- Email: [email protected]
Unsatisfied patients
COMMENTARIES
2016 (Peter Milgrom, DDS, University at Washington, e-mail communication, March 2015). We could be on the verge of witnessing big changes in our ability to slow the epidemic of caries observed in the overseas Third World as well the epidemic of caries seen in the Third World of “Medicaid reality” that exists in our own backyards. John C. Frachella, DMD Fossil, OR
http://dx.doi.org/10.1016/j.adaj.2015.05.006 Copyright ª 2015 American Dental Association. All rights reserved.
1. Berg JH. Glass ionomer cements. Pediatr Dent. 2002;24(5):430-438. 2. Council on Clinical Affairs, American Academy of Pediatric Dentistry. Policy on Interim Therapeutic Restorations (ITR). Adopted 2001, revised 2004, 2008, 2013. AAPD Reference Manual. 36(6):48-49. Available at: http://www.aapd.org/media/Policies_Guidelines/ P_ITR.pdf. Accessed May 8, 2015. 3. Mei ML, Li QL, Chu CH, Lo EC, Samaranayake LP. Antibacterial effects of silver diamine fluoride on multi-species cariogenic biofilm on caries. Ann Clin Microbial Antimicrob. 2013;12:4. 4. Rosenblatt A, Stamford TC, Niederman R. Silver diamine fluoride: a caries “silver-fluoride bullet”. J Dent Res. 2009;88(2):116-125. 5. Domino M. FDA’s reclassification of SDF as a fluoride could mean new treatment options. DrBicuspid.com. Available at: http://www. drbicuspid.com/index.aspx?sec¼ser&sub¼def& pag¼dis&ItemID¼317026. Accessed May 8, 2015. 6. Department of Health and Human Services, Food and Drug Administration. Indications For Use, Silver Dental Arrest. July 31, 2014. Available at: http://www.accessdata.fda. gov/cdrh_docs/pdf10/K102973.pdf. Accessed May 8, 2015. 7. Oregon Board of Dentistry. Minutes, December 19, 2014. Available at: http://www.oregon. gov/dentistry/docs/Minutes/BrdMtgMinutes2 0141219.pdf. Accessed April 3, 2015.
Kevin H. Ludwig, DDS Pediatric Dentist South Bend, IN
Authors’ response: We would like to thank Dr. Frachella for his letter regarding our article on stainless steel crowns placed with the Hall technique, and we’re pleased with his interest in our article. Most of his letter discusses the work that he has done with silver diamine fluoride, but he does suggest that silver diamine fluoride might enhance the success rate of the Hall technique. Certainly
496 JADA 146(7) http://jada.ada.org
this might be possible, and it could be added to the list of other questions needing to be answered regarding the use of the Hall technique. Having said that, the use of silver diamine fluoride could also be used with the traditional stainless steel crown preparation technique, as well as other restorative techniques, to see if it will enhance success rates. Although the success rate of stainless steel crowns is very high as it is, whether they are placed with the traditional or the Hall technique, anything that might increase the success rate further would be welcomed. The impact of silver diamine fluoride on the performance of restorative materials such as glass ionomer cements is not fully understood, and of course that raises other questions to be answered by research. His concluding comments that “We could be on the verge of witnessing big changes in our ability to slow the epidemic of caries .” is an interesting statement. We hope that is true, but we do not believe that restorative techniques will do much in the way of slowing the epidemic of caries. Restorations do little to prevent or cure the disease of caries. We must focus on stronger methods to address the social determinants on oral disease in children before we actually see a worldwide change in caries prevalence.1 Until then, continuing to refine our restorative techniques and preserving tooth structure will be of value.
Margherita Fontana, DDS, PhD Professor Department of Cariology Restorative Sciences and Endodontics School of Dentistry University of Michigan Ann Arbor, MI LaQuia A. Vinson, DDS, MPH Clinical Assistant Professor Department of Pediatric Dentistry School of Dentistry Indiana University Indianapolis, IN
July 2015
Jeffrey A. Platt, DDS, MS Associate Professor of Dental Materials and Ralph W. Phillips Scholar in Dental Materials School of Dentistry Indiana University Indianapolis, IN Jeffrey A. Dean, DDS, MSD Ralph E. McDonald Professor of Pediatric Dentistry and Professor of Orthodontics School of Dentistry Indiana University and Riley Hospital for Children Indianapolis, IN
http://dx.doi.org/10.1016/j.adaj.2015.05.007 Copyright ª 2015 American Dental Association. All rights reserved.
1. Casamassimo PS, Lee JY, Marazita ML, Milgrom P, Chi DL, Divaris K. Improving children’s oral health: an interdisciplinary research framework [published online ahead of print Aug. 13, 2014]. J Dent Res. 2014;93(10):938-942. http:// dx.doi.org/10.1177/0022034514547273.
UNSATISFIED PATIENTS
In January JADA’s Ethical Moment, “Dealing With Good Intentions That Go Bad” (JADA. 2015;146[1]:70, 72), Dr. Darryll Beard described a dentist concerned about several patients who recently transferred from the same dental facility. The patients’ stories were similar, and evidently all were unsatisfied with their treatment. An example given was a patient who made many visits over an 18-month period for a particular tooth that was finally extracted. Dr. Beard cited several sections of the American Dental Association Principles of Ethics and Code of Professional Conduct related this patient’s predicament: l.A, Patient Autonomy (“self-govemance”), 2.B, Nonmaleficence (“do no harm”), 3, Beneficence (“do good”), and 5.A, Veracity (“truthfulness”).1 Another principle to consider is 4.C, Justice (“fairness”). Justifiable Criticism. Dentists shall be obliged to report to the appropriate reviewing agency as determined by the local component or constituent society instances of gross or continual faulty treatment by other dentists.1
COMMENTARIES
However, before reporting anything to the local dental society for possible review, keep an open mind and contact the other dental offices first to verify the facts. As Davy Crockett said, “Always be sure you are right, then go ahead.”2 A key requirement for any profession is that members police themselves. Robert B. Stevenson, DDS, MS Columbus, OH
http://dx.doi.org/10.1016/j.adaj.2015.05.008 Copyright ª 2015 American Dental Association. All rights reserved.
1. American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012. Available at: http://www.ada.org/w/media/ADA/About% 20the%20ADA/Files/code_of_ethics_2012.ashx. Accessed May 8, 2015. 2. Groneman W. David Crockett: Hero of the Common Man. New York, NY: Forge Books; 2005.
Author’s response: I appreciate Dr. Stevenson bringing to light another dimension to the situation presented in my Ethical Moment article. If one notices a pattern of questionable treatment among several patients from another dental office, I wholeheartedly agree with Dr. Stevenson that consideration be given to discussing the cases with the practitioner. Having that conversation allows circumstances that might not otherwise be apparent to be brought to light; those circumstances should be considered when deciding whether the previous treatment should be reported to the proper reviewing agency pursuant to the provisions of Section 4.C of the American Dental Association Principles of Ethics and Code of Professional Conduct.1 Bear in mind that you should seek your new patients’ consent to discuss their treatment with their former dentist in order to protect the patients’ confidentiality under Section 1, Patient Autonomy.
Darryll L. Beard, DMD, FAGD Waterloo, IL
http://dx.doi.org/10.1016/j.adaj.2015.05.009 Copyright ª 2015 American Dental Association. All rights reserved.
1. American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012. Available at: http://www.ada.org/w/media/ADA/About% 20the%20ADA/Files/code_of_ethics_2012.ashx. Accessed May 8, 2015.
SELECTION BIAS
In Dr. Romina Brignardello-Petersen and colleagues’ February JADA article, “A Practical Approach to Evidence-Based Dentistry: IV: How to Use an Article About Harm” (Brignardello-Petersen R, CarrascoLabra A, Glick M, Guyatt GH, Azarpazhooh A. JADA. 2015;146 [2]:94-101), the authors provided useful guidelines for dentists deciding what type of studies to search and how to critically appraise an article about determining harm to patients. As the authors mentioned, the selection bias arises when the study population is not a random selection from the general target population for which the experiment result would be attributed. Although they mentioned some instances of selection bias in observational studies, there are some additional forms and scenarios of selection bias that have to be taken into account. For example, in observational studies, selection bias can be created as a result of reverse causation. In many case-control and cross-sectional study scenarios, the outcome may precede the exposure measurement. Therefore, observed relative risk of exposure or the observed association of the outcome with the measured exposure could be affected by the effect of the outcome on the exposure. For example, the association of periodontal disease with oral cancer can be partly attributed to the reverse causation of having oral
cancer and a radiotherapy or chemotherapy procedure on development of periodontal disease. Loss to follow-up, nonresponse bias, and missing data bias are other forms of selection bias.1 Although the authors properly mentioned sufficient follow-up time as a prerequisite of establishing a causal inference and diminishing selection bias, the presence of loss to followup, missing dental visits, and the cases in which patients are not responding to the questioner or missing clinical visits could be other sources of selection bias. In spite of the fact that the above-mentioned example of selection bias could potentially be minimized by using a meticulous study design, some sources of selection bias such as loss to follow-up or missing data are uncontrollable. For addressing the issue of selection bias in hazard estimation in dentistry and in general in dental literature, more rigorous epidemiologic analysis, including inverse probability weighting and stratification, should be considered.1,2 I agree with the authors that conducting randomized clinical trials cannot be used for hazard estimation, but the quality of observational studies that are being used for estimation of harm should be investigated thoroughly for presence of various type of biases and wider corrective methodological approach, such as low-biased meta-analysis yielding some new guidance for estimating these harms rather than relying on isolated research projects. Nevertheless, each wellconducted observational study can provide useful information about hazard risk. We should acknowledge that an isolated observational study, in the most optimistic situation and with assumption of minimal biases, just gives us a partial picture of the casualty. Most research is already addressed by different teams, and it is not convincing to emphasize a significant result of an isolated study.
JADA 146(7) http://jada.ada.org
July 2015 497
2016 (Peter Milgrom, DDS, University at Washington, e-mail communication, March 2015). We could be on the verge of witnessing big changes in our ability to slow the epidemic of caries observed in the overseas Third World as well the epidemic of caries seen in the Third World of “Medicaid reality” that exists in our own backyards. John C. Frachella, DMD Fossil, OR
http://dx.doi.org/10.1016/j.adaj.2015.05.006 Copyright ª 2015 American Dental Association. All rights reserved.
1. Berg JH. Glass ionomer cements. Pediatr Dent. 2002;24(5):430-438. 2. Council on Clinical Affairs, American Academy of Pediatric Dentistry. Policy on Interim Therapeutic Restorations (ITR). Adopted 2001, revised 2004, 2008, 2013. AAPD Reference Manual. 36(6):48-49. Available at: http://www.aapd.org/media/Policies_Guidelines/ P_ITR.pdf. Accessed May 8, 2015. 3. Mei ML, Li QL, Chu CH, Lo EC, Samaranayake LP. Antibacterial effects of silver diamine fluoride on multi-species cariogenic biofilm on caries. Ann Clin Microbial Antimicrob. 2013;12:4. 4. Rosenblatt A, Stamford TC, Niederman R. Silver diamine fluoride: a caries “silver-fluoride bullet”. J Dent Res. 2009;88(2):116-125. 5. Domino M. FDA’s reclassification of SDF as a fluoride could mean new treatment options. DrBicuspid.com. Available at: http://www. drbicuspid.com/index.aspx?sec¼ser&sub¼def& pag¼dis&ItemID¼317026. Accessed May 8, 2015. 6. Department of Health and Human Services, Food and Drug Administration. Indications For Use, Silver Dental Arrest. July 31, 2014. Available at: http://www.accessdata.fda. gov/cdrh_docs/pdf10/K102973.pdf. Accessed May 8, 2015. 7. Oregon Board of Dentistry. Minutes, December 19, 2014. Available at: http://www.oregon. gov/dentistry/docs/Minutes/BrdMtgMinutes2 0141219.pdf. Accessed April 3, 2015.
Kevin H. Ludwig, DDS Pediatric Dentist South Bend, IN
Authors’ response: We would like to thank Dr. Frachella for his letter regarding our article on stainless steel crowns placed with the Hall technique, and we’re pleased with his interest in our article. Most of his letter discusses the work that he has done with silver diamine fluoride, but he does suggest that silver diamine fluoride might enhance the success rate of the Hall technique. Certainly
496 JADA 146(7) http://jada.ada.org
this might be possible, and it could be added to the list of other questions needing to be answered regarding the use of the Hall technique. Having said that, the use of silver diamine fluoride could also be used with the traditional stainless steel crown preparation technique, as well as other restorative techniques, to see if it will enhance success rates. Although the success rate of stainless steel crowns is very high as it is, whether they are placed with the traditional or the Hall technique, anything that might increase the success rate further would be welcomed. The impact of silver diamine fluoride on the performance of restorative materials such as glass ionomer cements is not fully understood, and of course that raises other questions to be answered by research. His concluding comments that “We could be on the verge of witnessing big changes in our ability to slow the epidemic of caries .” is an interesting statement. We hope that is true, but we do not believe that restorative techniques will do much in the way of slowing the epidemic of caries. Restorations do little to prevent or cure the disease of caries. We must focus on stronger methods to address the social determinants on oral disease in children before we actually see a worldwide change in caries prevalence.1 Until then, continuing to refine our restorative techniques and preserving tooth structure will be of value.
Margherita Fontana, DDS, PhD Professor Department of Cariology Restorative Sciences and Endodontics School of Dentistry University of Michigan Ann Arbor, MI LaQuia A. Vinson, DDS, MPH Clinical Assistant Professor Department of Pediatric Dentistry School of Dentistry Indiana University Indianapolis, IN
July 2015
Jeffrey A. Platt, DDS, MS Associate Professor of Dental Materials and Ralph W. Phillips Scholar in Dental Materials School of Dentistry Indiana University Indianapolis, IN Jeffrey A. Dean, DDS, MSD Ralph E. McDonald Professor of Pediatric Dentistry and Professor of Orthodontics School of Dentistry Indiana University and Riley Hospital for Children Indianapolis, IN
http://dx.doi.org/10.1016/j.adaj.2015.05.007 Copyright ª 2015 American Dental Association. All rights reserved.
1. Casamassimo PS, Lee JY, Marazita ML, Milgrom P, Chi DL, Divaris K. Improving children’s oral health: an interdisciplinary research framework [published online ahead of print Aug. 13, 2014]. J Dent Res. 2014;93(10):938-942. http:// dx.doi.org/10.1177/0022034514547273.
UNSATISFIED PATIENTS
In January JADA’s Ethical Moment, “Dealing With Good Intentions That Go Bad” (JADA. 2015;146[1]:70, 72), Dr. Darryll Beard described a dentist concerned about several patients who recently transferred from the same dental facility. The patients’ stories were similar, and evidently all were unsatisfied with their treatment. An example given was a patient who made many visits over an 18-month period for a particular tooth that was finally extracted. Dr. Beard cited several sections of the American Dental Association Principles of Ethics and Code of Professional Conduct related this patient’s predicament: l.A, Patient Autonomy (“self-govemance”), 2.B, Nonmaleficence (“do no harm”), 3, Beneficence (“do good”), and 5.A, Veracity (“truthfulness”).1 Another principle to consider is 4.C, Justice (“fairness”). Justifiable Criticism. Dentists shall be obliged to report to the appropriate reviewing agency as determined by the local component or constituent society instances of gross or continual faulty treatment by other dentists.1
COMMENTARIES
However, before reporting anything to the local dental society for possible review, keep an open mind and contact the other dental offices first to verify the facts. As Davy Crockett said, “Always be sure you are right, then go ahead.”2 A key requirement for any profession is that members police themselves. Robert B. Stevenson, DDS, MS Columbus, OH
http://dx.doi.org/10.1016/j.adaj.2015.05.008 Copyright ª 2015 American Dental Association. All rights reserved.
1. American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012. Available at: http://www.ada.org/w/media/ADA/About% 20the%20ADA/Files/code_of_ethics_2012.ashx. Accessed May 8, 2015. 2. Groneman W. David Crockett: Hero of the Common Man. New York, NY: Forge Books; 2005.
Author’s response: I appreciate Dr. Stevenson bringing to light another dimension to the situation presented in my Ethical Moment article. If one notices a pattern of questionable treatment among several patients from another dental office, I wholeheartedly agree with Dr. Stevenson that consideration be given to discussing the cases with the practitioner. Having that conversation allows circumstances that might not otherwise be apparent to be brought to light; those circumstances should be considered when deciding whether the previous treatment should be reported to the proper reviewing agency pursuant to the provisions of Section 4.C of the American Dental Association Principles of Ethics and Code of Professional Conduct.1 Bear in mind that you should seek your new patients’ consent to discuss their treatment with their former dentist in order to protect the patients’ confidentiality under Section 1, Patient Autonomy.
Darryll L. Beard, DMD, FAGD Waterloo, IL
http://dx.doi.org/10.1016/j.adaj.2015.05.009 Copyright ª 2015 American Dental Association. All rights reserved.
1. American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012. Available at: http://www.ada.org/w/media/ADA/About% 20the%20ADA/Files/code_of_ethics_2012.ashx. Accessed May 8, 2015.
SELECTION BIAS
In Dr. Romina Brignardello-Petersen and colleagues’ February JADA article, “A Practical Approach to Evidence-Based Dentistry: IV: How to Use an Article About Harm” (Brignardello-Petersen R, CarrascoLabra A, Glick M, Guyatt GH, Azarpazhooh A. JADA. 2015;146 [2]:94-101), the authors provided useful guidelines for dentists deciding what type of studies to search and how to critically appraise an article about determining harm to patients. As the authors mentioned, the selection bias arises when the study population is not a random selection from the general target population for which the experiment result would be attributed. Although they mentioned some instances of selection bias in observational studies, there are some additional forms and scenarios of selection bias that have to be taken into account. For example, in observational studies, selection bias can be created as a result of reverse causation. In many case-control and cross-sectional study scenarios, the outcome may precede the exposure measurement. Therefore, observed relative risk of exposure or the observed association of the outcome with the measured exposure could be affected by the effect of the outcome on the exposure. For example, the association of periodontal disease with oral cancer can be partly attributed to the reverse causation of having oral
cancer and a radiotherapy or chemotherapy procedure on development of periodontal disease. Loss to follow-up, nonresponse bias, and missing data bias are other forms of selection bias.1 Although the authors properly mentioned sufficient follow-up time as a prerequisite of establishing a causal inference and diminishing selection bias, the presence of loss to followup, missing dental visits, and the cases in which patients are not responding to the questioner or missing clinical visits could be other sources of selection bias. In spite of the fact that the above-mentioned example of selection bias could potentially be minimized by using a meticulous study design, some sources of selection bias such as loss to follow-up or missing data are uncontrollable. For addressing the issue of selection bias in hazard estimation in dentistry and in general in dental literature, more rigorous epidemiologic analysis, including inverse probability weighting and stratification, should be considered.1,2 I agree with the authors that conducting randomized clinical trials cannot be used for hazard estimation, but the quality of observational studies that are being used for estimation of harm should be investigated thoroughly for presence of various type of biases and wider corrective methodological approach, such as low-biased meta-analysis yielding some new guidance for estimating these harms rather than relying on isolated research projects. Nevertheless, each wellconducted observational study can provide useful information about hazard risk. We should acknowledge that an isolated observational study, in the most optimistic situation and with assumption of minimal biases, just gives us a partial picture of the casualty. Most research is already addressed by different teams, and it is not convincing to emphasize a significant result of an isolated study.
JADA 146(7) http://jada.ada.org
July 2015 497