- Email: [email protected]
NONMETAL CROWNS
LETTERS and cannot afford. The contribution those dentists make through volunteering and providing pro bono services is outstanding and something for which the profession should be recognized. As Nelson Henderson said, “The true meaning of life is to plant trees under whose shade you do not expect to sit.” Cynthia L. Skigen, D.M.D. Jacksonville, Fla. DUALISTIC APPROACH
In their authors’ response (February JADA), Drs. Ferrari and Leonard1 cited an article we published2 to support the notion that “the dualistic approaches to TMD have little value.” While we agree with the limited value of the dualistic approach, it is not for the reason Drs. Ferrari and Leonard indicated. Had they read the article more carefully, they would have discovered a critique of the standard assumption that stress and psychological factors, or ST and PF, are prominent in the etiology of TMDs. Specifically, our data demonstrated that while pretreatment ST and PF levels are moderately related to initial TMD symptom severity, they are totally unrelated to treatment outcomes. They also demonstrated that TMD symptom improvement is moderately related to improvements in ST and PF. These findings suggest that, in many cases, psychological distress is equally likely to be “caused” by physiological TMD suffering as vice versa. Our data thus do not lend support to the “psycho” component of the “biopsychosocial” model Drs. Ferrari and Leonard propose. 772
Our research and clinical experience suggest that when patients enter our practices for TMD symptoms, the first reaction should be to treat those symptoms. Reducing TMD symptom severity in many patients often alleviates psychological distress. Among some patients, psychological distress is indeed present and needs to be considered. We are uncomfortable, however, with the assumption that patients’ psychological problems have “caused” their TMD and with the undue emphasis on psychological profiling and treatment in the discipline.
merely returning to a dualistic model. The way psychosocial factors operate in a biopsychosocial model is not in the production of symptoms, but in fashioning the pattern of symptom reporting, via symptom expectation, amplification and attribution, and allowing for further symptoms from that behavior. This is a complex relationship that cannot be glossed over easily, and the reader is referred elsewhere for an in-depth discussion.5-9 Robert Ferrari, M.D., F.R.P.C. Edmonton, Alberta, Canada Myer S. Leonard, M.D., D.D.S. Minneapolis
Gerald B. Wexler, B.Sc., D.D.S. Pamela A. Steed, D.D.S., M.S.D. Indianapolis 1. Ferrari R, Leonard MS. Authors’ response. JADA 1999;130:168,170. 2. Wexler GB, Steed PA. Psychological factors and temporomandibular outcomes. Cranio 1998;16(2):72-7.
Authors’ response: In response to Drs. Wexler and Steed, it was not our intent to quote their article to specifically support or refute a model, but rather because they have astutely questioned the value of dualistic models and are to be congratulated for doing so. Otherwise, we appreciate, as they do, that their study is incapable of adequately addressing the psychosocial factors involved in TMD following motor vehicle accidents, or the mechanisms, because only crosscultural studies have the high likelihood of doing so.1-4 Again, one does not support a biopsychosocial model by demonstrating how psychological factors act in generating psychogenic pain, as that is
1. Ferrari R, Schrader H, Obelieniene D. Prevalence of temporomandibular disorders associated with whiplash injury in Lithuania. Oral Surg Oral Med Oral Path Oral Radiol Endodontics (in press). 2. Bonk A, Ferrari R, Giebel GD, Edelmann M, Huser R. A prospective randomized, controlled outcome study of two trials of therapy for whiplash injury. J Musculoskeletal Pain (in press). 3. Partheni M, Constantoyannis C, Ferrari R, Nikiforidis G, Voulgaris S, Papadakis N. Prospective cohort outcome study of whiplash injury in Greece. J Musculoskeletal Pain (in press). 4. Obelieniene D, Schrader H, Bovim G, Miseviciene I, Sand T. Pain after whiplash: a prospective controlled inception cohort study. J Neurol Neurosurg Psychiatry 1999;66:27983. 5. Kwan O, Friel J. The dilemma of whiplash. Cephalalgia 1998;18(8):586-7. 6. Ferrari R. Whiplash-associated headache. Cephalalgia 1998;18(8):585-6. 7. Ferrari R. Whiplash encyclopedia. Gaithersburg, Md.: Aspen (in press). 8. Ferrari R, Kwan O, Russell AS, Schrader H, Pearce JMS. The best approach to the problem of whiplash? One ticket to Lithuania, please. Clin Exp Rheumatol (in press). 9. Ferrari R, Russell AS. Pain in the neck for a rheumatologist. Scand J Rheumatol (in press). NONMETAL CROWNS
The article entitled “PorcelainFused-to-Metal vs. Nonmetal Crowns” by Dr. Gordon J. Christensen (March JADA) was
JADA, Vol. 130, June 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
LETTERS quite informative. I read it with great interest, since I recently had worn an ArtGlass (Heraeus Kulzer) bridge on teeth nos. 2, 3 and 4. I had decided to opt for the ArtGlass in place of my conventional bridge after seeing all the nonmetal crown and bridgework displayed by various labs at the 1998 Greater New York Dental Meeting. I feel the nonmetal crowns had a definite disadvantage that was not mentioned in the article. They do not seem to adapt to the gingival margins as completely as a crown that is fabricated with a metal structure. The thinness and subsequent strength of the metalbased crown is very difficult to replicate with the varying types of nonmetal crowns. An advantage of the nonmetal crown that was not mentioned was the complete comfort it afforded due to its lightness. It is barely detectable to the wearer in the mouth, until sensitivity occurs because of open margins (however slight). Because of this problem, I went back to the metal crowns on the aforementioned teeth. Frances M. Fernandez, C.D.A. Roselle Park, N.J. MORE TO IT THAN ‘FIX MY TOOTH’
I’d like to point out some inconsistencies, respectfully, to the author’s assumptions in “Affordable Implant Prosthetics Using a Screwless Implant System” (December JADA, Norman J. Shepherd, D.M.D.). The author completely ignores the surgeon’s fees while discussing prosthetic fees. One of the cases exhibited was a full upper and lower one, involving
18 implants. Oral surgeons and periodontists charge, in my area of practice, $1,500 an implant. Perhaps in the illustrated case the average charge came to $1,000 an implant. Therefore, before the patient begins the restorative process, $18,000 has been allocated toward the implant case. The patient is concerned about his or her total cost. Not just the prosthetic cost. What is the patient wearing while waiting for healing? How much do those interim appliances cost? The author recommends a stent, made from waxed-up articulated study models, because they mechanically direct the surgeon’s bur, and the implant will be in the precise location that the restorative dentist requires. What is the fee allowance for upper and lower impressions, a bite registration appointment, a laboratory wax-up and subsequent processing of the necessary stents? Should that be part of the $600 crown fee? Another question for the author: Which is more accurate, castings made from an indirect impression of abutments, or the direct wax-up, over custom abutments from an analogue model? The surgeon who placed the implants in the illustrated case was indeed skillful. Many surgeons are less so. How does one compensate for the inadvertent placement of a nonparallel implant? Probably with additional laboratory fees and office visits. Patients sometimes make simple requests, such as, “Fix my tooth.” The answer is often significantly more complex than the simple request. Suggesting that a particular implant system is superior to
other implant systems because it is more cost-effective than the others, without science, is misleading. Stanley Markman, D.D.S., F.A.G.D. Ridgefield, N.J. Author’s response: I would like to thank Dr. Markman for taking time to analyze my article published in December JADA, and I would like to answer some of his thoughts. First of all, Dr. Markman points out that I ignored the surgical fees while discussing prosthetic fees. That is absolutely correct, since the point of the publication was affordable implant prosthetics. The cost of the implants, one could say, would be the same no matter which system was used, although, quite frankly, the noscrew system, such as the Bicon System (Bicon Dental Implants), can be placed at less of a fee than others simply because there are fewer components for the surgeon to purchase. This includes not only actual components that are utilized, such as the implant and the abutment, but also there is no need for the accessory components required to place a screw system, such as various screwdrivers and torque wrenches. The point of the article, however, had nothing to do with the surgery; it is simply the prosthetics that we are addressing. On the second point about the interim appliances and the cost of them, I think it becomes obvious that patients would wear what they had been wearing when they first came for treatment. If they were wearing a partial or full denture, they
JADA, Vol. 130, June 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
773
In their authors’ response (February JADA), Drs. Ferrari and Leonard1 cited an article we published2 to support the notion that “the dualistic approaches to TMD have little value.” While we agree with the limited value of the dualistic approach, it is not for the reason Drs. Ferrari and Leonard indicated. Had they read the article more carefully, they would have discovered a critique of the standard assumption that stress and psychological factors, or ST and PF, are prominent in the etiology of TMDs. Specifically, our data demonstrated that while pretreatment ST and PF levels are moderately related to initial TMD symptom severity, they are totally unrelated to treatment outcomes. They also demonstrated that TMD symptom improvement is moderately related to improvements in ST and PF. These findings suggest that, in many cases, psychological distress is equally likely to be “caused” by physiological TMD suffering as vice versa. Our data thus do not lend support to the “psycho” component of the “biopsychosocial” model Drs. Ferrari and Leonard propose. 772
Our research and clinical experience suggest that when patients enter our practices for TMD symptoms, the first reaction should be to treat those symptoms. Reducing TMD symptom severity in many patients often alleviates psychological distress. Among some patients, psychological distress is indeed present and needs to be considered. We are uncomfortable, however, with the assumption that patients’ psychological problems have “caused” their TMD and with the undue emphasis on psychological profiling and treatment in the discipline.
merely returning to a dualistic model. The way psychosocial factors operate in a biopsychosocial model is not in the production of symptoms, but in fashioning the pattern of symptom reporting, via symptom expectation, amplification and attribution, and allowing for further symptoms from that behavior. This is a complex relationship that cannot be glossed over easily, and the reader is referred elsewhere for an in-depth discussion.5-9 Robert Ferrari, M.D., F.R.P.C. Edmonton, Alberta, Canada Myer S. Leonard, M.D., D.D.S. Minneapolis
Gerald B. Wexler, B.Sc., D.D.S. Pamela A. Steed, D.D.S., M.S.D. Indianapolis 1. Ferrari R, Leonard MS. Authors’ response. JADA 1999;130:168,170. 2. Wexler GB, Steed PA. Psychological factors and temporomandibular outcomes. Cranio 1998;16(2):72-7.
Authors’ response: In response to Drs. Wexler and Steed, it was not our intent to quote their article to specifically support or refute a model, but rather because they have astutely questioned the value of dualistic models and are to be congratulated for doing so. Otherwise, we appreciate, as they do, that their study is incapable of adequately addressing the psychosocial factors involved in TMD following motor vehicle accidents, or the mechanisms, because only crosscultural studies have the high likelihood of doing so.1-4 Again, one does not support a biopsychosocial model by demonstrating how psychological factors act in generating psychogenic pain, as that is
1. Ferrari R, Schrader H, Obelieniene D. Prevalence of temporomandibular disorders associated with whiplash injury in Lithuania. Oral Surg Oral Med Oral Path Oral Radiol Endodontics (in press). 2. Bonk A, Ferrari R, Giebel GD, Edelmann M, Huser R. A prospective randomized, controlled outcome study of two trials of therapy for whiplash injury. J Musculoskeletal Pain (in press). 3. Partheni M, Constantoyannis C, Ferrari R, Nikiforidis G, Voulgaris S, Papadakis N. Prospective cohort outcome study of whiplash injury in Greece. J Musculoskeletal Pain (in press). 4. Obelieniene D, Schrader H, Bovim G, Miseviciene I, Sand T. Pain after whiplash: a prospective controlled inception cohort study. J Neurol Neurosurg Psychiatry 1999;66:27983. 5. Kwan O, Friel J. The dilemma of whiplash. Cephalalgia 1998;18(8):586-7. 6. Ferrari R. Whiplash-associated headache. Cephalalgia 1998;18(8):585-6. 7. Ferrari R. Whiplash encyclopedia. Gaithersburg, Md.: Aspen (in press). 8. Ferrari R, Kwan O, Russell AS, Schrader H, Pearce JMS. The best approach to the problem of whiplash? One ticket to Lithuania, please. Clin Exp Rheumatol (in press). 9. Ferrari R, Russell AS. Pain in the neck for a rheumatologist. Scand J Rheumatol (in press). NONMETAL CROWNS
The article entitled “PorcelainFused-to-Metal vs. Nonmetal Crowns” by Dr. Gordon J. Christensen (March JADA) was
JADA, Vol. 130, June 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
LETTERS quite informative. I read it with great interest, since I recently had worn an ArtGlass (Heraeus Kulzer) bridge on teeth nos. 2, 3 and 4. I had decided to opt for the ArtGlass in place of my conventional bridge after seeing all the nonmetal crown and bridgework displayed by various labs at the 1998 Greater New York Dental Meeting. I feel the nonmetal crowns had a definite disadvantage that was not mentioned in the article. They do not seem to adapt to the gingival margins as completely as a crown that is fabricated with a metal structure. The thinness and subsequent strength of the metalbased crown is very difficult to replicate with the varying types of nonmetal crowns. An advantage of the nonmetal crown that was not mentioned was the complete comfort it afforded due to its lightness. It is barely detectable to the wearer in the mouth, until sensitivity occurs because of open margins (however slight). Because of this problem, I went back to the metal crowns on the aforementioned teeth. Frances M. Fernandez, C.D.A. Roselle Park, N.J. MORE TO IT THAN ‘FIX MY TOOTH’
I’d like to point out some inconsistencies, respectfully, to the author’s assumptions in “Affordable Implant Prosthetics Using a Screwless Implant System” (December JADA, Norman J. Shepherd, D.M.D.). The author completely ignores the surgeon’s fees while discussing prosthetic fees. One of the cases exhibited was a full upper and lower one, involving
18 implants. Oral surgeons and periodontists charge, in my area of practice, $1,500 an implant. Perhaps in the illustrated case the average charge came to $1,000 an implant. Therefore, before the patient begins the restorative process, $18,000 has been allocated toward the implant case. The patient is concerned about his or her total cost. Not just the prosthetic cost. What is the patient wearing while waiting for healing? How much do those interim appliances cost? The author recommends a stent, made from waxed-up articulated study models, because they mechanically direct the surgeon’s bur, and the implant will be in the precise location that the restorative dentist requires. What is the fee allowance for upper and lower impressions, a bite registration appointment, a laboratory wax-up and subsequent processing of the necessary stents? Should that be part of the $600 crown fee? Another question for the author: Which is more accurate, castings made from an indirect impression of abutments, or the direct wax-up, over custom abutments from an analogue model? The surgeon who placed the implants in the illustrated case was indeed skillful. Many surgeons are less so. How does one compensate for the inadvertent placement of a nonparallel implant? Probably with additional laboratory fees and office visits. Patients sometimes make simple requests, such as, “Fix my tooth.” The answer is often significantly more complex than the simple request. Suggesting that a particular implant system is superior to
other implant systems because it is more cost-effective than the others, without science, is misleading. Stanley Markman, D.D.S., F.A.G.D. Ridgefield, N.J. Author’s response: I would like to thank Dr. Markman for taking time to analyze my article published in December JADA, and I would like to answer some of his thoughts. First of all, Dr. Markman points out that I ignored the surgical fees while discussing prosthetic fees. That is absolutely correct, since the point of the publication was affordable implant prosthetics. The cost of the implants, one could say, would be the same no matter which system was used, although, quite frankly, the noscrew system, such as the Bicon System (Bicon Dental Implants), can be placed at less of a fee than others simply because there are fewer components for the surgeon to purchase. This includes not only actual components that are utilized, such as the implant and the abutment, but also there is no need for the accessory components required to place a screw system, such as various screwdrivers and torque wrenches. The point of the article, however, had nothing to do with the surgery; it is simply the prosthetics that we are addressing. On the second point about the interim appliances and the cost of them, I think it becomes obvious that patients would wear what they had been wearing when they first came for treatment. If they were wearing a partial or full denture, they
JADA, Vol. 130, June 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
773