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. P rinted com m unications do not necessarily reflect the opinion or official policy of the Association. Your participation in this section is invited.
C ost co n ta in m en t by m a ch in e □ D r. K n u ts o n ’s “ C o m m e n ta ry ” led m e to th e article by B ailit and o th ers in th e July issu e of the A m e ri c a n Jou rn al o f P ublic H ealth. I w as im p ressed w ith th e straigh tfo rw ard s tatistical ap p ro ach to w h at c o s t c o n tain m en t d em an d s and w h at ty p es of d e n tis try are u sefu l, h e a lth fu l, or s tatistically w orth w h ile. I w as u n im p ressed w ith the lack of referen ce to or c o n ce rn for th e q uality of life and th o se th in g s th at co n trib u te to it. . . . A s a d ental co n su ltan t, I c a n speak from p erso n al e x p e rie n ce w h en it co m es to th e q u estion o f co st c o n ta in m e n t. D ep en d in g o n th e c o n strain ts em b od ied in th e c o n tra c t, the “ ab u sab ility” of m o st co n tra c ts is e x tre m e ly low . Q u e stio n s in v o lv in g sem an tics c a n arise in an y c o n tra ct. W h e re ite m s o f p ro fessio n al th o r o u g h n ess or ad eq u acy of treatm en t for a giv en p atien t are co n sid ered , a d en tal co n su lta n t (d entist) c a n , in m o st cases, cu t d irectly to th e p oin t of th e m o st p ro te ctio n for all p arties c o n ce rn e d . T h e treatin g d en tist has h is p rofession al treatm en t co n ce rn s s a t i s f i e d , th e p a t i e n t h a s h is c o m p r e h e n s iv e n e s s o f tr e a tm e n t m a in ta in e d , an d th e c o n tr a c t has been u p h eld w ith resp ect to w h ich treatm en ts are com p en sab le. I can n o t sep arate th e w h eat from th e ch aff a s easily as the statistician s w h en it co m es d ow n to the “ co n trib u tio n ” ce rta in serv ices m ake tow ard a p a t i e n t ’s (in s u re d ) to ta l d e n ta l h ealth . T o som e of us, all d en tistry is p rev en tiv e, an d , as su ch , con trib u tes to a b etter q uality of life th an w ou ld be p ossib le w ere d en tal treatm en t n ot allo w ed b ecau se of being s tatistically e x clu d e d .
T h o se w h o w ou ld look tow ard a m ech an ized y ard stick w h en m e a su r ing th e w orth of a d en tal c o n tra c t co v erag e w ou ld do w ell to in ject a to u ch o f h u m an ism in th e d elib era tio n . T o attem p t to en su re c o s t c o n ta in m en t th rou gh q u ality co n tro l is an in tellig en t ap p ro ach . H o w ev er, to u se an d abuse the co n ce p t of q uality c o n tro l by th e e lim in a tio n of th e m o re sop h isticated treatm en t m o d a l ities b ecau se th ey h av e a h igh er ser v ic e fee is b oth sh o rt-sig h te d and u n w arran ted by factu al exp erien ce. . . . H ard data frequ en tly do n o t a c cu rately su g g est th e soft state o f an art or a p erson . T o m e, th e h ap p y v e x ation of treatin g d issim ilar in d iv id u als is w h at k eeps m e sh ow ing u p at m y office in th e m orn ing. P erh ap s p e o p le w h o m a k e b ro a d g e n e r a l statem en ts on the w h ole of d en tal h u m an ity w ou ld do w ell to get to k n o w a few a to u ch m o re p erson ally. LAWRENCE J. SINGER, DDS WALLINGFORD, CONN
N e g le c tin g the prim ary teeth □ T h a n k y o u f o r b r i n g i n g D r. K u n tso n ’s co m m en ts to th e atten tio n of th e d en tists of A m erica in th e A u gu st issu e of The Journal. T h e e c o n o m ic s o f h e a lth c a r e w ou ld su p p o rt Dr. K n u tso n ’s a g ree m en t w ith B ailit and oth ers on the im p o rtan ce of establishin g a system of p riorities b ased on th e relativ e ef fectiv en ess of d ental h ealth serv ices (The Jou rnal, A u g u st). It is a m atter of sim p le a rith m e tic to co n clu d e th at o n ly a fractio n of th e p resen t back log of a c cu m u la te d n eed s co u ld be m et by th e p re s e n t d e n ta l m a n p o w e r, sh o u ld the d em an d arise.
It is w ith D r. K n u ts o n ’s r e c o m m en d atio n th at th e p rim ary teeth be e x c lu d e d from resto ra tiv e ca re th at I tak e stro n g e x c e p tio n . It is in c o n ceivab le th at o n e w h o h as been as clo se ly allied w ith p rev en tio n as Dr. K n u tso n c o u ld m a k e t h a t r e c o m m en d atio n . O ne m u st q u estion h ow h e relates th e la tte r to h i? r e c o m m e n d a tio n th a t o r th o d o n tic c a r e sh o u ld n ot be e x c lu d e d . T h e re la tion sh ip b etw een th e p rim ary d e n ti tio n and th e d ev elo p m en t of a n orm al o c c lu s io n in th e p erm an en t d en tition w as estab lish ed d e ca d e s ago. T o n e g le ct th e p rim ary teeth w ou ld only in c re a s e th e n u m b e r o f m a lo c c lu sio n s . an d w o u ld s e rio u s ly a ffect th eir severity . T o n eg lect th e h ealth of th e p ri m ary teeth is to d en y +h eir co n trib u tio n to th e g en eral h ealth and w e ll b eing of ch ild ren . In ab ility to ch e w h ealthful fo od s, th e p a in a sso ciated w ith d iseased teeth , an d th e relatio n ship of c h ro n ic in fectio n to sy stem ic d isease, su ch as rh e u m a tic fever, are obvious reaso n s for p ro m o tin g th e care of th e p rim ary teeth , n o t for n e g lectin g th em . In ad d itio n to th e im m ed iate re a son s for treatin g d iso rd ers of the p ri m ary d en titio n , th ere is th e lon g-term p r o b le m o f h e a l t h m a i n t e n a n c e w h ich is d ire ctly related to th e tra in in g o f ch ild ren to a c c e p t th e ca re of th e ir teeth as a lifetim e resp o n sib il ity, n ot on ly as an elem en t o f p rev en tio n of d isease, but as a facto r in the gen eral w ell-b ein g of th e in d iv id u al. T h at train in g m u st start v e ry early in life if it is to be effectiv e. S in ce th e early y ears of th is c e n tu ry, th e d en tal p rofession h as c a sti g a te d th o se d e n tis ts w h o ad v ise d p aren ts th at it w as n o t n e ce s sa ry to
JADA Vol. 99 October 1979 ■ 597
LETTERS TO THE EDITOR
restore carious primary teeth because “they are only baby teeth.” Neglect of the primary teeth now carries legal connotations, because such neglect is now considered to be child ne glect, not only by the dentists who treat children, but by state and local authorities who must deal with the outrages of child abuse and neglect. It is inconceivable that anyone as sociated with the development of dentistry for children and with a phi losophy of prevention of dental dis ease could, today, recom m end a plan ned n eg lect of the prim ary teeth— in essence recom m ending malpractice by virtue of n eglect.. . . SIDNEY I. KOHN, DDS, PRESIDENT A M ERICAN SOCIETY O F D ENTISTRY FOR CHILDREN
□ Comprehensive insurance is ex pensive whether you are insuring people’s dental health or their homes or automobiles. The cost of the insur ance can be reduced by instituting deductibles, exclusions, and limita tions. That is why I have a $250 de ductible on my automobile policy, and I can understand this concept in dental insurance. My objection is not to the exclusions or limitations uui iu making and applying moral judg ments to justify the exclusions when, in truth, the only justification is fi nancial. . . . Rather than saying, “Mr. Public, the United States cannot afford to give everyone comprehensive dental care—we can just afford the basics and if you want more you must pay for it,” Dr. Knutson is saying in effect that fixed bridges, periodontics, or m uch orthodontic service are of questionable, limited, and marginal worth, so we don’t provide them. . . . People understand that they cannot have everything and that there are priorities at every socio economic level. We must directly face the issue of dental health and its financing. We must provide basic services only, because that is all we can afford, but we must try to educate the public about their dental needs and let them decide how to spend their discretionary dollars, whether on color televisions or posterior fixed bridges. I do not understand how a public health person . . . can confuse the “value of a service” with the “ability to pay for that service.” JEROME M. SIM O N , DDS STA M FO RD , CO NN
Dr. K n utson r e p lie s □ My emphasis on dental care for teenagers in an effort to counteract common acceptance of the incremen tal care approach turned out to be misleading. It was misleading be cause, from the outset all children will be eligible for preventive ser vices, fillings in permanent teeth, and emergency care for the relief of pain and infection. There would be no phasing in by age or grade either from the bottom up or the top down. This was the operational basis of our Richmond, Ind, and Woonsocket, RI, dental care projects w hich were high ly su ccessfu l in con serving permanent teeth and reducing tooth mortality in elementary school chil dren. Currently, the proportion of pre school children receiving conserva tive treatment of caries in deciduous teeth is small and is highly correlated with family income. Personal contact with each member of the family should be enhanced by the program and should enable concerned den tists to increase, rather than decrease, conservative care of deciduous teeth, even if such care has to be paid for on a private practice basis. Of course, this is speculation, but worthy of a trial. JOH N W . K N U TSO N , DDS, DrPH LOS ANGELES
D en tal e x a m in in g b oard s □ With regard to “The necessity of updating dental examining boards” (The Journal, July), I can see no good service provided by the boards. If a dental school has a fully accredited faculty and curriculum, what good does a board exam serve? Can the board tell more of a person’s charac ter, dexterity, operative skills, or know ledge in 2xk days th at the school can in four years? Has there ever been a case where a graduate of an accredited dental school did not eventually pass a board exam ? I graduated a year ago and can tell from personal experience that “tak ing the boards” was 2xk days of h e ll..
necessity of updating dental examin ing boards” (The Journal, July), the willingness of the authors to focus on such an important area of our profes sional well-being is admirable. Few of us want more government control. Most of us, and certainly the public, can benefit from an effort to assure maintenance of top-notch pro fessional performance. Our dental boards must have professional sup port. Also, they need adequate time with the necessary staff to function as protectors of the public interest. . . . We should be supportive of their ef forts to improve the profession. However, it does happen that ex cellent student clinicians fail clinical board examinations while those with borderline skills p a ss .. . . Has any of us forgotten the worry, the tension, and the waiting for board results? After years of education, and iust be fore further investment in the future, we started our careers on a less than positive note. It was impossible for me in 1952 to understand how a few good board men could adjudge my clinical skills in 2V2 days; now that most of my time is devoted to teach ing, it is just as difficult for me to una e r s t a n a . T h e y e a rs h a v e n ot changed some legitimate question ing of the priority and m eaning fulness of these tests. I’d like to see some of our excellent examiners, teachers, young dentists, and students meet officially, ex change ideas, and make some pro gressive suggestions for improve ment in our testing system. . . . Sec ondly, we should be supportive of the examiners as they make addi tional efforts to assure quality per formances by licensed dentists. . . . As more time is required to assure professional excellence, the talented examiner will be needed in evaluat ing cases that peer review commit tees fail to solve. He may need to ap pear in court or in the legislature to explain dental rules and interpreta tions___ We need each other to reach our common goals. . . . JACK R. PA RRISH , DDS COLUM BUS, OH IO
B ia se s a n d o p in io n s DONALD L. FOW LER, DDS ORFORDVILLE, W IS
□ Although many of us probably find areas of disagreement with “The
□ In his review (The Journal, July), Dr. Corah described Stress and Re laxation; Application to Dentistry as a “biased and simplistic account of
C ost co n ta in m en t by m a ch in e □ D r. K n u ts o n ’s “ C o m m e n ta ry ” led m e to th e article by B ailit and o th ers in th e July issu e of the A m e ri c a n Jou rn al o f P ublic H ealth. I w as im p ressed w ith th e straigh tfo rw ard s tatistical ap p ro ach to w h at c o s t c o n tain m en t d em an d s and w h at ty p es of d e n tis try are u sefu l, h e a lth fu l, or s tatistically w orth w h ile. I w as u n im p ressed w ith the lack of referen ce to or c o n ce rn for th e q uality of life and th o se th in g s th at co n trib u te to it. . . . A s a d ental co n su ltan t, I c a n speak from p erso n al e x p e rie n ce w h en it co m es to th e q u estion o f co st c o n ta in m e n t. D ep en d in g o n th e c o n strain ts em b od ied in th e c o n tra c t, the “ ab u sab ility” of m o st co n tra c ts is e x tre m e ly low . Q u e stio n s in v o lv in g sem an tics c a n arise in an y c o n tra ct. W h e re ite m s o f p ro fessio n al th o r o u g h n ess or ad eq u acy of treatm en t for a giv en p atien t are co n sid ered , a d en tal co n su lta n t (d entist) c a n , in m o st cases, cu t d irectly to th e p oin t of th e m o st p ro te ctio n for all p arties c o n ce rn e d . T h e treatin g d en tist has h is p rofession al treatm en t co n ce rn s s a t i s f i e d , th e p a t i e n t h a s h is c o m p r e h e n s iv e n e s s o f tr e a tm e n t m a in ta in e d , an d th e c o n tr a c t has been u p h eld w ith resp ect to w h ich treatm en ts are com p en sab le. I can n o t sep arate th e w h eat from th e ch aff a s easily as the statistician s w h en it co m es d ow n to the “ co n trib u tio n ” ce rta in serv ices m ake tow ard a p a t i e n t ’s (in s u re d ) to ta l d e n ta l h ealth . T o som e of us, all d en tistry is p rev en tiv e, an d , as su ch , con trib u tes to a b etter q uality of life th an w ou ld be p ossib le w ere d en tal treatm en t n ot allo w ed b ecau se of being s tatistically e x clu d e d .
T h o se w h o w ou ld look tow ard a m ech an ized y ard stick w h en m e a su r ing th e w orth of a d en tal c o n tra c t co v erag e w ou ld do w ell to in ject a to u ch o f h u m an ism in th e d elib era tio n . T o attem p t to en su re c o s t c o n ta in m en t th rou gh q u ality co n tro l is an in tellig en t ap p ro ach . H o w ev er, to u se an d abuse the co n ce p t of q uality c o n tro l by th e e lim in a tio n of th e m o re sop h isticated treatm en t m o d a l ities b ecau se th ey h av e a h igh er ser v ic e fee is b oth sh o rt-sig h te d and u n w arran ted by factu al exp erien ce. . . . H ard data frequ en tly do n o t a c cu rately su g g est th e soft state o f an art or a p erson . T o m e, th e h ap p y v e x ation of treatin g d issim ilar in d iv id u als is w h at k eeps m e sh ow ing u p at m y office in th e m orn ing. P erh ap s p e o p le w h o m a k e b ro a d g e n e r a l statem en ts on the w h ole of d en tal h u m an ity w ou ld do w ell to get to k n o w a few a to u ch m o re p erson ally. LAWRENCE J. SINGER, DDS WALLINGFORD, CONN
N e g le c tin g the prim ary teeth □ T h a n k y o u f o r b r i n g i n g D r. K u n tso n ’s co m m en ts to th e atten tio n of th e d en tists of A m erica in th e A u gu st issu e of The Journal. T h e e c o n o m ic s o f h e a lth c a r e w ou ld su p p o rt Dr. K n u tso n ’s a g ree m en t w ith B ailit and oth ers on the im p o rtan ce of establishin g a system of p riorities b ased on th e relativ e ef fectiv en ess of d ental h ealth serv ices (The Jou rnal, A u g u st). It is a m atter of sim p le a rith m e tic to co n clu d e th at o n ly a fractio n of th e p resen t back log of a c cu m u la te d n eed s co u ld be m et by th e p re s e n t d e n ta l m a n p o w e r, sh o u ld the d em an d arise.
It is w ith D r. K n u ts o n ’s r e c o m m en d atio n th at th e p rim ary teeth be e x c lu d e d from resto ra tiv e ca re th at I tak e stro n g e x c e p tio n . It is in c o n ceivab le th at o n e w h o h as been as clo se ly allied w ith p rev en tio n as Dr. K n u tso n c o u ld m a k e t h a t r e c o m m en d atio n . O ne m u st q u estion h ow h e relates th e la tte r to h i? r e c o m m e n d a tio n th a t o r th o d o n tic c a r e sh o u ld n ot be e x c lu d e d . T h e re la tion sh ip b etw een th e p rim ary d e n ti tio n and th e d ev elo p m en t of a n orm al o c c lu s io n in th e p erm an en t d en tition w as estab lish ed d e ca d e s ago. T o n e g le ct th e p rim ary teeth w ou ld only in c re a s e th e n u m b e r o f m a lo c c lu sio n s . an d w o u ld s e rio u s ly a ffect th eir severity . T o n eg lect th e h ealth of th e p ri m ary teeth is to d en y +h eir co n trib u tio n to th e g en eral h ealth and w e ll b eing of ch ild ren . In ab ility to ch e w h ealthful fo od s, th e p a in a sso ciated w ith d iseased teeth , an d th e relatio n ship of c h ro n ic in fectio n to sy stem ic d isease, su ch as rh e u m a tic fever, are obvious reaso n s for p ro m o tin g th e care of th e p rim ary teeth , n o t for n e g lectin g th em . In ad d itio n to th e im m ed iate re a son s for treatin g d iso rd ers of the p ri m ary d en titio n , th ere is th e lon g-term p r o b le m o f h e a l t h m a i n t e n a n c e w h ich is d ire ctly related to th e tra in in g o f ch ild ren to a c c e p t th e ca re of th e ir teeth as a lifetim e resp o n sib il ity, n ot on ly as an elem en t o f p rev en tio n of d isease, but as a facto r in the gen eral w ell-b ein g of th e in d iv id u al. T h at train in g m u st start v e ry early in life if it is to be effectiv e. S in ce th e early y ears of th is c e n tu ry, th e d en tal p rofession h as c a sti g a te d th o se d e n tis ts w h o ad v ise d p aren ts th at it w as n o t n e ce s sa ry to
JADA Vol. 99 October 1979 ■ 597
LETTERS TO THE EDITOR
restore carious primary teeth because “they are only baby teeth.” Neglect of the primary teeth now carries legal connotations, because such neglect is now considered to be child ne glect, not only by the dentists who treat children, but by state and local authorities who must deal with the outrages of child abuse and neglect. It is inconceivable that anyone as sociated with the development of dentistry for children and with a phi losophy of prevention of dental dis ease could, today, recom m end a plan ned n eg lect of the prim ary teeth— in essence recom m ending malpractice by virtue of n eglect.. . . SIDNEY I. KOHN, DDS, PRESIDENT A M ERICAN SOCIETY O F D ENTISTRY FOR CHILDREN
□ Comprehensive insurance is ex pensive whether you are insuring people’s dental health or their homes or automobiles. The cost of the insur ance can be reduced by instituting deductibles, exclusions, and limita tions. That is why I have a $250 de ductible on my automobile policy, and I can understand this concept in dental insurance. My objection is not to the exclusions or limitations uui iu making and applying moral judg ments to justify the exclusions when, in truth, the only justification is fi nancial. . . . Rather than saying, “Mr. Public, the United States cannot afford to give everyone comprehensive dental care—we can just afford the basics and if you want more you must pay for it,” Dr. Knutson is saying in effect that fixed bridges, periodontics, or m uch orthodontic service are of questionable, limited, and marginal worth, so we don’t provide them. . . . People understand that they cannot have everything and that there are priorities at every socio economic level. We must directly face the issue of dental health and its financing. We must provide basic services only, because that is all we can afford, but we must try to educate the public about their dental needs and let them decide how to spend their discretionary dollars, whether on color televisions or posterior fixed bridges. I do not understand how a public health person . . . can confuse the “value of a service” with the “ability to pay for that service.” JEROME M. SIM O N , DDS STA M FO RD , CO NN
Dr. K n utson r e p lie s □ My emphasis on dental care for teenagers in an effort to counteract common acceptance of the incremen tal care approach turned out to be misleading. It was misleading be cause, from the outset all children will be eligible for preventive ser vices, fillings in permanent teeth, and emergency care for the relief of pain and infection. There would be no phasing in by age or grade either from the bottom up or the top down. This was the operational basis of our Richmond, Ind, and Woonsocket, RI, dental care projects w hich were high ly su ccessfu l in con serving permanent teeth and reducing tooth mortality in elementary school chil dren. Currently, the proportion of pre school children receiving conserva tive treatment of caries in deciduous teeth is small and is highly correlated with family income. Personal contact with each member of the family should be enhanced by the program and should enable concerned den tists to increase, rather than decrease, conservative care of deciduous teeth, even if such care has to be paid for on a private practice basis. Of course, this is speculation, but worthy of a trial. JOH N W . K N U TSO N , DDS, DrPH LOS ANGELES
D en tal e x a m in in g b oard s □ With regard to “The necessity of updating dental examining boards” (The Journal, July), I can see no good service provided by the boards. If a dental school has a fully accredited faculty and curriculum, what good does a board exam serve? Can the board tell more of a person’s charac ter, dexterity, operative skills, or know ledge in 2xk days th at the school can in four years? Has there ever been a case where a graduate of an accredited dental school did not eventually pass a board exam ? I graduated a year ago and can tell from personal experience that “tak ing the boards” was 2xk days of h e ll..
necessity of updating dental examin ing boards” (The Journal, July), the willingness of the authors to focus on such an important area of our profes sional well-being is admirable. Few of us want more government control. Most of us, and certainly the public, can benefit from an effort to assure maintenance of top-notch pro fessional performance. Our dental boards must have professional sup port. Also, they need adequate time with the necessary staff to function as protectors of the public interest. . . . We should be supportive of their ef forts to improve the profession. However, it does happen that ex cellent student clinicians fail clinical board examinations while those with borderline skills p a ss .. . . Has any of us forgotten the worry, the tension, and the waiting for board results? After years of education, and iust be fore further investment in the future, we started our careers on a less than positive note. It was impossible for me in 1952 to understand how a few good board men could adjudge my clinical skills in 2V2 days; now that most of my time is devoted to teach ing, it is just as difficult for me to una e r s t a n a . T h e y e a rs h a v e n ot changed some legitimate question ing of the priority and m eaning fulness of these tests. I’d like to see some of our excellent examiners, teachers, young dentists, and students meet officially, ex change ideas, and make some pro gressive suggestions for improve ment in our testing system. . . . Sec ondly, we should be supportive of the examiners as they make addi tional efforts to assure quality per formances by licensed dentists. . . . As more time is required to assure professional excellence, the talented examiner will be needed in evaluat ing cases that peer review commit tees fail to solve. He may need to ap pear in court or in the legislature to explain dental rules and interpreta tions___ We need each other to reach our common goals. . . . JACK R. PA RRISH , DDS COLUM BUS, OH IO
B ia se s a n d o p in io n s DONALD L. FOW LER, DDS ORFORDVILLE, W IS
□ Although many of us probably find areas of disagreement with “The
□ In his review (The Journal, July), Dr. Corah described Stress and Re laxation; Application to Dentistry as a “biased and simplistic account of
