Letters from Readers

Aug. 1, 2002
On first reading, I enjoyed Paul Homoly's article, "How 'Bout Them Apples?" in the May 2002 issue. I, too, have been guilty of denigrating some of my patients' insurance benefits and, in the future, will upgrade my approach to their very poor benefits.

'Coupon' pays for all costs of pie?

On first reading, I enjoyed Paul Homoly's article, "How 'Bout Them Apples?" in the May 2002 issue. I, too, have been guilty of denigrating some of my patients' insurance benefits and, in the future, will upgrade my approach to their very poor benefits. Upon reflecting on the article, though, it appears Dr. Homoly's discount coupon analogy is very misguided.

Our patients don't believe their insurance will give them a slight reduction in the cost of their dental care; rather, they expect their insurance to pay for their entire care. That is analogous to them expecting their coupon to pay for the entire bushel of apples and all other items necessary to make apple pies.

The correct analogy would be for the patients to inform the checkout girl that their coupon will cover all of the costs of making the pies. When they see the total cost of the items they chose for the pies, and, if the coupon didn't cover everything, their response would be to just send them the bill. Of course, they would expect to pay the bill when they receive it over the next year or so, interest free. That is a more accurate description of what occurs when patients present their insurance forms to a dental office and seek treatment under the program.

Robert A. Sonnes, DDS
Vancouver, Wash.

Chart off by millions

While catching up on my back issues of Dental Economics, I was drawn to Jean Sagara's article on implants (March 2002 issue). With a practice that is now 70 to 80 percent implant-related, these articles always catch my eye.

I truly agree that the potential for implant dentistry to grow will come on the efforts of restorative dentists. This will be accelerated when that segment of caregivers understand how routine placement can become in their own offices. Anyway, that is exactly what the manufacturers are banking on!

I do have a question for Jean. It is in regard to the chart found on page 64 titled, "Dental Implant Market, Segmented by Delivery Method." The chart's reference to "millions" cannot be correct. If I read the chart to add all the different segments together, your chart would only have about $3 million in 2001 for the entire United States?

This chart must be labeled wrong. It has to be significantly more than that. I would appreciate it if I could hear back on this matter.

Barry Franzen, DDS
Milwaukee, Wis.

Editor's Note: Indeed, Ms. Sagara did have something to say: "Thank you for your response to my article in the March 2002 Dental Economics. You are accurate in that the graph appears to be mislabled and I am grateful for the opportunity to correct this information.

"This graph was provided to me by The Millineum Research Group. The axis display is misleading, and I did not intend for it to be misleading. The breakdown is actually in hundreds of millions of dollars, not in millions of dollars, as is displayed. The overall summary total provided by The Millineum Research Group for 2001 is $120.2 million, which is much better news for the industry!

"The Millineum Group provided the correct information, and, somewhere during the editing process, I overlooked the change and take full responsibility for it."

Dr. Franzen responded: "Thanks Jean. I enjoyed the article. I was getting a little confused because I know what we gross in our office in implantology and that was a significant portion of the graph! You are right in your predictions as to the direction of dentistry. The implant companies are banking heavily on the fact the GP will start to place his/her own fixtures. The ACP and Dr. Felton are on a mission to make sure the surgical aspect of implantology is included in all prosthethic programs. There will be a huge shift with future implant services. It will, however, not be without significant battles. It should be fun!"

Counter points about lasers

It was a surprise to see a letter to the editor from Dr. Gerald Drury in the June 2002 issue of Dental Economics. As a periodontist, he has been a vehement critic of pulsed Nd:YAG laser use in periodontal therapy, laser ENAP, laser curettage, and laser sulcular debridement. Most of his activities, though, have been behind the scenes making personal accusations and complaints about us to the California Dental Board, the California State Attorney General (urging criminal charges be brought against us personally), and the FDA, instead of open commentary and professional, collegial discussions with those he so adamantly opposes.

In his first point he states, "The laser has not been approved by the FDA for a Modified Widman Flap or ENAP." Dr. Drury is confused about the role of the FDA and the purpose of FDA submissions by manufacturers. The FDA regulates claims that a manufacturer can make in the marketing of a device, after the company has submitted data on both safety and efficacy in order to demonstrate "substantial equivalency" for a particular "indication for use."

The purpose of most studies conducted by researchers on behalf of a manufacturer is to demonstrate equivalency, not superiority. The FDA does not ever intend for studies showing substantial equivalency to be the last word on the science. The FDA expects clinicians, academicians, and researchers to conduct additional studies, make observations, and report adverse findings to further expand on the body of evidence about a particular drug or device. Therefore, it is misleading and disingenuous for Dr. Drury and others in the AAP to assert that since the manufacturers have not demonstrated superiority to standard procedures, then the new methodology is somehow invalid, irrelevant, or worse - dangerous.

The FDA has cleared for marketing a pulsed Nd:YAG laser for laser periodontal therapy, laser curettage, and laser sulcular debridement to improve:

  • Gingival Index (GI) - improving the quality, quantity, and severity of disease
  • Gingival Bleeding Index (GBI) - reduce bleeding from the gums
  • Probe Depth (PD) - reduce the depth of the periodontal pocket
  • Attachment Level (AL) - increase the level of tissue attachment
  • Tooth Mobility (TM) - lessen loose teeth.

How any dentist chooses to then use that laser in their methodology of choice, whether in an ENAP-type technique (that includes scaling and root planning), open flap, or closed curettage is entirely legal and appropriate for the clinician to practice. In any clinical scenario, the FDA does not regulate the use or claims that dentists may make about their own use of a legally marketed device, laser or otherwise.

Therefore, Dr. Cortés is free to use her laser for Laser ENAP, and is also free to share with colleagues the results of her clinical laser periodontal experiences. That is the point of publishing clinical articles, so that our peers can review the work and make fair comment about it.

In Dr. Drury's second point he states, "No one has demonstrated that removal of the sulcular tissue alone with or without a laser leads to new attachment." Again, Dr. Drury is confused. Nowhere in the article by Dr. Cortés, and nowhere in anything we have ever written, published, or discussed about the laser ENAP technique does anyone suggest that scaling and root planning are not necessary. Quite the contrary. That has been a constant and recurring misrepresentation of the laser ENAP technique (not the same as scalpel ENAP) by Dr. Drury and his ilk since he began his campaign against laser ENAP several years ago.

Dr. Drury then writes, "If you bring laser [sic] energy into the intrabony defects, you are asking for serious collateral damage beyond that what is most likely already being caused to the pulp and adjacent hard tissues with your curettage procedure (especially at the 2.5 to 3.0 watt setting)."

With all due respect to Dr. Drury, he doesn't know what he is talking about. These sorts of statements by Dr. Drury are reckless and irresponsible. He justifies making these false and misleading statements from anecdotal reports of injuries where 12 to 35 watts of pulsed Nd:YAG laser energy was used by dentists with no training and completely beyond their scope of practice and FDA indications for use, and using a laser with dangerous energy configurations and waveform. That laser was removed from the market many years ago.

The facts are that the FDA has received only one adverse incident report of a pulsed Nd:YAG laser in over 13 years of clinical use, and literally millions of patients treated. Can anyone make the same claim for, say, high-speed handpieces or nickel titanium rotary endo files? No, Dr. Drury, a few legal anecdotes, or one adverse incident following a gingival troughing procedure prior to crown impression - does not a body of evidence make.

In our combined 25 years of using pulsed Nd:YAG lasers in the periodontal pocket, we simply have not seen the type of damage to bone, root, or pulpal tissues that Dr. Drury and his supporters would like the Dental Economics readership to believe. High-speed handpieces are far more dangerous and injurious to the hard and soft tissues of the mouth than our pulsed Nd:YAG laser has ever been - and they are not even FDA approved!

Dr. Drury and his allies need to stop reporting claims of dire consequences from using pulsed Nd:YAG laser in the periodontal pocket until they can provide more than anecdotal stories, new theories, and poorly designed lab experiments (for example, irradiating an extracted tooth perpendicular, dry, and with 250,000 Watts/cm2 of power) by conducting well-designed, prospective, longitudinal, blinded, multi-centered clinical trials to demonstrate the damage they allege is taking place. Until they do, the clinical, histological, and scientific data - long on file with the FDA as showing no injurious effects of pulsed Nd:YAG lasers on root surface, bone, or pulpal tissue - will have to put this issue to rest for the time being.

Dr. Drury unfortunately becomes personal and admonishes Dr. Cortés by writing, "… your first responsibility is to do no harm. A scientific review of the procedures you are advocating brings into question whether you are fulfilling that obligation." Dr. Drury unfairly questions the professional obligations, responsibilities, and integrity of Dr. Cortés toward her patients because she reports on positive clinical aspects of patient care using pulsed Nd:YAG lasers for periodontal treatment, which is within her scope of practice and training. Dr. Drury has a lot to learn about the scientific method, not to mention professional decorum.

The Hippocratic dictum that directs physicians to "… at least do not harm" is something Dr. Drury should not want to apply to laser ENAP in comparison to conventional, osseous, ressective, apically re-positioned flaps for the treatment of periodontal disease. But if Dr. Drury wants to discuss harm to patients, then we must talk about patient acceptance rates for conventional periodontal surgery. It is estimated that more than 100,000,000 American adults have moderate to severe periodontal disease, not counting gingivitis or early stage periodontal disease, and less than 3 percent receive conventional treatment in a given year.

Dr. Drury, that is an awful treatment rate for a disease your specialty is charged with treating. We would all be interested in knowing why you think it is that low? As general practitioners, we have had enough experience with your methods on our mutual patients to have our own opinion. If you and your specialty can't come up with another modality for treatment than what patients are already refusing to accept, then you all have abdicated your responsibilities to the profession, your specialty, and, most importantly, the public trust.

As professionals who are responsible to practice our art and science in manners and methods that benefit our patients, we are meeting the admonitions of Hippocrates: "As to diseases, make a habit of two things - to help, or at least to do no harm." We are helping our patients heal in ways you choose to not understand, and we are indeed doing no harm.

Robert H. Gregg II, DDS,
Delwin K. McCarthy, DDS
Co-Directors, Institute for Advanced Laser Dentistry

Deserving of the fees

I am rather baffled by the waffling and indecisiveness of Dr. Christensen regarding Class 2 composites vs. amalgams (June 2002 issue). Taking money out of a patient's decision is like taking the starch out of a potato - that is, no more potato!

Things cost money. Composites take more time to do - more instruments, more finishing - so charging the same ... well, I find this baffling. You really have to be on your game for composites, and, if you are, well, friends in the trenches, you fully deserve to be paid thusly. Contrary to Dr. Christensen, I find it patently impossible to take money out of this process. Things cost, so what is the big deal?

Also, what are moderate fees? What percentile? I perform well, I get paid well, just like Dr. Christensen. I just find it very hard to make much sense out of such an amorphous presentation that Dr. Christensen represents as something he might follow.

Michael L. Janket, DMD
Putnam, Conn.

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