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Premises tiow MlJCH IS TOO MUClI? S death of slugger Mickey Mantle. For many of us, Mickey was a childhood hero. For others, he was a sports icon- like other greats, his name and reputation spoke for thcmselvcs even if we remained unaware of the details of his career. everal months ago, baseball fans and Americans of all persuasions were saddened to hear of the Unfortunately, Mantle’s death was complicated in many minds by the circiimstances surrounding his demise. Mantle underwent an emergency liver transplant that “bought” hini about 8 weeks of addi- tional life. Many critics believed that the transplanted liver was essentially wasted-Mantle was discovered soon after to be suffering from life-threatening canccr. Questions surrounding the treat- ment of Mantle involved everything from possible cclebrity favoritism to the nagging question of “How much is too much?” when it conies to health care. John Banja, Emory 1Jniversity specialist in clinical ethics, noted, “Mayhc the ultimate value of this whole scenario is that we will look back on it and learn from it. It may sharpen our moral sensibility for the next time such a case appears.” A more critical viewpoint was expressed by Arthur (hplan, 1)irector of the Center for Bioethics at the Univcmity of Pennsylvania. He said, “If Mickey Mantle was the quin- tessential American hero, then Mickey Mantle’s health care was quintesscntially what’s wrong with American health carc-trying to chase long odds, at high costs, for duhious benefits. ’Ihking someone at 63 with three fatal diseases and trying to perform a liver transplant on them-if that’s not a recipe for futility, it would be hard to tell what counts as futility.” l‘he cthical and scientific factors involved make this, and other such cases, tricky indeed. In the world of dentistry, how much should we do to salvage a debilitated dentition at any age? What about the aged who suffcr from periodontal disease requiring extensive reconstruction with no guarantee that the outcome will be successful? Are wc better off extracting teeth and recommending implants? Is it strictly a question of expense, or should guidelines be established that determine whcn, where, and what to do? We have seen countless patients who have gone through niinierous reconstructions only to he finally informed that they will lose their dentition. We have worked with many others who, at a young age, were told they would lose their teeth to periodontal disease, but who wcrc successfully assisted in avoiding tooth loss. And most frequent of all, we have witnessed extractions in mouths where, after studying the x-ray films, there was no doubt that the power of restorative and periodontal therapy could have heen harnessed to save those teeth. What are the impact of finances, genetic factors, and eventual prognosis on the decision to pursue treatment? As our scientific and technologic prowess continues to improve, can this technology provide more efficient indicators ahout which treatments will be successful? Who defines futility? When is it time to do more? When must we accept defeat? Caplan comments, “It is un-American not to chase long odds. That’s one of the most difficult things we face as we look toward an aging population, more technology, and increasing medical costs: our societal inability to not pursue even the longest of odds.” We would welcome your thoughts on this complex, but relevant issue. Ronald E. Goldstein, DDS David A. Garher, DMD Editors- in- Chief Journal of Esthetic Dentistry VOI IIMk M. NllMRIH 2 49

HOW MUCH IS TOO MUCH?

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Premises

t i o w M l J C H IS T O O M U C l I ?

S death of slugger Mickey Mantle. For many of us, Mickey was a childhood hero. For others, he was a sports icon- like other greats, his name and reputation spoke for thcmselvcs even if we remained unaware of the details of his career.

everal months ago, baseball fans and Americans of all persuasions were saddened to hear of the

Unfortunately, Mantle’s death was complicated i n many minds by the circiimstances surrounding his demise. Mantle underwent an emergency liver transplant that “bought” hini about 8 weeks o f addi- tional life. Many critics believed that the transplanted liver was essentially wasted-Mantle was discovered soon after to be suffering from life-threatening canccr. Questions surrounding the treat- ment of Mantle involved everything from possible cclebrity favoritism to the nagging question of “How much is too much?” when it conies to health care.

John Banja, Emory 1Jniversity specialist in clinical ethics, noted, “Mayhc the ultimate value o f this whole scenario is that we will look back on it and learn from it. It may sharpen o u r moral sensibility for the next time such a case appears.” A more critical viewpoint was expressed by Arthur (hplan, 1)irector of the Center for Bioethics a t the Univcmity of Pennsylvania. He said, “If Mickey Mantle was the quin- tessential American hero, then Mickey Mantle’s health care was quintesscntially what’s wrong with American health carc-trying to chase long odds, at high costs, for duhious benefits. ’Ihking someone at 63 with three fatal diseases and trying t o perform a liver transplant on them-if that’s n o t a recipe for futility, it would be hard to tell what counts a s futility.” l ‘he cthical and scientific factors involved make this, and other such cases, tricky indeed.

I n the world of dentistry, how much should we do t o salvage a debilitated dentition a t any age? What about the aged who suffcr from periodontal disease requiring extensive reconstruction with no guarantee that the outcome will be successful? Are wc better o f f extracting teeth and recommending implants? Is it strictly a question of expense, or should guidelines be established that determine whcn, where, and what to do?

We have seen countless patients who have gone through niinierous reconstructions only t o he finally informed that they will lose their dentition. We have worked with many others who, a t a young age, were told they would lose their teeth to periodontal disease, but who wcrc successfully assisted in avoiding tooth loss. And most frequent of all, we have witnessed extractions in mouths where, after studying the x-ray films, there was no doubt that the power of restorative and periodontal therapy could have heen harnessed to save those teeth.

What are the impact of finances, genetic factors, and eventual prognosis o n the decision to pursue treatment? As our scientific and technologic prowess continues to improve, can this technology provide more efficient indicators ahout which treatments will be successful? Who defines futi l i ty? When is it time to do more? When must we accept defeat? Caplan comments, “It is un-American not to chase long odds. That’s one of the most difficult things we face as we look toward an aging population, more technology, and increasing medical costs: our societal inability to not pursue even the longest of odds.” We would welcome your thoughts on this complex, but relevant issue.

Ronald E . Goldstein, DDS David A . Garher, DMD Editors- in- Chief

Journal of Esthetic Dentistry

V O I I I M k M . N l l M R I H 2 4 9