Google almost convinced me to spend $400 on useless laser treatments
Online health information is terrible. How can we fix it?
"I really can't recommend it enough."
My dental hygienist had just finished fifteen minutes of brain-rattling tooth-scraping and was now trying to pitch me on a procedure involving lasers.
"Lasers?" I said lamely. "What are, uh…, the benefits of lasers?"
The DH swiveled and looked at me above her protective glasses—a look that indicated she pitied my profound gingival ignorance. "It zaps away all of the bacteria from the roots of your teeth. Amazing technology. I'd recommend it to anyone with your level of periodontal disease."
"I have periodontal disease?" That sounded serious.
"Not yet," she said, her voice filled with deadly caution. "But you have pre-periodontal disease. If it gets worse you'll have full-blown periodontitis." She mic-dropped her latex gloves into the trash.
"How much does it cost?" I asked, a little sheepishly. It seemed gauche to talk about money when my gum health was hanging on by a thread.
"Well unfortunately your insurance won't cover it," she said. "So it'll be about four-hundred dollars."
"Four…hundred…dollars?" My eyebrows hit the ceiling.
"Yup!" said the DH cheerfully. "Trust me, it's worth every penny."
The rest of our conversation was an awkward blur. Somehow I managed to fend off the DH and her expensive laser, but as I was leaving she mentioned—in an unmistakably threatening tone—that she'd made a note in my file and that I should strongly consider laser therapy at my next visit. I left the office feeling like I had postponed the inevitable.
But as I walked home my guilt turned to indignation. How was I supposed to make this decision? On the one hand I go to the dentist because they're the experts—but on the other hand I know that dental offices are businesses like any other, driven by the cold logic of capitalism to foist as many treatments onto their patients as possible. So how can I make sure that this laser thing is worth the cost?
Laser bacterial reduction (LBR) is just one example of the many high-stakes medical decisions that you and I and everyone else are forced to make constantly.
In the pre-Szaszian era, medicine was something that happened to you. You would put your health in your doctor's hands and they would unilaterally decide your course of treatment. But in today's patient-centered world, doctors are more like consultants: they provide suggestions, you Google those suggestions and provide counter-suggestions, your health professional Googles your counter-suggestions, etc. Medicine has become a three-way negotiation between you, your doctor, and The Algorithm.
In addition, most of today’s health decisions are made outside of MD-earshot. You're vegan and wondering if you should take a B12 supplement. You have a headache and aren't sure what painkiller to take. You want to avoid COVID and aren't sure what kind of mask to buy. These are all health decisions! And most of them are made by individuals, not by medical professionals.
Which brings me back to my dental hygienist and her expensive laser. I have six months until my next cleaning—that's six months to figure out if this treatment is worth it. But where do I start?
Hahaha just kidding. You're reading this in a year that starts with "2" so the only possible starting point is Google. Let's see what Google has to say about "laser bacterial reduction" (LBR):
The first thing I notice is the Google Scholar widget at the top. Nice! I'm all about evidence-based medicine, and the fact that Google's top results are three peer-reviewed articles is A+.
Or so I thought. The first study (Moritz 1997) is a small pilot study with only 50 subjects. It found that lased subjects had fewer bacteria around their gums—but there's no direct evidence that laser therapy fights periodontal disease.
The second study (Moritz 1998) is actually just a 6-month follow-up with the subjects from the first study. This study has some promising info: pocket depth (a direct measure of periodontal disease) was 1.9 mm shallower in lased patients than non-lased patients. But again, this was a 1998 pilot study with 50 subjects. Not exactly definitive.
The third study (Dewsnup 2009) is an in vitro study on 55 extracted teeth, comparing an erbium, chromium:yttrium-scandium-gallium-garnet laser (what?) with a sodium hypochlorite wash. I'm interested in a diode laser, on still-very-firmly-attached teeth, versus no treatment, so this isn't remotely relevant to my problem.
So far this is pretty weak evidence. But my gums are on the line here, so let's keep scrolling.
The next section is the "People also ask" section. It has four questions:
Is laser bacterial reduction worth it? Answer: "The benefits of Laser Bacterial Reduction make the treatment a worthwhile investment." Source: A dentist's office named, in all seriousness, "Fidler on the Tooth." There is zero evidence cited by Dr. Fidler's page, which exists to advertise the laser bacterial reduction offered by her office.
How long does laser bacterial reduction last? Answer: "Laser bacterial reduction therapy is a quick, painless procedure that can be added to your routine teeth cleaning." Source: Rachor Dental Care, another dentist's office. This Google Answer doesn't answer its own question, nor does the linked article, which is more (evidence-free) dental office marketing fluff.
Is laser treatment good for gum disease? Answer: "It is an excellent alternative to conventional gum surgery because it permits treatment without stitching or cutting and with less discomfort to the patient." This doesn't really answer my question, since I'm not comparing LBR with surgery. This answer is brought to you by a dental office out of Murfreesboro, TN, and the only citation is to a DentistryIQ page, which itself cites zero evidence to support its claims.
Is laser gum cleaning worth it? Answer: "Laser dental cleaning has proven to be effective at restoring the health of gums, allowing patients to keep their teeth as they grow older." Source: Active Dental, a Texas dentist's office. This answer is pretty relevant! But unfortunately the linked article doesn't cite a lick of evidence—you just have to take their definitely-very-biased word for it.
Okay—so far we have a single pilot study and four marketing blogs without even a suggestion of evidence. But what about the regular search results?
There's a version of this post where I go through each of the remaining ten search results and take tasteful-but-hilarious jabs at their jaw-dropping lack of evidence. What fun we would've had! But several close family members have gently suggested that I just summarize this bit instead.
So here's the bottom line: All ten search results are dental office marketing blogs and there isn't even a whiff of peer-reviewed evidence. Here's that sentence in helpful graphic form:
I.e., 14/17 results (82%) are literally trying to sell you the thing you're searching for, 2/17 are irrelevant research, and 1/17 is relevant but low-quality (and there are better articles to surface here, as we'll see below).
I found this horrifying. I come to Google because they're supposed to be the best. So here I am with a pretty basic question: "Does this laser bacterial reduction thing work?" and almost all of the results are marketing garbage.
And this kind of thing is far too common. How often has Google responded to your medical question with putrid, SEO-optimized landfill? Google has found 29,100,000 results for my query, but it's like an all-you-can-eat breakfast buffet that serves nothing but reconstituted eggs and Yoplait. You know there’s a gourmet, peer-reviewed omelet station around here somewhere, but you won't find it by wandering around the main rotunda of Google's sad smorgasbord.
And this is where we find ourselves. We've shrugged off the yoke of medical paternalism only to find ourselves wandering aimlessly in a jungle of unsubstantiated medical claims.
This is probably where most people would've stopped their research. But most people go outside! So I revved up all my favorite health databases and started a casual literature review.
I was hoping to find some systematic reviews of LBR studies. Systematic reviews form the apex of the Evidence Pyramid, and every 90s kid knows that the apex is the tastiest part of any good pyramid.
And I'm in luck! I found several reviews on the use of diode lasers to treat gum disease:
Sgolastra 2012. A systematic review of five RCTs, no significant effect.
Slot 2014. A systematic review of nine RCTs, no significant effect.
Roncati 2014. A systematic review of six RCTs (four of which used a diode laser), statistically significant but not clinically significant (i.e., a very small effect size).
Cobb 2017. A narrative review of 21 RCTs, no significant effect. “[T]he quality of the evidence is less than auspicious.”
Pawelczyk-Madalińska 2021. A systematic review of 15 RCTs, too much bias/heterogeneity to make conclusions.
These reviews tell quite a different story from the Google search results. One review found a tiny (“clinically insignificant”) effect, one review concluded that the evidence was too terrible to make any conclusions, and the three remaining reviews declared that diode lasers had no significant effect whatsoever.
This evidence might not be conclusive—but it is actionable! I'm trying to figure out if I should pay my DH $400 to sear my mouth with a sci-fi weapon—and these published reviews make it pretty clear that the only sane answer is "no."
Allow me to interrupt this gripping narrative to point out the absurdity of this situation. My DH clearly pushes this LBR thing on all her patients, and other dental office blogs I've read (see last section) make it pretty clear that any dentist's office with a diode laser thinks everyone would benefit from a regular laser touch-up. So how do most patients make this decision? Here are some guesses:
They say, "sure," and get LBR
They say, "I'll think about it," observe that the entire first page of Google results is rabidly pro-LBR, and get LBR
They say, "I'll think about it," spend four hours screening and synthesizing results from Cochrane, PubMed, Google Scholar, etc., and end up politely declining LBR
The problem is that strategy (3) is the only one that arrives at the "right" answer, but virtually nobody has the time or inclination to execute it. Since you've waded this far into a treatise on my gums, I suspect that you, dear reader, might be a (3)-type-person yourself—but I think we can agree that most people presented with my choice are going to get LBR.
So we've arrived at the punchline for this rambling periodontal memoir—the syllogism at the center of my obsession with consumer health information:
Consumers make most of their own health decisions
Consumer health information is atrocious
Ergo, consumers make bad health decisions
Premise (1) is true whether you like it or not. The rise of unregulated supplements, the increased emphasis on nutrition, the internet, and direct-to-consumer advertising have all conspired to put consumers at the center of their own healthcare. As mentioned earlier, most health decisions are made without doctorial input, and those decisions that do involve a doctor are often made with lots of patient input (e.g. "I desperately need that unpronounceable drug I saw in a vaguely cheerful TV spot once").
We can't put the patient-centered toothpaste back in the tube, so the only way out of this cruel logic is to attack premise (2): consumer health information is atrocious—so let's make it better. Accessible, high-quality health information is good for consumers and it's better for healthcare professionals, who can spend more time discussing reasonable treatments with well-informed patients and less time battling misleading DTC marketing campaigns.
This was my motivation for starting GlacierMD: I wanted to give consumers the information they needed to make evidence-based health decisions. And although I lost that battle (spectacularly) I'm still fighting the war! If this is a topic that interests you, I'd urge you to
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Online medical information is awful—but it doesn’t have to be!
But we were talking about my gums.
My next teeth cleaning had arrived, and I checked in for my appointment with more than the usual amount of dread. The front desk lady showed me to my room and closed the door ominously behind her.
I sat in that vinyl recliner for what seemed like hours, rehearsing exactly how I would reject LBR and trying to anticipate possible rebuttals from the DH. I considered the wisdom of moving to a new zip code and starting a new life with a new dentist. But just as I was about to bolt the door opened and in waltzed the DH.
But she wasn't my DH.
"Hi there…"—checks clipboard—"...Thomas." She looked up at me. "I'm Denise. Your regular hygienist had to pick up her kid from school, so I'll be subbing in today."
"Hi, uh…" I took a few moments to recover. "Nice to meet you."
I knew I was being abrupt and weird but I just couldn't contain myself. "My regular hygienist mentioned something about a laser thing," I say, pretending that my browser history wasn't bursting with LBR studies. "Is that something I should get?"
"Laser bacterial reduction?" This DH looks amused. "I don't usually recommend that for my patients—I find it's not very effective. Probably not worth the cost."
I laugh a little too loud.