- Email: [email protected]
PERIODONTITIS AND THE HEART
COMMENTARY
EDITORIAL
“medical clearance,” it does not shift liability for the treatment rendered by the dentist from the dentist to the consulting physician. The consulting physician likewise remains independently accountable for the accuracy of the information provided and the care he or she renders, but not for the acts or omissions of the treating dentist. The consulting physician could be held legally responsible for the treating dentist’s conduct only in the rare case in which the consulting physician acts in concert with the treating dentist or, in some way, manages or supervises the treating dentist’s care.5-15 Only treating dentists, exercising their clinical judgment, can provide true “clearance” for the treatment they provide. The dentists must first know which medical conditions require modifications for dental treatment. They must specifically request, through consultation or other means, all the relevant information necessary to make a clinically competent decision in that situation. Armed with the necessary information, the treating dentist must then involve the patient in the informed consent process and discuss the risks, benefits and alternatives of the given procedure. Factoring in all relevant information, including any information obtained in the medical consultation, the dentist must balance the pertinent evidence with the patient’s needs and desires
and make a clinical judgment in the best interests of the patient.16 Oral health care professionals function as primary caregivers in today’s health care environment. This endows them with the privilege of professional autonomy and control of their treatment decisions. At the same time, it burdens them with the ultimate accountability for their conduct. We cannot have it both ways. We cannot abdicate responsibility for treatment decisions to physicians and still maintain the status and privilege of a primary caregiver. Dentists stand in the best position to care for the oral health needs of medically complex patients. We, as dentists, receive adequate education and training to make these treatment decisions competently, and the law holds us legally accountable. “Medical clearance” is being used as a crutch, or a justification dentists feel comfortable using when they believe they do not have the necessary knowledge and judgment to provide safe and appropriate care. However, “medical clearance” is a fallacy that relies on a blind trust in the knowledge of the consulting physician to whom dentists erroneously abdicate accountability for their treatment decisions. It threatens the autonomy of dental professionals as primary health care providers—and it can put patients at risk. ■
Dr. Gary maintains a private practice in general dentistry in Depew, N.Y.; maintains a private practice in health care law in Williamsville, N.Y.; and is a clinical assistant professor in restorative dentistry, School of Dental Medicine, University at Buffalo, Buffalo, N.Y. Dr. Glick is the dean, School of Dental Medicine, University at Buffalo, The State University of New York. He also is the editor of The Journal of the American Dental Association. Address reprint requests to Dr. Glick at School of Dental Medicine, University at Buffalo, 325 Squire Hall, Buffalo, N.Y. 142148006, e-mail [email protected].
LETTERS
be no more than 550 words and must cite no more than five references. No illustrations will be accepted. A letter concerning a recent JADA article will have the best chance of acceptance if it is received within two months of the article’s publication. For instance, a letter about an article that
appeared in April JADA usually will be considered for acceptance only until the end of November. You may submit your letter via e-mail to [email protected]; by fax to 1312-440-3538; or by mail to 211 E. Chicago Ave., Chicago, Ill. 606112678. By sending a letter to the editor, the author acknowledges
ADA welcomes letters from readers on articles that have appeared in The Journal. The Journal reserves the right to edit all communications and requires that all letters be signed. Letters must
J
JADA 143(11)
1. Glick M. Dental-lore–based dentistry, or where is the evidence? JADA 2006;137(5): 576-578. 2. Schiller JS, Lucas JW, Ward BW, Peregoy JA. Summary health statistics for U.S. adults: National Health Interview Survey, 2010. National Center for Health Statistics. Vital Health Stat 2012;10(252). www.cdc.gov/nchs/data/series/sr_10/sr10_252. pdf. Accessed Oct. 4, 2012. 3. American Dental Association Division of Legal Affairs. A legal perspective on antibiotic prophylaxis. JADA 2003;134(9):1260. 4. American Dental Association Division of Legal Affairs. An updated legal perspective on antibiotic prophylaxis. JADA 2008;139(1 suppl):10S. 5. Alvarez v Prospect Hospital et al, 68 NY2d 320 (1986). 6. Sawh v Schoen, 215 AD2d 291, 627 NY S2d 7 (NY App Div 1st Dept 1995). 7. Lloyd v St. Vincent’s Manhattan Hospital, 920 NY S2d 346 (2011) (NY App Div 1st Dept 2011). 8. Lipton by Lipton et al v Kaye et al, 214 AD 2d 319 (NY App Div 1st Dept 1995). 9. Lopez v Aziz, 852 SW2d 303 (Tex Ct App 1993). 10. Huffman v Linkow Inst for Advanced Implantology, Reconstructive & Aesthetic Maxillo-Facial Surgery, 826 NY S2d 229 (2006) (NY App Div 1st Dept, 2006). 11. Burtman v Brown MD et al, 945 NY S2d 673 (2012) (NY App Div 1st Dept 2012). 12. In re Sealed Case, 67 F3d 965 (1995). 13. Hill v Kokosky, 186 Mich App 300 (1990). 14. Reynolds by Reynolds v Decatur Memorial Hospital, 277 Ill App 3d 80 (1996). 15. Kundert v Illinois Valley Community Hospital, 964 NE 2d 670 (2012); 2012 Ill App (3d) 110007. 16. Glick M. Clinical judgment: a requirement for professional identity. JADA 2011; 142(12):1333-1334.
http://jada.ada.org
Copyright © 2012 American Dental Association. All rights reserved.
November 2012
1181
COMMENTARY
LETTERS
and agrees that the letter and all rights of the author in the letter sent become the property of The Journal. Letter writers are asked to disclose any personal or professional affiliations or conflicts of interest that readers may wish to take into consideration in assessing their stated opinions. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated. PERIODONTITIS AND THE HEART
I would like to thank Drs. Panos Papapanou and Maurizio Trevisan for offering their perspective on the state of the science regarding periodontitis and atherosclerotic vascular disease (AVD) in their August JADA guest editorial, “Periodontitis and Atherosclerotic Vascular Disease: What We Know and Why It Is Important” (Papapanou PN, Trevisan M. JADA 2012;143[8]:826-828). As a periodontist with a background in public health and 28 years of private practice, I have been keenly interested in the research regarding the relationship between periodontal disease and chronic systemic diseases. It has been frustrating to try to evaluate the often disparate conclusions and results reported in our literature. The barriers to performing a definitive clinical study indeed seem daunting, thus leaving clinicians with difficult decisions regarding what to tell our patients and our colleagues. Further, the design of many studies often does not appear to truly represent what we are doing in the trenches as we care for our patients. Certainly, continued and expanded communication between clinicians and researchers seems crucial to this endeavor. And yet, this problem does not seem at all unique to perio1182 JADA 143(11)
http://jada.ada.org
dontal research. Recently, our colleagues in medicine have been grappling with fundamental issues ranging from the use and validity of prostatespecific antigen screening to whether or not to recommend stress testing for asymptomatic patients.1,2 It has been suggested that both have led to unnecessary and significant morbidity. Happily, as stated in this editorial, “the risks associated with the treatment of periodontitis are low and are outweighed by therapymediated benefits.” In his December 2011 JADA column,3 Dr. Gordon Christensen suggested that dentistry is returning to its roots. We have historically been on the forefront of offering preventive services to the public. Regardless of the present lack of research establishing a definitive causal relationship between periodontitis and AVD, the prevention and appropriate treatment of periodontal disease carry their own obvious intrinsic value for a healthy lifestyle. We must not let misleading and inaccurate information deter us from delivering this valuable message. Thank you for publishing this valuable resource. Steve J. Kerpen, DMD, MPH Clinical Assistant Professor Hofstra North Shore-LIJ School of Medicine at Hofstra University Hempstead, N.Y. Adjunct Assistant Clinical Professor Department of Epidemiology and Health Promotion School of Dentistry New York University New York City 1. U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendations. www.uspreventiveservicestaskforce.org/ prostatecancerscreening/prostatefinalrs.htm. Accessed Sept. 28, 2012. 2. Moyer VA; on behalf of the U.S. Preventive Services Task Force. Screening for coro-
nary heart disease with electrocardiography: U.S. Preventive Services Task Force recommendations (published ahead of print July 31, 2012). Ann Intern Med doi:10.7326/00034819-157-7-201210020-00520. 3. Christensen GJ. Dentistry’s forced return to its roots. JADA 2011;142(12): 1393-1395.
CARIES CLASSIFICATION
It is sad to see that, in trying to create a new model for caries classification, Dr. Julian Fisher and Dr. Michael Glick, for the FDI World Dental Federation Science Committee, in their June JADA editorial, “A New Model for Caries Classification and Management: The FDI World Dental Federation Caries Matrix” (JADA 2012;143[6]:546-551), merely perpetuate a fundamental misunderstanding of dental caries that pervades the profession. Dental caries is a disease process and not a hole in a tooth. The unfortunate conflation of the disease with the effects of the disease (carious lesions) is common in both dental practice and dental research. This confusion has had a terrible effect on efforts to diagnose and treat one of the most common diseases. As long as a hole in the tooth is the disease itself, then filling the hole should cure the disease, goes the logic. However, research consistently shows that this is not the case; restorative dentistry does not address the underlying cause of tooth defects, and patients who are not treated for the disease continue to develop lesions, necessitating more restorative procedures.1-4 The authors don’t seem to understand this distinction or else they would have titled their work, “A New Model for Carious Lesion Classification and Management.” If they had, their work well may have been a contribution to lesion identification and management, but, as is, it does nothing to further the understanding and treatment of the disease that causes lesions.
November 2012
Copyright © 2012 American Dental Association. All rights reserved.
EDITORIAL
“medical clearance,” it does not shift liability for the treatment rendered by the dentist from the dentist to the consulting physician. The consulting physician likewise remains independently accountable for the accuracy of the information provided and the care he or she renders, but not for the acts or omissions of the treating dentist. The consulting physician could be held legally responsible for the treating dentist’s conduct only in the rare case in which the consulting physician acts in concert with the treating dentist or, in some way, manages or supervises the treating dentist’s care.5-15 Only treating dentists, exercising their clinical judgment, can provide true “clearance” for the treatment they provide. The dentists must first know which medical conditions require modifications for dental treatment. They must specifically request, through consultation or other means, all the relevant information necessary to make a clinically competent decision in that situation. Armed with the necessary information, the treating dentist must then involve the patient in the informed consent process and discuss the risks, benefits and alternatives of the given procedure. Factoring in all relevant information, including any information obtained in the medical consultation, the dentist must balance the pertinent evidence with the patient’s needs and desires
and make a clinical judgment in the best interests of the patient.16 Oral health care professionals function as primary caregivers in today’s health care environment. This endows them with the privilege of professional autonomy and control of their treatment decisions. At the same time, it burdens them with the ultimate accountability for their conduct. We cannot have it both ways. We cannot abdicate responsibility for treatment decisions to physicians and still maintain the status and privilege of a primary caregiver. Dentists stand in the best position to care for the oral health needs of medically complex patients. We, as dentists, receive adequate education and training to make these treatment decisions competently, and the law holds us legally accountable. “Medical clearance” is being used as a crutch, or a justification dentists feel comfortable using when they believe they do not have the necessary knowledge and judgment to provide safe and appropriate care. However, “medical clearance” is a fallacy that relies on a blind trust in the knowledge of the consulting physician to whom dentists erroneously abdicate accountability for their treatment decisions. It threatens the autonomy of dental professionals as primary health care providers—and it can put patients at risk. ■
Dr. Gary maintains a private practice in general dentistry in Depew, N.Y.; maintains a private practice in health care law in Williamsville, N.Y.; and is a clinical assistant professor in restorative dentistry, School of Dental Medicine, University at Buffalo, Buffalo, N.Y. Dr. Glick is the dean, School of Dental Medicine, University at Buffalo, The State University of New York. He also is the editor of The Journal of the American Dental Association. Address reprint requests to Dr. Glick at School of Dental Medicine, University at Buffalo, 325 Squire Hall, Buffalo, N.Y. 142148006, e-mail [email protected].
LETTERS
be no more than 550 words and must cite no more than five references. No illustrations will be accepted. A letter concerning a recent JADA article will have the best chance of acceptance if it is received within two months of the article’s publication. For instance, a letter about an article that
appeared in April JADA usually will be considered for acceptance only until the end of November. You may submit your letter via e-mail to [email protected]; by fax to 1312-440-3538; or by mail to 211 E. Chicago Ave., Chicago, Ill. 606112678. By sending a letter to the editor, the author acknowledges
ADA welcomes letters from readers on articles that have appeared in The Journal. The Journal reserves the right to edit all communications and requires that all letters be signed. Letters must
J
JADA 143(11)
1. Glick M. Dental-lore–based dentistry, or where is the evidence? JADA 2006;137(5): 576-578. 2. Schiller JS, Lucas JW, Ward BW, Peregoy JA. Summary health statistics for U.S. adults: National Health Interview Survey, 2010. National Center for Health Statistics. Vital Health Stat 2012;10(252). www.cdc.gov/nchs/data/series/sr_10/sr10_252. pdf. Accessed Oct. 4, 2012. 3. American Dental Association Division of Legal Affairs. A legal perspective on antibiotic prophylaxis. JADA 2003;134(9):1260. 4. American Dental Association Division of Legal Affairs. An updated legal perspective on antibiotic prophylaxis. JADA 2008;139(1 suppl):10S. 5. Alvarez v Prospect Hospital et al, 68 NY2d 320 (1986). 6. Sawh v Schoen, 215 AD2d 291, 627 NY S2d 7 (NY App Div 1st Dept 1995). 7. Lloyd v St. Vincent’s Manhattan Hospital, 920 NY S2d 346 (2011) (NY App Div 1st Dept 2011). 8. Lipton by Lipton et al v Kaye et al, 214 AD 2d 319 (NY App Div 1st Dept 1995). 9. Lopez v Aziz, 852 SW2d 303 (Tex Ct App 1993). 10. Huffman v Linkow Inst for Advanced Implantology, Reconstructive & Aesthetic Maxillo-Facial Surgery, 826 NY S2d 229 (2006) (NY App Div 1st Dept, 2006). 11. Burtman v Brown MD et al, 945 NY S2d 673 (2012) (NY App Div 1st Dept 2012). 12. In re Sealed Case, 67 F3d 965 (1995). 13. Hill v Kokosky, 186 Mich App 300 (1990). 14. Reynolds by Reynolds v Decatur Memorial Hospital, 277 Ill App 3d 80 (1996). 15. Kundert v Illinois Valley Community Hospital, 964 NE 2d 670 (2012); 2012 Ill App (3d) 110007. 16. Glick M. Clinical judgment: a requirement for professional identity. JADA 2011; 142(12):1333-1334.
http://jada.ada.org
Copyright © 2012 American Dental Association. All rights reserved.
November 2012
1181
COMMENTARY
LETTERS
and agrees that the letter and all rights of the author in the letter sent become the property of The Journal. Letter writers are asked to disclose any personal or professional affiliations or conflicts of interest that readers may wish to take into consideration in assessing their stated opinions. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated. PERIODONTITIS AND THE HEART
I would like to thank Drs. Panos Papapanou and Maurizio Trevisan for offering their perspective on the state of the science regarding periodontitis and atherosclerotic vascular disease (AVD) in their August JADA guest editorial, “Periodontitis and Atherosclerotic Vascular Disease: What We Know and Why It Is Important” (Papapanou PN, Trevisan M. JADA 2012;143[8]:826-828). As a periodontist with a background in public health and 28 years of private practice, I have been keenly interested in the research regarding the relationship between periodontal disease and chronic systemic diseases. It has been frustrating to try to evaluate the often disparate conclusions and results reported in our literature. The barriers to performing a definitive clinical study indeed seem daunting, thus leaving clinicians with difficult decisions regarding what to tell our patients and our colleagues. Further, the design of many studies often does not appear to truly represent what we are doing in the trenches as we care for our patients. Certainly, continued and expanded communication between clinicians and researchers seems crucial to this endeavor. And yet, this problem does not seem at all unique to perio1182 JADA 143(11)
http://jada.ada.org
dontal research. Recently, our colleagues in medicine have been grappling with fundamental issues ranging from the use and validity of prostatespecific antigen screening to whether or not to recommend stress testing for asymptomatic patients.1,2 It has been suggested that both have led to unnecessary and significant morbidity. Happily, as stated in this editorial, “the risks associated with the treatment of periodontitis are low and are outweighed by therapymediated benefits.” In his December 2011 JADA column,3 Dr. Gordon Christensen suggested that dentistry is returning to its roots. We have historically been on the forefront of offering preventive services to the public. Regardless of the present lack of research establishing a definitive causal relationship between periodontitis and AVD, the prevention and appropriate treatment of periodontal disease carry their own obvious intrinsic value for a healthy lifestyle. We must not let misleading and inaccurate information deter us from delivering this valuable message. Thank you for publishing this valuable resource. Steve J. Kerpen, DMD, MPH Clinical Assistant Professor Hofstra North Shore-LIJ School of Medicine at Hofstra University Hempstead, N.Y. Adjunct Assistant Clinical Professor Department of Epidemiology and Health Promotion School of Dentistry New York University New York City 1. U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendations. www.uspreventiveservicestaskforce.org/ prostatecancerscreening/prostatefinalrs.htm. Accessed Sept. 28, 2012. 2. Moyer VA; on behalf of the U.S. Preventive Services Task Force. Screening for coro-
nary heart disease with electrocardiography: U.S. Preventive Services Task Force recommendations (published ahead of print July 31, 2012). Ann Intern Med doi:10.7326/00034819-157-7-201210020-00520. 3. Christensen GJ. Dentistry’s forced return to its roots. JADA 2011;142(12): 1393-1395.
CARIES CLASSIFICATION
It is sad to see that, in trying to create a new model for caries classification, Dr. Julian Fisher and Dr. Michael Glick, for the FDI World Dental Federation Science Committee, in their June JADA editorial, “A New Model for Caries Classification and Management: The FDI World Dental Federation Caries Matrix” (JADA 2012;143[6]:546-551), merely perpetuate a fundamental misunderstanding of dental caries that pervades the profession. Dental caries is a disease process and not a hole in a tooth. The unfortunate conflation of the disease with the effects of the disease (carious lesions) is common in both dental practice and dental research. This confusion has had a terrible effect on efforts to diagnose and treat one of the most common diseases. As long as a hole in the tooth is the disease itself, then filling the hole should cure the disease, goes the logic. However, research consistently shows that this is not the case; restorative dentistry does not address the underlying cause of tooth defects, and patients who are not treated for the disease continue to develop lesions, necessitating more restorative procedures.1-4 The authors don’t seem to understand this distinction or else they would have titled their work, “A New Model for Carious Lesion Classification and Management.” If they had, their work well may have been a contribution to lesion identification and management, but, as is, it does nothing to further the understanding and treatment of the disease that causes lesions.
November 2012
Copyright © 2012 American Dental Association. All rights reserved.