I appreciate Dr. Krebs’ interest in the subject, and respect and agree with most of the views expressed in his letter. It appears, however, that Dr. Krebs has misunderstood the intent of my editorial.
I am sorry that I did not make the purpose of the editorial clear, and that I insulted him. Perhaps by being deeply engrossed in periodontics, he may have missed the overt over-treatment promoted in the "literature," on the lecture circuit and in financially oriented, commercially offered programs.1
When stating the objectives of the minimally invasive dentistry orientation, I stated on page 1563 that "the group is interested in promoting optimum, minimally invasive treatment for all patients in all areas and specialties of dentistry." This includes conventional and conservative periodontal therapy, either of which may be minimally invasive for the specific disease condition.
I have long supported, accomplished and taught optimal periodontal therapy; consulted with and referred to periodontists; and observed the variability in long-term results obtained by conventional periodontal therapy. When conventional periodontal therapy is indicated and the patient will accept it, the therapy should be accomplished. The challenges with this suggestion are the millions of patients in the United States who will not accept or cannot afford conventional periodontal therapy.
Additionally, on a broader scale, there are many patients who are receiving complex overall dental therapy without proper informed consent about the treatment alternatives for their specific needs, the advantages and disadvantages of each, the costs of each, and the potential results of doing no treatment at all.
Any observant practitioner knows that the untreated periodontal disease in America is overwhelming and that, with the exception of the small amount of periodontal treatment provided by the few highly skilled, competent periodontists and some general dentists, the disease goes largely untreated.
Fortunately, dental hygienists are providing some therapy for periodontal conditions to help satisfy the enormous need not being treated by periodontists or general dentists. Periodontal disease prevention and therapy is taught very well in U.S. dental schools; however, it is my candid observation from polling thousands of dentists in continuing education programs that the amount of periodontal therapy, including conservative and surgical concepts, provided by general practitioners in the United States is negligible.
In spite of the skill of the periodontal community of specialists in providing periodontal care, the obvious emphasis on implant placement by practicing periodontists has, in my opinion and observation, distracted from conventional periodontal therapy. The psychological and physiological reasons for this change are obvious.
After placing many implants, I can state that the surgical placement of implants in healthy patients with adequate bone is relatively simple, predictable and pleasing to the patient, while the outcome of conventional surgical periodontal therapy is far less predictable and satisfying to some patients.
My editorial was aimed at discouraging "overtreatment," not at depreciating the value of conventional treatment when indicated. One of our responsibilities to the public is to prevent or treat disease with minimal or no negative effects. The rampant overtreatment readily observed in many areas of dentistry from almost any dental "journal" or magazine is pathetic, in my opinion. I encourage practitioners to treat patients as we would like to be treated ourselves, without a dominant orientation toward money. I am sure that Dr. Krebs and the Academy would agree with that opinion.
In summary, I feel that the profession at large overtreats dental caries and knows about, but seldom treats, periodontal disease. With regard to periodontal therapy specifically, it is my opinion that methods need to be developed to motivate more conventional and conservative periodontal therapy by general dentists2 for the vast majority of the U.S. population that is now untreated.
There are too few periodontists to handle the current need for periodontal therapy. Clearly, but "anecdotal[ly]" to use Dr. Krebs’ word, implementation of periodontal therapy is now a significant void in our responsibility to the public. The need for periodontal therapy for the public is not diminishing.
I am willing to help the Academy in their efforts to promote and encourage an increased interest in periodontal therapy throughout the profession. I see the problem; however, the global need for periodontal therapy is out of my realm of primary concern as a practicing prosthodontist, researcher and educator.
Dr. Krebs may be interested to know that I have had numerous positive letters, e-mails and calls about the editorial he criticized. Apparently, many dentists are in favor of minimally invasive dentistry, with its varied interpretations.
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