain the core of their income. Best practice for the majority of people seeking help from an osteopath is reassurance and advice to stay positive and active. This doesn’t pay well, so instead patients are given a course of manual therapy and extended ‘maintenance sessions’, both of which are of little to no short-term benefit and absolutely no long-term benefit.

But we all know that osteopaths earn more than physiotherapists right? Again, no clear data. In my experience of working in private multi-disciplinary practices, the flow of work heading the way of physiotherapists is far more consistent, given the long-established referral pathways from within the NHS and private medical insurance. Also, the NHS provides solid financial benefits and security that are not available in the parochial, private environments that osteopaths have to work in. Public and student perception of the likely earnings of an osteopath is remarkably high but there is a large swathe of osteopaths that never make a decent living from it. It is tragic to see otherwise intelligent people plough their money, time and effort into an alternative medicine cult. The same time and money could be spent pursuing a career that offers a net benefit to society and provides significant opportunity for personal development and progress, intellectually and financially.

The exultation of historical leading figures, derision of those questioning the status quo, veneration of tutors, delusions of grandeur and unshakable faith in the veracity of osteopathy are difficult influences to identify and navigate as a young student. Undergraduates need to be taught to think critically, both scientifically and philosophically. And this is especially crucial in the quagmire of alternative medicine; as the world is awash with misinformation about health. We should engender a clarity of thought, appropriate scepticism and strength of character that enables people to call bullshit sooner rather than later, in the face of such patent nonsense.

Numerous times I have been assured that osteopaths receive a similar level of education to doctors (albeit for a shorter duration), however, the serious academic training that occurs in actual medical schools makes this claim risible. Osteopaths mostly seem to think far too highly of their training; which is, in fact, fairly rudimentary. (Speaking as someone who has recently observed for a number of days in a leading teaching clinic in the UK.)

If you wish to study a musculoskeletal therapy, please, for the sake of your mental health, your financial income, your family and the good of the public; study physiotherapy. There is value in helping people deal with physical pain, the use of therapeutic exercise, and certain forms of manual therapy. Osteopathy, however, has nothing uniquely effective to offer and forms one of the most over-rated careers imaginable.

An exhaustive study of homeopathic remedies for Eczema“, this is the title of an article I just stumbled across. It leaves no doubt that homeopathy is effective for eczema (which is also what I was told all those years ago when I trained in a homeopathic hospital). Here are a few excerpts from the article:

The appropriate internal remedy will usually be one of the following, according to the indications:

Aconite

In the simpler forms of eczema, and when there is much febrile disturbance. Acute cases, with stinging and pricking of the skin, in plethoric persons.

Alumina

Hard crusts on the scalp, face and extremities. Gnawing itching, worse in the evening, not relieved by scratching. Aggravated on alternate days and from eating new potatoes. Dryness of the skin.Constipation.

Ammonium carbonicum

Eczema in the bends of the extremities. Excoriations between the legs, and about the anus and genitals. Violent itching relieved by scratching. Aggravated by either cold applications or hot poultices. In children.

Ammonium muriaticum

Anacardium orientale

Acute eczema on the face, neck and chest. Intense itching usually aggravated, but occasionally relieved by scratching. Redness of the skin with eruption of small vesicles. Sensitiveness to draught.

Antimonium crudum

Pustular eczema about the face and joints. Painful cracks in the corners of the mouth. Violent itching and burning, better in the open air, worse after bathing. Thick, heavy, yellow crusts upon the face. Gastric derangement with thick white coated tongue. In children who grow fat.

Antimonium tartaricum

Eruptions about the nose and eyes, neck and shoulders, and back of the ears. Vesicles surrounded by a red areola. Pustules, as large as peas. Itching worse in the evening, better in the open air. Eruption leaves bluish-red stains upon the face. Child wants to be carried; cries if touched.Desire for acids ; aversion to milk. Rattling cough.

Apis mellifica

Red and edematous skin, with burning and stinging. Better from cold applications, worse after warm applications. Large vesicles. Urine scanty and high colored.

Argentum nitricum

Eczema on the genitals. Urging to urinate. In children who eat too much sweets.

Arsenicum album

Eczema on the face, legs and genitals. Intense burning of the surface. Itching worse during the first hours of sleep. Better from external heat ; worse from cold or from scratching. Dry scaly eruption with parchment-like skin. Falling out of hair in patches. Useful in chronic cases.

Arundo

Eruption on the chest, upper extremities and behind the ears. Intolerable itching, crawling sensation, especially over the loins and shoulders. In young children.

Astacus fluviatilis

Thick crusts on the scalp. Enlargement of the lymphatic glands. Clay colored stools.

Aurum muriaticum

Smarting, itching papular eruption on the lips or above the pubis. Constant desire to be out in the open air. In corpulent old people. After abuse of mercury.

END OF QUOTE

And the evidence, where is the evidence for these seemingly detailed recommendations?

The answer is, there is none, at least not in this article.

So, I look into Medline. Apart from some observational studies, the most recent relevant paper on controlled clinical trials happens to be my very own systematic review published in the British Journal of Dermatology entitled “Homeopathy for eczema: a systematic review of controlled clinical trials.” Here is its abstract:

BACKGROUND:

Homeopathy is often advocated for patients with eczema.

OBJECTIVES:

This article systematically reviews the evidence from controlled clinical trials of any type of homeopathic treatment for any type of eczema.

METHODS:

Electronic searches were conducted in Medline, Embase and the Cochrane Library with no restrictions on time or language. In addition, the bibliographies of the retrieved articles and our departmental files were hand searched. All controlled trials of homeopathy in patients with eczema were considered. Their methodological quality was estimated using the Jadad score.

RESULTS:

One randomized and two nonrandomized clinical trials met the inclusion criteria. All were methodologically weak. None demonstrated the efficacy of homeopathy.

CONCLUSIONS:

The evidence from controlled clinical trials therefore fails to show that homeopathy is an efficacious treatment for eczema.

________________________________________________________________

So, what does that tell us?

I think it demonstrates the following relevant points:

  • Homeopaths seem convinced to be able to treat eczema effectively.
  • They teach this to junior clinicians and tell it to their patients.
  • They trumpet this message out on the internet (a Google search on ‘homeopathy for eczema’ generates 242 000 hits).
  • They even claim that they have done ‘exhaustive studies’ that prove their point.
  • Yet, the actual evidence fails to show that homeopathy works for eczema.

Does that mean homeopaths are lying?

Does that mean homeopaths mislead their patients thus causing needless suffering?

Does that mean homeopaths care more about their cash-flow than the welfare of their patients?

What do you think?

The indefatigable Robert Mathie has published another systematic review/meta-analysis, and yet again he failed to come up with a convincingly positive result. This new paper reviews randomised controlled trials (RCTs) of individualised homeopathic treatment (IHT) in which the control (comparator) group was other than placebo (OTP). Its stated aim was to determine the comparative effectiveness of IHT on health-related outcomes in adults and children for any clinical condition that has been the subject of at least one OTP-controlled trial. 

For each eligible trial, published in the peer-reviewed literature up to the end of 2015, the authors assessed its risk of bias (internal validity) using the Cochrane tool, and its relative pragmatic or explanatory attitude (external validity) using the 10-domain PRECIS tool. All RCTs were categorised according to whether they examined IHT as an alternative treatment (study design Ia), adjunctively with another intervention (design Ib), or compared with a no-intervention group (design II). For each RCT, the researchers identified a ‘main outcome measure’ to use in meta-analysis: ‘relative effect size’ was reported as odds ratio (OR; values >1 favouring homeopathy) or standardised mean difference (SMD; values < 0 favouring homeopathy).

Eleven RCTs, representing 11 different medical conditions, were eligible for inclusion in this systematic review. Five of the RCTs (four of which in design Ib) were judged to have pragmatic study attitude, two were explanatory, and four were equally pragmatic and explanatory. Ten trials were rated ‘high risk of bias’ overall: one of these, a pragmatic study with design Ib, had high risk of bias solely regarding participant blinding (a bias that is intrinsic to such trials); the other trial was rated ‘uncertain risk of bias’ overall. Eight trials had data that were extractable for meta-analysis: for 4 heterogeneous trials with design Ia, the pooled OR was statistically non-significant; collectively for three clinically heterogeneous trials with design Ib, there was a statistically significant SMD favouring adjunctive IHT; in the remaining trial of design 1a, IHT was non-inferior to fluoxetine in the treatment of depression.

The authors concluded that due to the low quality, the small number and the heterogeneity of studies, the current data preclude a decisive conclusion about the comparative effectiveness of IHT. Generalisability of findings is limited by the variable external validity identified overall; the most pragmatic study attitude was associated with RCTs of adjunctive IHT. Future OTP-controlled trials in homeopathy should aim, as far as possible, to promote both internal validity and external validity.

Considering that almost all of the authors are known proponents of homeopathy – Mathie himself is employed by the London-based ‘Homeopathy Research Institute’ – one has to applaud their rigour and enthusiasm in publishing negative findings about their trade. But why so complicated? I would have thought that a much simpler conclusion would have been clearer: THESE ANALYSES FAILED TO GENERATE EVIDENCE TO SUGGEST THAT HOMEOPATHY IS EFFECTIVE.

 

By guest blogger Hans-Werner Bertelsen

Any material used in dentistry may provoke an individual local or systemic reaction, including an allergic response to its use. Due to the high toxicity of mercury, in so-called alternative dentistry, the removal of amalgam fillings is often recommended. ‘Amalgam sanitations’ often are a major component of the treatment portfolios of practitioners of this so-called alternative dentistry.

While amalgam fillings have excellent material properties, such as high marginal stability, quick processing, reliable hardening even in moist environments, good longevity under moist and warm conditions, they also have one property that is highly problematic in the long term: they are prone to corrosion. Old amalgam fillings will corrode after years and decades, without exception. The resulting oxidation products not only modify the metal microstructure, but they also change the spatial dimensions of the amalgam fillings. In dental materials science, this process is known as mercuroscopic expansion. [18]

The “German Amalgam Trial (GAT)”, large scale, 12-year study, tried to determine the mercury exposure from amalgam fillings in more detail. The study initially surveyed 6744 patients regarding their complaints. In a subset of the study population (n=27), the mercury burden of those with amalgam fillings to those without amalgam fillings was compared using serum and urine samples.

[19,20] Inorganic mercury levels in blood and urine correlated in a highly significant manner with the presence of amalgam fillings. In patients with amalgam fillings, serum levels of mercury were increased 3.5 fold, urine levels were even more elevated and 4 times as high as those of patients without amalgam fillings. [19] Unfortunately, the GAT study did not examine the degree of corrosion present in the fillings, nor did it investigate mercury levels in tissues.

While the GAT study’s cytotoxic examinations showed no harmful effects at the cellular level, and found that low-dose effects consisted merely of “reduced adaptability of the cells post-amalgam exposure,” [20] entirely different cellular reactions may be observed when corrosion factors are taken into account. Under these conditions, Ursula Teichmann described a clearly cytotoxic reaction: “Corroded amalgams were shown to be clearly more toxic than non-corroded amalgams. Only in non-corroded amalgams a dependence of toxicity on the copper content of the samples was found.” [23] (Quote translated from German). While these cytotoxic effects were observed in vitro, they correspond perfectly to long-term observations from dental clinical practice. These observations show no softening of the dentin substance underneath old, corroded amalgam fillings, because the strong cytotoxic effect no bacteria will grow at the amalgam/dentin interface. Teichmann’s testing methods have become a standard of dental materials research. [24]

A review of various studies measuring the release of mercury vapors in the oral cavity showed an up to 15-fold increase after subjects had chewed gum. [21] The lungs will absorb 80% of the mercury vapors found in tidal air, and mercury vapor is considered to be most relevant in terms of its toxicological effects. The highest release rates of mercury vapor are observed during the placing and the removal of amalgam fillings. [22]

Within the moist and warm environment of the oral cavity, metal oxides will form due to gradual oxidation processes on any amalgam surface, both at the interface of the filling and the oral cavity, and at the interface of filling and dentin substance. It has been shown that ions diffuse into the dentin at the filling/dentin interface, and that they pass on into deeper tissue layers. [22]

Metal oxides also form at the occlusal surfaces of amalgam fillings, and these may successively erode, pass on to the digestive tract, and eventually may be metabolized. Oxidation processes not only release ions of copper (Cu2+), zinc (Zn2+), and tin (Sn2+), but also mercury ions (Hg2+). Problematic are in particular the mercury ions (Hg2+) from mercury salts that were formed by oxidation processes. These ions may displace the body’s own calcium ions (Ca2+) as central ions in chelate complexing agents. Due to their proven high neurotoxicity, mercury-containing substances should, therefore, be banned from everyday use. The Minamata Convention on Mercury triggered an EU-wide ban, effective July 1st, 2018, on the use of amalgam fillings in the treatment of children, adolescents, pregnant and nursing women.

Practitioners of so-called alternative dentistry routinely offer their patients homeopathic “detoxification treatments.” These are entirely useless because they do not contain any pharmacologically active substances that would be required for the removal of toxic substances. At best, they may have a placebo effect.

Effective procedures for the removal of heavy metals from the body do exist, however. They have been adapted from intensive medicine settings where they are used for the treatment of acute poisoning in emergencies. These procedures are referred to as chelation therapies and rely on substances such as 2,3-dimercaptopropane-1-sulfonate (DMPS). Chelation therapies have a high risk of side effects, and, therefore, are not recommended for alternative medicine detoxification procedures in case of suspected low-dose, chronic heavy metal poisoning. There are no scientifically proven methods for heavy metal removal in the chronic, low-dose range. [25]

Due to its major side effects, in scientifically based medicine, DMPS is only used to treat acute poisoning. Complexing agents cannot distinguish between vital minerals and harmful heavy metals. When chelation therapy is applied indifferently, it may, therefore, cause mineral imbalances and mineral deficiencies. In view of the long-term risks of mercury-containing dental fillings, and given the availability of other materials, it makes sense to strictly avoid amalgam in dental fillings. Despite the availability of alternative materials, and of effective preventive measures, dental amalgam continues to be used at a rate of on average 75 tons per year in the European Union. [26,27]

If amalgam use in dentistry is to be avoided in the future, massively more tooth decay prevention measures will be necessary in order to achieve a population-wide preservation of teeth. In children diagnosed with an increased susceptibility to dental decay, immediate therapeutic and preventive measures are needed, including a change in dietary habits. In Scandinavian countries that banned amalgam use many years ago, measures such as these have become everyday standards. If, on the other hand, the ban of amalgam in the EU is not accompanied by individualized, targeted, and effective prevention measures, we may be faced with similar dramatic developments and massive dental impairments, including their systemic medical and psychosocial consequences, as we have seen in patients from Russia. [26]

Summary and Conclusion

The procedures touted by practitioners of so-called alternative dentistry are unnecessary. This is because they are either not effective (e.g., homeopathic ‘removal’ of mercury), or because they have no relevant significance (e.g., the Prognos® measuring device for determining mercury exposure, or the LTT for material testing, or so-called dental projections as diagnostic tools for general medical conditions), or because they have a worrisome risk-benefit ratio (e.g., the use of DMPS to treat suspected chronic mercury exposure from amalgam, or bone trimming for suspected residual osteitis). It is a chastening thought that these ‘complementary’ dental procedures, while completely irrelevant, have become established in dental practice, and that by now three professional societies have formed in this field in Germany alone. In addition, insurance business models focusing on this market have emerged because so far no regulatory mechanisms in the field of continued medical education have been established to address this situation. As a result, an increasing number of unregulated courses is being offered. It seems paradoxical that the perpetuating demand is such that even state dental medical boards can no longer resist it and have begun offering classes of dubious nature in order to not miss out on this obviously booming market.

In order to preserve high quality standards in dental medicine, it seems imperative and essential to establish suitable regulatory and supervisory mechanisms. This would be surprisingly easy to achieve: Regulatory bodies might appoint continuing medical education representatives tasked with evaluating the methods to be taught. They should have no difficulty determining whether these methods are based in sound science or rather in a belief system that will not hold up to scientific scrutiny. Should continuing dental medical education remain unregulated, however, the quality of dental care will certainly be negatively affected. [28,29]

Acknowledgements

Ulrike Walter-Lipow, Bremen, Germany, provided the English translation of the first version of this manuscript.

Conflicts of Interest

The author declares no conflicts of interest with regard to this paper.

References

18. Marxkors, R.; Meiners, H. Taschenbuch der zahnärtzlichen werkstoffkunde. Deutscher Zahnärzte Verlag: 2005

19. Klinikum rechts der Isar, TU München. Forschungsprojekt Amalgam GAT German Almagam Trial press release. 2008.

20. Kluckhuhn, C. Forschungsprojekt Amalgam: GAT (German Amalgam Trial). In zm online, Deutscher Ärzteverlag: 2008.

21. Roberts, H.W.; Charlton, D.G. The release of mercury from amalgam restorations and its health effects: A review. Operative Dentistry 2009, 34, 605-614.

22. Schmalz, G. Biokompatibilität von Kompositkunststoffen und Amalgam – ein Vergleich. In Zahnheilkunde Management Kultur, Spitta GmbH: online, 2017.

23. Teichmann, U. Cytotoxizität der Non-gamma2-Amalgame im korrodierten und nicht-korrodierten Zustand unter Berücksichtigung ihres Kupfergehaltes. Doctoral dissertation, RWTH Aachen, Aachen, 1989.

24. Teichmann, U.; Wienands, J.; Damaske, D. Wissenschaftliches Engagement. http://www.zahngesund-in-frechen.de/zahnarzt_zahnaerzte_frechen/mod_content_page/seite/Wissenschaftliches_Engagement/index.html (May 11, 2018),

25. Nonnenmacher, A. Chelat-Therapie. http://symptomat.de/Chelat-Therapie (May 11),

26. Bertelsen, H.-W. Sechs Ziele und sechs Wege zur Verringerung der Quecksilber-Belastung durch Amalgam – ein Plädoyer für einen nationalen Ausstiegsplan. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen 2015, 109, 271-273.

27. BIO Intelligence Service Study on the potential for reducing mercury pollutionfrom dental amalgam and batteries – final report prepared for the European Commision – DG ENV; 2012; p 246.

28. Bertelsen, H.-W. Die Notwendigkeit einer Grenzdefinition im Bereich der ärztlichen Fortbildung. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen 2015, 109, 89-91.

29. Uhlmann, B. Wenn der Zahnarzt Esoterik anbietet. Süddeutsche Zeitung August 2, 2017.

By guest blogger Hans-Werner Bertelsen

It is possible to have an allergic reaction to the materials used in dentistry. These reactions may be type I reactions (immediate) or type IV reactions (delayed). While type I reactions are characterized by the release of humorally active substances and may lead to asthmatic attacks, mucosal swelling, and the much dreaded anaphylactic shock, type IV reactions are characterized by the formation of incomplete antigens (haptens) that bind to tissue proteins to form complete antigens. According to the relevant medical guidelines, diagnosing an allergy requires that allergy testing is used to confirm any allergy suspected based on clinical symptoms.

In the field of so-called alternative dentistry, testing is by far more extensive. Testing of dental materials is conducted in countless variations, and it also contributes to the marketing efforts in this field.

Moreover, testing is not limited to materials, but extended to teeth that have undergone root canal procedures, and to areas of the jaw bone, in particular the spongiosa. Practitioners will conduct so-called muscle testing and declare teeth with previous root canal procedures or fully healed wounds from previous tooth extractions pathological areas in need of sanitation. Testing is usually done with various devices that are of a dubious, but always impressive nature, and that are referred to by mysterious names. Practitioners use so-called electromedical diagnostic procedures to generate a diagnosis that they will present to the patient as an objectively established fact. A staggering number of electromedical diagnostic procedures is available. As G.-M. Ostendorf reports, “there is a barely manageable variety of these unconventional electromedical methods, which is all the more confusing as publications on these methods are usually not circulated outside interested parties.” (Quote translated from German)

The following list (based on Ostendorf’s work) does not claim to be exhaustive:

* Electroacupuncture according to Voll (EAV)

* Bioelectronic function diagnostics

* Vega testing

* Electrophysical terminal point diagnostics

* Electroneural diagnostics according to Croon

* Mora therapy

* Bioresonance therapy

* Biophysical information therapy

* Mora color therapy

* Multi-resonance therapy

* Metabolism testing and treatment device

* Matrix regeneration therapy

* Decoder dermography

All of these mysterious measuring techniques used in dental material testing are intended to detect incompatible materials used in dental prostheses the patient has previously received. Whenever subjected to closer scrutiny, however, incompatibilities postulated based on electromedical diagnostic procedures are found to be non-existent.

A scientific study has shown that results of the aforementioned electromedical diagnostic and treatment procedures cannot be reproduced and that they do not deliver any diagnostic value that goes beyond that of the use of divining rods. [11]

If you want to believe the apologists of the so-called alternative dentistry, testing of the materials used in dental procedures can also be accomplished entirely without any complicated equipment. According to statements made by the proponents of the so-called “applied kinesiology,” health information and the therapeutic consequences they require, can also be determined simply by getting physically close to the patient. Using this approach, the “therapist” senses a patient’s muscle activity and believes he or she can derive information on the patient’s health from this sensation. However, aside from generating physical closeness, the methods of applied kinesiology have been shown not to have any evidential value, and they have also been shown to be invalid in terms of diagnostics. [12]

Any positive resonance on the patient’s part to treatments following the approach of applied kinesiology is most likely due to the physical closeness between the “therapist” and the patient. This type of placebo effect should not be underestimated, and may lead to positive subjective assessments of the treatment by the patient. The fact that touching the patient during dental treatments can be very effective is readily illustrated using the gag reflex that may be triggered during impression taking: When the dentist hugs the patient this reflex is interrupted immediately. The hugging creates a sudden distraction and stimulus satiation in regions of the brain that are not involved in the gag reflex.

When comprehensive treatments are initiated based on the type of divining-rod-like misdiagnosis described above, dramatic consequences such as mutilations of the jaw bone and severe restrictions of masticatory function can arise [4-6,13].

As early as 1992, forensic medicine professor I. Oepen warned that “Unconventional, i.e. disputed medical methods are offered to many patients. However, the propagated effects of such methods could not be confirmed by controlled studies. So neither any risk taken by the use of these methods, can be justified nor are any costs for treatment vindicated [14].”

When it comes to material testing, laboratory medicine plays a special role, as it uses blood analysis to generate a medical diagnosis. These analytical procedures, e.g., the lymphocyte transformation test (LTT), are often very expensive while of very low specificity, which renders them useless for diagnosing potential allergic reactions to the metals used in the mouth. Due to the limited significance of these test results, testing generates costs without providing any benefit to the affected patients–aside from the potential benefit to the local economy.

In allergy diagnostics, the level of significance and interpretation associated with test results depends on the type of allergy present. On the one side, measuring IgE antibodies to pollen, dust mite, and animal hair antigens is of high diagnostic value. When it comes to variations of type IV allergic reactions, on the other side, the situation is different. These include the so-called contact allergies such as allergic reactions to metals in the mouth. Procedures for diagnosing contact allergies often deliver false-positive results, which makes them useless for diagnosing metal allergies in dentistry, as Harald Renz, director of the Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics, of Philipps-Universität Marburg, explained to me:

“Interpreting the results of the LTT and other cellular tests is significantly complicated by the possibility of false-positive and false-negative findings. The LTT is not fully standardized, and it is a complex test that requires not only a lot of experience in conducting the test itself, but also in interpreting the results. Anyone performing this test has to adhere, without fail, to the quality assurance requirements as outlined by the test manufacturer. In addition, the test exhibits large inter-individual variability, and there are no ‘standard’ or ‘reference’ values. The only thing the LTT actually detects is whether the specific immune system has mounted a T-cell response to the metal in question. Positive and negative controls have to be tested as well.

Furthermore, there also are differences in the clinical significance between different metals: While its sensitivity to beryllium and nickel is sufficient, data for other metals are still lacking, and this is true also for metals that are relevant in dental implants and prostheses. What is particularly important: A positive test result on its own is not equivalent to a clinical diagnosis! Any test result needs to be interpreted in conjunction with all clinical findings for the patient in order to reach a meaningful conclusion. Furthermore, a single positive test result does not indicate that the patient is currently and acutely exposed to the metal in question. The exposure may have happened years ago, and may still produce a positive result. This is due to memory cells that may be circulating in the blood stream.”(Translated from German)

When disease is clearly present, it is, therefore, reckless to focus on a possible material intolerance without conducting sound diagnostic testing. Major damages may arise, e.g., because adequate therapy is not sought. To illustrate these types of damages, Ostendorf cites the case of a patient who was suffering from initially undiagnosed sleep apnea. This in turn caused a lack of oxygen and of relaxing periods of deep sleep, which led to daytime fatigue. As a reaction to this situation, the patient developed major mental problems. A physician practicing homeopathy conducted “resonance testing” on this patient, and the results, in conjunction with the physician’s considerable level of ignorance, led to a diagnosis of “exposure to pollutants.” The sheer number and duration of measurements and tests not only prolonged the patient’s suffering, it eventually led to the patient becoming suicidal. [15]

It is obvious that this is not an isolated case, and that similar misdiagnoses will be frequent for mental health issues as well.

An unpleasant diagnosis, such as depression, is often not readily accepted by affected patients, and is likely to be ignored. For these patients, it may be much easier to accept an external cause of their suffering than to face the idea of being mentally ill. Providing them with the false diagnostic pathway of ‘material intolerance’ may be very tempting to them. At one ‘holistically oriented’ dental office, the author experienced first-hand how patients were told that their suffering from depression was a reaction to material intolerance, all with the aim of generating large revenues from prostheses. Instead of suggesting a psychiatric examination in order to find the real reasons of their mental issues, the dentist suggested an external cause. Providing such a false diagnostic path may not only cause significant and sustained damage to the masticatory system, but it may also prevent appropriate and timely treatment. [16,17]

References

11. Ostendorf, G.-M. Spezielle Diagnostik im Überblick Teil 1: Unkonventionelle elektromedizinische Diagnose- und Therapiemethoden im Überblick. In Naturheilverfahren und unkonventionelle medizinische Richtungen, Springer Verlag: 2003.

12. Ernst, E. Komplementärmedizinische Diagnoseverfahren (Diagnostic methods in complementary medicine). Deutsches Ärzteblatt 2005, 102, 3034-3037.

13. Nimtz-Köster, R. Störfelder im Gebiss. Der Spiegel 2002.

14. Oepen, I. Kritische Bewertung unkonventioneller diagnostischer und therapeutischer Methoden in der Zahnheilkunde (Critical evaluation of unconventional diagnostic and therapeutic methods in dentistry). Fortschritte der Kieferorthopädie (Journal of Orofacial Orthopedics) 1992.

15. Ostendorf, G.-M. Elektroakupunktur nach Voll (EAV) – ein kritischer Kommentar. skeptiker 2018, 17-19.

16. Berger, U. Die Praxis der “Alternatvmedizin”: Ein Insider berichtet. In Kritisch gedacht, 2012; Vol. 2018.

17. Prchala, G. Weg mit der Zusatzbezeichnung “Homöopathie”. In zm online, Deutscher Ärzteverlag: 2018.

I know, I have reported about the risks of chiropractic manipulations many times before. But I will continue to do so, because the subject is important and mentioning it might save lives.

The purpose of this study from the US was to determine the frequency of patients seen at a single institution who were diagnosed with a cervical vessel dissection related to chiropractic neck manipulation.  The researchers identified cases through a retrospective chart review of patients seen between April 2008 and March 2012 who had a diagnosis of cervical artery dissection following a recent chiropractic manipulation. Relevant imaging studies were reviewed by a board-certified neuroradiologist to confirm the findings of a cervical artery dissection and stroke. The investigators also conducted telephone interviews to ascertain the presence of residual symptoms in the affected patients.

Of the 141 patients with cervical artery dissection, 12 had documented chiropractic neck manipulation prior to the onset of the symptoms that led to medical presentation. The 12 patients had a total of 16 cervical artery dissections. All 12 patients developed symptoms of acute stroke. All strokes were confirmed with magnetic resonance imaging or computerized tomography. The researchers obtained follow-up information on 9 patients, 8 of whom had residual symptoms and one of whom died as a result of his injury.

The authors concluded that, in this case series, 12 patients with newly diagnosed cervical artery dissection(s) had recent chiropractic neck manipulation. Patients who are considering chiropractic cervical manipulation should be informed of the potential risk and be advised to seek immediate medical attention should they develop symptoms.

Cerebellar and spinal cord injuries related to cervical chiropractic manipulation were first reported in 1947. By 1974, there were 12 reported cases. Non-invasive imaging has since greatly improved the diagnosis of cervical artery dissection and of stroke, and cervical artery dissection is now recognized as pathogenic of strokes occurring in association with chiropractic manipulation.

The authors also point out that another institution had previously described 13 stroke cases after chiropractic manipulation. The patients at both institutions were relatively young and incurred substantial residual morbidity. A single patient at each institution died. If these findings are representative of other institutions across the United States, the incidence of stroke secondary to chiropractic manipulation may be higher than supposed. To assess this problem further, a randomized prospective cohort study could establish the relative risk of chiropractic manipulation of the cervical spine resulting in a cervical artery dissection. But such a study may be methodologically prohibitive. More feasible would be a case-control study in which patients who had experienced cervical artery dissection were matched with subjects who had not incurred such injuries. Comparing the groups’ odds of having received chiropractic manipulation demonstrated that spinal manipulative therapy is an independent risk factor for vertebral artery dissection and is highly suggestive of a causal association.

I very much agree with the authors when they sate that until the actual level of risk from chiropractic manipulation is known, patients with neck pain may be better served by equally effective passive physical therapy exercises.

In other words: there is very little reason to recommend chiropractic care for neck pain (or any other condition).

Many experts have pointed out that the subluxation myth (which is at the core of chiropractic history, theory and practice) lacks sufficient evidence to even reach the level of a theoretical construct. In fact, it is no more than pseudoscientific dogma. I have discussed the issue repeatedly, for instance here, here and here.

The myth continues to generate fierce debate within and outside the chiropractic profession. This survey sought to determine how many chiropractic institutions worldwide still use the term in their curricula.

Forty-six chiropractic programs (18 from US and 28 non-US) were identified from the World Federation of Chiropractic Educational Institutions list. Websites were searched for curricular information September 2016– September 2017. Some data were not available on line, so email requests were made for additional information. Two institutions provided additional information. The total number of mentions of subluxation in course titles, technique course (Tech) descriptions, principles and practice (PP) descriptions, and other course descriptions were reported separately for US and non-US institutions. Means for each category were calculated. The number of course titles and descriptions using subluxation was divided by the total number of courses for each institution and reported as percentages.

Means for use of subluxation by US institutions were: total course titles = .44; Tech = 3.83; PP = 1.50; other = 1.16. For non-US institutions, means were: total course titles = .07; Tech = .27; PP = .44; other = 0. The mean total number of mentions was 6.94 in US vs. 0.83 in non-US institutions. Similarly, the mean course descriptions was 6.50 in US vs. 0.72 in non-US intuitions. The term subluxation was found in all but two US course catalogues. The use of subluxation in US courses rose from a mean of 5.53 in 2011 to 6.50 in 2017. US institutions use the term significantly more frequently than non-US.

The authors comment that unscientific terms and concepts should have no place in modern education, except perhaps in historical context. Unless these outdated concepts are rejected, the chiropractic profession and individual chiropractors will likely continue to face difficulties integrating with established health care systems and attaining cultural authority as experts in conservative neuro-musculoskeletal health care.

This paper prompted a comment in ‘The Chronicle of Chiropractic‘. It is full with ad hominem attacks against the authors. In the comments section of this blog, we have ample evidence that this is one thing in which chiropractors often excel. Here are a few quotes:

While one should be aware of Fake News these days, chiropractors should be aware of Fake Research by the likes of Mirtz and Perle and anything published by this journal tool of the subluxation deniers club…

Among other things, Perle believes the subluxation construct is “scientifically unsubstantiated” and that those focusing on subluxation are practicing a “pseudo-religion”…

It is another great case study in the use of logical fallacies – particularly the straw man fallacy, and the liberal use of unreferenced opinions presented as facts…

END OF QUOTES

For once, I do sympathise with chiropractors; they clearly are in a pickle:

  • Abandoning subluxation is scientifically necessary, as otherwise chiropractors will become the laughing stock of the healthcare community (to a degree, this has already happened; so, there is not much time!).
  • Abandoning subluxation would quickly lead to the end of chiropractic, as it would ‘degrade’ chiropractors to some sort of inferior physiotherapist and thus threaten their right to exist.

Dammed if they do, and dammed if they don’t!

 

 

I have mentioned lymph drainage before. It is a gentle massage technique applied along the lymph vessels and nodes to stimulate lymph flow. All sorts of extraordinary claims are made for this treatment. In  particular, lymphoedema after surgery for breast cancer, which can be a debilitating complication, is claimed to be preventable with this approach. This seems vaguely plausible, but does it really work?

This study tested whether manual lymphatic drainage (MLD) or active exercise (AE) are associated with improvements in shoulder range of motion (ROM), wound complication and changes in the lymphatic parameters after breast cancer (BC) surgery, and whether these parameters have an association with lymphoedema formation in the long run.

The researchers conducted a clinical trial with 106 women undergoing radical BC surgery. Women were matched for staging, age and body mass index and were allocated to AE or MLD, twice weekly during one month after surgery. The wound was evaluated two months after surgery. ROM, upper limb circumference measurement and upper limb lymphoscintigraphy were performed before surgery, and 2 and 30 months after surgery.

The incidence of seroma, dehiscence and infection did not differ between groups. Both groups showed ROM deficit of flexion and abduction in the second month postoperative and partial recovery after 30 months. Cumulative incidence of lymphoedema was 23.8% and did not differ between groups (p = 0.29). Concerning the lymphoscintigraphy parameters, there was a significant convergent trend between baseline degree uptake (p = 0.003) and velocity visualization of axillary lymph nodes (p = 0.001) with lymphoedema formation. A reduced marker uptake before or after surgery predicted lymphedema formation in the long run (>2 years). None of the lymphoscintigraphy parameters were shown to be associated with the study group. Age ≤39 years was the factor with the greatest association with lymphedema (p = 0.009). In women with age ≤39 years, BMI >24Kg/m2 was significantly associated with lymphedema (p = 0.017). In women over 39 years old, women treated with MLD were at a significantly higher risk of developing lymphedema (p = 0.011).

The authors concluded that lymphatic abnormalities precede lymphedema formation in BC patients. In younger women, obesity seems to be the major player in lymphedema development and, in older women, improving muscle strength through AE can prevent lymphedema. In essence, MLD is as safe and effective as AE in rehabilitation after breast cancer surgery.

I am not sure I agree with these conclusions; to me, they seem a bit over-optimistic. The results fail to show that MLD is clinically effective, as both AE and MLD might be equally ineffective. In fact, in the discussion section of the paper the authors state that their study suggests that AE may be more effective than MLD for the prevention of lymphedema in women older than 39 years.

So far, only very few controlled clinical trials tested the MLD effects in the prevention of lymphedema after  breast cancer. Some suggested that MLD administered early in the postoperative period can effectively prevent lymphedema, whereas others failed to find positive effects of MLD. Thus the question whether MLD is effective for lymphoedema after breast cancer remains open.

For once, the call for more and better research seems justified.

As this press-release is important and entirely self-explanatory, I will post it here without comment (other than congratulating the CFI for their action and encouraging organisations in other countries to follow suit) :

The Center for Inquiry has filed a lawsuit in the District of Columbia on behalf of the general public against drug retailer CVS for consumer fraud over its sale and marketing of useless homeopathic medicines. CFI, an organization advancing reason and science, accused the country’s largest drug retailer of deceiving consumers through its misrepresentation of homeopathy’s safety and effectiveness, wasting customers’ money and putting their health at risk.

Click here to access the official complaint (PDF).

Homeopathy is an 18th-century pseudoscience premised on the absurd, unscientific notion that a substance that causes a particular symptom is what should be ingested to alleviate it. Dangerous substances are diluted to the point that no trace of the active ingredient remains, but its alleged effectiveness rests on the nonsensical claim that water molecules have “memories” of the original substance. Homeopathic treatments have no effect whatsoever beyond that of a placebo.

“Homeopathy is a total sham, and CVS knows it. Yet the company persists in deceiving its customers about the effectiveness of homeopathic products,” said Nicholas Little, CFI’s Vice President and General Counsel. “Homeopathics are shelved right alongside scientifically-proven medicines, under the same signs for cold and flu, pain relief, sleep aids, and so on.”

“If you search for ‘flu treatment’ on their website, it even suggests homeopathics to you,” said Little. “CVS is making no distinction between those products that have been vetted and tested by science, and those that are nothing but snake oil.”

Apart from being a waste of money, choosing homeopathic treatments to the exclusion of evidence-based medicines can result in worsened or prolonged symptoms, and in some cases, even death. Several products have been found to contain poisonous ingredients which have affected tens of thousands of adults and children in just the last few years.

“CVS is taking cynical advantage of their customers’ confusion and trust in the CVS brand, and putting their health at risk to make a profit,” said Little. “And they can’t claim ignorance. If the people in charge of the country’s largest pharmacy don’t know that homeopathy is bunk, they should be kept as far away from the American healthcare system as possible.”

“We made a number of efforts to discuss this situation with CVS, but the concerns we raised were ignored,” said Robyn Blumner, president and CEO of CFI. “Homeopathy is a multi-billion dollar consumer fraud. If CVS would rather line its pockets than protect Americans’ health, we have no choice but to take this fight to the courts.”

CFI has for many years lobbied for tighter regulation of homeopathic products, and has been invited by the Food and Drug Administration and the Federal Trade Commission to provide expert testimony. As a result, the FTC declared in 2016 that the marketing of homeopathic products for specific diseases and symptoms is only acceptable if consumers are told: “(1) there is no scientific evidence that the product works and (2) the product’s claims are based only on theories of homeopathy from the 1700s that are not accepted by most modern medical experts.” And last year, the FDA announced a new “risk-based” policy of regulatory action against homeopathic products.

“CVS should be warned, the evidence for our case is extremely strong,” said Blumner. “And if CVS’s endorsement of homeopathy is any indication, evidence will not be their strong suit.”

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