The New Jerusalem – William Blake
I will not cease from mental fight,
Nor shall my sword sleep in my hand
Till we have built Jerusalem
In England’s green and pleasant land.
Thank you for your commentary on Part II of the Endodontic Implant Algorithm. A response in this modality is complicated, like one hand clapping; however, I shall try to engage you in constructive dialogue. I’m a dentist, not an ‘endodontist’, my vision for treatment is the well being and the welfare of the individuals I treat by providing required services with the best of my clinical and conceptual ability. Whether or not a practice is limited in the range of its service mix, bias is not on the curriculum of post-graduate dental schools. However, evidence based treatment planning and execution is, and for those who truly understand comprehensive care, we represent a manifestation of any small group dynamic that requires teamwork to carry a project to fruition.
Dr. George Zarb put the University of Toronto on the world stage with his institutional review of osseointegration; Dr. Shimon Friedman has done the same with his extraordinary Treatment Outcome studies recognized globally as the most cogent compilation and analysis of multi-variate issues pertaining to functional endodontic success. Issues relating to caries, fracture, periodontal involvement and most importantly poor coronal restorations were factored into the results. None of these were substantiated by anecdote or experiential bias.
Hearsay and aberrant commentary in a social setting is not reflective of fact or validation. Every practitioner acts within the realm of his or her conscience, ethics and understanding. I have to believe that when asked to do anything that may be questionable, ethics come to the fore and the practitioner’s response is consistent with what is appropriate for the patient in question and not based on fiduciary interest.
If there is a singular failing in the “referral” system, it is in the scope, range and degree of communication and interplay re; treatment planning. This is increasingly less of a concern in an Internet driven world of communication of text and images; however, one cannot deny that most patients are not inculcated in the manner in which to provide, “chief complaint, onset, duration and intensity of pain”, nor do most referral slips come with an expansive explanation of all aspects of the case discussion. You will never supersede a world in which exchange of opinion can be misconstrued by some as challenge and the focal point, the patient’s requirements, stops being the centrepoint.
You will notice I referenced foundational dentistry in the article, not endodontics or implants. The right treatment implies the use of an algorithm which is nothing more than a step-by-step procedure for solving a problem; I trust that I was able to achieve this within the scope of a journal publication. I’m not certain of where you have obtained your “facts” regarding how “dentists and/or endodontists” have failed to do the appropriate due diligence on behalf of their patients. There is an under’tone’ in your letter that concerns me, as the explosion of the service mix in dentistry in the past decade may well have forced the train to derail from the fundamental biologic tenets that drive the profession.
The profession, not necessarily the practitioner, has to some degree been market driven, not science driven. There is an old joke about dentists practicing venereal disease, “you know, where every tooth is cut down for a veneer!” I would suggest that failure to adhere to the most basic fundamentals of occlusion and all the other biologic mandates in the headlong rush to white front teeth and a big smile carries the connotation of complicity to a much greater degree than those you reference. As a member of the endodontic discipline, I feel you are denigrating the endless self-analysis by endodontic researchers whose studies address every conceivable aspect of the eradication of pathologic vectors in the root canal system and at the same time, seek to determine the variables of structural integrity that ascertain the predictability in rehabilitation. I sincerely wish that implant outcome studies were conducted with the same level of sophistication as the profundity of endodontic treatment outcome studies.
The appropriate response to any counterpoint is to always take the more elevated position; I would however, suggest that there are times, when taking off the gloves and letting fly might prove more satisfying. Suffice it to say, that in regard to the concerns about bias dictating treatment planning, I’d opt to lose the battle every time out to save a natural tooth, than to capitulate. The end game for any gatekeeper is winning the war, and in this case, the war is about recognizing disease early, treating teeth with sound principles and technique and to allow everyone to share in the process… rather than faulting endodontists, you’d perhaps be better to fault the licensing bodies who mandate that an endodontist’s area of expertise ends at the orifice, who fail to include procedure codes for coronal sealing in the fee guides, but that is a discussion for another time.
Kenneth S. Serota, DDS, MMSc