Crisis in Morality
It seems we live in times of terrorist attacks on the innocent brought on by ignorance, hatred, dogmatism, and perhaps insanity. We all also experience uncertainty in the form of political polarization of our values and the advent of "fake news" and forgetting the implicative meaning of words. This all leads us to feel anxious about the future of our country and our way of life.
. I am trying to pause for a moment in order to comprehend it all. Unfortunately, my ability to fully understand all of this is limited by my education, background, and experience, and so I prefer to refrain from further comment or opinion. I do, however, understand to a much greater degree the field that I have chosen as my specialty, periodontology.
As a dental student I learned that periodontitis is usually a chronic, insidious, hidden, inflammatory disease that is frequently asymptomatic, and even when there are signs of the disease, laypeople and members of the dental profession unfortunately are not very alarmed by it. Typically it is slow, cyclic, and may eventually lead to tooth loss. It might be acute or chronic, progressive or stagnant, active or inactive, reversible or irreversible, uncomfortable or asymptomatic, disfiguring or unnoticeable, easy or difficult to treat. We consider bacterial-immune system interaction to be the primary etiology, but there are a variety of local, systemic, and environmental contributing factors. There is a requirement to evaluate each patient and site separately as the disease can manifest in many different ways, and what may be an appropriate treatment for one patient or one site may not be appropriate for another.
What does all of this mean? First and foremost, it requires a correct diagnosis, but not all of us have the same diagnostic skills. Not all of us have the necessary background and understanding required to assign a proper prognosis. Not all of us have the same experience and expertise necessary to determine the appropriate periodontal therapy, and some of us lack the skills to carry out that therapy.
To become a trained periodontist is not a simple undertaking. It requires three years of study beyond dental school. Part of the purpose of the training is to plant the seeds for the development of an expert in the field. Whether or not these seeds will be cultivated depends on the individual and sometimes the circumstances he or she finds themselves involved in. Nevertheless, the periodontal residents are trained to be scientists and are familiar with the scientific method. They are taught to be familiar enough with the periodontal literature to understand the pros and cons of various therapeutic options.
What I sometimes see today are a lot of “self-made” experts who are subscribing to and advocating quick-fix technology and pharmacotherapeutics as a routine treatment for periodontal diseases. I see companies advertising in conventional and social media claiming they have a pill, rinse, tray, paste, laser or whatever that they have as the solution for treating their gum disease. I see people with periodontitis being told that they don’t have to give up their smile or put up with the ravages of gum disease, just have their “bad teeth” removed and replaced with dental implants and simply screw in a new set of teeth. Never mind that many times these teeth could be saved with appropriate therapy. (The average loss of teeth in patients with periodontitis undergoing proper periodontal maintenance therapy is only one tooth in a ten year period).
Is this not playing on public ignorance and fear? Are there biological and financial consequences to the long-term use of low-dose doxycycline? Do mouthwashes and toothpaste really do the job? Are lasers really a substitute for, or an improvement to, conventional periodontal therapy? Is there any strong evidence that they can truly regenerate the periodontal or peri-implant tissues? Are implants always the best solution for dealing with compromised teeth ( peri-implantitis is demonstrating epidemic proportions)?
I frequently read articles in non-refereed journals misquoting or deleting relevant scientific literature, then advocating a technique or protocol to treat periodontitis, despite little or no scientific evidence to support it. Are we ignoring the potential damage some of these therapies can do if not directly, indirectly by giving false expectations to our patients? I see advertisements in reputable dental journals in the form of display ads advocating the use of topical antimicrobials to significantly reduce periodontal pockets when used with scaling and root planning. Have you looked into what they consider significant? Is pocket reduction the be all and end all of periodontal therapy? Won’t the pockets come back and the disease continue to progress if we leave behind calculus in active therapy and don't maintain properly?
Whatever happened to comprehensive diagnosis and treatment planning shared by the periodontist and restorative dentist? Don’t we need to give the patient the pros and cons of all treatment options before we recommend any particular treatment. What has happened to trying to save teeth as a preference to dental implants?
May I suggest to you, my readers, that before advocating or instituting the quick fix therapies I have mentioned, you read their scientific references carefully, as well as references they may have selectively omitted. This might give you a better perspective as to the real value of these therapies. If you still have questions about the validity of these claims, contact experts in the field who have no financial interests in these products or therapies and see how they feel about it. Ask these questions: Why are the vast majority of periodontists not buying lasers? Why are they reluctant to prescribe low-dose doxycycline? Why don’t they routinely use topical or systemic antimicrobials in their therapy? Could it be the scientists are not convinced by the science? Take your periodontist to lunch and ask these questions.
The crisis in morality that I referred to in the title of this editorial is honesty. Honesty requires one to look at all of the evidence as well as the quality of the evidence before coming to a personal decision as to which therapies are based on good science and which are based on poor science, hearsay, or manipulated statistics. Honesty requires knowing what can be accomplished with proper periodontal therapy and being willing to refer if necessary.
Remember, a lot of people are very sincere about their beliefs (meaning that they believe what they are saying), but few people are truly honest
about their beliefs (meaning they have done their homework and looked at the entire picture before coming to a conclusion). Dentistry is not only a business, it is a profession, and as such we have the public trust to be honest regardless of the consequences, financial or otherwise.
Reference: Modified from Journal of the Western Society of Periodontology, Drury,G.I., Vol 49, No. 3-2001
Gerald I. Drury is WLADS Ethics Chair, Clinical Professor and Course Director Advanced Periodontology at USC, Editor of the Journal of the Western Society of Periodontology and former Chairman of the American Board of Periodontology. He is a past president of the California Society of Periodontists and the Western Society of Periodontology, and Chair for Periodontology Peer Review for CDA. He is a past trustee of the American Academy of Periodontology.
