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MANDATORY OR ELECTIVE?
L E T T E R S
reader again in the Results section, closed the article by devoting a full paragraph to that point and then strategically made that paragraph the last one in the Discussion section. Drs. Bader and Shugars take issue with our sentence, “Blacks and people who seek care on a problem-oriented basis are at greater risk of developing [fractures].” As a stand-alone sentence, we agree that the typical reader might misinterpret our intent. In retrospect, we wish that we had added at the end of that sentence a phrase such as “keeping in mind the limitations of the consecutive prevalence method.” We do not believe that this study is flawed, much less seriously so. It simply has limitations, limitations that we emphasized throughout the article. We believe that this study is a substantive contribution to the literature. Before we analyzed these data, we thought that the incidence of these events would be quite low, and that we as dental clinicians may be doing more dental treatment than necessary to prevent low-probability events. We were surprised that the incidence of these conditions was quite high, especially keeping in mind that our incidence estimate is a lower-bound one (that is, the true incidence could only be higher). Undoubtedly, because fractures could be treated in the dental office before we were able to observe them, the real incidence figure is significantly higher, which in our opinion makes our article even more compelling. To our knowledge, this is the first study to measure restoration and cusp frac-
tures in a representative, community-based sample of dentate adults. We are grateful for comments made by the anonymous JADA reviewers, and to The Journal for helping us communicate these findings to the scientific and clinical audience. Marc W. Heft, D.M.D., Ph.D. Teresa A. Dolan, D.D.S., M.P.H. Ulrich Foerster, D.D.S. University of Florida Gainesville Gregg H. Gilbert, D.D.S., M.B.A. University of Alabama at Birmingham MANDATORY OR ELECTIVE?
I read with interest the recent article by Dr. Gordon Christensen (“Elective vs. Mandatory Dentistry,” October JADA). I agree with his premise, but would like to respectfully disagree with some of his statements. I don’t think all or nearly all knowledgeable dentists would agree about what is mandatory or elective. I believe this is determined by each doctor and how much disease he or she is willing to accept. The same can be said for patients. When we say, “You should brush more,” and send them on their way, have we treated them to the best of our ability or accepted this level of disease? For example, does gingivitis require “mandatory” treatment? Does periodontitis? If so, does a three-month recall constitute mandatory treatment? It is the standard of care but excluded by most insurance companies! Does frank caries require mandatory treatment if it doesn’t hurt and isn’t causing
systemic problems? How does this differ from early periodontal disease or gingivitis? The same question applies for ditched margins or the edentulous case Dr. Christensen uses as an example. Finally, what about occlusal disease? There is no question that abfractions, severe wear and anterior tooth destruction from over-closed bites is pathological and, in most cases, treatable, but many patients, dentists and certainly insurance companies find treating these things elective. The reality is, people can and do live with these pathological conditions constantly. As I said earlier, it is simply a matter of how much disease we are willing to accept! I am often considered to be overtreating (certainly by the insurance companies) when I recommend eight-week recall intervals for some periodontal patients despite the fact that it is what is needed to control their (not some average patient’s) periodontal disease. The same for recommending an indirect composite inlay or onlay when an amalgam would “do.” Unfortunately, we have shot ourselves in the foot by accepting, in many cases, oral disease as “normal” and accepting the cheapest alternative as the standard. I, and many others who have coached me, contend that nearly all dental treatment is elective. People have proven beyond a shadow of a doubt that they can live without teeth. It is simply a question of what people want. If they want the best we can offer, nearly every patient can have a truly healthy mouth. The problem for me comes when it is the dentist and not the patient choosing (and worse
JADA, Vol. 132, February 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.
145
L E T T E R S
yet, the insurance company) what level of disease to accept. Most patients are not given the option to have ideal treatment, and that is our profession’s downfall. J. Mark Jensen, D.M.D. Moscow, Idaho Author’s response: I appreciate hearing Dr. Jensen’s beliefs on this concept. It is obvious that many dental and other medical treatments are elective. However, the typical practicing dentist can usually differentiate between those items that are necessary and those that can wait. In my own practice, I treat those things that I would want treated in my own mouth. Certainly that would be true of any other medical condition in the body. We can wait until a skin lesion turns into overt cancer, or we can treat it before that time. I appreciate Dr. Jensen’s thoughts on the subject and trust that our views are quite similar. Gordon J. Christensen, D.D.S., M.S.D., Ph.D. Provo, Utah COMPOSITES VS. AMALGAMS
Dr. Karl Leinfelder’s brief comments on the durability of composites vs. dental amalgams (“Do Restorations Made of Amalgam Outlast Those Made of Resin-Based Composite?”, August JADA) leave disturbing questions unanswered. Why does the resin “encourage the growth of microorganisms” under fillings and not under sealants? Dr. Ronald Jordan convinced me in 1986 that sufficient research had been done to jus146
tify a switch from dental amalgams to composite in posterior teeth. It was necessary to wait another year before dentin bonding agents were available in the United States, so for about a year these restorations were placed with glass ionomer bases. However, I’ve used just composite with dentin adhesives since 1987 (no more amalgam), and there seem to be no problems with wear or recurrent caries. Of course, crowns are still indicated in bruxers, and others are advised that that alternative is available if needed, but overall crowns are used a lot less than in the old days before dentine adhesives and goodquality posterior composites. It seems reasonable to expect this switch from dental amalgams to bonded composites will reduce the incidence of fractured cusps, reduce periodontal disease owing to less extensive subgingival margins, and reduce the need for endodontics owing to good sealing of dentin, which has not suffered quite so much trauma to begin with. It seems likely the real culprit, when “the rate of secondary caries associated with resin-based composite restorations is substantially higher than that associated with amalgam restorations,” is the bacteriologically sloppy technique most of us settled into, knowing that we could get away with it (even before we understood how the amalgam vapors were helping us). I challenge Dr. Leinfelder to cite a study in which cavities were prepared with rubber-dam isolation and an assist from Fusayama’s cavity-detecting dye where he can demonstrate substantially higher secondary
caries. It just isn’t going to happen. It is too bad that so many dental schools pay lip service to teaching rubber dam technique, yet so many students graduate feeling very uncomfortable and inept with this approach to operative dentistry. Leon L. Wiggin, D.D.S. Oneonta, N.Y. Author’s response: Posterior composite resins can be considered as having two distinctly different personalities. One that is properly and carefully inserted into the cavity preparation is characterized by excellent performance. As mentioned in Dr. Wiggin’s letter, the composite resin restoration has the potential for supporting tooth structure and thereby reducing the potential for fractured cusps. Furthermore, as he states, the potential for bonding the composite resin to the preparation permits the operator to be considerably more conservative in terms of cavity design. This, of course, can lead to better tissue response, since in many cases it may not be necessary to extend the preparation to the gingival tissue. When placed properly and in accordance with the concepts supported by clinical research, the posterior composite resin can last as long as a corresponding amalgam restoration. In addition, the potential for esthetics is, of course, far superior. The other personality of posterior composite resin restorations is far different. When handled inappropriately, this material can create serious clinical conditions far worse than amalgam. These include
JADA, Vol. 132, February 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.
reader again in the Results section, closed the article by devoting a full paragraph to that point and then strategically made that paragraph the last one in the Discussion section. Drs. Bader and Shugars take issue with our sentence, “Blacks and people who seek care on a problem-oriented basis are at greater risk of developing [fractures].” As a stand-alone sentence, we agree that the typical reader might misinterpret our intent. In retrospect, we wish that we had added at the end of that sentence a phrase such as “keeping in mind the limitations of the consecutive prevalence method.” We do not believe that this study is flawed, much less seriously so. It simply has limitations, limitations that we emphasized throughout the article. We believe that this study is a substantive contribution to the literature. Before we analyzed these data, we thought that the incidence of these events would be quite low, and that we as dental clinicians may be doing more dental treatment than necessary to prevent low-probability events. We were surprised that the incidence of these conditions was quite high, especially keeping in mind that our incidence estimate is a lower-bound one (that is, the true incidence could only be higher). Undoubtedly, because fractures could be treated in the dental office before we were able to observe them, the real incidence figure is significantly higher, which in our opinion makes our article even more compelling. To our knowledge, this is the first study to measure restoration and cusp frac-
tures in a representative, community-based sample of dentate adults. We are grateful for comments made by the anonymous JADA reviewers, and to The Journal for helping us communicate these findings to the scientific and clinical audience. Marc W. Heft, D.M.D., Ph.D. Teresa A. Dolan, D.D.S., M.P.H. Ulrich Foerster, D.D.S. University of Florida Gainesville Gregg H. Gilbert, D.D.S., M.B.A. University of Alabama at Birmingham MANDATORY OR ELECTIVE?
I read with interest the recent article by Dr. Gordon Christensen (“Elective vs. Mandatory Dentistry,” October JADA). I agree with his premise, but would like to respectfully disagree with some of his statements. I don’t think all or nearly all knowledgeable dentists would agree about what is mandatory or elective. I believe this is determined by each doctor and how much disease he or she is willing to accept. The same can be said for patients. When we say, “You should brush more,” and send them on their way, have we treated them to the best of our ability or accepted this level of disease? For example, does gingivitis require “mandatory” treatment? Does periodontitis? If so, does a three-month recall constitute mandatory treatment? It is the standard of care but excluded by most insurance companies! Does frank caries require mandatory treatment if it doesn’t hurt and isn’t causing
systemic problems? How does this differ from early periodontal disease or gingivitis? The same question applies for ditched margins or the edentulous case Dr. Christensen uses as an example. Finally, what about occlusal disease? There is no question that abfractions, severe wear and anterior tooth destruction from over-closed bites is pathological and, in most cases, treatable, but many patients, dentists and certainly insurance companies find treating these things elective. The reality is, people can and do live with these pathological conditions constantly. As I said earlier, it is simply a matter of how much disease we are willing to accept! I am often considered to be overtreating (certainly by the insurance companies) when I recommend eight-week recall intervals for some periodontal patients despite the fact that it is what is needed to control their (not some average patient’s) periodontal disease. The same for recommending an indirect composite inlay or onlay when an amalgam would “do.” Unfortunately, we have shot ourselves in the foot by accepting, in many cases, oral disease as “normal” and accepting the cheapest alternative as the standard. I, and many others who have coached me, contend that nearly all dental treatment is elective. People have proven beyond a shadow of a doubt that they can live without teeth. It is simply a question of what people want. If they want the best we can offer, nearly every patient can have a truly healthy mouth. The problem for me comes when it is the dentist and not the patient choosing (and worse
JADA, Vol. 132, February 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.
145
L E T T E R S
yet, the insurance company) what level of disease to accept. Most patients are not given the option to have ideal treatment, and that is our profession’s downfall. J. Mark Jensen, D.M.D. Moscow, Idaho Author’s response: I appreciate hearing Dr. Jensen’s beliefs on this concept. It is obvious that many dental and other medical treatments are elective. However, the typical practicing dentist can usually differentiate between those items that are necessary and those that can wait. In my own practice, I treat those things that I would want treated in my own mouth. Certainly that would be true of any other medical condition in the body. We can wait until a skin lesion turns into overt cancer, or we can treat it before that time. I appreciate Dr. Jensen’s thoughts on the subject and trust that our views are quite similar. Gordon J. Christensen, D.D.S., M.S.D., Ph.D. Provo, Utah COMPOSITES VS. AMALGAMS
Dr. Karl Leinfelder’s brief comments on the durability of composites vs. dental amalgams (“Do Restorations Made of Amalgam Outlast Those Made of Resin-Based Composite?”, August JADA) leave disturbing questions unanswered. Why does the resin “encourage the growth of microorganisms” under fillings and not under sealants? Dr. Ronald Jordan convinced me in 1986 that sufficient research had been done to jus146
tify a switch from dental amalgams to composite in posterior teeth. It was necessary to wait another year before dentin bonding agents were available in the United States, so for about a year these restorations were placed with glass ionomer bases. However, I’ve used just composite with dentin adhesives since 1987 (no more amalgam), and there seem to be no problems with wear or recurrent caries. Of course, crowns are still indicated in bruxers, and others are advised that that alternative is available if needed, but overall crowns are used a lot less than in the old days before dentine adhesives and goodquality posterior composites. It seems reasonable to expect this switch from dental amalgams to bonded composites will reduce the incidence of fractured cusps, reduce periodontal disease owing to less extensive subgingival margins, and reduce the need for endodontics owing to good sealing of dentin, which has not suffered quite so much trauma to begin with. It seems likely the real culprit, when “the rate of secondary caries associated with resin-based composite restorations is substantially higher than that associated with amalgam restorations,” is the bacteriologically sloppy technique most of us settled into, knowing that we could get away with it (even before we understood how the amalgam vapors were helping us). I challenge Dr. Leinfelder to cite a study in which cavities were prepared with rubber-dam isolation and an assist from Fusayama’s cavity-detecting dye where he can demonstrate substantially higher secondary
caries. It just isn’t going to happen. It is too bad that so many dental schools pay lip service to teaching rubber dam technique, yet so many students graduate feeling very uncomfortable and inept with this approach to operative dentistry. Leon L. Wiggin, D.D.S. Oneonta, N.Y. Author’s response: Posterior composite resins can be considered as having two distinctly different personalities. One that is properly and carefully inserted into the cavity preparation is characterized by excellent performance. As mentioned in Dr. Wiggin’s letter, the composite resin restoration has the potential for supporting tooth structure and thereby reducing the potential for fractured cusps. Furthermore, as he states, the potential for bonding the composite resin to the preparation permits the operator to be considerably more conservative in terms of cavity design. This, of course, can lead to better tissue response, since in many cases it may not be necessary to extend the preparation to the gingival tissue. When placed properly and in accordance with the concepts supported by clinical research, the posterior composite resin can last as long as a corresponding amalgam restoration. In addition, the potential for esthetics is, of course, far superior. The other personality of posterior composite resin restorations is far different. When handled inappropriately, this material can create serious clinical conditions far worse than amalgam. These include
JADA, Vol. 132, February 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.