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THE EDITOR'S CORNER

THE EDITOR'S CORNER

A Good Word for Placebos

Although several authors have recently explored the concept of the placebo,1-3 there is scant evidence that dentists generally or orthodontists specifically have given much heed to the topic, apart from its association with pain, the effect of hypnosis on patient anxiety and discomfort, and the phenomenon of sham occlusal equilibration. In light of the placebo's proven ability to favorably affect treatment outcomes, this neglect may be a serious mistake.

There is not much doubt that the healing arts have become considerably more scientific and reliable over the past 100 years; they have at least moved away from the enemas, leeches, and thermal insults that were once considered vital parts of the medical armamentarium. Nevertheless, doctors and their patients continue to ascribe healing powers to therapies that have no intrinsic value for the treated condition. Consider, for example, the widespread, medically pointless, and expensive use of antibiotics for patients with colds and flus caused by viruses.

Some studies, including one by the U.S. Office of Technology Assessment, have suggested that only 20% of modern medical remedies have been proven effective scientifically. The rest have not been fully tested through empirical trials. This is not to say that these therapies offer no benefits; most of them do, but Walter Brown, a psychiatrist at Brown University School of Medicine, suggests that many of the benefits may result from the placebo effect. In the course of his studies over the past two decades, Dr. Brown has found that the placebo effect is a powerful part of healing, and that doctors should consciously try to harness it.

The Latin word placebo literally means, "I shall please", and in the 12th century was the first word of the vespers for the dead. By the 1300s, the word had developed a connotation of insincerity, because of professional mourners who were paid to sing placebos for people they didn't know. This pejorative meaning carried over into the medical lexicon, so that the placebo becameknown as a medicine given to please patients rather than to benefit them. Even today, placebos are derided as inactive, nonspecific, and pharmaceutically inert.

This description is clearly inaccurate, however, since placebos do elicit beneficial responses, are no less specific than many valid and accepted therapies, and are not totally inert. A patient who receives a placebo in a double-blind clinical study, just like a patient who receives the "real" medication, gets a thorough medical evaluation, an opportunity to discuss the condition with professionals, and a diagnosis and treatment plan. The placebo patient can also take advantage of the enthusiasm and optimism of the therapists and their staffs. The healing environment can be a powerful antidote to illness, and the simple decision to seek treatment gives the patient a sense of control.

The symbols and rituals of healing--the doctor's office, the hospital or clinic, the examination instruments, the white uniforms--are icons of competence and reliability. An explanation of the illness and a prognosis, even when unfavorable, can reduce fear of the unknown, reassure patients about future care, and relieve uncertainty and anxiety. The patient's expectation of improvement is also important in the placebo transaction: researchers have consistently found that patients who think they will improve are more likely to do so.

Back in the 1950s, Henry K. Beecher of Harvard University noted that placebos gave relief to 30-40% of patients with a wide range of ailments, including pain, high blood pressure, angina, asthma, and cough. In some types of cases, he found even higher success rates. Dr. Brown has noted that placebos seem to be more effective against conditions in which stress is a factor. Under stress, the immune system becomes less effective and more susceptible to disease. Dr. Brown feels that if doctors can free themselves to see placebos--like many conventional remedies--as broadly effective therapies whose actions are incompletely understood and that tend to be more effective against some conditions than others, they should be able to offer placebos honestly and plausibly.

In areas of dentistry where stress plays a definite role, such as dental phobias, TMD, periodontal disease, bruxism, and treatment compliance, clinicians have a fertile field for research about a mechanism they are now largely ignorant of, as well as the opportunity to develop some safe, effective, and inexpensive alternatives to conventional therapies. It would greatly benefit orthodontists and their patients if a clear understanding existed about the what, where, when, why, and how of placebos' actions, so that this knowledge could be universally appreciated and applied.

LARRY W. WHITE, DDS, MSD

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