Dental diseases and procedures are common, troublesome, and expensive, exceeding spending on other major health conditions, such as diabetes, ischemic heart disease, hypertension, dementias, and breast cancer, in the US. Dental issues are relevant for internists because unmet dental care needs can be painful for patients. Excluding teeth from medical health care is arbitrary.
Evidence-based medicine, a movement that gained prominence in the 1990s, has profoundly affected the practice of medicine. Unfortunately, little progress has been made on using data from clinical trials to determine best practices for dental care. Instead, most dental care relies on practice patterns influenced by the economic pressures of running a dental practice, dentists’ professional training and opinions, and patients’ expectations, all of which tend to favor excessive diagnoses and interventions. The result is that while many people who have low income go without any dental care, those who can pay are subjected to overdiagnosis and overtreatment.
Overdiagnosis
Overdiagnosis occurs when conditions that will never cause harm are identified. Unnecessary treatments resulting from overdiagnosis subject patients to potential harm and waste valuable resources that could be used for necessary and effective treatments.
For example, dentists may treat early noncavitated caries lesions, aiming to prevent more advanced lesions, such as dentine cavities. A noncavitated caries lesion is a demineralized enamel spot (white spot lesion) without evidence of cavitation. The majority of white spot lesions will not progress,1 and there is no evidence that early treatment, except with fissure sealants, is generally more effective than no treatment in preventing dentine cavities.2 Paradoxically, these sealants are frequently overlooked or underused by dentists. Dental cavities are routinely filled in children, despite evidence that dental pain and infection rates due to dental cavities in primary teeth are similar (about 40%) in children who are randomized to teeth being filled or not being filled.3
Decline in Caries and the Impact on Dentists’ Workload
In the 1970s, there was an unexpected, extraordinary decline in the number of cavitated caries lesions seen in dental patients.4 This decline in the number of patients’ cavitated caries lesions affected dentists’ workload and has played a role in overdiagnosis and treatment in dentistry so that dentists can support their practices. This financial need led to more recommendations for regular 6-month visits.5 Two randomized clinical trials failed to demonstrate that 6-month intervals between dental checkups result in better oral health compared with longer intervals (up to 24 months), which led the authors of a Cochrane review to conclude: “Whether adults see their dentist for a check-up every 6 months or at personalized intervals based on their dentist’s assessment of their risk of dental disease does not affect tooth decay, gum disease, or quality of life. Longer intervals (up to 24 months) between checkups may not negatively affect these outcomes.”6 Nonetheless, the standard for dental visits remains every 6 months.
Scaling and Polishing
Another commonly performed procedure is scaling and polishing to prevent periodontitis, a common condition in middle-aged persons. Scaling removes plaque and calculus from the crown and root surfaces of the teeth and is performed using hand or ultrasonic scalers. Polishing, which entails the mechanical removal of extrinsic stains and deposits, is typically done using a rubber cup or bristle brush loaded with a prophylaxis paste.
The assumption has been that scaling and polishing can prevent gingivitis and periodontitis, thus potentially preventing tooth loss, pain, and mobility. However, to our knowledge there are no published clinical trials assessing these outcomes.7 The existing evidence only evaluates short-term surrogate outcomes. It suggests that treating periodontitis, specifically through root planing, leads to a slight enhancement in the gum-to-tooth attachment level among individuals with moderate to severe periodontitis.8 However, there does not appear to be any advantage to scaling and polishing for adults without periodontitis.9
Changing Financial Incentives
The prevailing dental economic model based on fee-for-service creates an environment of dental overdiagnosis and overtreatment. At the same time, many persons who do not have dental insurance cannot afford to pay out of pocket for dental care, creating a situation where people with low income or who are part of a racial and ethnic minority group are often underdiagnosed and undertreated. A value-based model, in which dentists are paid to maintain oral health rather than to deliver treatments like fillings, cleanings, and fluoride applications, could be more positive for oral health. A study conducted in Rio de Janeiro (and coauthored by one of us [P.N.]) found that, among patients without treatment indications, an average of 2 teeth were treated during a 6-month follow-up period. This number increased to 3.6 teeth if the patient had changed dentists.10 A clear need exists for trials to compare different methods of paying dentists to assess the impact on oral health and on overtreatment and undertreatment.
What Is the Way Forward?
We do not want to give the impression that dental care is not important. On the contrary, dental pain, oral abscesses, broken teeth, and inflamed tissues surrounding the teeth are common presentations to medical professionals, especially those working in urgent care settings. Similarly, good dentition is nutritionally important for eating a full diet and psychologically essential to a person’s sense of appearance. However, dental procedures should be based on effectiveness and safety.
It is true that many important dental outcomes (eg, tooth loss) may take a long time to assess. On the other hand, the human mouth offers an easy trial design in which some procedures, such as filling a tooth, could be determined by randomization when there is more than 1 tooth in the mouth with a cavity. Other common abnormalities can impact adjacent teeth (eg, periodontitis) and require a refined design (eg, randomization to quadrants or sextants).
Identifying which dental procedures are beneficial and ensuring that relevant dental associations update their guidelines accordingly provide an opportunity to allocate resources to those who need them the most. The aim is to reduce overdiagnosis and overtreatment while increasing necessary treatment.
Corresponding Author: Paulo Nadanovsky, DDS, PhD, Oswaldo Cruz Foundation, FIOCRUZ, Brazil, Rua Leopoldo Bulhões 1480, Manguinhos, Rio de Janeiro 21041-210, Brazil ([paulo.nadanovsky@gmail.com](mailto:paulo.nadanovsky@gmail.com)).
Published Online: May 6, 2024. doi:10.1001/jamainternmed.2024.0222
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank Steven Woloshin, MD, MS, The Center for Medicine and the Media, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, and The Lisa Schwartz Foundation for Truth in Medicine, for his invaluable intellectual contributions to the development, writing, and critical revision of this paper. Dr Woloshin was not compensated for his contributions.

Understanding Media Consumption for Newborns and Young Children

The Recommendations from Golden Poppy School

1. Limit Screen Time for Infants: The American Academy of Pediatrics (AAP) recommends no screen time for children under 18 months, except for video chatting. Infants need interactions with caregivers and the physical world to promote healthy brain development.
2. Quality Interactions Over Screens: For 3 month olds watching tv or newborns and young infants, interactions with caregivers, such as talking, singing, and playing, are crucial for language development and bonding. These real-world interactions provide more meaningful stimulation than passive screen viewing.
3. Avoid TV Exposure in Background: It's important to avoid keeping the television on as background noise, especially around infants. This can be distracting and interfere with their ability to focus and learn from their immediate environment.

Why Avoid TV for Newborns?

1. Developmental Concerns: Babies' brains are rapidly developing, and exposure to screens at such a young age may interfere with crucial developmental processes, including language acquisition, social skills, and attention span.
2. Sleep Disruption: Screen time, particularly before bedtime, can disrupt sleep patterns in infants and young children, leading to difficulties in falling asleep and staying asleep.
3. Overstimulation: The fast-paced visuals and sounds of television can be overstimulating for newborns, who benefit most from calm and predictable environments.

Alternative Activities Encouraged by Golden Poppy School

1. Interactive Play: Engage newborn watching tv with toys, rattles, and colourful objects. This helps stimulate their senses and promotes physical and cognitive development.
2. Reading Together: Establish a routine of reading books aloud to your newborn. This supports language development and fosters a love for books and learning.
3. Tummy Time: Encourage tummy time sessions to strengthen neck and shoulder muscles, which are essential for later milestones like crawling and sitting.

Watching TV with Older Children

1. Quality Programming: When older children watch TV with newborn children, they prioritise educational and age-appropriate content that encourages critical thinking and creativity.
2. Co-viewing and Discussion: Watch programs with your child and discuss the content. This helps children process what they're watching and reinforces positive media habits.
3. Setting Limits: Establish clear guidelines for screen time and ensure that it doesn't replace other essential activities such as physical play, reading, and social interaction.

The Role of Parents in Media Literacy

Conclusion

Even with a stock exhaust, you and your performance car of choice could have the privilege of paying the City of New York $800 for a noise violation. Thanks to a new noise violation pilot program aimed at curbing loud exhausts and excessive honking with smart cameras and microphones, the potential for punitive punishment is on the rise for enthusiasts across all five boroughs.
Certainly, there is a decibel limit to the pops and crackles that even us enthusiasts can endure, and the tolerance of the general public often falls far below that line. Particularly in the wake of the pandemic, the prevalence of gun-shot-like backfires has turned public perception sour on modified cars, leading local officials in both New York and California to take action on such quality-of-life issues.
Specifically, New York City approved a pilot program of noise-monitoring cameras in December 2023, arming each borough with at least five of the newly developed cameras.
The program is young, but it has the potential to be a major pain even for drivers of unmodified cars.
Operated jointly by the New York City Department of Environmental Protection and the Department of Transportation, the conjoined camera and microphone operate much like speed or red light cameras, snapping pictures of the offender's license plate and issuing a fine to the registered owner. Unlike speed light cameras, however, the locations of the noise-monitoring cameras have not been initially disclosed to the general public.
Fitted with sensitive microphones, the $35,000 cameras detect and capture everything from loud exhausts and backfires to honking and blasting music. Eighty-five decibels is the threshold for receiving a fine, which starts at $800 for a first offense and rises to $2,500 for repeat offenders. For reference, the Center for Disease Control and Prevention places the average environmental noise level of city traffic inside a car at 85 decibels, indicating that City officials are targeting those who go above and beyond a normative sound level.
"We’re going after those who are potentially using an illegal vehicle, a modified vehicle, some that are really acting loudly," NYC Council Majority Leader Keith Powers said in a statement last year. "Even in the city that doesn’t sleep, New Yorkers deserve some peace and quiet."
Officials like Powers assured everyday drivers that the program isn't about penalizing unmodified vehicles or the occasional honk. In practice, however, that promise hasn't exactly panned out for people like Jerry H (who wished to keep their last name anonymous), who received an $800 noise violation ticket in his bone stock 2010 Porsche 911 Carrera S.
Traversing across the east end of Manhattan's 36th Street and funneling into the blue-and-yellow tiled Queens-Midtown Tunnel, Jerry was commuting home to the outer reaches of Queens. Making the light-to-light slog that is Manhattan traffic, Jerry accelerated to the penultimate light before hitting the tunnel, focused on getting home. Weeks later, he received a notice in the mail that he had been caught violating the Stop Spreading the Noise Act.
With a 3.8-liter flat-six, a stock exhaust, and on a relatively slow section of road, Jerry was initially puzzled by the violation. Sure, he admits to hitting 35 mph in a 25 mph zone, but he wasn't speeding excessively or wringing out the rear-mounted engine, either. With $800 on the line and a car that he thought would be exempt from such fines, Jerry built a defense and filed an appeal with the Office of Administrative Trials and Hearings.
Armed with an independent decibel test, certified documents proving the 997 was stock, and questions about the calibration of the cameras, Jerry appealed the violation and lost not once but twice. Up against lawyers for the Department of Environmental Protection, he queried them about the once-a-year calibration of the camera, the sonic combination of rear-engine induction and exhaust noise, and even the gearing in his car.
On the other side of the virtual bar, lawyers for the City mounted a defense with video footage not previously provided to the owner of the 911. The footage, analyzed by Road & Track, shows a 997-generation 911 accelerating up to a light and a series of red dots marking sound waves exceeding 85 decibels. The dots lock onto the car as well as the street, scaffolding, and buildings beside it. According to the documents provided by the DEP, the 997's signature flat-six rose to 90.4 decibels at its loudest.
In the judge's eyes, that was evidence enough to uphold the violation against Jerry in both appeals, regardless of the stock exhaust fitted to the car. This sets a precedent much like a California case involving a stock Hyundai Elantra N, in that owners can be heavily penalized for simply buying and owning a factory vehicle. No matter the age or factory status of the vehicle, New York City's pilot program can and will get you for being too loud.
"It just makes no sense to not have exemptions," Jerry said in an interview with Road & Track. "And it's pretty clear that automakers don't want to get involved with this. They want nothing to do with this."
Jerry is not alone in this frustration, either. Prior to the official approval of the pilot program in 2023, the DEP has been running a small noise camera test program since 2021, issuing as many as 218 noise violations for allegedly modified mufflers last year. Additionally, court documents cite another case of a stock car, a 2018 Jaguar F-Type, receiving and being held to the $800 violation fine for making 86 decibels of noise earlier this year. That's one decibel over the limit.
California's current noise enforcement standards are actually looser than NYC's, with a standard of 95 decibels for cars and 80 for motorcycles built after 1985. Similarly, California's enforcement standards don't charge first-time offenders and even offer payment waivers for those not able to pay the fine or adequately repair their car. No such exemptions or caveats exist in the text of the NYC Council bill. Globally, Berlin, Paris, and the United Kingdom have also trialed such decibel monitoring devices, and other U.S. cities are considering it, too.
"The NYC Noise Code has a strict standard of 76 dB(A). DEP enforces if the vehicle creates noise of more than 85 dB(A) at 50 feet," a spokesperson for the DEP said in a statement to Road & Track. "Stock vehicles that emit excessive levels of noise result from actions taken by the driver. That is why the standard of law is no person shall cause or permit the exceedance of the decibel standard."
While the precedent set by Jerry's experience is a worrying one for car enthusiasts, motorcyclists, and anyone ready to test the limits of their sound system this summer, it's worth noting that noise pollution is indeed a major problem in New York City, too. Research from 2014 estimated that around 90 percent of New York City residents are exposed to levels of noise exceeding the Environmental Protection Agency's noise limit guidelines. The results of this aren't catastrophic in the short term but can develop into cognitive issues over time.
Specifically, research shows that prolonged sleep disruption, hearing loss, hypertension, and heart disease are all linked to consistent noise pollution. Additionally, the impacts of noise are specifically detrimental to children, yielding decreased memory, struggling reading skills, and lower test scores when consistently exposed to high levels of noise. With noise monitored by New York City’s Department of Health and Mental Hygiene as well as 311 noise complaint data, the top sonic offenders in NYC are unsurprisingly traffic, sirens, and construction.

The central goal of conservation genetics is to protect the remaining genetic diversity of populations and species that are at risk due to significant anthropogenic impact, as well as to safeguard the evolutionary processes of ecosystems (Frankham et al. 2002). Genetic studies are an indispensable and fundamental component of any conservation project, including rewilding strategies. In this respect, the IUCN (IUCN/SSC 2013) proposes: 1) analyze the genetic variability of the remaining populations prior to management action; 2) in the case of reintroductions, the founder individuals should not be related; 3) in supplementations, founders from the genetic group of the original or remaining population should preferably be used; 4) in the case of translocations, replacement of the remaining genetic variation by the introduced variation should be avoided; and 5) genetic monitoring should be conducted after active management. Taking these recommendations into account, we will describe the genetic aspects of an example of supplementation (reinforcement in English, according to IUCN/SSC 2013) and one of reintroduction (reintroduction in English, according to IUCN/SSC 2013) of a carnivore in Argentina: the jaguar in El Impenetrable National Park (PNEI; Chaco province) and in the Iberá Protected Areas (APs).
If a species persists in small and fragmented populations, genetic drift can cause the loss or fixation of different alleles in each population, leading to their differentiation. As a result, only part of the original genetic variation is preserved in each fragment. Genetic studies of the remaining jaguar populations in Argentina using microsatellites (Font 2016; Robino 2022) showed that the population of the Atlantic Forest is significantly differentiated from the populations of the Chaco and Yungas. The latter, although ecologically isolated today (Thompson & Velilla 2017; Paviolo et al. 2019), do not show significant genetic differentiation. All of them present unique alleles: 13 alleles in the Atlantic Forest, six in the Chaco, and five in the Yungas (Robino 2022). This result indicates that during the process of population contraction of the species over the last 200 years, not only has genetic variability been lost, but it has also not been distributed uniformly among the fragments. Most of the unique variants of each population are at low frequency, so it is essential that management ensures their persistence (Hedrick & Fredikson 2010; Henkel et al. 2012; Hammerly et al. 2016).
In 2019, the first record of a male jaguar (named Qaramtá) was obtained in PNEI after seven years. In February 2020, the National Parks Administration convened various stakeholders involved in the conservation of the species with the aim of making decisions to protect the individual in the PNEI and discuss the possibility of conducting a managed crossing to conserve its genetic pool. Experts involved from the beginning in the "Experimental Center for Jaguar Breeding (CECY)" project in Iberá (see Solís et al. 2014: 7) expressed that the best option from a genetic standpoint was the crossing of Qaramtá with a female of Chaco origin, so as not to dilute his genetic pool. Finally, it was decided to transfer to the PNEI a captive female (named Tania) who had previously served as a breeder in the CECY, daughter of a captive female with supposed origin in the Yungas and an unknown father. In this regard, Di Martino et al. (2022: 86) report "(...) a genetics expert of this species opined that the transfer of Tania and pairing her with Qaramtá should not be carried out because the female possessed Yungas and not Chaco genetics. The jaguar does not present significant genetic differences related to biogeographical regions throughout its distribution area (from the southern United States to northern Argentina)." This statement is not correct as it confuses genetic lineage (resulting from the evolutionary history of the species) with genetic differentiation. Numerous works demonstrate the existence of genetic differentiation among jaguar populations from various ecoregions (Haag et al. 2010; Valdez et al. 2015; Srbek-Araujo et al. 2018; Lorenzana et al. 2020, 2021; Kantek et al. 2021; Robino 2022). This population differentiation must necessarily be considered when supplementing an existing population, as in the case of PNEI, since it is necessary to avoid the replacement of its unique genetic variation by genomes from other populations (called "genetic swamping" in English, Frankham et al. 2011; Russello & Jensen 2018). Genetic management of reintroductions is different: since the species is extinct, it is recommended to introduce as much genetic variability as possible. Ideally, a greater number of founders will represent a larger proportion of the wild genetic variability, but this number is limited in large mammals and those classified as "Critically Endangered" (i.e., the jaguar in Argentina; Paviolo et al. 2019). In these cases, it is crucial to minimize the coefficient of relatedness among the founders, which can be estimated using molecular markers (Queller & Goodnight 1989; Lynch & Ritland 1999; Wang 2014). Relatedness in small populations leads to inbreeding, whose consequences include increased susceptibility to diseases, reduced fertility, and lower survival of offspring (Frankham 2008). A notable example of the negative impact of relatedness and inbreeding is the management of the captive population of the Asiatic lion, Panthera leo leo. After its population had been reduced to 20 individuals in 1990, nine individuals from a captive population in India were transferred to three European zoos under the "European Endangered Species Program". By 2009, the number of captive individuals in Europe was 93. Simultaneously, the mortality rate of cubs during the first month of life increased, reaching 68.4% (Dorman 2009). A genetic study of the nine founder individuals (Atkinson et al. 2018) found that six of them had a common ancestor two generations back, resulting in three of them having the coefficient of relatedness equivalent to full siblings and two to half siblings. Just 20 years after the transfer, despite initial reproductive success, the relatedness among the founders caused the collapse of the species in captivity (Atkinson et al. 2018).
In Iberá, where a rewilding strategy for jaguars is being implemented (Di Martino et al. 2022), an initially unrelated breeding pair was introduced between 2016 and 2017 based on the analysis of molecular markers (Mirol et al. 2015). In subsequent years, other releases were made, but from 2018 onwards, genetic analyses ceased to be carried out by the initially convened experts (following Resolution No. 383/2018 of the Ministry of Environment and Sustainable Development). We now present a theoretical analysis of the relatedness among the individuals of the founding population based on the scant public information available. While we recognize that this situation is not ideal, it allows us to preliminarily characterize the current and future scenario of this new population. The theoretical coefficients of relatedness are defined based on the proportion of the genome shared by two individuals given their familial relationship (e.g., parents/children= 0.5, full siblings= 0.5, half siblings= 0.25) and range between 0 and 0.5. In Iberá, the average coefficient of relatedness of the eight founder individuals is 0.32 (i.e., greater than that corresponding to half siblings). This level of relatedness endangers their long-term survival (see also National Directorate of Conservation notes, National Parks Administration NO-2021-122825059-APN-DNC and NO-2021-125785497-APN-DNC). After these releases, the birth of five new cubs was recorded (see media communications). Given the reproductive age of the released individuals, it is likely that in all cases the male breeder was the same individual, also father of all previous litters. If this were the case, it would result in an increase in the average relatedness in the population.
A relatively effective measure to counteract the negative effects of relatedness among founder individuals is genetic rescue (Tallmon et al. 2004; Whiteley et al. 2015; Hoffman et al. 2021), which involves the translocation of individuals from other populations to increase genetic variability. A paradigmatic and successful case is that of the Florida panther, Puma concolor coryi. In 1980, there was a single population of 20-25 adults showing numerous morphological and health problems. The first genetic analyses of this population date back to 1990 (O’Brien 1990), and genetic monitoring has continued to the present. After intense debate in 1995, it was decided to introduce eight females from the Texas puma population. By 2010, there was an increase in population size, effective population size, and genetic diversity in the Florida population (Johnson et al. 2010). A recent study (Van de Kerk et al. 2019) shows that despite the initial success of the program, genetic drift and inbreeding continue to occur at levels that increase the probability of quasi-extinction (less than 10 individuals in 100 years) tenfold. These authors propose that the survival of the Florida panther genetically depends on the introduction of between 5 and 10 individuals from other populations every 20 years. Hedrick et al. (2019) present similar results in the population of wolves, Canis lupus, in Isle Royale National Park (USA): several instances of genetic rescue produced positive effects only in the short term, and currently, the population is on the verge of extinction.
Di Martino et al. (2022) suggest that the inbreeding produced by the relatedness among the founder individuals of the Iberá jaguar population could be counteracted in the future through genetic rescue, as occurred with the Florida panther. However, there are fundamental differences between the two cases. In Florida, the panthers were not extinct, and genetic rescue was the only alternative for their survival. In Iberá, the jaguar was reintroduced, thus there is the possibility to avoid mating between related individuals. Secondly, in the case of the Florida panther, genetic studies were conducted from the start, used in all management decisions, and made public at every stage, not only through publications (see references in Van de Kerk et al. 2019) but also in decision-making by the US Fish and Wildlife Service (US Fish & Wildlife Service 1987; Seal 1994). In the case of the jaguar, genetic analyses were not considered in the management, suggesting a hypothetical genetic rescue in the future. Postponing the resolution of a problem that could have been avoided from the beginning involves considerable risks and does not guarantee successful outcomes, hence it should not be considered a panacea for the problems of inbreeding (Hedrick & García-Dorado 2016).
Finally, it is important to mention that evolutionary processes occur at the level of the complete genome and not only on adaptive genes. Future environmental changes and associated selective pressures are unpredictable, so it is necessary to ensure the presence of genomic-level genetic variability for the persistence of populations and species. The proposals arising from genetic studies are not based on a "taxonomic tyranny," defined by Di Martino et al. (2022: 87) as an eagerness to preserve supposed genetic differences at all costs. On the contrary, these proposals are based on abundant scientific information, and their central aim is that management actions result in the conservation of biodiversity beyond the few generations (in an evolutionary sense) that may be included in rewilding programs.

1. Metal Gear Rising: Revengeance (2013): Fast-paced sword battles and strategic boss fights with awesome music!
2. Furi (2016): Non-stop action boss battles that get harder as you play!
3. Hollow Knight (2017): Tons of challenging and fair boss fights in a beautiful world!
4. Devil May Cry 5 (2019): Stylish and fun combat with a fantastic final showdown!
5. Cuphead (2017): Classic cartoon style game with many challenging boss battles!
6. Final Fantasy 7 Remake (2020): Amazing remakes of classic boss fights with epic music!
7. Monster Hunter World (2018) + Iceborne Expansion: Huge variety of unique monsters to hunt and strategize against!
8. God of War 3 (2010): Epic battles against the Greek gods in a grand adventure!
9. Shadow of the Colossus (2005): Unforgettable fights against giant creatures that feel like puzzles!
10. The Soulsborne Series + Sekiro + Elden Ring (2009-2022): Brutal but fair boss fights that require skill and strategy!

• Kingdom Hearts II (memorable duels)
• Returnal (bullet-hell battles)
• Maliketh the Black Blade (Elden Ring) (unleash your fury!)
• Ori and the Will of the Wisps (artistic battles)
• Batman: Arkham City (strategic and cinematic fights)