Wrestling over words

Guidelines recently released by the AAP have put general dentists on edge. -- Is this the beginning of a civil war in dentistry?

Editor’s Note: On Sept. 5, 2006, the American Academy of Periodontology (AAP) released what it called, “Guidelines for the Management of Patients with Periodontal Diseases.” The guidelines were intended to help clinicians identify if and when a patient should be referred to a periodontist. The guidelines have been disputed by the Academy of General Dentistry (AGD), a group that feels general dentists are well qualified to treat cases of periodontal disease. The following is an interview with Dr. Bruce DeGinder, the president of the AGD (pictured at left). In this interview, he details why the AGD is upset with the guidelines.

Dental Economics: What is at the root of the concerns the AGD has over the AAP’s new guidelines?

Dr. DeGinder: I think the ultimate goal for the AGD is to see the record set straight. We are very frustrated with the wording of the AAP guidelines. The reality is that very little of the feedback we were asked to provide to the AAP was incorporated into the guidelines. A lot of people have told me how shocked they are that the AGD would be in support of these guidelines, and I’ve had to tell them that we do not support them. We have sent a letter voicing our concerns to the AAP but have had very little response addressing those concerns. The tone and the wording of the document is a concern to us. Periodontists are not the only dental professionals who can treat periodontal disease. The first document we saw was 1.5 pages. The final document was five pages. We were very surprised to see these guidelines were published as their final document and our input did not account for the increase in volume.

DE: What feedback that the AGD provided was left out of the AAP guidelines?

Dr. DeGinder: One of the biggest concerns was that we never got to review the “revised AAP guidelines” to even offer our feedback. There were several pages of feedback provided by then-AGD president Dr. Bruce Burton to the AAP in response to its initial request for feedback on AAP Referral Guidelines, which were less than half the length of the final guidelines released on co-management of periodontal patients. A notation such as, “A combination of two or more of these risk factors/indicators may make even slight to moderate periodontitis particularly difficult to manage,” may discourage general practitioners from managing these patients. There is also the suggestion that practitioners often aggravate periodontal disease by failing to make timely referrals. In addition, there is also a “laundry list” of periodontal procedures that imply only a periodontist should be treating these conditions regardless of a general dentist’s prior training and experience.

DE: What has been the AAP’s response to the AGD’s concerns?

Dr. DeGinder: Not as much has happened as we hoped. We have voiced our concerns, but have heard little back. We really don’t want this to become interpreted as a document to be used as an overall guideline in medicolegal terms. If you look at the AGD and ADA guidelines for referral, they are very comprehensive. It’s important to have the general dentist as the quarterback looking at all of the needs of the patient. Certainly there are concerns with periodontal disease and the oral-systemic link, but general dentists are knowledgeable about this link as well. General dentists can be very accomplished when it comes to periodontal procedures.

DE: What has been the membership’s response?

Dr. DeGinder: We communicated with the membership when the guidelines first appeared. We wanted to set the record straight with our members. They listened to us and responded. More than 1,800 e-mails were sent to the AAP office in the first week after our informational e-mail. Our membership said they wanted to get involved, and they did. I began my term as AGD president in August, and I was pleasantly amazed to see how many members were passionate enough to write an e-mail to express their concerns.

DE: What is the AGD’s primary concern with the AAP guidelines, and how would the AGD like to see it changed?

Dr. DeGinder: The AGD would like to see the AAP rescind its guidelines in the current form to allow for a true collaborative effort involving all interested parties.

DE: Does the AGD support any sort of classification of periodontal disease that would clarify which disease stages can be treated by general dentists and which should be referred to periodontists?

Dr. DeGinder: The AGD believes that a general dentist should treat periodontal disease to the level that he or she has attained appropriate continuing education and training. This position mirrors the American Dental Association’s position as enunciated in the ADA’s code of ethics.

DE: In the AGD’s opinion, how will these guidelines affect general dentists?

Dr. DeGinder: We believe these guidelines could have many negative effects on general dentists and the patients we serve. The guidelines may interfere with the general dentist serving as the overall coordinator for our patients’ dental needs. They potentially could become a medico-legal document creating many unintended consequences. For example, if just one court ruled that these guidelines were the new standard of care, it could prevent general dentists in that jurisdiction from performing periodontal procedures. Many patients who live in rural parts of the country do not have easy access to a periodontist, and these guidelines would create an instant dilemma for the general dentists currently treating those Level 3 type patients, as identified by the AAP. In addition, other specialties within the profession may feel the need to develop their own guidelines, further splintering the profession. We believe our patients are best served when the whole profession is united towards the mutual development of oral health initiatives.

DE: How would you characterize the AGD’s relationship with the specialty groups?

Dr. DeGinder: We try to maintain a good relationship with them. We try to meet with the specialty groups and explore joint ventures that will advance dentistry. All of us want to focus on improving the overall dental health of our patients. It’s important for all of us to focus on that goal. We all need to work together. The strength of the dental profession has always been cooperation among practitioners. In Virginia (where Dr. DeGinder practices), specialists are always eager to work together with the general dentists, and I’ve always enjoyed that relationship.

DE: As a general dentist, what is your view of the current oral-systemic link buzz?

Dr. DeGinder: I certainly do not think the link between oral and overall health has been blown out of proportion. It’s exciting to be a part of the profession right now with this new research. I would certainly think the AAP would be excited about the focus on the oral-systemic link. There have also been a number of medications that have come out recently to help patients battle periodontal disease.

DE: Do you see the role of the general dentist changing in the near future?

To review the AAP’s guidelines, log on to:
www.perio.org/consumer/patient-management.htm

To review the AGD’s set of guidelines, log on to: www.agd.org/files/agdnews/
agd%20referral%20guidelines.doc

Response from the
American Academy of Periodontology

Editor’s Note: Obviously both sides of the argument must be presented. We asked Dr. Don Clem (pictured at left), a spokesperson for the AAP, to explain the AAP's position on the controversy.

DE: What was the initial reason for developing the guidelines?

Dr. Clem: There is concern that specialists are seeing patients later in the disease process. As risk factors continue to be identified, the Academy, as the recognized specialty of periodontology, feels that identifying patients at highest risk for periodontal diseases would help general dentists and specialists manage these patients. It is important that periodontists and other dentists have a basis for developing individual protocols for co-managing these patients.

In light of emerging evidence regarding adjunctive treatments and perio/systemic links, communication between the dentist and periodontist is especially important in establishing responsibilities for periodontal treatment and maintenance. The Guidelines can help answer the sometimes-difficult questions of if and when a patient should be referred to a periodontist. For example, some patients present with periodontal problems that say partnering with a periodontist should happen promptly after diagnosis by the primary oral care provider. When a patient’s problems are less serious, partnering with a periodontist would likely or may be advantageous, especially if the disease is resistant to initial therapies provided by the dentist.

DE:One of the chief concerns voiced by the AGD is that some of the group’s initial feedback was disregarded in the AAP’s final guidelines. How does the AAP respond to this concern?

Dr. Clem: AGD’s concern was that their initial feedback was disregarded in total. In fact, all of AGD’s concerns were carefully considered. Many important changes were made in the final document as a result of the thoughtful response from AGD. For example:

1) The AAP Task Force insisted that the document consisting of four parts (Introduction, Body, FAQ’s, Definition of Terms) be considered integral parts of the Guidelines. This is because any separation of these key elements leaves the document open for misinterpretation and essentially invalidates its content and meaning.

2) The document specifically states, as a result of AGD comments to the draft, that “The Academy believes that all dentists have the right to practice according to their education training and experience.” Also the Guidelines repeatedly emphasize the ability of dentists to treat periodontal diseases either within the context of their own training or within the context of co-management with a periodontist.

3) In response to AGD input, the Academy was concerned that misinterpretation of Guideline language in the initial draft might occur. As a result, the Academy has defined key Guideline terms very precisely in an effort to prevent subjective interpretation of their meaning. For example, the strongest recommendation used in the guidelines is the word “should,” which is defined as “a highly desirable direction but does not mean mandatory.” This is because, as dentists who have completed postgraduate study in an ADA recognized specialty, it only makes sense that periodontists are most likely to see patients with higher disease severity and/or higher risk profiles. The Academy recognizes that some dentists have acquired broad skills that enable them to treat a wide variety of cases, so this recommendation, while highly desirable, is not mandatory and is so stated in the guidelines. The Academy is grateful for the input from the AGD and other dental organizations. However, their participation in the development process does not signify endorsement of the Guidelines. The Guidelines are an Academy document and do not purport to represent the views of any other organization.

DE: Does the AAP feel general dentists have the necessary training to treat periodontal disease?

Dr. Clem: The Academy recognizes, and the Guidelines acknowledge, that all dentists have the right to practice according to their education, training, and experience. These Guidelines are offered as a tool for dentists to quickly identify those patients at greatest risk for periodontal diseases and progression. The Guidelines do not indicate that periodontists are the only individuals qualified to treat these high-risk patients. They do suggest, however, that periodontists are the best-qualified individuals to do so by virtue of their education and training in a three-year postgraduate specialty program. This should come as no surprise to anyone, as this training is documented through accreditation standards published by the Commission on Dental Accreditation, which operates under the auspices of the ADA. The ADA also indicates that dental specialties are recognized in those areas where advanced knowledge and skills are essential to maintain or restore oral health. While continuing education is important for all dentists, the complete scope, experience and breadth of knowledge in any specialty can rarely be fully realized other than in an accredited postgraduate training program. General dentists competently render most of the periodontal care in this country. It is unlikely, however, that the majority of general dentists can offer the full scope of periodontal therapy in cases demonstrating high risk factors. These risk factors, outlined in the Guidelines, may complicate disease management regardless of disease severity. The Guidelines are designed to help general dentists establish protocols for treatment and/or referral based on their individual expertise in providing periodontal care, which varies. That is why the Guidelines state: “Some patients can be well managed within the general dental practice, whereas others would benefit from co-management with a periodontist.”

DE: Is the Academy considering revising the Guidelines?

Dr. Clem: The Guidelines are not up for revision at this time. They are scheduled for review in 2009, and the Academy is committed to working with the dental community in clarifying any issues that may arise. We have extended an invitation to communities of interest, including the AGD, to discuss these guidelines in a constructive format to improve the periodontal health of the patients we serve. The Academy looks forward to discussions with all organizations within the dental community to work in a collegial and cooperative manner to make these guidelines the best they can be and continue the long standing tradition of the unique partnership that periodontists and other dentists have in the best interests of patients. In the final analysis, is not the patient’s welfare the ultimate guideline?