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HEALTH CARE REFORM
L E T T E R S
LETTERS
J
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 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 June. You may submit your letter via e-mail to “jadaletters@ ada.org”; by fax to 1-312-440-3538; or by mail to 211 E. Chicago Ave., Chicago, Ill. 60611-2678. By sending a letter to the editor, the author acknowledges and agrees that the letter and all rights of the author in the letter sent become the property of The Journal. 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. HEALTH CARE REFORM
Dr. James Bader’s essay in December JADA, “Challenges in Quality Assessment of Dental Care” (JADA 2009;140[12]: 1456, 1458-1464), is both stimulating and timely, given the current focus on health care reform. As both a clinician and dental director of a major dental benefits plan, I find it is an elusive goal to recommend what is effective for my patients as well as what is effective for a community of patients/subscribers. Empirically and through clinical experience, I know what works—that is, what is 246
JADA, Vol. 141
http://jada.ada.org
effective—and what doesn’t work—that is, what is not effective. I also recognize that this thought/decision process, more often than not, is anecdotal and not based on sound science. I find this disturbing on both the individual and community levels. Like most dentists, I have changed over the years since graduation from dental school. Some of what I thought to be appropriate I now consider inappropriate and vice versa. However, most of those changes were based on experience or expert opinion delivered at some continuing education course or in a magazine article. Since participating in the ADA Evidence-Based Dentistry (EBD) Champion Conference two years ago and attending the EBD course this fall at the Forsyth Institute, I have gained a new awareness. I have moved from a state of “unconscious incompetence” to “conscious incompetence.” I now know what I do not know. It is time we questioned all the answers. My only reserve and hesitation is in regard to diagnostic codes. I completely agree with Dr. Bader and others who support the need for such codes if we are going to measure outcomes. Furthermore, I understand that, without the ability to measure outcomes, it is virtually impossible to determine efficacy. In a research setting or even in a controlled clinical environment, such as the Pearl Network, diagnostic codes would be valuable and have meaning. However, in the realm of general clinical practice, the value of diagnostic codes would be diluted, and outcome assessments could be erroneous. What we need are clear diagnostic definitions. March 2010
As suggested by Dr. Bader, we can extrapolate the diagnosis on the basis of the treatment performed. If we have a claim for direct restorations, we can presume the diagnosis is caries. But clearly, that is not so. It could be a fractured restoration, attrition, erosion or a cosmetic replacement of amalgam for composite. Furthermore, one dentist’s diagnosis of caries may not be another dentist’s diagnosis. The same is true of periodontal disease—the other major dental disease. We see a significant number of claims for scaling and root planing for which one could extrapolate a diagnosis of periodontal disease. However, on review of radiographs and records, it is clear that periodontal disease is not evident. If we don’t start with an agreed-on diagnosis, then treatment outcomes will be erroneous. We need to resolve this discrepancy. As a profession, we need to embrace and accept the challenges Dr. Bader has set forth in his essay or we cease to be a profession. I commend JADA and its editor for publishing this important and timely essay. Clayton Pesillo, DMD Lewisburg, Pa.
Author’s response: I thank Dr. Pesillo for his thoughtful comments, and I fully agree with his concern over the definitional clarity demanded by diagnostic codes. However, I do not think that this need for clarity precludes the use of diagnostic codes in general practices. In fact, definitions for most diagnoses are quite clear, but the application of the definition to a particular patient requires determinations that are inherent-
LETTERS
J
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 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 June. You may submit your letter via e-mail to “jadaletters@ ada.org”; by fax to 1-312-440-3538; or by mail to 211 E. Chicago Ave., Chicago, Ill. 60611-2678. By sending a letter to the editor, the author acknowledges and agrees that the letter and all rights of the author in the letter sent become the property of The Journal. 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. HEALTH CARE REFORM
Dr. James Bader’s essay in December JADA, “Challenges in Quality Assessment of Dental Care” (JADA 2009;140[12]: 1456, 1458-1464), is both stimulating and timely, given the current focus on health care reform. As both a clinician and dental director of a major dental benefits plan, I find it is an elusive goal to recommend what is effective for my patients as well as what is effective for a community of patients/subscribers. Empirically and through clinical experience, I know what works—that is, what is 246
JADA, Vol. 141
http://jada.ada.org
effective—and what doesn’t work—that is, what is not effective. I also recognize that this thought/decision process, more often than not, is anecdotal and not based on sound science. I find this disturbing on both the individual and community levels. Like most dentists, I have changed over the years since graduation from dental school. Some of what I thought to be appropriate I now consider inappropriate and vice versa. However, most of those changes were based on experience or expert opinion delivered at some continuing education course or in a magazine article. Since participating in the ADA Evidence-Based Dentistry (EBD) Champion Conference two years ago and attending the EBD course this fall at the Forsyth Institute, I have gained a new awareness. I have moved from a state of “unconscious incompetence” to “conscious incompetence.” I now know what I do not know. It is time we questioned all the answers. My only reserve and hesitation is in regard to diagnostic codes. I completely agree with Dr. Bader and others who support the need for such codes if we are going to measure outcomes. Furthermore, I understand that, without the ability to measure outcomes, it is virtually impossible to determine efficacy. In a research setting or even in a controlled clinical environment, such as the Pearl Network, diagnostic codes would be valuable and have meaning. However, in the realm of general clinical practice, the value of diagnostic codes would be diluted, and outcome assessments could be erroneous. What we need are clear diagnostic definitions. March 2010
As suggested by Dr. Bader, we can extrapolate the diagnosis on the basis of the treatment performed. If we have a claim for direct restorations, we can presume the diagnosis is caries. But clearly, that is not so. It could be a fractured restoration, attrition, erosion or a cosmetic replacement of amalgam for composite. Furthermore, one dentist’s diagnosis of caries may not be another dentist’s diagnosis. The same is true of periodontal disease—the other major dental disease. We see a significant number of claims for scaling and root planing for which one could extrapolate a diagnosis of periodontal disease. However, on review of radiographs and records, it is clear that periodontal disease is not evident. If we don’t start with an agreed-on diagnosis, then treatment outcomes will be erroneous. We need to resolve this discrepancy. As a profession, we need to embrace and accept the challenges Dr. Bader has set forth in his essay or we cease to be a profession. I commend JADA and its editor for publishing this important and timely essay. Clayton Pesillo, DMD Lewisburg, Pa.
Author’s response: I thank Dr. Pesillo for his thoughtful comments, and I fully agree with his concern over the definitional clarity demanded by diagnostic codes. However, I do not think that this need for clarity precludes the use of diagnostic codes in general practices. In fact, definitions for most diagnoses are quite clear, but the application of the definition to a particular patient requires determinations that are inherent-