Readers' Forum

March 1, 2003
I was disappointed that Ms. Bernie chose to respond (December 2002 issue) to my critique (November 2002 issue) of her article on full-mouth disinfection (September 2002 issue), as if she had been personally attacked.

Quality instrumentation still remains the key

Dear RDH:
I was disappointed that Ms. Bernie chose to respond (December 2002 issue) to my critique (November 2002 issue) of her article on full-mouth disinfection (September 2002 issue), as if she had been personally attacked. My goal was to point out the shortcomings of her opinion-biased article, not her. As I stated, I don't know Ms. Bernie. Regarding her remark: "... classifying him and his ilk as anything but part of the controversy," I can only assume that she is referring to periodontists as a group, since most of us practice evidence-based therapy, which she disparages in her statement: "... while evidence-based therapy is all the rage, how does it truly apply in reality?" I wonder, to whose reality she is referring?

After reading again her original article and my response, I stand by my statements as written and don't believe that I am at all "confused." Her attempt to "muddy the water" by nitpicking between one or two (within a 24-hour time span) appointments is a weak, if not downright petty, argument, although some FMD protocols do indeed recommend completion of all instrumentation in a single appointment.

Ms. Bernie's second point of rebuttal, that the "primary focus of the article was to question treatment completion time involved with SRP protocols and to call for standardization of such processes U" is neither stated nor implied anywhere in her article that I could determine. Therefore, one must assume she decided that this was its focus only after someone called into question her "expertise."

Furthermore, I don't understand why she chose to attempt to discredit Dr. Greenstein's very comprehensive, excellent review article on FMD, except as an effort to, in her own words, "propagate confusion."

He clearly and concisely discussed all of the literature on this subject, very objectively, as he does in all of his excellent review articles, in a highly respected, refereed journal. Perhaps, since the literature doesn't clearly support her viewpoint, she believes that it isn't worth considering.

To restate my primary disagreement with Ms. Bernie's article: The number of appointments utilized for scaling and root planing is not what's important. The quality of the instrumentation is. Full-mouth disinfection with chlorhexidine rinses, tongue scraping, and other local delivery antimicrobials have not been clearly shown to significantly enhance treatment response from mechanical instrumentation in most cases.

To state otherwise is disingenuous. Furthermore, the idea of routinely utilizing local delivery antimicrobials in conjunction with scaling and root planing can lead to a "slippery slope" of potentially thinking they can make up for inadequate mechanical instrumentation, which they most certainly cannot.

As I have told the hygienists in our practice on a number of occasions, "If you adequately remove the deposits mechanically, in most cases you probably don't need adjunctive therapies and, if you don't do an adequate job mechanically, these adjunctive therapies probably aren't going to save you."

I realize that dental hygiene, on a day-to-day basis, can become mundane, if one lets it. However, one simply cannot get around the importance of excellent root surface instrumentation in periodontal therapy. Call it what you want: Scaling and root planing, root surface debridement, soft-tissue management (some would say mismanagement), full-mouth debridement, nonsurgical periodontal therapy, it has to be thorough (See the excellent article titled "Disease Masking: A Hazard of Nonsurgical Periodontal Therapy" by Greenwall, Bissada and Dodge in Periodontal Insights, December 1998, in this regard).

In conclusion – and this is indeed my conclusion to this debate — I would advise Ms. Bernie to focus more on the "science" and less on the "art" of dental hygiene when she writes on this type of topic. Her thinly veiled implication that because I didn't agree with her article there is somehow a lack of "mutual respect" for dental hygienists on my part, couldn't be further from the truth.

As I stated in my original response, I am married to an exceptional woman, who is not only an incredible clinician, but also an award-winning educator and dental hygiene program director. I employ 10 very talented hygienists and two female periodontists in a large, multi-office, multi-doctor periodontal specialty practice.

We all practice from a basis of mutual respect to provide our patients with the best that modern periodontal therapy has to offer. We constantly evaluate the literature, our own therapies, and treatment outcomes. When a better way presents itself — evidence-based, of course — we consider incorporating it into our treatment protocols.

Finally, I don't know what Ms. Bernie was referring to when she quoted Einstein's definition of insanity and her "hope that the insanity will stop." I do know that in our practices we attain excellent outcomes from repeating the same activity over and over. That is the nature of the beast. Instead, to summarize my position on this topic, I would like to offer the following quote by Dr. Ruth Westheimer: "It is not the size or shape of the tool that's important, but how you use it."
Benson C. Duff, DDS, MS, MSBA
Grand Blanc, Michigan

Hygienists can think too!

Dear RDH,
After reading the Readers' Forum response by Dr. Duff (November 2002 issue) to Ms. Bernie's article, I felt I needed to respond! I take exception to his comment, "After further critiquing it with my hygienists and associate periodontists and realizing that a relatively large number of dental hygienists read and perhaps accept Ms. Bernie's 'opinion-biased' comments as indisputable scientific facts ... which has the potential to impact clinical practice by many conscientious dental hygiene practitioners, who may obtain their literature updates from magazines such as RDH and who may not be as adept at assessing the validity of literature as others ..."

I don't know about other schools, but my education actually involved a course on evaluating the content of what is read. My current professional literature reading extends far beyond RDH magazine! Actually, I view RDH magazine as a resource for invaluable information regarding the profession of dental hygiene, both scientific and nonscientific.

I find his stance that a "relatively large number of dental hygienists" have no other source of information other than RDH magazine insulting.

I find it even further troubling that he read and critiqued the article at the request of his wife who is a dental hygiene program director. Did she not feel capable of addressing this issue? Does she feel that the education being provided by the dental hygiene program she directs to be inadequate to equip dental hygienists to use their critical thinking skills?

I attended Kristy Menage Bernie's course at the Chicago Mid-Winter meeting last year and actually had been doing full-mouth perio instrumentation for about a year prior to attending the meeting. It was nice to see an article to "refresh" my memory of the course.

We all have our own opinions and/or fact-based reality in our treatment modalities. While Dr. Duff is certainly entitled to his opinion regarding Ms. Bernie's article, I find his assumption that hygienists can't interpret scientific facts very insulting.
Pam Mecagni, RDH
Peru, Illinois

Circumstantial evidence about the 'link?'

Dear RDH:
I enjoyed reading the latest issue of RDH (January 2003 issue) but was a little concerned about "Periodontal Disease and Atherosclerosis," which mentions some flawed studies about perio and cardiovascular disease (CVD).

The problem with the connection between these two diseases is that co-founding variables are not mentioned. Patients with perio and CVD usually do not take care of their bodies. They smoke, drink, pig out on excessive fats, and don't brush or floss very well. That is why they have perio and CVD. The relationship between perio and CVD is circumstantial. Other bad habits, not considered in these studies, cause the problems.

That is the reason why these studies are not valid. This point has been expressed in numerous articles. It is sort of like blaming eye glasses for deaths because so many old people (who die) wear glasses.

It is unfortunate that some people in dentistry are trying to use this bad data as a way of inaccurately "promoting" dentistry and hygiene. Please pass this message along to your readers.
E.J. Neiburger, DDS
Waukegan, Illinois


The article in the January 2003 issue, "Periodontal disease and atherosclerosis," makes a reference to risk-scoring tables to help find a risk score in predicting a heart attack. Unfortunately, the details about where to obtain the risk-scoring tables was deleted prior to publication. Readers can use an online risk calculator to predict risk of having a heart attack in the next 10 years. Visit and click on "Health Tools" and then "Risk Assessment." We regret the delay in offering this information to our readers.

Don't criticize the working mother

Dear RDH:
For the first time in my life, I feel that I must comment on an article I've read in a magazine. The funny thing is — the thing that has my defenses up and my temper flared — has nothing to do with the actual subject of the article in question. It is, instead, a three-line snotty remark in the introduction to this article that I feel has no place in a professional magazine.

I refer to is the article, "Unstuck from the Old Routine (January 2002 issue)," in which Shirley Gutkowski comments, "During my first summer, I did a stint for Dr. D., filling in for his hygienist who was on maternity leave. She was on her fourth child with her fourth husband, getting disability/unemployment for those three months. Some people know how to work the system."

Well, let me tell you something, Shirley. I am currently on an extended maternity leave, due to unforeseen complications with my pregnancy. I will be out of work a total of seven months, and collecting disability for most of that time. Oh, do I know how to work the system! Funny that your comment came right in the same issue as the salary survey, which gives us some facts to work with. Like the fact that disability pays me each week what I could make in just one day in the office. Or the fact that many hygienists — myself included — do not receive sick pay or vacation benefits.

Now, let me give you some other facts. Like the fact that I worked the first five months of my pregnancy, even when I was nauseated and exhausted beyond belief. Not once did I call in sick. I planned to work right up until the last two weeks of my pregnancy, and then take three months off, just like the person you declared was "working the system." I planned to take disability payments for the eight weeks allowed for a normal pregnancy by New York state, and go unpaid for the other four weeks. That would've been a total of about $1,200, before taxes. Yeah, that's working the system all right!

It was going to make things a bit tight for us, but we had planned for it. Now, the doctor has taken me out of work four months early.— and no we didn't plan for that. It's small consolation that I'll now be able to "work the system" for a whole $150 a week. But, we will do it, without question. Do you know why? Because she is my daughter. Her health and safety come before any job or any amount of money.

The fact is, Shirley, that if I were to work now, I would put her at risk for premature birth. Not just by a couple of weeks, but by enough time that she may not live or be healthy. The fact is, after she is born (God willing, full term), breastfeeding is the healthiest and best way for me to feed and care for her, and that requires that I am not back at the office, where the schedule does not allow ample time to stop and use a breast pump.

I want to be with her every minute that I can. I want to be the one to change her diapers and hold her when she cries and rock her to sleep. I probably won't be getting much sleep myself in those first few months — what new mother does? Do you seriously think I should be ready to jump out of bed, bright-eyed, get ready and be there to greet my 8 a.m. patient after a night of poopy diapers and 2 a.m. feedings? Or do you think I should somehow leave all those responsibilities to someone else, perhaps my husband, who, of course also has a job to be to at 8 a.m.?

No! Disability should actually pay us more, and maternity leaves should be made longer. These are our children we're talking about. They are the ones who deserve the very best we can give them.

I love my job. I think the world of my employers and I dearly miss my co-workers and my patients. I also really miss getting that paycheck every two weeks. But my family is far more important to me than any job or any amount of money could ever be. If you think I'm less of a person for that, then I pity you, and I pity your children.

Now, incidentally, this is my first child and my first and only husband. If you think you have the right to judge this other hygienist because of the number of husbands and children she has had, you are even more arrogant than I thought. This woman may have made many marital mistakes, but who are you to suggest that it makes her role as a mother any less significant?

Not that I expect any miracles, but Shirley, I think you owe us an apology.
Janice L. Reeves, RDH
Saratoga Springs, New York

Editor's Note: In retrospect, I probably should have, as the editor, deleted the last sentence of the statement that offended you. I know that the remark was not intended to be an insult toward working mothers or even women who do need social assistance during trying times. Ms. Gutkowski also raised a large family while juggling her dental hygiene career. I hope, by the time you read this, you are enjoying the addition of a wonderful, healthy daughter to your family. I also would like to ask readers: Is dentistry sensitive enough to the needs of working mothers who are trying to juggle a career in the profession while being the best Mom they possibly can?

Two-year 'tier' can be exciting too

Dear RDH:
In response to the "Tiers for our trade" article (October 2002 issue), we (two-year graduates of an accredited associate of applied science in dental hygiene degree program) disagree with your "tiers" of hygienists. First of all, we worked very long and very hard for our associate's degrees. Our instructors there not only taught us great clinical skills, but also great people skills. We were extremely prepared for the national board exam and our NERB clinical exam.

As far as we are concerned, if these exams are passed and you are granted a state license — which gives us the rights and privileges mentioned in all tiers — how are those who take a few extra credits any better of a hygienist than we are?

How boring it would be to sit around and polish teeth all day like it is claimed our two-year degree is worth. The periodontal disease that is treated in our office is handled very professionally. It is followed up with a periodontal program designed by us, the two on-staff hygienists. The doctor who employ us keeps us advanced with continuing education courses that go above and beyond the 20 required credits every two years.

We feel that if your higher level tiers need so much education, why not use those extra years, credits, and time to become a dentist!
Jennifer L. Smith, RDH
Carol L. Maluchnik, RDH
Osceola Mills, Pennsylvania

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