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A FLAWED REPORT ON FRACTURES?
L E T T E R S
1. Payment P, Richardson L, Siemiatycki J, Dewar R, Edwardes M, Franco E. A randomized trial to evaluate the risk of gastrointestinal disease due to consumption of drinking water meeting current microbiological standards. Am J Public Health 1991;81(6):703-8.
LICENSURE
I just had to weigh in on the examination subject (“The Perfect Patient,” October JADA) because it has been a sore point with me for years. I have been practicing for 15-plus years now and still feel that the [examining boards] do nothing to protect the public. There were a few classmates who passed the clinical exams whom I would not want treating me because of marginal skills. There were fine students who failed because of patient noshows or unacceptable lesions. The exam did nothing but cause them emotional and financial hardship. It is crazy to put all eight years of college on the line like that. A number of years ago, I had an opportunity to go to Florida but had to forgo it because of the restraints of getting licensed there. My friend, who is a surgeon, had no problem getting a license to practice medicine there. If the public needed protection, you would think it would be more necessary for a surgeon. If a person graduates from an accredited school, we should have confidence in that training and allow people to practice where they want without restraint. Stephen M. Saracino, D.M.D. Raynham, Mass. A FLAWED REPORT ON FRACTURES?
The article by Drs. Marc Heft, Gregg Gilbert, Teresa Dolan 144
and Ulrich Foerster (“Restoration Fractures, Cusp Fractures and Root Fragments in a Diverse Sample of Adults: 24-Month Incidence,” October JADA) has two serious flaws. These flaws should be identified to prevent readers from drawing incorrect conclusions from the article. First, the article incorrectly refers to the information reported as “incidence” or “rates of occurrence” for cusp and restoration fractures. The authors correctly point out in the Abstract and the Discussion sections that the article actually reports consecutive prevalence comparisons, based on clinical examinations two years apart. Consecutive prevalence studies can only be used to calculate incidence when the event of interest is permanent and cannot be obscured by subsequent treatment before the next examination. Clearly this is not the case for cusp or restoration fracture. Unfortunately, the term “incidence” and related terms are used indiscriminately throughout all sections of the article, including the title, leading less cautious readers to assume that incidence data have been determined, when in fact they have not. The second flaw also is related to the method used for determining “incidence.” The conclusion states, “Blacks and people who seek care on a problem-oriented basis are at greater risk of developing [fractures].” This observation is obviously confounded by the effect of treatment done on teeth that fractured between the two examinations. Clearly, those who seek care less often will be less likely to receive treatment
for fractures and, hence, will be more likely to exhibit fractured teeth at the second exam. Thus, the conclusion must be considered flawed. We urge readers to regard the study’s findings with skepticism, and The Journal’s reviewers to be more attentive to such fundamental flaws in the future. Jim Bader, D.D.S., M.P.H. Dan Shugars, D.D.S., Ph.D. Department of Operative Dentistry University of North Carolina Chapel Hill Authors’ response: We understand the concerns of Drs. Bader and Shugars regarding use of the terms “consecutive prevalence” and “incidence.” However, we disagree with their statement that “consecutive prevalence studies can only be used to calculate incidence when the event of interest is permanent … .” We did, in fact, measure incidence, albeit by using a toothspecific consecutive prevalence method. Using this method, the tooth-specific new events are observable, although the incidence estimate is of necessity a lower-bound estimate. We share Drs. Bader’s and Shugar’s concern about communicating to the typical reader the distinction between consecutive prevalence and incidence. This is why we made such a point of being careful to communicate to the reader exactly what we mean by those terms and their limitations. We also agree that readers should keep these distinctions in mind when making inferences from this study. This is why we emphasized this point in the Abstract, reminded the
JADA, Vol. 132, February 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.
1. Payment P, Richardson L, Siemiatycki J, Dewar R, Edwardes M, Franco E. A randomized trial to evaluate the risk of gastrointestinal disease due to consumption of drinking water meeting current microbiological standards. Am J Public Health 1991;81(6):703-8.
LICENSURE
I just had to weigh in on the examination subject (“The Perfect Patient,” October JADA) because it has been a sore point with me for years. I have been practicing for 15-plus years now and still feel that the [examining boards] do nothing to protect the public. There were a few classmates who passed the clinical exams whom I would not want treating me because of marginal skills. There were fine students who failed because of patient noshows or unacceptable lesions. The exam did nothing but cause them emotional and financial hardship. It is crazy to put all eight years of college on the line like that. A number of years ago, I had an opportunity to go to Florida but had to forgo it because of the restraints of getting licensed there. My friend, who is a surgeon, had no problem getting a license to practice medicine there. If the public needed protection, you would think it would be more necessary for a surgeon. If a person graduates from an accredited school, we should have confidence in that training and allow people to practice where they want without restraint. Stephen M. Saracino, D.M.D. Raynham, Mass. A FLAWED REPORT ON FRACTURES?
The article by Drs. Marc Heft, Gregg Gilbert, Teresa Dolan 144
and Ulrich Foerster (“Restoration Fractures, Cusp Fractures and Root Fragments in a Diverse Sample of Adults: 24-Month Incidence,” October JADA) has two serious flaws. These flaws should be identified to prevent readers from drawing incorrect conclusions from the article. First, the article incorrectly refers to the information reported as “incidence” or “rates of occurrence” for cusp and restoration fractures. The authors correctly point out in the Abstract and the Discussion sections that the article actually reports consecutive prevalence comparisons, based on clinical examinations two years apart. Consecutive prevalence studies can only be used to calculate incidence when the event of interest is permanent and cannot be obscured by subsequent treatment before the next examination. Clearly this is not the case for cusp or restoration fracture. Unfortunately, the term “incidence” and related terms are used indiscriminately throughout all sections of the article, including the title, leading less cautious readers to assume that incidence data have been determined, when in fact they have not. The second flaw also is related to the method used for determining “incidence.” The conclusion states, “Blacks and people who seek care on a problem-oriented basis are at greater risk of developing [fractures].” This observation is obviously confounded by the effect of treatment done on teeth that fractured between the two examinations. Clearly, those who seek care less often will be less likely to receive treatment
for fractures and, hence, will be more likely to exhibit fractured teeth at the second exam. Thus, the conclusion must be considered flawed. We urge readers to regard the study’s findings with skepticism, and The Journal’s reviewers to be more attentive to such fundamental flaws in the future. Jim Bader, D.D.S., M.P.H. Dan Shugars, D.D.S., Ph.D. Department of Operative Dentistry University of North Carolina Chapel Hill Authors’ response: We understand the concerns of Drs. Bader and Shugars regarding use of the terms “consecutive prevalence” and “incidence.” However, we disagree with their statement that “consecutive prevalence studies can only be used to calculate incidence when the event of interest is permanent … .” We did, in fact, measure incidence, albeit by using a toothspecific consecutive prevalence method. Using this method, the tooth-specific new events are observable, although the incidence estimate is of necessity a lower-bound estimate. We share Drs. Bader’s and Shugar’s concern about communicating to the typical reader the distinction between consecutive prevalence and incidence. This is why we made such a point of being careful to communicate to the reader exactly what we mean by those terms and their limitations. We also agree that readers should keep these distinctions in mind when making inferences from this study. This is why we emphasized this point in the Abstract, reminded the
JADA, Vol. 132, February 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.