Why do all the ol' timers tell me to specialize?

[job314]

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i've been told great things about general dentistry but every time i meet an older general dentist they tell me the same thing - "there is no future in general dentistry you must specialize". i know that specialists make more money and work less hours but i cant understand why these gp's are so against general dentistry considering that they're all successful. it's not an area thing cause one was from Virginia, one from Mass, and one from CT????

trying to decide if they're implying that specializing is just preferable or if being a gp is that bad?

 

[groundhog]

Seeking counsel from the "old timers" is wise. However, you must be able to discern if their suggestions are based upon what they wish they would have done in their era or based upon their ability to project the direction of their profession into the future. I'm not in the dental profession, but I am one who believes that dentistry is actually a medical speciality in itself and that modern technology combined with social/economic forces will eventually result in more and more GP's performing many of the procedures now relegated to dental specialists.

 

[Frank Cavitation]

I also don't see why there is no future for GPs... it's simply more convenient for patients to deal with one guy for all dental needs of the family. If a GP takes continuing ed and tackles a good variety of cases there's no reason why they can't do lots of endo perio etc. It is already common to get braces from a GP; most kids don't have severely crooked teeth requiring specialist attention.

 

[ItsGavinC]

Frank and groundhog both had great posts.

There is a reason the ol' timers are ol' timers, as logic tells us. They've been around the block a time or two, and they probably have certain ideas and quotas firmly implanted in their heads.

Perhaps they wish that they had specialized, or perhaps they saw too much of their income going to specialists in their area. The list could go on and on.

What is important is the a quick glimpse at the role that GPs play in the profession today. Such a glimpse can reassure you that the position of the GP is not going anywhere.

GP offers more variation on work, and the ability to perform to your own expectations.

 

[badaboom]

Originally posted by Frank Cavitation
I also don't see why there is no future for GPs... it's simply more convenient for patients to deal with one guy for all dental needs of the family. If a GP takes continuing ed and tackles a good variety of cases there's no reason why they can't do lots of endo perio etc. It is already common to get braces from a GP; most kids don't have severely crooked teeth requiring specialist attention.

i totally agree...

and another good thing about being a GP... if there's a pain-in-the-butt case/patient u can always refer it to a specialist...

 

[Stomatologist]

This's a good question we must all deal with.

Should we specialize? It is hard to tell. On one side, yes, we'll make more money, have complete knowledge on a particular subject. On the other, we have to put with more years of school, concentrate in a limited amount of procedures, deal with extremely difficult cases, etc, etc, etc.

I'm at the point in which, I'll specialize but will not limit my practice. In other words, I'm considering not anouncing myself as a specialist, but as a general dentists.

At the end of the day, it all comes down to how much money you'll be making. Having a constant stream of cases referred by GPs will get you more money than doing cleanings and fillings.

That's just my opinion. Hope it helps.

 

[ItsGavinC]

Originally posted by Stomatologist

I'm at the point in which, I'll specialize but will not limit my practice. In other words, I'm considering not anouncing myself as a specialist, but as a general dentists.

Isn't it part of the ethical code of dentistry that specialists ONLY practice their specialty? Specializing limits your practice just by the inheriant fact that you are a specialist. In dentistry, there isn't any ethical way around this, and to announce yourself as a GP certainly won't win you friends in the dental community.

A GP can do whatever he feels he is capable of, but must refer the things he cannot knowingly do well on, while a specialist is not to perform any procedures that fall under the scope of general dentistry.

I believe that a specialist who is found to be performing general procedures may have his license revoked.

 

[ItsGavinC]

In regards to my last post, the ADA Council on Ethics, Bylaws, and Judicial Affairs lists the following in the ADA Principles of Ethics and Code of Professional Conduct:

The practice carried on by dentists who are specialists shall be limited exclusively to the special area(s) of dental practice obtained by the dentist. The special areas of dental practice and an appropriate certifying board must be approved by the ADA. Specialists must have successfully completed an education program accredited by the Commision on Dental Accreditation, two or more years in length, as specified by the Council on Dental Education and Licensure. (Section 5.H. - Limitation of Practice)

 

[ItsGavinC]

Stomatologist,

The more I think about it, the more I believe that your statement "announce as specialist" has something to do with it.

Does not announcing allow you to practice under the scope of a GP, and also work with the higher education received via the specialty?

I realize you know more about this than I do, and I'd like to learn all the ins and outs. Please correct me if I'm wrong in my previous posts.

Thanks!

 

[Frank Cavitation]

here's my take on it... I'm not an expert on licensing laws tho.

It should be possible to undergo training to become a specialist and then forsake the license and just keep the GP license. Then you will have the skills of a specialist but freedom of a GP. If at some point in time you want to put your specialist designation on your door, you need to satisfy requirements like exams and registration fees etc. I doubt most people would spend the extra time and lost income (studying instead of practicing) to go through specialty training and then not opt to get the license and charge higher fees.

My question is about GPs who limit their practice... I hear it's possible to say "restricted to endo" but not be an endodontist. Now, aren't there laws against refusing to treat patients? What if someone comes in with a badly broken tooth requiring extraction, and he doesn't want to go to another dentist? As a GP I am licensed to extract, so is it my responsibility? What if, as a GP restricting himself to endo, I don't have forceps?

 

[emporio]

isn't it true that a specialist can also work on other areas? a specialist must have gone through dental school... that gives them right to be a gp. and their post-doc program gives them more knowledge in their specialty. my orthodontist does almost everything. it's just that he has more knowlege in orthodontics than gps.

 

[aphistis]

Originally posted by Frank Cavitation
Now, aren't there laws against refusing to treat patients? What if someone comes in with a badly broken tooth requiring extraction, and he doesn't want to go to another dentist? As a GP I am licensed to extract, so is it my responsibility?

Frank, yes, there are laws against refusing service, but their application is limited. These laws refer to refusing individuals on an individual, discriminatory basis. That is, you can't refuse treatment to a patient you're qualified to treat, because they're, say, HIV-positive...but if your practice is focused on endodontics and someone comes in needing massive orthodontic treatment, you can certainly ship them somewhere else. Performing a procedure you're not comfortable with is itself a big violation of professional ethics (not to mention a potential liability landmine). In practice, the refusal-of-service laws essentially look at whether your treatment of the patient in question is consistent with otherwise reasonable operation of your practice. If you go out of your way to avoid treating someone, you're screwed, but if you decide you don't want to do extractions in your practice, no one can make you.

Now, having talked myself in circles with all that 😕 I'm in a dental ethics class as we speak. I'll ask the prof about it tomorrow and see what she has to say, then report back here.

 

[Frank Cavitation]

thanks aphistis...

ethics is a whole can o' worms... What if I get really nervous when my patient tells me they got HepB or HIV? I can imagine how my life would be ruined if my jitters causes me to tear my gloves, or if the patient bites down on me by accident. I hear it's illegal to put double gloves to treat an HIV patient... hey sorry to hear you got ethics class... I am on summer holidays now (working at the clinic though).

emporio: I notice you are a new dental student... I apologize if this insults your intelligence, but can you please elaborate what you mean by your "orthodontist does almost everything"? It's plausible for an ortho specialist to give x-rays and dental exams, and have a hygienist do cleaning. However we're debating if that same guy can put in fillings and do crown/bridge. You are sure that your ortho guy is not GP or pedodontist right?

 

[Supernumerary]

isn't it true that a specialist can also work on other areas? a specialist must have gone through dental school... that gives them right to be a gp. and their post-doc program gives them more knowledge in their specialty. my orthodontist does almost everything. it's just that he has more knowlege in orthodontics than gps.

It's true that the specialist has the training to work in all areas of general practice, but he is limited ethically to practicing within his own specialty. And it's not just a matter of ethics; it's a matter of not pissing off your referral base. 🙂

Think about it this way - you're a GP and send off a good patient for some perio surgery. The periodontist decides he'd like to do a little general practice so he does some crown and bridge that the patient needs as well. If you find out about this are you ever going to refer to this specialist again? No way!!! It would only take the wrath of a few GPS to completely demolish a specialty practice. For a specialist to work outside his specialty would be professional suicide. It's just not gonna happen. 🙂

 

[UBTom]

DOCUMENTATION. Your first and best line of defense if someone decides to litigate. Always document in the patient chart why you are referring the patient elsewhere, and do it in detail. For example "Dilacerated roots appear to need extraction in surgical setting-- Refer to oral surgeon."

 

[angelic02]

Originally posted by Frank Cavitation
thanks aphistis...

ethics is a whole can o' worms... What if I get really nervous when my patient tells me they got HepB or HIV? I can imagine how my life would be ruined if my jitters causes me to tear my gloves, or if the patient bites down on me by accident. I hear it's illegal to put double gloves to treat an HIV patient... hey sorry to hear you got ethics class... I am on summer holidays now (working at the clinic though).

emporio: I notice you are a new dental student... I apologize if this insults your intelligence, but can you please elaborate what you mean by your "orthodontist does almost everything"? It's plausible for an ortho specialist to give x-rays and dental exams, and have a hygienist do cleaning. However we're debating if that same guy can put in fillings and do crown/bridge. You are sure that your ortho guy is not GP or pedodontist right?

Why would it be illegal to put on double gloves in order to treat an HIV patient?

 

[Supernumerary]

And in response to the intial post - I've actually heard just the opposite. I've had several people tell me that specialty practice sounds neat and glamorous when you're in school but to think long and hard about general practice.

-GPs have more flexibility in where they can set up practice.
-They can do as much or as little of any procedure they want. Hate perio? You'll never have to touch it. Love endo? Buy a scope, take all the CE you can handle and you're off and running.
-There is no reason for a GP to ever be bored with his practice. He can go as deep into any of the specialties he wants to. There is enough out there to keep a guy busy learning for his entire career. For those of you that read DentalTown, look at Rod Kurthy; he says he refers almost nothing but ortho ('cause he doesn't like it 🙂 )
-And best of all, if you know you want general practice right from the get go, you've got a long, wide and tall margin for slacking off during school.

Of course you're not going to see GPs doing orthognathic surgery, but there really are very few restraints on how or what the GP chooses to practice. For right now, I've got my sights on general practice, but I'm gonna try and keep my options open by getting good grades and doing research. Not that any of this actually means anything since I don't even start for another month. I'm sure I'll change my mind about a dozen times before the end of the first year. 😉

 

[Stomatologist]

Hi all,

It is just a matter of not severing ties with GPs refering you cases.

You could be an specialist, not limit your practice, not advertising yourself as such, and work as a GP. This will give you the advantage of taking up all GP cases plus those of your specialty. This type of setting, I believe is good for having other practicioners working under your belt.

I've also seen this on foreign dentists whom were specialists in their respective countries. They come here, pass the boards, but having the training take GP cases plus those of thier specialty.

Obviously, this makes no sense in a setting in which you have a large referal base giving a constant flow of patients.

Best wishes,

 

[Supernumerary]

Also, since it was brought up - I've always wondered about the guys that run "limited" practices. There are quite a few guys here in town with signs reading "practice limited to endodontics." As a gp, if you were going to refer, wouldn't you feel you owed it to your patient to send them to someone who was board certified? I've often wondered how these doctors are getting referrals. Maybe there just aren't enough endos to go around here in Georgia. 😕 🙂 Anybody have any insight into these types of practices?

 

[Stomatologist]

Hi again,

It is my believe that those who limit their practice to a particular field are in fact specialists. At least, I know several practitioners following this trend.

Is true, I would only refer my patients to the most qualified individual to carry out the procedure. It is just a way of avoiding a malpractice suit and givin the best possible care to the patient.

Cheers,

 

[emporio]

Frank,
my dentist graduated from baylor dental, and had post-doc training at baylor (ortho.) he has a business in atlanta. i went to see him cuz i had two broken teeth with cavities. i had root canals done on both, extracted one, placed crown and bridge on the other. he specializes in ortho. but every time i went to see him, he seemed to have more patients with non-ortho treatments.

Super,
you're in GA?

 

[ItsGavinC]

The ADA Principles of Ethics and Code of Professional Conduct, found on the ADA website, discusses "limiting your practice" and how to convey that to customers. It also talks about how "specializing in endodontics" does NOT mean you are an endodontist with the equivalent training.

Pretty interesting reading material.

 

[emporio]

Frank,
you're not insulting my intelligence... i saw his baylor diploma placed right next to his baylor ortho. certificate in his office. also, a friend of mine had his braces done there. thus, my dentist/orthodontist seems like he could do almost anything. but what do i know... just starting dental school next month. (just writing what i've experienced/observed)

 

[ItsGavinC]

Originally posted by emporio
isn't it true that a specialist can also work on other areas? a specialist must have gone through dental school... that gives them right to be a gp. and their post-doc program gives them more knowledge in their specialty. my orthodontist does almost everything. it's just that he has more knowlege in orthodontics than gps.

If he has announced himself to the public as an Orthodontist (a graduate of the ADA specialty, NOT just a GP who specializes in orthodontics), then he should NOT be doing GP work. It is unethical. Specialists, as determined by the ADA, are to focus ONLY on their specialized area, not general dentistry.

This system keeps the wheels turning nicely, and everybody enjoys a good referral system.

 

[ItsGavinC]

Originally posted by emporio
Frank,
my dentist graduated from baylor dental, and had post-doc training at baylor (ortho.) he has a business in atlanta. i went to see him cuz i had two broken teeth with cavities. i had root canals done on both, extracted one, placed crown and bridge on the other. he specializes in ortho. but every time i went to see him, he seemed to have more patients with non-ortho treatments.

Same deal with this guy. In reality, if all the information is correct, he should NOT be doing crowns, bridges, fillings, etc.

 

[Supernumerary]

Same deal with this guy. In reality, if all the information is correct, he should NOT be doing crowns, bridges, fillings, etc.

I can think of an exception to this rule, though. I shadowed at a practice where a GP and ortho were partners. The orthodontist helped out from time to time doing general dentistry when the GP needed a hand or was on vacation or something. Kind of a nice setup really.

Hey emporio, yeah, I'm in Augusta. Are you starting at MCG in August?

 

[emporio]

super,
no, i'll be attending columbia. i didn't apply to mcg. i'm trying to get out of georgia hehe.. i grew up in new york, so ny feels more comfortable. are u a dental student at mcg? starting this fall? anyways, good luck.

 

[mcataz]

I don't know enough about dentistry to make a valid comment. But I'll put my two cents in. I was over at my buddy's house yesterday. He is a general dentist and he was asking me for advice on editing his phone book ad for his practice. And we were arguing over the terms "smile enhancement" vs. "smile design." And then I saw all these other general dentistry ads in the yellow pages. All the ads seemed really cheesy like a Realtor's ad or some ambulance chasing lawyer's ad. It made me realize that there are a lot of general dentists in practice. And marketing plays a big part with being a general dentist. It seemed like these general dentists were going to desperate means to try and separate themselves and appear to be unique. I have to be honest and say that aspect of dentistry didn't appeal to me. Of course, my friend is doing really well in his practice and I'm sure all those dentists in those ads are doing quite well. But it was kind of a cheesy aspect. And the guy who sold his practice to my friend sold it to go into a pedo residency.

There just aren't a lot of specialists. And there will always be some fru fru people who will feel good about themselves for sending their kid toa pedodontist versus a general dentist. If I'm having root canal work done, I would probably feel better about seeing an endodontist just to be on the safe side.

Still, it seems like all the glamourous cosmetic dentistry is done by general dentists. And they have flexibility in regards to what they can practice. You have to like that.

 

[augustdds]

First, as a specialist you MAY make more money than a GP. I know I make more than some specialists and less than others. The reason why specialists make more is that their practice is usually limited to expensive procedures and are paid at a higher rate than GPs. I get $850 for a molar root canal while the specialist that does the same endo and gets $1200(and I mean the same, if you are doing endo, perio or oral surg., you MUST do it at the same level as a specialist or you are doing your patients a disservice and if sued are held to the same standard of care)

I'm not doing $1200 root canals 8 hours a day, I have a few less expensive fillings, crowns, and even some holes in the schedule. So a specialist produces more as well as nets more as his overhead would be at least the same as mine, and most likely less.

Second, if you call yourself a specialist and do general dentistry it is against the ADA code of ethics. You will lose your referal base. I would not refer to an endodontist that was doing two or three endos a day. I want someone who eats drinks and sleeps endo. You can be a specialist, not call yourself one and do your own stuff. You just won't have the referal base that fuels a specialists practice.


Of coursed I am a general dentist and am biased. I do not think that the future of dentistry is in the hands of specialists. One constant compliment I get from my patients is that they become "one stop shoppers" in my practice. I refer out ortho that cannot be done with invisalign, unruly kids, some 3rds, and difficult endo. That being said it works out to being very little. The benefit of being a GP besides the variety is that you have thousands of referal sources (patients) versus a handfull of GPs refrring to a specialist. I try not too, but if a patients gets mad and leaves my practice, it sucks but it is not devastating. If a specialist loses a large referer, than it can really effect your bottom line.

If I was to specialize (and now I would not) I would do endo. Not a lot of endodontists, usually see about 8 patients per day, make more than any other specialists, and you get the gratification of relieving a patients pain.

But in summary, I would steer most into becomming GPs, soak up as many procedures that specialists do in dental school, do a GPR or AEGD (residencies in general dentistry) and focus on not just doing specialty proicedures, but do them as well as specialists.


August

 

[ItsGavinC]

Originally posted by augustdds

If I was to specialize (and now I would not) I would do endo. Not a lot of endodontists, usually see about 8 patients per day, make more than any other specialists, and you get the gratification of relieving a patients pain.

Plus, a very low overhead!

 

[Frank Cavitation]

stomatologist: you mean a foreign specialist becoming a GP here and then limiting their practice to their specialty, right? cuz it's doubtful someone would go to all the trouble of becoming a specialist, then calling themselves a GP restricted to one thing.
comment regarding restricted GP... if there was a guy who has taken courses, done endo for 20 years, has all the state-of-the-art equipment and is courteous etc, I might consider referring out to him. I don't think his work is worse than a new grad specialist.

I don't have a good opinion of specialists who step over the line, even if it's a walk-in patient and not a stolen referral... is this their form of revenge against GPs infringing onto their realm?

emporio: thanks for clarifying, sorry if I sounded nasty... I bet your dentist is sacrificing overhead to give some variety to his workday

gavinc: is endo really low overhead? I'd figure a new practice would probably include digital radiography and endodontic microscope, which might cost as much as 200k. so far the endo equipment I've been using at school has been very expensive... computerized motors, system-b heating, and all those files...

 

[aphistis]

"Revenge"? Turf infringement? Nuh-uh.

There is no holier-than-thou writ indicating particular procedures are only to be performed by their respective specialists. Nor is there any ethical problem with it. Any GP who can perform a procedure to standard is welcome to it; most referrals come from dents who either aren't comfortable with doing a procedure or just plain don't like it.

GPs can perform specialty procedures; specialists <b>cannot</b> reach back to general dent.

 

[Frank Cavitation]

aphistis,

I hope specialists are all like that, but at my school we learn dreadfully little ortho, and some other instructors are suggesting that it's a conspiracy by the ortho assoc so that we'd have to refer out everything having to do with ortho. I have no stats with me, so I can't really say if the increased confidence of GPs actually makes a dent in the huge pile of work available to specialists...

 

[odie77]

this week i just started as an assistant
at a dental practice, and the very first
thing that the doctor says to me when
i sit down is, "so, do you want to specialize
after dental school? you know, you WILL
see the complete elimination of cavities
sometime in your lifetime"

uh, it looks like we'll one day have 150,000
GP's with practices specifically limited to ortho... 😱


on another note, while an endo IS one of the highest
paid specialists, he also has the highest
malpractice premiums... thought I don't know
how high compared to an average GP...

 

[ItsGavinC]

Originally posted by Frank Cavitation

gavinc: is endo really low overhead? I'd figure a new practice would probably include digital radiography and endodontic microscope, which might cost as much as 200k. so far the endo equipment I've been using at school has been very expensive... computerized motors, system-b heating, and all those files...

My understanding is that it has the lowest overhead of any specialty -- which means more money directly in the pocket.

 

[critterbug]

"you know, you WILL see the complete elimination of cavities sometime in your lifetime"

Could you please elaborate. This comment intrigues me. Was he refering to the caries vaccine?

If what he says is true, that would indeed decrease the demand for GP. And don't forget that lack of cavities in the general population will also have a direct effect (in terms of decreased demand) on all specialties, except maybe ortho.

 

[UBTom]

Naw... Decreased cavities won't hurt GPs that much. There are still plenty of stuff for GPs to do, like non-surgical periodontal supportive care, restoration of teeth damaged through incidents other than cavities, such as sports injuries, occlusal trauma, etc., basic oral surgery like taking out 3rd molars or premolars for orthodontic reasons, yadda yadda the list goes on.

As far as the population becoming totally caries free, I think there is still a long ways to go. There will ALWAYS be people who don't know any better and do not take good care of their teeth and eat high-sucrose diets (which Mr. Strep Mutans loves) and don't live in areas with fluoridated water. The stuff I see right now while I'm working at Bellevue Hospital's Oral Surgery unit convinces me of this fact-- 90% of the patients who show up for extractions have very poor oral health because they don't take good care of themselves.

I'm willing to bet that 50 years from now (well after my retirement!) there will still be plenty of cavities to fill. 😀

 

[ItsGavinC]

Tom's comments are true. Regarding the mythical caries vacine, it will never impact the dental profession. Insurance companies won't pay for it, and people won't get it.

We all know LOTS of things that are bad for us, and LOTS of ways to put an end to those things, but few of us ever get off our buts and do it. Our patients are no different. There will ALWAYS be caries and always be a need for GPs.

 

[Frank Cavitation]

I think the way a theoretical caries vaccine works (learned from dental biochem class) is by inhibiting the proliferation of acid-producing bacteria. So, regardless of oral health or dietary factors no caries will result... the person's mouth can be a pool of plaque and he can eat all the toffees he wants without getting caries. And it will be administered along with the other vaccines like measles or polio; even the most hygiene-disadvantaged of us will receive it.

Despite this, I don't think such a vaccine will emerge in the forseeable future. Certainly indiscriminate killing of microbes can't be good for us; it will lead to opportunistic infections. Selective neutralization sounds a bit far fetched at the moment.

UBTom: I think you answered yourself in your first paragraph. Think about the percentage of work you do in the "non-caries" category. In addition, if people stop having caries they will show up less often for checkups, and without microbial catalysis perio disease won't progress fast enough to need treatment.

 

[critterbug]

And it will be administered along with the other vaccines like measles or polio; even the most hygiene-disadvantaged of us will receive it.

Even if this vaccine is proven safe and becomes widespread preventive treatment for caries, I HIGHLY doubt that this vaccine will be mandatory for children before starting school. Here in Texas, a law was just passed which gives parents the right to choose whether or not there kids willl be vaccinated. The once-mandatory vaccinations are for communicable diseases that pose a threat to other students,faculty, and community in general which is why the are required.

Additionally, this vaccine seems promising nonetheless. Just think of all the millions of teeth it will save, especially those in third world countries. However, it does seem like a double edge sword for those of us going into the profession. But, who knows. I'm sure there will always be a need for cosmetic dentistry!! Can't vaccinate genetics!!

 

[Frank Cavitation]

critterbug,

that's a good point, seeing how people are angry with mandatory water fluoridation there will always be those who refuse the vaccination.



Anyway, there was a thread asking how dentistry will be in 15 years... Even without the caries vaccine, there are fewer and fewer edentulous people around. With improving dental IQ the elderly are keeping at least some of their teeth to a very old age, and I think eventually there will not be enough complete denture cases for educational purposes! In the future if caries continues to drop it'll be hard to teach how to make preps!

 

[UBTom]

Hi Frank,

I've looked at the literature for this caries vaccine. The most popular form seems to be a liquid (derived from tobacco!) which the dentist will have to apply to a patient's teeth monthly. Monthly!

(the NIH has a report on the vaccine here at http://www.nidr.nih.gov/research/cariesvaccine01283003.asp )

It's not like fluoridated water that someone can just drink from the tap. The person will have to have the presence of mind/will to show up to the dentist's office every month to have this done. This means compliance will be a very big problem.

And Gavin mentioned the biggest hurdle in implementing a vaccination program-- cost. Somebody is going to have to pay for the monthly administration of this stuff.

I think it will be a useful adjunct for those who are really conscious of their oral health, and when combined with a regimen of regular care, checkups and preventive measures like sealants it will be very effective, but on its own? A caries vaccine is definitely no panacea.

 

[Frank Cavitation]

UBTom,

All you are saying is that the caries vaccine in its current form is not a viable alternative to good ol' brushing/flossing/prophy. Drugs evolve, and I don't think you can discount the possibility that the vaccine can be reformulated so that it needs to be administered something like once every year.

Reduction in caries formation is not the goal... the average person with good saliva flow and oral hygiene practice already is in the low risk category. It has to be complete elimination of caries pathogen.

Insurance companies are just math-minded gamblers who place bets when the odds are in their favor. As long as the vaccine is cheaper than, and can effectively replace, dental checkups they will jump on the bandwagon.

 

[UBTom]

Hi Frank,

The vaccine is a misnomer.

It does NOT, repeat, does NOT induce some sort of long-term B-cell-mediated active immune response as most vaccines do. The caries vaccine is a topical solution that is applied to teeth like a fluoride varnish to provide passive immunity that decreases as time passes as it dilutes away.

I don't care how well you formulate that sucker, if it is topical, it ain't going to stay on your enamel surface for a whole year.

And mind you, dental checkups are NOT for caries detection alone. A caries vaccine most assuredly will NOT obviate the need for checkups. Kids need regular checkups to ensure correct eruption sequence and position as well as skeletal development (Orthognathic Surgery anyone?). Adults will need regular checkups for things like periodontal health (Guided Tissue Regeneration, anyone?). In this respect a caries vaccine will save insurance companies VERY LITTLE.

Especially for the first 15 years when the company that patents it can charge ridiculous prices for it!

A caries vaccine is nice, but I said it before and I'll say it again: It ain't no panacea.

 

[Frank Cavitation]

UBTom,

The inadequate vaccine you mention is what we have now. Fluoride varnishes and gels typically last 6-12 months, so that is the logical next step. Suppose they embed the antigen into a sealant for slow release. There are all sorts of imaginable ways to achieve that goal, and it's not as far-fetched as say, implanting tooth germs in an edentulous area to generate a third set of dentition. Yeah, that's science fiction now, but they were investigating it in a paper last year (J.Dent.Res, Oct02).

I'll admit that I am clueless about the price of vaccines; the government in my country has paid for all of mine. In terms of insurance though, if they find the vaccine comes out cheaper than the cost of checkups and fillings, maybe they will stop providing coverage on checkups! How dastardly is that? But insurance companies are not saints.

As for your reasons for dental checkups, I think the possibility of orthognathic surgery is not on the minds of 99% of the population. Also, it does not prevent occlusal/esthetic problems; it's more of a corrective procedure that is performed after the child has finished growing (thus does not necessitate annual checkups). Regular ortho treatment? For most parents it's ok to take the kid to an orthodontist once crooked teeth develop; after all, there's no sense starting treatment until the outcome is predictable.

My argument for perio checkup is that if they can prevent caries-forming bacteria from binding, something that inhibits subgingival attachment is also possible. Since perio disease is systemic (unlike caries) it might actually be easier to make something long-lasting. A quick search on Google showed that preliminary stuff is happening in that field as well.

Assuming I graduate, I'll be a dentist just like you; of course I wouldn't want to become unemployed. I'm not trying to diss our profession, just pointing out the fact that there are hundreds of scientists spending their lives on oral biology research, and something is bound to happen. At the same time, new dental procedures are being developed, and my hope is that if we have to abandon the old techniques and principles, we can occupy our time with new treatments.

 

[UBTom]

Hi Frank,

Cost and Compliance. Those are the two main issues I've been hitting on all this time. Until all those "miracle cures" become as easy to apply as drinking tap water and as cheap as fluoridating said tap water, caries will NEVER be completely eliminated. NEVER.

The reason why I brought up orthognathic surgery? That's what happens when a problem that would have been MUCH cheaper to fix if intercepted earlier WITH REGULAR CHECKUPS was left alone. And yes, you can intercept kids with Skeletal Class II and III growth patterns when they are as young as 6 (when they are easy and cheap to treat!). That's my point why a caries vaccine will NEVER obviate the need for regular checkups. I've said it before and I'll say it again: NEVER.

Ditto for Perio health maintenance. Periodontal disease may have a systemic component, sure. BUT! I don't care how healthy you are, if you have calculus bridges and gross plaque accumulation, you WILL have periodontal disease no matter how healthy the rest of your body is. That's something you need to take care of, again, with REGULAR CHECKUPS.

Sure, when the insurance companies see enrollment drop because they don't cover checkups and people are getting all sorts of expensive-to-fix problems like the ones mentioned above that would have been cheaper to fix if intercepted earlier, these insurance companies will lose money. As a future dentist, I have no problem with that. 😀

My views stand.

 

[Frank Cavitation]

UBTom,

ok, you have raised valid points... but let me take another stab at this. 🙂

orthognathic surgery. I'll use the issue of compliance against your own argument. From my copy of contemporary ortho it seems severe/extreme malocclusion only occurs in ~5% of the population. If checking for this type of growth pattern was the major reason for a kid to visit the dentist, who would bother to go every 6-12 months? It's like a 20 year old guy getting PSA checked. Sure, there's the odd person developing prostate cancer at an early age, but in general people look at the risks and think it'll never happen to them... and this is cancer we're talking about. From watching the tonight show we all know large jaws don't kill.

another point about ortho: even this specialty will see effects of reduced caries incidence. Many children need braces as a result of mesial drift due to early loss of a primary molar. This segment of the population will no longer be subject to dental crowding if the vaccine is effective.

perio: as your article states, the mechanism of the caries vaccine is to inhibit colonization and biofilm formation. Now I have never seen this in action, but wouldn't this create "teflon teeth" onto which plaque and calculus can't grip? Also, my point about "systemic" was concerning the inflammatory response to bacteria at the pocket level. The components of the theoretical vaccine should reside in the bloodstream, leading the immune system to destroy perio bacteria without inciting the inflammation cascade.

Well, since you stand by your views, how about I make some concessions: Not everyone will use the caries vaccine, but those who get it will be, for the most part, freed from dental work.

 

[ehop24]

Originally posted by UBTom

The most popular form seems to be a liquid (derived from tobacco!) which the dentist will have to apply to a patient's teeth monthly.

I don't know. According to this quote, GP's could be in big trouble. Not only will the vaccine be incredibly addictive, dentists may be viewed negatively after the TRUTH campaign targets us for their anti-nicotine commercials.

 

[critterbug]

LOL

 

[UBTom]

Heh... Addictive caries vaccines? Maybe that would be a good thing. 😛 Seriously though, that tobacco-derived vaccine is actually a purified IgA produced by genetically-modified tobacco plants (Cario Rx, being developed by a company called Planet Biotechnology) and probably have little if any nicotine. We can probably expect it to be held up for testing by the FDA for years though before it ever sees the light of day.

Anyway... I have some more discussion here for Frank:

The thing with our saliva is that it forms the pellicle on our teeth which provides a surface of attachment for all the bacteria. Unless we can figure a way to prevent the pellicle from forming, there isn't any way to "teflon-ize" our teeth so that nothing can stick to them. The vaccine might prevent Strep Mutans from sticking to teeth, but I don't think it would have much effect on the other bugs that causes periodontal disease like Porphorymonas Gingivalis, Bacteroides Forsythus or Strep Sanguis etc. That's why I think periodic checkups and regular cleanings are still important.

A systemic vaccine unfortunately will not do much to destroy periodontitis-causing bacteria because there is no bloodflow in our sulcular pockets (normally anyway, heh) and definitely none above the gumline unless you have a mucosal laceration or something!. 😀

We can prevent inflammatory breakdown of our periodontium right now using Doxycycline, which is a tetracycline derivative. It does NOT act through killing bacteria though because there is no way for our bloodstream to deliver it into our periodontal pockets. It works by inhibiting the metalloproteinases active during inflammation that would otherwise destroy collagen and thus periodontal attachment. However, this does NOT remove the etiology (i.e. the cause of the inflammation)!

As far as regular checkups for kids go: I'm not just talking about severe malocclusion. You can have your teeth all nice and straight with good archforms but still have a Skeletal Class II or Class III relationship. These definitely need to be intercepted as early as possible unless you want to grow up looking like Beavis (Skeletal Class III, mandibular prognathic) or Butthead (Skeletal Class II maxillary prognathic or mandibular retrognathic).

This is Definitely NOT comparable to a 20-year-old guy being screened for PSA-- Dental checkups for kids are definitely appropriate no matter which way you cut it.

"Yeah! Angle Class I occlusion RULES!!" Huh huh, huh huh huh.

Gimme some credit here. I might have fallen asleep in class a few times (who hasn't?) but for the most part I've paid attention in lecture in the past three years. 😉