PERSPECTIVE J Oral Maxillofac Surg 72:658-659, 2014
Asymptomatic Third Molars Under Nominalist and Essentialist Lenses V. Wallace McCarlie, MA, DMD, PhD,* and Daniel L. Orr II, DDS, PhD, JD, MDy addressed and considered, optimally combining nominalist and essentialist philosophies for the patient’s long-term benefit. In general, however, practitioners unconsciously holding one view (or emphasizing one view) as opposed to the other will most assuredly treat patients differently, for better or worse, depending on whichever view they lean toward. Baelum et al2 stated that the classic medical model of differential diagnosis does not apply to dentistry because practitioners look for signs and symptoms, not fundamental causes, of disease. They argued that dentists detect rather than diagnose. Although some may understand their point, there is no evidence that physicians are any more immune than dentists from looking for symptoms rather than causes (Zachar and Kendler3 establish this point). In addition, although the medical model generally favors essentialism, even if it does so tacitly rather than explicitly,3 this does not necessarily mean that physicians use the model in practice. Again, essentialists, whether knowingly or unwittingly, believe in stressing the underlying nature of illness. Conversely, in nominalism, when clinicians or researchers characterize or categorize signs and symptoms, they often do so without meaningful reference to any underlying disease process. Of course, nominalism (or at least that which holds to the moderate view of nominalism) does not entirely ignore an underlying cause of disease even if it focuses on signs and symptoms. Also, essentialism does not fully disregard signs and symptoms as clues to the underlying cause of disease. What dentists and physicians actually do includes detection and diagnosis. The former is focused on signs and symptoms; the latter is focused more on causes. Diagnosis implies essentialism; detection implies nominalism. The major shortcoming of essentialism is that it is less focused on the patient and treatment, but instead on underlying truths. For example, researchers have
Craniofacial diseases can be viewed from an essentialist, a nominalist, or a dual point of view. This article sheds light on these paradigms through which disease is viewed in medicine and dentistry and provides clinical examples. The authors conclude that it is important to see disease from the essentialist and nominalist perspectives to advance the clinical and translational nature of dentistry. Essentialism is the notion that underlying every properly defined disease is an unchanging reality causing illness. Conversely, nominalism is not concerned with underlying causes, but rather with signs and symptoms of illness.1,* Although essentialists focus on the underlying nature of illness, nominalists focus on its manifestation. An example of the difference between an essentialist’s approach to patient care and a nominalist’s approach is as follows. Malignant hypertension should be treated immediately, so the practical nominalist might administer a drug such as nitroprusside. However, the essentialist will try to determine the underlying cause before treating the patient. In a perfect world, the 2 approaches would be applied, that is, treating the life-threatening problem first and then determining its cause to provide long-term control. Hence, once the emergency issue is temporarily controlled, the underlying acute or chronic pathology can be
*Assistant Professor, Department of Pediatric Dentistry and Orthodontics, East Carolina University, School of Dental Medicine, Greenville, NC. yProfessor and Director, Oral and Maxillofacial Surgery and Anesthesiology, University of Nevada, School of Dental Medicine, Las Vegas, NV. Address correspondence and reprint requests to Dr McCarlie: Department of Pediatric Dentistry and Orthodontics, East Carolina University, School of Dental Medicine, 1851 MacGregor Downs Road, Mail Stop 701, Greenville, NC 27834-4354; e-mail: mccarlievw@ecu .edu Received October 23 2013 Accepted December 3 2013
* The seldom discussed dichotomy between essentialism and nominalism in dental medicine parallels, to some extent, the
Ó 2014 American Association of Oral and Maxillofacial Surgeons
divide between realism and nominalism in philosophy, which has
0278-2391/13/01500-0$36.00/0
undergone many iterations. Essentialism is a better term in
http://dx.doi.org/10.1016/j.joms.2013.12.003
science than realism because realism has different connotations.1
658
659
MCCARLIE AND ORR
recently illustrated that some diseases have fundamental underlying biomolecular properties, called shared pathogenesis, that contribute to a host of clinically distinct diseases.4 A major weakness of nominalism is that it does not focus on causes, which, for instance, may be an important key to prevention. Nominalist treatment of symptoms does not necessarily prevent illness, and essentialism does not focus on clinical outcomes. In the extreme, essentialists might watch disease progress past the point of no return, so to speak, such as watching a carious lesion progress to the point when what would have been a routine restorative treatment now requires endodontic therapy or extraction. Limited-view nominalists might hastily perform irreversible procedures to the patient’s detriment, such as placing restorations in noncavitated, demineralized lesions that could have been remineralized.5 An example of the importance of not focusing solely on symptoms (nominalism) is the case of asymptomatic impacted third molars. Life-threatening head and neck pathology, such as space infections, necrotizing fasciitis, osteomyelitis, and cysts or tumors, may arise from initially asymptomatic third molar impactions that have not been objectively evaluated and addressed appropriately in a timely fashion. There is now significant evidence supporting the removal of impacted teeth if case-specific diagnosis shows that the impactions will likely be a future problem, whether locally or systemically (as the 2007 American Association of Oral and Maxillofacial Surgeons White Paper on Third Molar Data affirms).6 The popular term asymptomatic does not indicate that there is no disease, only that there are no symptoms. Thus, essentialism plays a key role in best treating patients. At times, dental researchers coming from a more nominalist point of view have categorically published opinions that asymptomatic oral and maxillofacial conditions, such as impacted third molars, simply do not require removal. This view is not only a gross oversimplification but also would lead to, in many cases, deleterious outcomes for patients. Oral and maxillofacial surgeons would be well served to effectively articulate essentialist and nominalist points of view to patients,
health professional colleagues, and even the popular media when necessary. Understanding craniofacial disease from these 2 views is vital to improving health care in patients. However difficult to understand, researchers can fulfill an important function in searching for the underlying (and ultimately complex) causes of craniofacial disease, such as dental caries, third molar pathology, and every other craniofacial disease. Juxtaposed to the researchers are the clinicians who can fulfill the function of ameliorating patient symptoms by providing expert treatment. However, that treatment will only be refined and improved as researchers better understand how to prevent caries or when clinicians practice third molar removal according to the evidence, which leads back to essentialism. Harmonizing the 2 paradigms in dentistry overcomes respective essentialist and nominalist shortcomings. Clinical researchers and attentive practitioners are well positioned to investigate and understand the 2 approaches in furthering the art and science of dental medicine. By doing so, practitioners can continue to provide the highest level of patient care. As dental specialists, oral and maxillofacial surgeons may, because of their advanced training and knowledge, be well positioned to effectively articulate nominalist and essentialist notions of disease relative to pathology within their purview—not only for the benefit of their patients, but also for the sake of nonspecialist dentists and physicians in sister professions.
References 1. Scadding JG: Essentialism and nominalism in medicine: Logic of diagnosis in disease terminology. Lancet 348:594, 1996 2. Baelum V, Heidmann J, Nyvad B: Dental caries paradigms in diagnosis and diagnostic research. Eur J Oral Sci 114:263, 2006 3. Zachar P, Kendler KS: Psychiatric disorders: A conceptual taxonomy. Am J Psychiatry 164:557, 2007 4. Zhernakova A, van Diemen CC, Wijmenga C: Detecting shared pathogenesis from the shared genetics of immune-related diseases. Nat Rev Genet 10:43, 2009 5. Ismail AJ: Clinical diagnosis of precavitated carious lesions. Community Dent Oral Epidemiol 25:13, 1997 6. American Association of Oral and Maxillofacial Surgeons. Evidence-based third molar surgery. Available at: http://www. aaoms.org/docs/evidence_based_third_molar_surgery.pdf. Accessed December 27, 2013
Asymptomatic Third Molars Under Nominalist and Essentialist Lenses V. Wallace McCarlie, MA, DMD, PhD,* and Daniel L. Orr II, DDS, PhD, JD, MDy addressed and considered, optimally combining nominalist and essentialist philosophies for the patient’s long-term benefit. In general, however, practitioners unconsciously holding one view (or emphasizing one view) as opposed to the other will most assuredly treat patients differently, for better or worse, depending on whichever view they lean toward. Baelum et al2 stated that the classic medical model of differential diagnosis does not apply to dentistry because practitioners look for signs and symptoms, not fundamental causes, of disease. They argued that dentists detect rather than diagnose. Although some may understand their point, there is no evidence that physicians are any more immune than dentists from looking for symptoms rather than causes (Zachar and Kendler3 establish this point). In addition, although the medical model generally favors essentialism, even if it does so tacitly rather than explicitly,3 this does not necessarily mean that physicians use the model in practice. Again, essentialists, whether knowingly or unwittingly, believe in stressing the underlying nature of illness. Conversely, in nominalism, when clinicians or researchers characterize or categorize signs and symptoms, they often do so without meaningful reference to any underlying disease process. Of course, nominalism (or at least that which holds to the moderate view of nominalism) does not entirely ignore an underlying cause of disease even if it focuses on signs and symptoms. Also, essentialism does not fully disregard signs and symptoms as clues to the underlying cause of disease. What dentists and physicians actually do includes detection and diagnosis. The former is focused on signs and symptoms; the latter is focused more on causes. Diagnosis implies essentialism; detection implies nominalism. The major shortcoming of essentialism is that it is less focused on the patient and treatment, but instead on underlying truths. For example, researchers have
Craniofacial diseases can be viewed from an essentialist, a nominalist, or a dual point of view. This article sheds light on these paradigms through which disease is viewed in medicine and dentistry and provides clinical examples. The authors conclude that it is important to see disease from the essentialist and nominalist perspectives to advance the clinical and translational nature of dentistry. Essentialism is the notion that underlying every properly defined disease is an unchanging reality causing illness. Conversely, nominalism is not concerned with underlying causes, but rather with signs and symptoms of illness.1,* Although essentialists focus on the underlying nature of illness, nominalists focus on its manifestation. An example of the difference between an essentialist’s approach to patient care and a nominalist’s approach is as follows. Malignant hypertension should be treated immediately, so the practical nominalist might administer a drug such as nitroprusside. However, the essentialist will try to determine the underlying cause before treating the patient. In a perfect world, the 2 approaches would be applied, that is, treating the life-threatening problem first and then determining its cause to provide long-term control. Hence, once the emergency issue is temporarily controlled, the underlying acute or chronic pathology can be
*Assistant Professor, Department of Pediatric Dentistry and Orthodontics, East Carolina University, School of Dental Medicine, Greenville, NC. yProfessor and Director, Oral and Maxillofacial Surgery and Anesthesiology, University of Nevada, School of Dental Medicine, Las Vegas, NV. Address correspondence and reprint requests to Dr McCarlie: Department of Pediatric Dentistry and Orthodontics, East Carolina University, School of Dental Medicine, 1851 MacGregor Downs Road, Mail Stop 701, Greenville, NC 27834-4354; e-mail: mccarlievw@ecu .edu Received October 23 2013 Accepted December 3 2013
* The seldom discussed dichotomy between essentialism and nominalism in dental medicine parallels, to some extent, the
Ó 2014 American Association of Oral and Maxillofacial Surgeons
divide between realism and nominalism in philosophy, which has
0278-2391/13/01500-0$36.00/0
undergone many iterations. Essentialism is a better term in
http://dx.doi.org/10.1016/j.joms.2013.12.003
science than realism because realism has different connotations.1
658
659
MCCARLIE AND ORR
recently illustrated that some diseases have fundamental underlying biomolecular properties, called shared pathogenesis, that contribute to a host of clinically distinct diseases.4 A major weakness of nominalism is that it does not focus on causes, which, for instance, may be an important key to prevention. Nominalist treatment of symptoms does not necessarily prevent illness, and essentialism does not focus on clinical outcomes. In the extreme, essentialists might watch disease progress past the point of no return, so to speak, such as watching a carious lesion progress to the point when what would have been a routine restorative treatment now requires endodontic therapy or extraction. Limited-view nominalists might hastily perform irreversible procedures to the patient’s detriment, such as placing restorations in noncavitated, demineralized lesions that could have been remineralized.5 An example of the importance of not focusing solely on symptoms (nominalism) is the case of asymptomatic impacted third molars. Life-threatening head and neck pathology, such as space infections, necrotizing fasciitis, osteomyelitis, and cysts or tumors, may arise from initially asymptomatic third molar impactions that have not been objectively evaluated and addressed appropriately in a timely fashion. There is now significant evidence supporting the removal of impacted teeth if case-specific diagnosis shows that the impactions will likely be a future problem, whether locally or systemically (as the 2007 American Association of Oral and Maxillofacial Surgeons White Paper on Third Molar Data affirms).6 The popular term asymptomatic does not indicate that there is no disease, only that there are no symptoms. Thus, essentialism plays a key role in best treating patients. At times, dental researchers coming from a more nominalist point of view have categorically published opinions that asymptomatic oral and maxillofacial conditions, such as impacted third molars, simply do not require removal. This view is not only a gross oversimplification but also would lead to, in many cases, deleterious outcomes for patients. Oral and maxillofacial surgeons would be well served to effectively articulate essentialist and nominalist points of view to patients,
health professional colleagues, and even the popular media when necessary. Understanding craniofacial disease from these 2 views is vital to improving health care in patients. However difficult to understand, researchers can fulfill an important function in searching for the underlying (and ultimately complex) causes of craniofacial disease, such as dental caries, third molar pathology, and every other craniofacial disease. Juxtaposed to the researchers are the clinicians who can fulfill the function of ameliorating patient symptoms by providing expert treatment. However, that treatment will only be refined and improved as researchers better understand how to prevent caries or when clinicians practice third molar removal according to the evidence, which leads back to essentialism. Harmonizing the 2 paradigms in dentistry overcomes respective essentialist and nominalist shortcomings. Clinical researchers and attentive practitioners are well positioned to investigate and understand the 2 approaches in furthering the art and science of dental medicine. By doing so, practitioners can continue to provide the highest level of patient care. As dental specialists, oral and maxillofacial surgeons may, because of their advanced training and knowledge, be well positioned to effectively articulate nominalist and essentialist notions of disease relative to pathology within their purview—not only for the benefit of their patients, but also for the sake of nonspecialist dentists and physicians in sister professions.
References 1. Scadding JG: Essentialism and nominalism in medicine: Logic of diagnosis in disease terminology. Lancet 348:594, 1996 2. Baelum V, Heidmann J, Nyvad B: Dental caries paradigms in diagnosis and diagnostic research. Eur J Oral Sci 114:263, 2006 3. Zachar P, Kendler KS: Psychiatric disorders: A conceptual taxonomy. Am J Psychiatry 164:557, 2007 4. Zhernakova A, van Diemen CC, Wijmenga C: Detecting shared pathogenesis from the shared genetics of immune-related diseases. Nat Rev Genet 10:43, 2009 5. Ismail AJ: Clinical diagnosis of precavitated carious lesions. Community Dent Oral Epidemiol 25:13, 1997 6. American Association of Oral and Maxillofacial Surgeons. Evidence-based third molar surgery. Available at: http://www. aaoms.org/docs/evidence_based_third_molar_surgery.pdf. Accessed December 27, 2013
