Dentists and Doctors

dentists in the world. You already have a decent number of female col­ leagues, and there are going to be many more. How about doing us the courtesy of addressing us correctly? D IA N E L. M A R K O W IT Z T U F T S U N IV E R S IT Y

On high blood pressure m The article, “ High blood pressure detection by dentists,” by C. L. Ber­ man, M. A. Guarino, and S. M. Giovannoli (Aug j a d a ) , points up a very real service which the dental profes­ sion may bring to its patients. We have been teaching this for a number of years in the academic en­ vironment, and it is most gratifying to see this article from a practicing clin­ ician. There is another cogent albeit selfserving reason the dentist should de­ termine a patient’s blood pressure and that is for his own medico-legal pro­ tection.1 It provides him a base line of information about that patient and a warning when it is notably elevated or depressed to make a careful de­ cision as to what treatment and drug therapy he should or should not pro­ vide. Berman suggests investigation of the differences between the findings of his study and mine using a dental school population of patients. Both of us are probably correct. The differ­ ence lies in the criteria we used. Us­ ing the 150/90 or higher values of hy­ pertension which his group used, I found 7.7% as compared with his 4%5%. Age and race differences, and my small sample size (244), might credibly account for the remaining 3% differ­ ence. I used either systolic pressures of 140 mm Hg or diastolic pressures of 90 mm Hg or higher as indications of hypertension to arrive at the 31.1% incidence of hypertension in the school patient group. This points out the problem of de­ ciding at what point a casual blood pressure indicates hypertension. Emotional changes, stress, a recent meal, sexual excitement, a full blad­ der, and other influences can raise blood pressure, and there are fluctua­ tions from day to day, hour to hour,

and even minute to minute observable when using automated sphygmomanometry. These fluctuations should not be used as an excuse for the dentist not to routinely check the patient’s blood pressure at initial examination and periodic reexaminations. Deci­ sion as to when he should refer the pa­ tient for further medical evaluation is a matter of judgment based on knowl­ edge of current research, his own ex­ perience, and contacts with medical colleagues. Present opinion is that normal blood pressure for all ages is from 90-120 systolic and 60-80 diastolic.2'4 Delp and Manning3 make special note that the age-plus-100 criterion for systolic pressure is superstition. Although a few categorize 150/90 as the upper limit of normal, more evidence seems to indicate 140 systolic and 90 diastolic as the beginning of hypertension. Burch5 indicates 135/90 as hyper­ tensive in young adults; several authors2,3,6 say above 140/90 is definite­ ly abnormal, and studies by Finnerty,7 Choquette and Ferguson,8 and Fin­ nerty and others9use 140 and 90 as the beginning of hypertension of signifi­ cance. Page and Sidd10 refer to the “ Build and Blood Pressure Study of the Society of Actuaries” in 1959, and point out that higher mortality is pre­ dicted not only by slight increases in systolic and diastolic pressure above normal but even exists within the “ ac­ cepted normal range’’ with lower mor­ tality occurring with lowest pressures. They go on to state that systolic pres­ sure is a stronger determinant of cor­ onary heart disease except in younger men. Peart11 feels mean pressure rise is the most important. With the Fram­ ingham and other studies which have been and are being pursued, it seems not unreasonable to conjecture that the upper limits of acceptable normal blood pressure may be reduced to the 135/85 figures—perhaps, even lower. If we as dentists have a responsi­ bility to determine the presence of hy­ pertension in our patients, and I strongly believe we do, we need to be acquainted with at least some of the studies cited above and know in some detail also those factors, such as cuff size related to arm size, auscultatory gap, and so forth, which can result in erroneous findings.

To those who are interested in fur­ ther information on determining blood pressure, may I suggest three concise free pamphlets, Recom mendations

fo r H um an B lood Pressure D eter­ m ination by Sphygmomanometers,

published by the American Heart As­ sociation, and Sphygmomanometers, Principles and Precepts and The C lin ­

ical M easurem ent o f B lood Pressure,

both published by W. A. Baum Com­ pany, Inc., Copiague, NY 11726. 1. DDS, given legal guide on how to avoid malpractice threats. Dent Times, Nov 15,1967. 2. Collins, L.H., and Crane, M.P. Internal medicine in dental practice, ed 6. Philadel­ phia, Lea & Febiger, 1965, p 36. 3. Delp, M.H., and Manning, R.T. Major’s physical diagnosis, ed 7. Philadelphia, W. B. Saunders Co., 1968, p 134. 4. Adams, F.D. Physical diagnosis, ed. 14. Baltimore, Williams and Wilkins, 1958, p 234. 5. Burch, G.E. A primer of cardiology, ed. 4. Philadelphia, Lea & Febiger, 1971, p 196. 6. Conn, H.L., and Horwitz, O. Cardiac and vascular diseases. Philadelphia, Lea & Fe­ biger, 1971, vol. 2, p 883. 7. Finnerty, F.A., Jr. Hypertension is dif­ ferent in blacks. JAMA 216:1634, June 7,1971. 3. Choquette, G., and Ferguson, R.J. Blood pressure reduction in “ borderline" hyper­ tensives following physical training. CMAJ 108:699, March 17, 1973. ' 9. Finnerty, F.A. Jr.; Shaw, L.W.; and Himmelsback, C.K. Hypertension in the inner city. II. Detection and followup. Circulation 58:76, Jan 1973. 10. Page, L.B., and Sidd, J.J. Medical man­ agement of primary hypertension. N Engl J Med 187:960, 1972. 11. Peart, W.S. Arterial hypertension. In Beeson and McDermott, Cecil Loeb textbook of medicine, ed. 13. Philadelphia, W. B. Saun­ ders Co., 1971, p 1050. HUBERT W . M ERCHANT, DDS M E D IC A L C O L L E G E O F G E O R IG A

D entists and doctors m Some dentists are annoyed by the vernacular expression, “ doctors and dentists.” A dentist is a member of a learned profession, holds an earned doctorate degree from a university, and is certainly entitled to the doctor’s title. He is just as much a doctor as a physician, but then so are those with doctorates in other professions. The literal meaning of doctor is “ learned teacher,” and the first indi­ viduals granted this rank were theolo­ gians or “ doctors of the church.” The first physicians were accorded no title;

LETTERS TO THE EDITOR / JADA, Vol. 87, O cto ber 1973 ■ 783

in some countries they were later called professor, and finally, doctor. Today the title refers to anyone with a doctoral degree, but customarily the noun is used to designate a medical doctor. The noun has even become an acceptable verb meaning to treat or administer to the sick. The fact that most patients refer to having either a doctor’s or a dentist’s appointment does not imply anything derogatory toward the latter. It is simply semantic custom. While a den­ tist has every right to be offended if a patient should refer to a physician as doctor and to a dentist as mister, he reveals an inferiority complex by tak­ ing offense at being called a dentist, for that is exactly what he is. The goal of any true professional man is to enhance the prestige of his own particular profession, not to dis­ guise it or borrow from the prestige of another. JO H N H . M O S T E L L E R , DDS M O B IL E , ALA

Electric pulp testers a The “ Reports of Councils and Bu­ reaus” of the American Dental As­ sociation rightly enjoy an enormous prestige among dentists all over the world. They usually are regarded as authoritative, and it is, therefore, all the more regretful when one finds a re­ port which does not measure up to the usual standard. One such report was the one on electric pulp testers in your April is­ sue under the authorship of H. Dean Millard. Although he refers to the article by Obwegeser and Steinhäuser,1 it is quite apparent that he has neither un­ derstood their article nor tested the “ Odontotest” described by them. There is no conflict between the studies of Reynolds2 on the one hand and Obwegeser and Steinhäuser on the other hand. Reynolds used the Naylor thermoelectric pulp tester to apply stimuli of heat and cold to the teeth concerned. The lowest tempera­ ture utilized by him was 20 C, while Obwegeser’s study utilizes a tempera­ ture of -7 8 C. Reynolds did not even report on the

use of ice made in a refrigerator. This is regarded by all endodontic author­ ities3-6 as an effective means of pulp testing. It seems a pity that Dr. Mil­ lard’s report made no reference to this method. There is no doubt that the electric pulp tester is an important diagnostic aid for evaluation of pulp vitality. However, it has certain disadvan­ tages, and G rossm an7 lists the follow­ ing: “ It may give a false response'for vitality . . . in a tooth with a putres­ cent pulp, due to moisture . . . and teeth with full crowns—either gold or porcelain—cannot be tested unless a test cavity is prepared through the crown so as to provide contact with tooth structure.” Such a test cavity must be fairly wide to ensure that the pulp tester electrode does not touch the metal of the crown. When using the electric pulp tester, the tooth has to be isolat­ ed with cotton rolls to exclude mois­ ture, and compressed air is used to dry the area. The electrode has to be ap­ plied carefully to the tooth substance while the intensity of the current has to be increased gradually. Applica­ tion to metallic fillings is not permis­ sible as these would conduct current more readily than enamel. All in all, electric vitality tests are time-con­ suming and are, therefore unfortun­ ately, often omitted. Most of the disadvantages listed above can be overcome by using the instrument described by Obwegeser and Steinhauser. It consists basically of a cylinder of liquid carbon dioxide, which is used in such a way that only liquid rather than gaseous C O 2 can escape from it. As the liquid C O 2 passes through the fine orifice, the pressure reduces to that of atmospheric and some of the C O 2 evaporates while the remainder is converted into dry ice. This has a temperature of —78 C. The dry ice is caught in a thin tube 5 mm in internal diameter, and it then has to be com­ pressed by means of a plunger. The tube and the plunger are picked up to­ gether and the dry ice is applied to the tooth. The entire preparation of the dry ice is carried out by the chairside as­ sistant, who simply hands the tube

786 a LETTERS TO THE EDITOR / JADA, Vol. 87, October 1973

containing the dry ice together with the plunger to the operator. He ap­ plies it to the tooth of the patient. It may be applied anywhere on the tooth, particularly, of course, on metal as this conducts the cold very well. This also applies to full metal crowns which can now be tested with ease. Bonded crowns also may be tested if the dry ice is applied to the metal. It also is used for fractured teeth which are covered with temporary metal crowns. In all these cases, the need for a test cavity is obviated. Because of its intense cold, dry ice is much more effective than a stick of normal ice made in a refrigerator. Among other advantages of the meth­ od are that there are no false positive readings in cases of moist gangrene, and that in cases of hyperemia or early pulpitis, there is a sustained or linger­ ing pain response which is quite dif­ ferent from that which is exhibited by a normal pulp. The greatest advantage of the meth­ od, however, lies in its extreme speed. The tooth requires no isolation what­ soever, and pulp tests on the entire mouth can be carried out in less than two minutes. Unfortunately, how­ ever, this method is not without dis­ advantages. Cylinders need refilling, but, if they are handled carefully and if they are turned off immediately after use, this need only be done once every four to six weeks—depending on use. In addition, the method is not ef­ fective with partially calcified pulps or in elderly patients where there is a great deal of secondary dentin. In such cases, the electric pulp tester often still will indicate vitality, albeit at a higher reading. In practice, therefore, when a negative response is found to the “ Odontotest” in a tooth without obvious pathosis or metal restorations and in an elderly patient, it is wise to resort to the electric pulp tester. The method of using dry ice for pulp testing has found wide acceptance both in Europe and in Australia. Many European dental schools teach the method. In fact, Fischer8 regards it as the only satisfactory method of pulp testing, while Andreasen9 advocates the use of dry ice for fractured teeth. Further references to the use of dry ice will be found in Adreasen’s work. The Obwegeser apparatus has been