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Hepatitis B
LETTERS TO THE EDITOR THE JOURNAL devotes this section to com m ent by readers on topics of current interest to dentistry. The editor reserves the right to edit all com m unications to fit available space and requires that all letters be signed. Printed com m unications do not necessarily reflect the opinion or official policy of
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the A ssociation. Your participation in this section is invited.
H epatitis B □ T h e article s reg ard in g h e p a titis B (February) are w ell w ritte n , tim ely , an d in fo rm ative. T h e increase in h e p a titis B ex p o su re to th e d en tal profes sio n is sig n ific an t, an d the po ten tial loss of p rac tice tim e, n o t to m e n tio n th e h e a lth c o n s e q u e n c e s , can h av e d rastic resu lts. I w o u ld lik e to p o in t out, how ever, tw o re c e n t articles of in te rest in ou r p r e s e n t k n o w le d g e of h e p a titis B. F irst, th ro u g h n ew e r so p h istica te d rad io im m u n e a s s a y p r o c e d u r e s , serologic ev id en c e of h ep a titis B su r face a n tig en h a s b een d em o n strated as so o n as six d ays after h ep a titis B ex p o s u re .1 T e stin g su c h as th is ca n im m e a s u ra b ly sh o rte n th e tim e w h e n h e p a titis B im m u n e glo b u lin can be ad m in istered . A seco n d article,2 rep o rted in the ADA N ew s, O ct 27, 1980, rep o rts the d e v e lo p m e n t o f an a lm o st s p e c ific v accin e ag a in st h e p a titis B, tested at th e N ew Y ork B lood C enter, w h ich d e creases ac u te h e p a titis B by 92% an d h ep a titis B an tig en e m ia by 88%. T his co u ld re p re se n t a m ajor b reak th ro u g h in co n tro llin g h ep a titis B am ong su s c ep tib le groups. In an ed ito rial in th e N e w E ngland Journal o f M e d ic in e ,3 an o th e r in te re st ing fin d in g w as b ro u g h t out; nam ely, th a t th is v ac cin atio n m ay w ell be effec tiv e even after ex p o su re by an a c c id e n ta l n eed le injection. T his, of course, w o u ld b e of extrem e in terest a n d im p o rtan ce to th o se of us in th e d en tal profession. M ore in d e p th articles in T he Jour n a l, s u c h as th o s e o n h e p a titis B, w o u ld b e w elcom ed, I’m sure, by our profession. I, for one, w o u ld ce rtain ly en co u rage th is ty p e of in form ation for o u r m em b ersh ip . SIDNEY L. BRONSTEIN, DDS, MScD UNIVERSITY OF COLORADO DENVER 1. K rugm an, S., and others. Viral hepatitis, Type B. N ew Engl J Med 300(3):101-106, 1979. 2. Szm uness, W., and others. H epatitis B vac 612 ■ JADA, Vol. 102, May 1981
cine. New Engl J Med 303(15):833-841,1980. 3. Dienstag, J.L. Editorial. Toward the control of hepatitis B. New Engl J M ed 303(15):874-876, 1980.
□ I w ish to co m m en d T he Jo u rn al (February) for th e tim ely series of a rti cles on h e p a titis B. T h is is a to p ic of special in te rest to d en tistry , a n d one th a t is co n tin u ally ch an g in g w ith n ew discoveries or dev elo p m en ts. For th e m o st part, th e four articles w ere ex cel le n t an d p ro v id e d a sig n ific an t am o u n t of info rm atio n to th e profession. H ow ever, I w ish to take issu e w ith b o th Dr. S h ield s a n d Dr. A lex an d er in th e ir re spective articles in w h ic h th e y in d i cate th a t th e “best available te s t” for detecting h e p a titis B carriers (HBsAg) is “ u n re lia b le ,” a n d w o u ld d etect o nly “ 20% to 50% ” o r “ 30% to 60% ” of th e carriers. I b eliev e th e se statistics are b ased on o u td a te d referen ces (1972 an d 1977) an d are no lo n g er v alid . T he c u rren t test of ch o ice for d e te c tio n of h ep a titis B carriers (p ersisten t HBsAg) is a ra d io im m u n e assay (RIA) m eth o d w h ic h is extrem ely sen sitiv e. A bbott L aborato ries te stin g sy stem , A usria II-12 5, is su c h a te st w ith w h ich th e m a n u fa ctu re r claim s a d etectio n reliab ility of 99.4% . O th er RIA te sts are also available for th e oth er an tig en an tib o d y system s asso ciated w ith h e p atitis A an d B. T herefore, as w e h av e su ch a reliab le te st m e th o d available, screen in g p a tie n ts w ith a histo ry of h e p a titis is n o w a very u sefu l, realistic, a n d ad v isab le practice. I w o u ld encourage th e p ra c ticing d e n tist to req u est th is test from h is local clin ic al laboratory w h e n a p propriate. DONALD A. FALACE, DMD UNIVERSITY OF KENTUCKY LEXINGTON, KY
HEPATITIS
HBV
□ I am resp o n d in g to Dr. U ri H ang o rsk y ’s article (January) in w h ich h e rep o rted th e resu lts of h is stu d y re g ard in g th e reliab ility of lic en su re ex a m in a tio n s in e v a lu a tin g c l in ic a l co m p eten ce. H is d ata raised d istu rb in g q u estio n s ab o u t th e effectiveness of th e N orth East R egional B oard (NERB) in cu llin g th e in ferio r from th e su p e rio r fourthy ea r d e n ta l stu d e n t. Dr. H an g o rsk y p o in te d o u t th a t, a lth o u g h n ea rly a t h i r d o f th e f a ilin g c a n d id a te s in sch o o l A ran k e d in th e u p p e r th ird of th e ir g rad u a tin g class, all th e c a n d i dates ran k in g in th e b o tto m 10% of t h e ir g r a d u a tin g c la s s p a s s e d th e NERB ex am in atio n s. If lic e n su re ex am in atio n s do n o t fu l fill th e ir p u rp o se of sep aratin g th e in co m p ete n t from th e co m p eten t p rac ti tio n ers, h o w ca n th ey b e ju stified ? H ow c a n a g rad u ate of an a c cred ited d en tal sc h o o l pass n u m e ro u s clin ical a n d d id a c tic ex am in atio n s, p ass p arts I a n d II of th e N atio n al Board, b u t “fa il” a state o r reg io n al licen su re ex a m in a tio n ? S u re ly a co n sisten t p erfo rm an ce d u rin g th ree to four years of profes sio n a l sch o o l is a m ore reliab le in d ic a tio n of a b ility th a n a th re e -d a y w h irlw in d . A s w e h av e su ch rig o ro u s sta n d ard s for ac cred itatio n of o u r d en tal schools, it seem s th a t licen su re ex am in atio n s are re d u n d a n t. T h e criteria u sed by th e d en tal sch o o ls a n d th e NERB are q u ite sim ilar. H ow m an y ex am in atio n s m u st w e take? Is th e in v estm en t of effort, tim e, an d m oney by b oth th e b o ard a n d th e ca n d id a tes really w o rth it? It is d i f f i c u l t to d is c a r d l o n g sta n d in g tra d itio n s even w h en th e y no lo n g er se rv e th e ir o rig in a l p u rp o se. D entists are a group of p ro fessio n als w h o are alw ays search in g for a “b etter w a y . ’’ I h o p e w e can ap p ly th is a ttitu d e as w e ree v alu a te o u r p rese n t lic en su re system . I u rg e th e A m erican D ental A sso ciatio n to take th e lead in in v e s tig a tin g m o re effective w ays to assure clin ic al co m p eten ce in o u r profession. DEBORAH WHITMAN-BARTINE, DMD WAUKEGAN, ILL
Licensure exam inations
the A ssociation. Your participation in this section is invited.
H epatitis B □ T h e article s reg ard in g h e p a titis B (February) are w ell w ritte n , tim ely , an d in fo rm ative. T h e increase in h e p a titis B ex p o su re to th e d en tal profes sio n is sig n ific an t, an d the po ten tial loss of p rac tice tim e, n o t to m e n tio n th e h e a lth c o n s e q u e n c e s , can h av e d rastic resu lts. I w o u ld lik e to p o in t out, how ever, tw o re c e n t articles of in te rest in ou r p r e s e n t k n o w le d g e of h e p a titis B. F irst, th ro u g h n ew e r so p h istica te d rad io im m u n e a s s a y p r o c e d u r e s , serologic ev id en c e of h ep a titis B su r face a n tig en h a s b een d em o n strated as so o n as six d ays after h ep a titis B ex p o s u re .1 T e stin g su c h as th is ca n im m e a s u ra b ly sh o rte n th e tim e w h e n h e p a titis B im m u n e glo b u lin can be ad m in istered . A seco n d article,2 rep o rted in the ADA N ew s, O ct 27, 1980, rep o rts the d e v e lo p m e n t o f an a lm o st s p e c ific v accin e ag a in st h e p a titis B, tested at th e N ew Y ork B lood C enter, w h ich d e creases ac u te h e p a titis B by 92% an d h ep a titis B an tig en e m ia by 88%. T his co u ld re p re se n t a m ajor b reak th ro u g h in co n tro llin g h ep a titis B am ong su s c ep tib le groups. In an ed ito rial in th e N e w E ngland Journal o f M e d ic in e ,3 an o th e r in te re st ing fin d in g w as b ro u g h t out; nam ely, th a t th is v ac cin atio n m ay w ell be effec tiv e even after ex p o su re by an a c c id e n ta l n eed le injection. T his, of course, w o u ld b e of extrem e in terest a n d im p o rtan ce to th o se of us in th e d en tal profession. M ore in d e p th articles in T he Jour n a l, s u c h as th o s e o n h e p a titis B, w o u ld b e w elcom ed, I’m sure, by our profession. I, for one, w o u ld ce rtain ly en co u rage th is ty p e of in form ation for o u r m em b ersh ip . SIDNEY L. BRONSTEIN, DDS, MScD UNIVERSITY OF COLORADO DENVER 1. K rugm an, S., and others. Viral hepatitis, Type B. N ew Engl J Med 300(3):101-106, 1979. 2. Szm uness, W., and others. H epatitis B vac 612 ■ JADA, Vol. 102, May 1981
cine. New Engl J Med 303(15):833-841,1980. 3. Dienstag, J.L. Editorial. Toward the control of hepatitis B. New Engl J M ed 303(15):874-876, 1980.
□ I w ish to co m m en d T he Jo u rn al (February) for th e tim ely series of a rti cles on h e p a titis B. T h is is a to p ic of special in te rest to d en tistry , a n d one th a t is co n tin u ally ch an g in g w ith n ew discoveries or dev elo p m en ts. For th e m o st part, th e four articles w ere ex cel le n t an d p ro v id e d a sig n ific an t am o u n t of info rm atio n to th e profession. H ow ever, I w ish to take issu e w ith b o th Dr. S h ield s a n d Dr. A lex an d er in th e ir re spective articles in w h ic h th e y in d i cate th a t th e “best available te s t” for detecting h e p a titis B carriers (HBsAg) is “ u n re lia b le ,” a n d w o u ld d etect o nly “ 20% to 50% ” o r “ 30% to 60% ” of th e carriers. I b eliev e th e se statistics are b ased on o u td a te d referen ces (1972 an d 1977) an d are no lo n g er v alid . T he c u rren t test of ch o ice for d e te c tio n of h ep a titis B carriers (p ersisten t HBsAg) is a ra d io im m u n e assay (RIA) m eth o d w h ic h is extrem ely sen sitiv e. A bbott L aborato ries te stin g sy stem , A usria II-12 5, is su c h a te st w ith w h ich th e m a n u fa ctu re r claim s a d etectio n reliab ility of 99.4% . O th er RIA te sts are also available for th e oth er an tig en an tib o d y system s asso ciated w ith h e p atitis A an d B. T herefore, as w e h av e su ch a reliab le te st m e th o d available, screen in g p a tie n ts w ith a histo ry of h e p a titis is n o w a very u sefu l, realistic, a n d ad v isab le practice. I w o u ld encourage th e p ra c ticing d e n tist to req u est th is test from h is local clin ic al laboratory w h e n a p propriate. DONALD A. FALACE, DMD UNIVERSITY OF KENTUCKY LEXINGTON, KY
HEPATITIS
HBV
□ I am resp o n d in g to Dr. U ri H ang o rsk y ’s article (January) in w h ich h e rep o rted th e resu lts of h is stu d y re g ard in g th e reliab ility of lic en su re ex a m in a tio n s in e v a lu a tin g c l in ic a l co m p eten ce. H is d ata raised d istu rb in g q u estio n s ab o u t th e effectiveness of th e N orth East R egional B oard (NERB) in cu llin g th e in ferio r from th e su p e rio r fourthy ea r d e n ta l stu d e n t. Dr. H an g o rsk y p o in te d o u t th a t, a lth o u g h n ea rly a t h i r d o f th e f a ilin g c a n d id a te s in sch o o l A ran k e d in th e u p p e r th ird of th e ir g rad u a tin g class, all th e c a n d i dates ran k in g in th e b o tto m 10% of t h e ir g r a d u a tin g c la s s p a s s e d th e NERB ex am in atio n s. If lic e n su re ex am in atio n s do n o t fu l fill th e ir p u rp o se of sep aratin g th e in co m p ete n t from th e co m p eten t p rac ti tio n ers, h o w ca n th ey b e ju stified ? H ow c a n a g rad u ate of an a c cred ited d en tal sc h o o l pass n u m e ro u s clin ical a n d d id a c tic ex am in atio n s, p ass p arts I a n d II of th e N atio n al Board, b u t “fa il” a state o r reg io n al licen su re ex a m in a tio n ? S u re ly a co n sisten t p erfo rm an ce d u rin g th ree to four years of profes sio n a l sch o o l is a m ore reliab le in d ic a tio n of a b ility th a n a th re e -d a y w h irlw in d . A s w e h av e su ch rig o ro u s sta n d ard s for ac cred itatio n of o u r d en tal schools, it seem s th a t licen su re ex am in atio n s are re d u n d a n t. T h e criteria u sed by th e d en tal sch o o ls a n d th e NERB are q u ite sim ilar. H ow m an y ex am in atio n s m u st w e take? Is th e in v estm en t of effort, tim e, an d m oney by b oth th e b o ard a n d th e ca n d id a tes really w o rth it? It is d i f f i c u l t to d is c a r d l o n g sta n d in g tra d itio n s even w h en th e y no lo n g er se rv e th e ir o rig in a l p u rp o se. D entists are a group of p ro fessio n als w h o are alw ays search in g for a “b etter w a y . ’’ I h o p e w e can ap p ly th is a ttitu d e as w e ree v alu a te o u r p rese n t lic en su re system . I u rg e th e A m erican D ental A sso ciatio n to take th e lead in in v e s tig a tin g m o re effective w ays to assure clin ic al co m p eten ce in o u r profession. DEBORAH WHITMAN-BARTINE, DMD WAUKEGAN, ILL