- Email: [email protected]
Licensure—suggestions for change
JAD A L etters
to the
E d it o r ]ADA 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 typed, double-spaced, and signed. No more than ten references should be given w ith each letter. Printed com m unications do not necessarily reflect the opinion or official policy of the Association. Your participation in this section is invited.
Pediatric anesthesia guidelines □ Recently, the A m erican Academy of Pediatric Dentistry, in cooperation w ith the A m erican Academy of Pediatrics, de veloped “G uidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients.” These guidelines were published in the A u g u s t 1 9 8 5 is s u e o f P e d i a t r i c s (76(2):317-321, 1985). It is the belief of the academ y that these guidelines can serve a useful purpose for the dental com m unity at large, not just for pediatric dentists. I urge dentists to ob tain copies of these guidelines for their use. S ingle copies of th e g u id elin es are available from the A m erican Academy of Pediatrics, publications departm ent, Box 927, Elk Grove Village, IL 60007. J. DAVID GAYNOR, DDS PRESIDENT, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY SACRAMENTO, CA
For the patient’s health □ Dr. McCarthy should be congratulated for once again bringing to our attention the im portance of obtaining a thorough m edical history from our dental patients in “A new, patient-adm inistered m edical history developed for dentistry” (Octo ber). . . . During the more than 40 years in w hich I practiced or taught, it was gratify ing to see the increase in dentistry’s con cern for the m edical problem s of our pa tients as show n by the increasing sophis tication of the health histories we take. My first office on the second floor of a building was selected in part because of the sim ple belief that that was a good way to screen for m edical problems. If the pa tient could climb the stairs w ithout diffi 906 ■ JADA, Vol. I l l , December 1985
culty, it w as safe to provide treatment. from alcohol, drug, or gaseous ad dic T o d a y , a n i n t e r a c t i v e , p a t i e n t - tion?” If yes, appropriate treatm ent m od adm inistered com puter program for p a ification can be done; if no, there is no tient evaluation incorporates the features problem, or if the patient lied, the dentist of the ADA questionnaire and those ex should be relieved of ethical and legal plained in the McCarthy article. This pro responsibilities. And although not a large gram, after com pletion of in put by the part of the recovering population, there patient, prints a history listing the p a are some people who are addicted to vari tie n t’s problem s, highlighting those of a ous gases, and nitrous oxide is probably m ore significant nature, lists the drugs the no. 2 or 3 preference among dental ta k e n , an d p rin ts a re m in d e r lis t of professionals. HERBERT R. HEDGE, DDS suggested actions based on the patient’s OTTUMWA, IA problem list, w ith suggestions for further evaluation if indicated and for m onitor ing of the treatm ent program. The patient Prudence in practice need not interact w ith the com puter but may com plete a questionnaire that then □ I w ould like to share my experiences in can be entered into the com puter. The eq u ip p in g an office (E m p h a sis, S ep dentist th en has a signed record plus a tem ber). I am a g en eral p rac titio n er. com puter record, for ready reference. The W hen I started out, I was b ro k e. . .For the step from there to retrieval of information first year in practice, I rented a 12- x 14-ft based on disease, age, or gender is made (168 sq ft) room in a building next to an established dentist. I paid him for the use easily should it ever be desired. HUBERT W. MERCHANT, DDS of his darkroom and reception area. . . . I AUGUSTA, GA b o rro w ed m oney from th e bank and bought a m inim um of equipm ent at a □ I suggest adding the w ord alcoholism good discount. to Dr. Frank M cCarthy’s m edical history, I w orked in one room for a year and to read Alcoholism /D rug A ddiction in moved to a new building w ith a 650-sq-ft section 9. . . . office. As I needed them, I furnished three My personal history is shared by m any op erato ries, a laboratory, a recep tio n recovering alcoholics. It has been m any room, a business office, a darkroom, and a years since I w ent through treatm ent for private office. alcoholism, and w ith no recent hospitali After 33 years, I still practice in this zations, I w ould answ er no to question 4 .1 office w ith the same equipm ent. . . . I buy was an alcoholic and, therefore, m ight m y equipm ent from a local dental supply deny the “ drug addiction” question. . . . I com pany and they service it. I use a mail did not have liver or yellow jaundice dis order house and buy in bulk my expend ease or hepatitis (nor did I have gingivitis, able supplies twice a year, w ith a great despite a poor diet). Therefore, I could savings. . . . slip through the questionnaire w ithout I have never used a so-called real “den revealing that I am a recovering alcoholic. tal consulting firm .” In fact, once I had to I consider m yself a drug addict, and my ask one overbearing soul to leave my of d rug w as alcohol. H ow ever, m any of fice. I have listened to their lectures at t h o s e r e c o v e r in g fro m a lc o h o lis m m eetings but never in my office. Ask a strongly deny that they are drug addicts. dentist, he is the best consultant in the A lthough the “pure alcoholic” (who uses world for you. alcohol exclusively) is becoming extinct, I w ant to tell fellow dentists that you the active but predom inantly drug-using d o n ’t need a 2,000-sq-ft office w ith an addict w ill deny vehem ently all addic elaborate dental set-up to make a good tions, including alcoholism . But once living practicing dentistry. in to tre a tm e n t, th a t sam e a d d ic t fre RUFUS G. HOOVER, DDS CHARLOTTE, NC q u en tly w ill acknow ledge alcoholism (and perhaps not the drug addiction), be cause it is more socially (and legally) ac Licensure—suggestions for change ceptable to be a recovering alcoholic. To identify the recovering addict, I long □ The interest of Association members have recom m ended a separate yes or no in licensing procedures is understand question, “Are you in a recovery status able. If the intent of those procedures has
L e t t e r s to E d it o r
the
not been corrupted, it certainly gives that appearance and, as a consequence, ad versely reflects on organized dentistry. The reason (correct me if I’m wrong) is that the dental com ponent of every state board is suggested by organized d en tistry. Even if we are concerned only w ith public relations, there is the place to be gin. In the E m phasis article on licensure (July), Dr. Paul Buxton, chairm an of the Alaska State Board of Dental Examiners, is quoted as saying, . . there’s a real problem in getting dental care to all the population that actually w ants it,” and “Licensing by credentials caused another problem . There is no way for the board to call a state board about m ilitary person n e l.” I w ould like to quote from a letter w rit te n 20 years ago from th e secretarytreasurer of the Alaska State Board of Den tal Exam iners w ho replied to my inquiry about reciprocity. T he need for dentists in Alaska is not as acute (as published). There are approxim ately 120 dentists in the US Public Health Service, Army, Navy, and Air Force w ho take care of our sizable native and m ilitary populations. The rem ainder of the civilian population is taken care of by approxim ately 80 private practitio ners. The total statistical figures w ould run 250,000 total population w ith 200 dentists, or a ratio of approxim ately 1,250 per dentist, w hich is w ell below the national average of approxi m ately 1,800 per dentist. . . . Alaska law does provide for tem porary perm its to be issued for a year for the practice of dentistry in isolated areas w hose population is u n d er 3,000 and in w hich there is no resident dentist w ith in a 25-m ile radius.
This was part of a reply to a sim ple request for inform ation about reciprocity. AARON LIFSHIN, DDS ASTON, PA
□ Dr. Barry J. Blutig’s letter on licensure (October) is an exam ple of logic and pro fessionalism . Dr. Blutig properly directs
h is fo cu s on co m p eten cy a ssu ran ce , w hich is the fundam ental reason for state board examinations. It is clear that the m ajo rity of new graduates pass state board exam inations on their first attem pt (currently more than 90% in Florida). The problem exists w ith, and the com plaints largely come from, dentists whose didactic and clinical com petencies have d im inished during the years after gradua tion. It is w ell know n among dental edu cators that national board scores trail off a p p ro x im a te ly 5 years a fter g ra d u a tion. . . . A dditionally, a substantial num ber of candidates in certain states are graduates of u n a c c re d ited schools. T hese “ eco nom ic refugees” usually come from Third W orld countries and from proprietary schools in the Far East and the Caribbean Basin. Interestingly, the “exclusionary” Sun Belt states m aintain easy access to the licensure process for these as w ell as dom estic graduates. On the other hand, m any of the so-called Frost Belt states have added statutory and regulatory re strictions to foreign graduate licensure, and their residents com plain about a lack of m obility in the U nited States for them selves. The contem porary practice of m edicine is replete w ith quality assurance m echa nism s: internships, residencies, specialty boards and hospital credentials, utiliza tion review, peer review, and tissue and other committees. The practicing physi cian is scrutinized by all of these com pe tency assessm ents as a daily fact of pro fessional life. W hat m ethods of continu ing com petency assessm ent exist for the m ajority of dentists who do not intern, serve a residency, or actively practice in a n accredited hospital? I subm it that the “act” that dentistry should “ clean u p ” is the lack of continu in g com p etency assurance. . . . W hen dentistry makes significant strides in con tin u in g co m p ete n cy a ssu ra n c e , state board exam inations will be a great deal less desirable than they now are to legis lators and to m any of us in the profession. ROBERT T. FERRIS, DDS, PhD ALTAMONTE SPRINGS, FL
□ . . . The topic of licensure by creden
tials seem s critically im portant to the dental practitioner. If the letters on this topic are any indication, the majority of our profession favors some sort of change in the licensing process—w hether it’s via a general practice residency, licensure by credentials, or reciprocity. The current exam ination procedure by state and regional boards is antiquated and fails in its original purpose: to protect the public from incom petency. If we need to upgrade our graduation requirem ents, or if w e need to put more em phasis on peer review, let’s do it! As others have said, the only way to make these changes is to act as a unified voice . . . to enact change on a statewide basis. JEFF D. MALYON, DDS TROUTDALE, OR
Keyes method—proved or tested? □ The report by Dr. Thomas Rams and o th ers, “ L o ng-term effects of m icrob io lo g ic a lly m o d u la te d p e rio d o n ta l therapy on advanced adult periodontitis” (September), seems designed to prove the au th o rs’ treatm ent m ethod rather th an test the m ethod against controls, w hich is the purpose of genuine scientific inquiry. The experim ent had too m any variables to establish causation; 46 of 47 patients needed tetracycline therapy before their periodontal health improved. It is no sur prise that infections w ill respond favor ably to antibiotics, but we question the consequences and m edical appropriate ness of continued tetracycline therapy. The authors’ conclusion that periodon tal su rg e ry is u n n e c e ssa ry is u n ju s tified. . . . JOHN E. DODES, DDS MARVIN J. SCHISSEL, DDS WOODHAVEN, NY
Corrections □ Corrections for the Em phasis (Octo ber) article on restorative dentistry in clude: On page 555, the legend for Figure a should read: Badly broken-dow n canine w ith m echanical perforation on the m e sial surface. O n p a g e 5 5 7 , th e r e p l y b y D r.
Left ■ Maximum intercuspation lacking anterior contact or potential for guidance and posterior disclusion. Middle ■ Direct bond composite resin has been added to lingual side of canine. It has been adjusted to contact in maximum intercuspation and is shaped to mimic palatal platform of carefully adjusted Hawley bite plane. Right ■ Lingual view o f canine platform. Note articulating paper marking canine and premolars in maximum intercuspation and guidance pattern established on canine platform in lateral excursive movement.
908 ■ JADA, Vol. I l l , December 1985
to the
E d it o r ]ADA 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 typed, double-spaced, and signed. No more than ten references should be given w ith each letter. Printed com m unications do not necessarily reflect the opinion or official policy of the Association. Your participation in this section is invited.
Pediatric anesthesia guidelines □ Recently, the A m erican Academy of Pediatric Dentistry, in cooperation w ith the A m erican Academy of Pediatrics, de veloped “G uidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients.” These guidelines were published in the A u g u s t 1 9 8 5 is s u e o f P e d i a t r i c s (76(2):317-321, 1985). It is the belief of the academ y that these guidelines can serve a useful purpose for the dental com m unity at large, not just for pediatric dentists. I urge dentists to ob tain copies of these guidelines for their use. S ingle copies of th e g u id elin es are available from the A m erican Academy of Pediatrics, publications departm ent, Box 927, Elk Grove Village, IL 60007. J. DAVID GAYNOR, DDS PRESIDENT, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY SACRAMENTO, CA
For the patient’s health □ Dr. McCarthy should be congratulated for once again bringing to our attention the im portance of obtaining a thorough m edical history from our dental patients in “A new, patient-adm inistered m edical history developed for dentistry” (Octo ber). . . . During the more than 40 years in w hich I practiced or taught, it was gratify ing to see the increase in dentistry’s con cern for the m edical problem s of our pa tients as show n by the increasing sophis tication of the health histories we take. My first office on the second floor of a building was selected in part because of the sim ple belief that that was a good way to screen for m edical problems. If the pa tient could climb the stairs w ithout diffi 906 ■ JADA, Vol. I l l , December 1985
culty, it w as safe to provide treatment. from alcohol, drug, or gaseous ad dic T o d a y , a n i n t e r a c t i v e , p a t i e n t - tion?” If yes, appropriate treatm ent m od adm inistered com puter program for p a ification can be done; if no, there is no tient evaluation incorporates the features problem, or if the patient lied, the dentist of the ADA questionnaire and those ex should be relieved of ethical and legal plained in the McCarthy article. This pro responsibilities. And although not a large gram, after com pletion of in put by the part of the recovering population, there patient, prints a history listing the p a are some people who are addicted to vari tie n t’s problem s, highlighting those of a ous gases, and nitrous oxide is probably m ore significant nature, lists the drugs the no. 2 or 3 preference among dental ta k e n , an d p rin ts a re m in d e r lis t of professionals. HERBERT R. HEDGE, DDS suggested actions based on the patient’s OTTUMWA, IA problem list, w ith suggestions for further evaluation if indicated and for m onitor ing of the treatm ent program. The patient Prudence in practice need not interact w ith the com puter but may com plete a questionnaire that then □ I w ould like to share my experiences in can be entered into the com puter. The eq u ip p in g an office (E m p h a sis, S ep dentist th en has a signed record plus a tem ber). I am a g en eral p rac titio n er. com puter record, for ready reference. The W hen I started out, I was b ro k e. . .For the step from there to retrieval of information first year in practice, I rented a 12- x 14-ft based on disease, age, or gender is made (168 sq ft) room in a building next to an established dentist. I paid him for the use easily should it ever be desired. HUBERT W. MERCHANT, DDS of his darkroom and reception area. . . . I AUGUSTA, GA b o rro w ed m oney from th e bank and bought a m inim um of equipm ent at a □ I suggest adding the w ord alcoholism good discount. to Dr. Frank M cCarthy’s m edical history, I w orked in one room for a year and to read Alcoholism /D rug A ddiction in moved to a new building w ith a 650-sq-ft section 9. . . . office. As I needed them, I furnished three My personal history is shared by m any op erato ries, a laboratory, a recep tio n recovering alcoholics. It has been m any room, a business office, a darkroom, and a years since I w ent through treatm ent for private office. alcoholism, and w ith no recent hospitali After 33 years, I still practice in this zations, I w ould answ er no to question 4 .1 office w ith the same equipm ent. . . . I buy was an alcoholic and, therefore, m ight m y equipm ent from a local dental supply deny the “ drug addiction” question. . . . I com pany and they service it. I use a mail did not have liver or yellow jaundice dis order house and buy in bulk my expend ease or hepatitis (nor did I have gingivitis, able supplies twice a year, w ith a great despite a poor diet). Therefore, I could savings. . . . slip through the questionnaire w ithout I have never used a so-called real “den revealing that I am a recovering alcoholic. tal consulting firm .” In fact, once I had to I consider m yself a drug addict, and my ask one overbearing soul to leave my of d rug w as alcohol. H ow ever, m any of fice. I have listened to their lectures at t h o s e r e c o v e r in g fro m a lc o h o lis m m eetings but never in my office. Ask a strongly deny that they are drug addicts. dentist, he is the best consultant in the A lthough the “pure alcoholic” (who uses world for you. alcohol exclusively) is becoming extinct, I w ant to tell fellow dentists that you the active but predom inantly drug-using d o n ’t need a 2,000-sq-ft office w ith an addict w ill deny vehem ently all addic elaborate dental set-up to make a good tions, including alcoholism . But once living practicing dentistry. in to tre a tm e n t, th a t sam e a d d ic t fre RUFUS G. HOOVER, DDS CHARLOTTE, NC q u en tly w ill acknow ledge alcoholism (and perhaps not the drug addiction), be cause it is more socially (and legally) ac Licensure—suggestions for change ceptable to be a recovering alcoholic. To identify the recovering addict, I long □ The interest of Association members have recom m ended a separate yes or no in licensing procedures is understand question, “Are you in a recovery status able. If the intent of those procedures has
L e t t e r s to E d it o r
the
not been corrupted, it certainly gives that appearance and, as a consequence, ad versely reflects on organized dentistry. The reason (correct me if I’m wrong) is that the dental com ponent of every state board is suggested by organized d en tistry. Even if we are concerned only w ith public relations, there is the place to be gin. In the E m phasis article on licensure (July), Dr. Paul Buxton, chairm an of the Alaska State Board of Dental Examiners, is quoted as saying, . . there’s a real problem in getting dental care to all the population that actually w ants it,” and “Licensing by credentials caused another problem . There is no way for the board to call a state board about m ilitary person n e l.” I w ould like to quote from a letter w rit te n 20 years ago from th e secretarytreasurer of the Alaska State Board of Den tal Exam iners w ho replied to my inquiry about reciprocity. T he need for dentists in Alaska is not as acute (as published). There are approxim ately 120 dentists in the US Public Health Service, Army, Navy, and Air Force w ho take care of our sizable native and m ilitary populations. The rem ainder of the civilian population is taken care of by approxim ately 80 private practitio ners. The total statistical figures w ould run 250,000 total population w ith 200 dentists, or a ratio of approxim ately 1,250 per dentist, w hich is w ell below the national average of approxi m ately 1,800 per dentist. . . . Alaska law does provide for tem porary perm its to be issued for a year for the practice of dentistry in isolated areas w hose population is u n d er 3,000 and in w hich there is no resident dentist w ith in a 25-m ile radius.
This was part of a reply to a sim ple request for inform ation about reciprocity. AARON LIFSHIN, DDS ASTON, PA
□ Dr. Barry J. Blutig’s letter on licensure (October) is an exam ple of logic and pro fessionalism . Dr. Blutig properly directs
h is fo cu s on co m p eten cy a ssu ran ce , w hich is the fundam ental reason for state board examinations. It is clear that the m ajo rity of new graduates pass state board exam inations on their first attem pt (currently more than 90% in Florida). The problem exists w ith, and the com plaints largely come from, dentists whose didactic and clinical com petencies have d im inished during the years after gradua tion. It is w ell know n among dental edu cators that national board scores trail off a p p ro x im a te ly 5 years a fter g ra d u a tion. . . . A dditionally, a substantial num ber of candidates in certain states are graduates of u n a c c re d ited schools. T hese “ eco nom ic refugees” usually come from Third W orld countries and from proprietary schools in the Far East and the Caribbean Basin. Interestingly, the “exclusionary” Sun Belt states m aintain easy access to the licensure process for these as w ell as dom estic graduates. On the other hand, m any of the so-called Frost Belt states have added statutory and regulatory re strictions to foreign graduate licensure, and their residents com plain about a lack of m obility in the U nited States for them selves. The contem porary practice of m edicine is replete w ith quality assurance m echa nism s: internships, residencies, specialty boards and hospital credentials, utiliza tion review, peer review, and tissue and other committees. The practicing physi cian is scrutinized by all of these com pe tency assessm ents as a daily fact of pro fessional life. W hat m ethods of continu ing com petency assessm ent exist for the m ajority of dentists who do not intern, serve a residency, or actively practice in a n accredited hospital? I subm it that the “act” that dentistry should “ clean u p ” is the lack of continu in g com p etency assurance. . . . W hen dentistry makes significant strides in con tin u in g co m p ete n cy a ssu ra n c e , state board exam inations will be a great deal less desirable than they now are to legis lators and to m any of us in the profession. ROBERT T. FERRIS, DDS, PhD ALTAMONTE SPRINGS, FL
□ . . . The topic of licensure by creden
tials seem s critically im portant to the dental practitioner. If the letters on this topic are any indication, the majority of our profession favors some sort of change in the licensing process—w hether it’s via a general practice residency, licensure by credentials, or reciprocity. The current exam ination procedure by state and regional boards is antiquated and fails in its original purpose: to protect the public from incom petency. If we need to upgrade our graduation requirem ents, or if w e need to put more em phasis on peer review, let’s do it! As others have said, the only way to make these changes is to act as a unified voice . . . to enact change on a statewide basis. JEFF D. MALYON, DDS TROUTDALE, OR
Keyes method—proved or tested? □ The report by Dr. Thomas Rams and o th ers, “ L o ng-term effects of m icrob io lo g ic a lly m o d u la te d p e rio d o n ta l therapy on advanced adult periodontitis” (September), seems designed to prove the au th o rs’ treatm ent m ethod rather th an test the m ethod against controls, w hich is the purpose of genuine scientific inquiry. The experim ent had too m any variables to establish causation; 46 of 47 patients needed tetracycline therapy before their periodontal health improved. It is no sur prise that infections w ill respond favor ably to antibiotics, but we question the consequences and m edical appropriate ness of continued tetracycline therapy. The authors’ conclusion that periodon tal su rg e ry is u n n e c e ssa ry is u n ju s tified. . . . JOHN E. DODES, DDS MARVIN J. SCHISSEL, DDS WOODHAVEN, NY
Corrections □ Corrections for the Em phasis (Octo ber) article on restorative dentistry in clude: On page 555, the legend for Figure a should read: Badly broken-dow n canine w ith m echanical perforation on the m e sial surface. O n p a g e 5 5 7 , th e r e p l y b y D r.
Left ■ Maximum intercuspation lacking anterior contact or potential for guidance and posterior disclusion. Middle ■ Direct bond composite resin has been added to lingual side of canine. It has been adjusted to contact in maximum intercuspation and is shaped to mimic palatal platform of carefully adjusted Hawley bite plane. Right ■ Lingual view o f canine platform. Note articulating paper marking canine and premolars in maximum intercuspation and guidance pattern established on canine platform in lateral excursive movement.
908 ■ JADA, Vol. I l l , December 1985