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Finding a fracture
LETTERS
TO
THE
E D ITO R
soon enough, supporting tissue can be grafted from the palate. Fur thermore, to take a greater chance of mouth cancer as a substitute for lung cancer doesn’t seem reason able. “I don’t think we need even dis cuss chewing on the basis of it being ugly, disgusting, or unsani tary, especially for our school-age children. It is simply an unhealthy practice... .If I am irate any anyone it is the total medical community, which has not taken a strong pub lic stance in opposition to the frankly very appealing advertising campaign aimed at our children. (The Carlton Fisk and Walt Garri son television commercials are examples.)” CHARLES G. REITINGER, DDS GUNNISON, COLO
Finding a fracture □ The article “Fracture of the an terior nasal spine” (The Journal, Sep tember) has some misleading infor mation. The frequency of fracture of the anterior nasal spine may be low and there may be no reported cases in the literature. However, the conclu sion that such fractures may be missed because clinicians do not in clude lateral radiographs of the face in differential diagnosis is com pletely unjustified. Because the nasal bone is the most frequently fractured of the facial bones,1,2 and other midfacial frac tures are often detectable in the lat eral radiographs of the face, this and the occipito-mental (Water’s) view have been routine for differential diagnosis of midfacial fractures.1,3,4 The posteroanterior and lateral oblique views of the mandible are in dicated for suspected fracture of the mandible, and the submento-vertex and Towne’s views are supplemental for fracture of the condyles and zygomatic arches. There is no justifi able reason for these extra views for diagnosis of fracture of the anterior nasal spine if there are adequate his tory and symptoms and if a good clin ical examination is done. The authors may be correct in as suming that such fractures are fre quently missed, but a quick review of the literature would indicate that the reason is . . . our not putting enough emphasis on the importance of his954 ■ JADA, Vol. 99, December 1979
cal examination were the primary keys to diagnosis. JAY L. SONNENSHEIN, DDS DOUGLAS S. MOST, DDS MORTON MALKIN, DDS BROOKLYN
National Health Service
tory, symptoms, and clinical exami nation. . . . WENDELL S. MORRISON, DDS, MPH CHAPEL HILL, NC 1. Schultz, R.C. Facial injuries. Chicago, Year Book Medical Publishers, 1977. 2. Waite, D.E. Textbook of practical oral surgery. Philadelphia, Lea & Febiger, 1978. 3. Kruger, G.O., ed. Textbook of oral surgery. St. Louis, Mosby, 1979. 4. Converse, J.M. Kazanjian & Converse’s surgical treatment of facial injuries. Baltimore, Williams and Wilkins, 1974.
Authors’ com m ent: Our article was prepared for the purpose of bringing an unusual fracture to the attention of our colleagues. It was a straight forward case. The history was not obscure, and the clinical picture of a laceration at the mucobuccal fold was easily noted. The diagnosis could not be made on the basis of the history and the clinical examination alone. The fracture could be con firmed only with a straight lateral ra diograph (Illustration). It is quite true that the nasal bone is the most frequently fractured of the facial bones. However, the anterior nasal spine is not part of the nasal bone complex and is, in fact, a pro cess of the maxilla, some centimeters distant. Moreover, the routine nasal bone radiographs often exclude the anterior nasal spine because of the cone. Dr. Morrison is correct in stressing the importance of history taking and clinical examination in diagnosis; this is emphasized in the teaching program at our institution. However, there must be cases to cite in which, unlike our case, the history and clini
□ Dr. Waldman’s informative article on dentistry in the the British Na tional Health Service (The Journal, September) made interesting read ing. However, as a general dentist within the system for some 22 years, I feel I must reply and put the practi tioner’s point of view across. It is ob vious to me that Dr. Waldman was primarily in contact with the British academic establishment of the dental schools rather than the grass roots of the health service. They are poles apart for all practical purposes. In 22 years of practice, I had more than a surfeit of socialized dentistry. At its inception, what appeared to be a new and challenging era for the young id e a listic graduate soon turned into a monstrous nightmare fashioned by successive govern ments. The profession was wooed into a scheme with promises that soon were forgotten. The paymaster was the state, and one danced to whatever tune was being played at the time. We suffered cut after cut in our schedule of fees. Very soon, qual ity dentistry was sacrificed for the conveyor belt product. We became masters at improvization. Amalgam crowns were the order of the day. Fixed prosthodontics was something of the distant past. Extractions and flipper type dentures constituted a large part of one’s daily routine. We were expected to produce a satisfac tory complete upper and lower den ture for the derisory sum of $28 which, by the way, included the technician’s fee. The rest of our fee schedule would boggle any Ameri can dentist’s mind. Indeed, I would be embarrassed to present one here. We carried on year after year with hope and optimism, although our complaints were utterly disregarded. Eventually the sustained discontent lowered morale to the point of silent revolt. The public had been brain washed into thinking that compre hensive dental care was available. They soon realized that anything more than utility had to be paid for
TO
THE
E D ITO R
soon enough, supporting tissue can be grafted from the palate. Fur thermore, to take a greater chance of mouth cancer as a substitute for lung cancer doesn’t seem reason able. “I don’t think we need even dis cuss chewing on the basis of it being ugly, disgusting, or unsani tary, especially for our school-age children. It is simply an unhealthy practice... .If I am irate any anyone it is the total medical community, which has not taken a strong pub lic stance in opposition to the frankly very appealing advertising campaign aimed at our children. (The Carlton Fisk and Walt Garri son television commercials are examples.)” CHARLES G. REITINGER, DDS GUNNISON, COLO
Finding a fracture □ The article “Fracture of the an terior nasal spine” (The Journal, Sep tember) has some misleading infor mation. The frequency of fracture of the anterior nasal spine may be low and there may be no reported cases in the literature. However, the conclu sion that such fractures may be missed because clinicians do not in clude lateral radiographs of the face in differential diagnosis is com pletely unjustified. Because the nasal bone is the most frequently fractured of the facial bones,1,2 and other midfacial frac tures are often detectable in the lat eral radiographs of the face, this and the occipito-mental (Water’s) view have been routine for differential diagnosis of midfacial fractures.1,3,4 The posteroanterior and lateral oblique views of the mandible are in dicated for suspected fracture of the mandible, and the submento-vertex and Towne’s views are supplemental for fracture of the condyles and zygomatic arches. There is no justifi able reason for these extra views for diagnosis of fracture of the anterior nasal spine if there are adequate his tory and symptoms and if a good clin ical examination is done. The authors may be correct in as suming that such fractures are fre quently missed, but a quick review of the literature would indicate that the reason is . . . our not putting enough emphasis on the importance of his954 ■ JADA, Vol. 99, December 1979
cal examination were the primary keys to diagnosis. JAY L. SONNENSHEIN, DDS DOUGLAS S. MOST, DDS MORTON MALKIN, DDS BROOKLYN
National Health Service
tory, symptoms, and clinical exami nation. . . . WENDELL S. MORRISON, DDS, MPH CHAPEL HILL, NC 1. Schultz, R.C. Facial injuries. Chicago, Year Book Medical Publishers, 1977. 2. Waite, D.E. Textbook of practical oral surgery. Philadelphia, Lea & Febiger, 1978. 3. Kruger, G.O., ed. Textbook of oral surgery. St. Louis, Mosby, 1979. 4. Converse, J.M. Kazanjian & Converse’s surgical treatment of facial injuries. Baltimore, Williams and Wilkins, 1974.
Authors’ com m ent: Our article was prepared for the purpose of bringing an unusual fracture to the attention of our colleagues. It was a straight forward case. The history was not obscure, and the clinical picture of a laceration at the mucobuccal fold was easily noted. The diagnosis could not be made on the basis of the history and the clinical examination alone. The fracture could be con firmed only with a straight lateral ra diograph (Illustration). It is quite true that the nasal bone is the most frequently fractured of the facial bones. However, the anterior nasal spine is not part of the nasal bone complex and is, in fact, a pro cess of the maxilla, some centimeters distant. Moreover, the routine nasal bone radiographs often exclude the anterior nasal spine because of the cone. Dr. Morrison is correct in stressing the importance of history taking and clinical examination in diagnosis; this is emphasized in the teaching program at our institution. However, there must be cases to cite in which, unlike our case, the history and clini
□ Dr. Waldman’s informative article on dentistry in the the British Na tional Health Service (The Journal, September) made interesting read ing. However, as a general dentist within the system for some 22 years, I feel I must reply and put the practi tioner’s point of view across. It is ob vious to me that Dr. Waldman was primarily in contact with the British academic establishment of the dental schools rather than the grass roots of the health service. They are poles apart for all practical purposes. In 22 years of practice, I had more than a surfeit of socialized dentistry. At its inception, what appeared to be a new and challenging era for the young id e a listic graduate soon turned into a monstrous nightmare fashioned by successive govern ments. The profession was wooed into a scheme with promises that soon were forgotten. The paymaster was the state, and one danced to whatever tune was being played at the time. We suffered cut after cut in our schedule of fees. Very soon, qual ity dentistry was sacrificed for the conveyor belt product. We became masters at improvization. Amalgam crowns were the order of the day. Fixed prosthodontics was something of the distant past. Extractions and flipper type dentures constituted a large part of one’s daily routine. We were expected to produce a satisfac tory complete upper and lower den ture for the derisory sum of $28 which, by the way, included the technician’s fee. The rest of our fee schedule would boggle any Ameri can dentist’s mind. Indeed, I would be embarrassed to present one here. We carried on year after year with hope and optimism, although our complaints were utterly disregarded. Eventually the sustained discontent lowered morale to the point of silent revolt. The public had been brain washed into thinking that compre hensive dental care was available. They soon realized that anything more than utility had to be paid for