- Email: [email protected]
Antimicrobial Agents and Periodontal Disease
always practice dentistry—the opportunity to be there for your children is fleeting. L yn n B rosy, D.M.D. R eno, Nev. INTELLECTUAL DISHONESTY?
I cannot u n derstand why, in “T reating TM Disorders: A Survey on Diagnosis, Etiology and M anagem ent” by Drs. Jeffrey Ju st, H arold Perry and C harles Greene (September), groups whose mem bers do not use electro-biologic diagnostic procedures (those nasty controversial ones) were asked about them while groups whose m em bers do use them were ignored. I can’t understand it, but being aw are of the reality of political chicanery, I can accept it as a fact of life. W hat is unacceptable is draw ing a blanket conclusion from one premise. In this case, an JtmgKHKk article (which may well be in error) jjr evaluating sono- jfL graphy was used to condemn all electro biologic diagnostic procedures. Forgive me if I construe this as intellectual dishonesty. W hen one-third to one-half of respondents “don’t know w hether these aids should be used in diagnosis” it does not necessarily reflect skepticism. A more correct conclusion could be th a t those respondents simply did not know anything about them . A research paper should not editorialize. T hank goodness cardiologists have progressed beyond the “I can do it ju s t as well with only a stethoscope” approach. M onitoring biologic functions is also a fact of life. F ra n cis X. Spika, D.D.S. La Crosse, Wis. 14
JADA, Vol. 123, February 1992
A u th ors’ com m ents: It’s h ard to understand why a person whose “TMD group” was not surveyed by us chooses to characterize th a t as “political chicanery.” This survey, which included two m ajor groups interested in TMD and three groups interested in orthodontics, did not deliberately (or politically) exclude any group; however, Dr. Spika’s letter gives us a pretty strong indication of w hat his group’s response bias would have been. W hat we consider to be more im portant is the validity of the issue his letter raises, namely: Why did so m any respondents say either “no” or “don’t know” when asked about the use of socalled electro-biologic diagnostic procedures? Dr. Spika concludes th a t this shows th a t respon dents did not know anything about such proce dures. A more careWf ful reading of w f our discussion about those res ponses would have shown th a t we cited six references (not ju st one) dealing w ith technological diagnosis. All of these raised serious questions about the clinical use of technological m odalities in the diagnosis of TMD. Indeed, one of the references (No. 72) cited an entire issue of the California D ental Association Journal which included several negative review articles on this subject. Therefore, we concluded th a t m any respondents to our survey, having read the relevant literature, believe th a t currently available technological devices for the diagnosis of TMD are not
adequate for th a t purpose. They simply do not m eet the criteria for specificity and sensitivity, which are required for their routine use. Luckily, cardiologists do have several acceptable diagnostic devices, so any reader who suffers palpitations while reading our paper can seek an accurate diagnosis for th a t problem. Jeffrey K. Ju st, D.D.S. H arold T. P erry, D.D.S. C h arles S. G reene, D.D.S. ANTIMICROBIAL AGENTS AND PERIODONTAL DISEASE
The article “U sing Antimicrobial Agents to M anage Periodontal D iseases,” by Dr. R.J. Genco (September), raises some interesting questions. Why should new, expensive antibiotics, often restricted in hospitals to the use in serious, life-threatening infections, be touted for use in periodontal disease? As the author him self points out, indiscrim inate use m ay induce or select antibiotic resista n t strains of bacteria. As a n example, Augmentin should not be used in chronic infections, b u t is best used to control serious, acute infections. In Table 1, Cipro appears superior to penicillins, only against A.a., and yet costs approxim ately $100 for a tenday course, as opposed to less th an $10 for penicillin and tetracycline. The potential use of systemic antibiotics to tre a t low grade chronic periodontal infections in millions of patients will soon dim inish the value and efficacy of these new, potent drugs against serious infections. While the sale of hundreds of millions of doses of Cipro and Augm entin m ight be pleasing to their
m anufacturers, it is appalling to those who understand th a t it is medically more valid to restrict th eir use. Older, less expensive and equally as useful antibio tics, such as penicillin and te tra cycline, should be the drugs of choice, even for refractory perio dontal disease (unresponsive to m echanical therapy). M orton H. G oldberg, D.M.D., M.D. H artford, Conn. A u th or’s com m ents: Dr. Goldberg has raised th e issue of the cost of antibiotics for the use in treatm en t of periodontal dis ease, and has also questioned the overuse of antibiotics to di m inish th eir value and efficacy. Both points are im portant and need to be addressed. The issue of cost is of considerable concern. I feel th a t my article does point out th a t the use of antibiotics is reserved for unique situations, and I did not suggest th a t they be used to tre a t chronic periodontal infections in “millions” of patients, as Dr. Goldberg has m isinterpreted. These antibiotics were suggested for use only in refractory patients. Although we do not have a good estim ate of the num ber of such patients, they are probably a very small percentage of periodontal patients who are treated w ith m echanical therapy. The realization th a t organism s such as Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans and Prevotella intermedia are serious pathogens is a fairly new concept based on hum an and anim al studies. Elim ination of these pathogens from the hum an oral cavity, w here they are associated w ith periodontal 16
JADA, Vol. 123, February 1992
lesions and can also cause more serious infections in m an, is clearly justified. Form er concepts of periodontal disease as a low grade, smoldering infection, as Dr. Goldberg feels, have been supplanted by our new understanding th a t periodontal pathogens are often of high virulence and can cause serious infections. I t is clear th a t anti-infective approaches to suppression of these m organisms are m feasible and reasonable when 1 ^ they are identified 1 in refractory cases of periodontal disease. W hen their antibiotic susceptibilities are known, it is reasonable to select an effective antibiotic to reduce their num bers. Microbial diagnostic services are available for identifying periodontal pathogens, determ ining th eir antibiotic susceptibility and m onitoring th eir suppression or elim ination after therapy. R obert J. G enco, D.D.S., Ph.D . B u ffalo, N.Y. NATIONAL HEALTH CARE SYSTEM
O ur health care system certainly is a mess. No one will deny th at. Now w ith an election on the horizon, we have the awful opportunity to quickly m ake it worse. Please, for the sake of organized dentistry, let's not get on the bandwagon to be a part of the medical health care program, but let's wait to see how it "sugars out." We can in sert ourselves later if th e system ever works. The socialistic approach of pouring public money into the issue is causing the economies of
England and C anada to crumble. Government inefficiency and bureaucracy in the Medicaid program is perhaps one of the most significant reasons why private health care is so expensive. Medicaid pays betw een 40 percent and 60 percent of the tru e cost for th e services ft received. This discount m eans ■ th a t the private sector m ust H m ake up the difference plus A pay 100 percent of its share. T hat is why the am ount is staggering. Blame has been shifted to disguise the tru e reasons for the m ess to unethical and overpaid providers. The fact is th a t if we were to cut doctors' salaries in h a lf we would only reduce the total health care cost by 8 percent! Unethical providers are present but rare. The m ost im portant issue is the concept of personal responsibility for health. A "big brother" approach will only lead us fu rth er away from it. If one leads a lifestyle of excessive eating, drinking, drugs, ab erran t sex and a disregard for personal fitness, whose problem is it? Sadly, m any people frequently get w hat they deserve. For the vast m ajority of Americans, health is (or was) a choice, regardless of income. Let's help people to m ake better choices. D ale R. N eil, D.D.S. S tow e, Vt. CORRECTION
In th e report “Sterilization required for infection control” (December), the second tem p erature reading labeled Dry heat should be 160 C (320 F), not 340 F.
I cannot u n derstand why, in “T reating TM Disorders: A Survey on Diagnosis, Etiology and M anagem ent” by Drs. Jeffrey Ju st, H arold Perry and C harles Greene (September), groups whose mem bers do not use electro-biologic diagnostic procedures (those nasty controversial ones) were asked about them while groups whose m em bers do use them were ignored. I can’t understand it, but being aw are of the reality of political chicanery, I can accept it as a fact of life. W hat is unacceptable is draw ing a blanket conclusion from one premise. In this case, an JtmgKHKk article (which may well be in error) jjr evaluating sono- jfL graphy was used to condemn all electro biologic diagnostic procedures. Forgive me if I construe this as intellectual dishonesty. W hen one-third to one-half of respondents “don’t know w hether these aids should be used in diagnosis” it does not necessarily reflect skepticism. A more correct conclusion could be th a t those respondents simply did not know anything about them . A research paper should not editorialize. T hank goodness cardiologists have progressed beyond the “I can do it ju s t as well with only a stethoscope” approach. M onitoring biologic functions is also a fact of life. F ra n cis X. Spika, D.D.S. La Crosse, Wis. 14
JADA, Vol. 123, February 1992
A u th ors’ com m ents: It’s h ard to understand why a person whose “TMD group” was not surveyed by us chooses to characterize th a t as “political chicanery.” This survey, which included two m ajor groups interested in TMD and three groups interested in orthodontics, did not deliberately (or politically) exclude any group; however, Dr. Spika’s letter gives us a pretty strong indication of w hat his group’s response bias would have been. W hat we consider to be more im portant is the validity of the issue his letter raises, namely: Why did so m any respondents say either “no” or “don’t know” when asked about the use of socalled electro-biologic diagnostic procedures? Dr. Spika concludes th a t this shows th a t respon dents did not know anything about such proce dures. A more careWf ful reading of w f our discussion about those res ponses would have shown th a t we cited six references (not ju st one) dealing w ith technological diagnosis. All of these raised serious questions about the clinical use of technological m odalities in the diagnosis of TMD. Indeed, one of the references (No. 72) cited an entire issue of the California D ental Association Journal which included several negative review articles on this subject. Therefore, we concluded th a t m any respondents to our survey, having read the relevant literature, believe th a t currently available technological devices for the diagnosis of TMD are not
adequate for th a t purpose. They simply do not m eet the criteria for specificity and sensitivity, which are required for their routine use. Luckily, cardiologists do have several acceptable diagnostic devices, so any reader who suffers palpitations while reading our paper can seek an accurate diagnosis for th a t problem. Jeffrey K. Ju st, D.D.S. H arold T. P erry, D.D.S. C h arles S. G reene, D.D.S. ANTIMICROBIAL AGENTS AND PERIODONTAL DISEASE
The article “U sing Antimicrobial Agents to M anage Periodontal D iseases,” by Dr. R.J. Genco (September), raises some interesting questions. Why should new, expensive antibiotics, often restricted in hospitals to the use in serious, life-threatening infections, be touted for use in periodontal disease? As the author him self points out, indiscrim inate use m ay induce or select antibiotic resista n t strains of bacteria. As a n example, Augmentin should not be used in chronic infections, b u t is best used to control serious, acute infections. In Table 1, Cipro appears superior to penicillins, only against A.a., and yet costs approxim ately $100 for a tenday course, as opposed to less th an $10 for penicillin and tetracycline. The potential use of systemic antibiotics to tre a t low grade chronic periodontal infections in millions of patients will soon dim inish the value and efficacy of these new, potent drugs against serious infections. While the sale of hundreds of millions of doses of Cipro and Augm entin m ight be pleasing to their
m anufacturers, it is appalling to those who understand th a t it is medically more valid to restrict th eir use. Older, less expensive and equally as useful antibio tics, such as penicillin and te tra cycline, should be the drugs of choice, even for refractory perio dontal disease (unresponsive to m echanical therapy). M orton H. G oldberg, D.M.D., M.D. H artford, Conn. A u th or’s com m ents: Dr. Goldberg has raised th e issue of the cost of antibiotics for the use in treatm en t of periodontal dis ease, and has also questioned the overuse of antibiotics to di m inish th eir value and efficacy. Both points are im portant and need to be addressed. The issue of cost is of considerable concern. I feel th a t my article does point out th a t the use of antibiotics is reserved for unique situations, and I did not suggest th a t they be used to tre a t chronic periodontal infections in “millions” of patients, as Dr. Goldberg has m isinterpreted. These antibiotics were suggested for use only in refractory patients. Although we do not have a good estim ate of the num ber of such patients, they are probably a very small percentage of periodontal patients who are treated w ith m echanical therapy. The realization th a t organism s such as Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans and Prevotella intermedia are serious pathogens is a fairly new concept based on hum an and anim al studies. Elim ination of these pathogens from the hum an oral cavity, w here they are associated w ith periodontal 16
JADA, Vol. 123, February 1992
lesions and can also cause more serious infections in m an, is clearly justified. Form er concepts of periodontal disease as a low grade, smoldering infection, as Dr. Goldberg feels, have been supplanted by our new understanding th a t periodontal pathogens are often of high virulence and can cause serious infections. I t is clear th a t anti-infective approaches to suppression of these m organisms are m feasible and reasonable when 1 ^ they are identified 1 in refractory cases of periodontal disease. W hen their antibiotic susceptibilities are known, it is reasonable to select an effective antibiotic to reduce their num bers. Microbial diagnostic services are available for identifying periodontal pathogens, determ ining th eir antibiotic susceptibility and m onitoring th eir suppression or elim ination after therapy. R obert J. G enco, D.D.S., Ph.D . B u ffalo, N.Y. NATIONAL HEALTH CARE SYSTEM
O ur health care system certainly is a mess. No one will deny th at. Now w ith an election on the horizon, we have the awful opportunity to quickly m ake it worse. Please, for the sake of organized dentistry, let's not get on the bandwagon to be a part of the medical health care program, but let's wait to see how it "sugars out." We can in sert ourselves later if th e system ever works. The socialistic approach of pouring public money into the issue is causing the economies of
England and C anada to crumble. Government inefficiency and bureaucracy in the Medicaid program is perhaps one of the most significant reasons why private health care is so expensive. Medicaid pays betw een 40 percent and 60 percent of the tru e cost for th e services ft received. This discount m eans ■ th a t the private sector m ust H m ake up the difference plus A pay 100 percent of its share. T hat is why the am ount is staggering. Blame has been shifted to disguise the tru e reasons for the m ess to unethical and overpaid providers. The fact is th a t if we were to cut doctors' salaries in h a lf we would only reduce the total health care cost by 8 percent! Unethical providers are present but rare. The m ost im portant issue is the concept of personal responsibility for health. A "big brother" approach will only lead us fu rth er away from it. If one leads a lifestyle of excessive eating, drinking, drugs, ab erran t sex and a disregard for personal fitness, whose problem is it? Sadly, m any people frequently get w hat they deserve. For the vast m ajority of Americans, health is (or was) a choice, regardless of income. Let's help people to m ake better choices. D ale R. N eil, D.D.S. S tow e, Vt. CORRECTION
In th e report “Sterilization required for infection control” (December), the second tem p erature reading labeled Dry heat should be 160 C (320 F), not 340 F.