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MORE ABOUT BISPHOSPHONATES: Response from the ADA Council on Scientific Affairs
L E T T E R S
venous pamidronate in children and adolescents with osteogenesis imperfecta types I, III, and IV. Pediatrics 2003;111(5 Pt 1):10301036. 2. Brumsen C, Hamdy NA, Papapoulos SE. Long-term effects of bisphosphonates on the growing skeleton: studies of young patients with severe osteoporosis. Medicine (Baltimore) 1997;76(4):266-283. 3. Grier RL 4th, Wise GE. Inhibition of tooth eruption in the rat by a bisphosphonate. J Dent Res 1998;77(1):8-15. 4. Kamoun-Goldrat A, Ginisty D, Le Merrer M. Effects of bisphosphonates on tooth eruption in children with osteogenesis imperfecta. Eur J Oral Sci 2008;166(3):195-198. 5. Gould TRL, Melcher AH, Brunette DM. Location of progenitor cells in periodontal ligament of mouse molar stimulated by wounding. Anat Rec 1977;188(2):133-141.
Response from the ADA Council on Scientific Affairs: The Council thanks Dr. Hodgson for his comments. We agree that bisphosphonate use in children for the treatment of osteogenesis imperfecta has the potential to affect tooth eruption and exfoliation and growth of the craniofacial complex. The expert panel anticipates updates to its recommendations for managing the care of patients receiving bisphosphonate therapy, and will consider including a discussion of the dental implications of bisphosphonate therapy in pediatric populations in those future updates. ADVICE QUESTIONED
I read with some concern Dr. Roger Levin’s March column, “Achieving Maximum Success and Maximum Happiness” (JADA 2009;140[3]:361-362). When supposed leaders in “management” are writing articles like this, and our major journal is publishing them, it should concern all dentists. My worries are twofold. First, his classification of dentists into four categories must be looked at in the context of what has happened to physicians here in the United States. During the period from the late 830
JADA, Vol. 140
http://jada.ada.org
1960s to the early 1980s, our brethren in medicine collectively made the decision to move from being “Level III” practitioners to “Level IV” practitioners. They certainly made more money. By delegating so many of the nonmedical tasks in their practices, they were able to maximize their most profitable activities and duties. But the party was short-lived. By delegating so much of the business and management power to others, they essentially gave away control over their own practices and career destinies. At some point, hospital corporations, insurance companies and the government figured out that they, not the physicians, were in control. Today, with rare exceptions, most physicians and surgeons are employees with little ability to control their own destinies or policies–well-compensated employees, to be sure, but employees nonetheless. Health care increasingly is predicated on what is best for bureaucrats and administrators, not patients and the true providers of health care. The problems with our health care system, and the desire by the current administration in Washington and elsewhere to create a de facto socialized, centrally planned health care system, are to one extent or another the result of this willing abdication of responsibility by physicians to have a hand in how their practices are run. In order to make a few more dollars, the medical community, like the biblical Esau, sold its birthright. In other words, when there was a mass conversion of physicians from Level III to Level IV practitioners, physicians lost something of tremen-
dous importance to the insurance and hospital corporation industries–and worse, to government–that they likely will never get back: the ability to determine their own path and their own destiny. Most dentists are Level III practitioners. But, while Dr. Levin considers this a bug, I, and I would guess many of my colleagues, consider it a desirable feature. I recommend Glenn Reynolds’s excellent book, “An Army of Davids,”1 on this subject. I would gladly give up a few dollars of income, and accept the minor increase in stress in my life, to maintain the selfdetermination that I now have. If we all went to Level IV, there would be nothing to stop our profession from suffering the same fate as did physicians. The physicians of 30 years ago may have had great stress reduction and terrific bottom lines as a result of going to the Level IV model, but the physicians of today are wondering whether their ability to plan treatment in the best interests of their patients will be savaged by insurance whimsy or government fiat. I’ll pass on that stress, thank you. Additionally, I have noticed a disturbing tendency of Dr. Levin in this and other recent columns to promote the spending of money by dentists on consultants (including a recent column in which he advocated spending on consulting versus equipment purchases in a down economy2). As Dr. Levin is in the consulting industry and derives an income stream that could be affected by these admonitions, this has the appearance of impropriety and conflict of interest. If such marketing of his
July 2009
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
venous pamidronate in children and adolescents with osteogenesis imperfecta types I, III, and IV. Pediatrics 2003;111(5 Pt 1):10301036. 2. Brumsen C, Hamdy NA, Papapoulos SE. Long-term effects of bisphosphonates on the growing skeleton: studies of young patients with severe osteoporosis. Medicine (Baltimore) 1997;76(4):266-283. 3. Grier RL 4th, Wise GE. Inhibition of tooth eruption in the rat by a bisphosphonate. J Dent Res 1998;77(1):8-15. 4. Kamoun-Goldrat A, Ginisty D, Le Merrer M. Effects of bisphosphonates on tooth eruption in children with osteogenesis imperfecta. Eur J Oral Sci 2008;166(3):195-198. 5. Gould TRL, Melcher AH, Brunette DM. Location of progenitor cells in periodontal ligament of mouse molar stimulated by wounding. Anat Rec 1977;188(2):133-141.
Response from the ADA Council on Scientific Affairs: The Council thanks Dr. Hodgson for his comments. We agree that bisphosphonate use in children for the treatment of osteogenesis imperfecta has the potential to affect tooth eruption and exfoliation and growth of the craniofacial complex. The expert panel anticipates updates to its recommendations for managing the care of patients receiving bisphosphonate therapy, and will consider including a discussion of the dental implications of bisphosphonate therapy in pediatric populations in those future updates. ADVICE QUESTIONED
I read with some concern Dr. Roger Levin’s March column, “Achieving Maximum Success and Maximum Happiness” (JADA 2009;140[3]:361-362). When supposed leaders in “management” are writing articles like this, and our major journal is publishing them, it should concern all dentists. My worries are twofold. First, his classification of dentists into four categories must be looked at in the context of what has happened to physicians here in the United States. During the period from the late 830
JADA, Vol. 140
http://jada.ada.org
1960s to the early 1980s, our brethren in medicine collectively made the decision to move from being “Level III” practitioners to “Level IV” practitioners. They certainly made more money. By delegating so many of the nonmedical tasks in their practices, they were able to maximize their most profitable activities and duties. But the party was short-lived. By delegating so much of the business and management power to others, they essentially gave away control over their own practices and career destinies. At some point, hospital corporations, insurance companies and the government figured out that they, not the physicians, were in control. Today, with rare exceptions, most physicians and surgeons are employees with little ability to control their own destinies or policies–well-compensated employees, to be sure, but employees nonetheless. Health care increasingly is predicated on what is best for bureaucrats and administrators, not patients and the true providers of health care. The problems with our health care system, and the desire by the current administration in Washington and elsewhere to create a de facto socialized, centrally planned health care system, are to one extent or another the result of this willing abdication of responsibility by physicians to have a hand in how their practices are run. In order to make a few more dollars, the medical community, like the biblical Esau, sold its birthright. In other words, when there was a mass conversion of physicians from Level III to Level IV practitioners, physicians lost something of tremen-
dous importance to the insurance and hospital corporation industries–and worse, to government–that they likely will never get back: the ability to determine their own path and their own destiny. Most dentists are Level III practitioners. But, while Dr. Levin considers this a bug, I, and I would guess many of my colleagues, consider it a desirable feature. I recommend Glenn Reynolds’s excellent book, “An Army of Davids,”1 on this subject. I would gladly give up a few dollars of income, and accept the minor increase in stress in my life, to maintain the selfdetermination that I now have. If we all went to Level IV, there would be nothing to stop our profession from suffering the same fate as did physicians. The physicians of 30 years ago may have had great stress reduction and terrific bottom lines as a result of going to the Level IV model, but the physicians of today are wondering whether their ability to plan treatment in the best interests of their patients will be savaged by insurance whimsy or government fiat. I’ll pass on that stress, thank you. Additionally, I have noticed a disturbing tendency of Dr. Levin in this and other recent columns to promote the spending of money by dentists on consultants (including a recent column in which he advocated spending on consulting versus equipment purchases in a down economy2). As Dr. Levin is in the consulting industry and derives an income stream that could be affected by these admonitions, this has the appearance of impropriety and conflict of interest. If such marketing of his
July 2009
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.