- Email: [email protected]
Referral Rapport
oping a pre- and postnatal clinic, plus care for infants to five years of age. There is a public school (grades one through six) with 200 students and a private church school with 150 stu dents. I examined all children in both schools and did extractions for the most urgent cases. Casual examina tion showed that more than 80% of the children needed operative work. We gave toothbrushing instructions and gave the youngsters toothbrushes; flossing will come later. There is a high degree of anterior interproximal and lingual caries which has led to early loss of the anterior teeth due to the fact that the children routinely suck on raw sugar cane. This is about the only “ sweet” or candy they have. Due to the very early loss of primary teeth, there is much crowd ing and especially canine malalign ment. In order not to make this a report of statistics and cases, let me reiterate that there is much dental care greatly needed, and the dentist’s wife is more than welcome to act as an assistant. Recently, I gave a slide presenta tion for a component of a district so ciety, hoping that I might sign up some volunteers. If any other society or group would be interested in my pre sentation, they can write to me at 22190 Garrison Ave, Suite 303, Dear born, Mich 48124. HAROLD K. BURCH, DDS DEARBORN, MICH
C om m ents on article m I have read with interest J. S. Giansanti’s article on “ A kindred showing hypocalcified amelogenesis imper fecta.” Dr. Giansanti’s propositus was de scribed as being autosomal dominant, while C. Schulze’s proband was in the classification of sex-linked dominant (March jada). Due to the confusion regarding the etiology of amelogenesis imperfecta, the following might be applicable: —the three common inheritance patterns all may be involved as etio logical factors by inspection of the pedigree.
—since in amelogenesis imperfecta various gradations of hypomaturation are observed, the factor of expressiv ity comes into play. The patients with amelogenesis in the pedigree may pre sent the same genotype, but the ap pearance of the phenotypes would dif fer due to the genome interacting with a multitude of environmental factors. —or, the phenomenon of nonpene trance may result in the expressivity of a mutant gene varying from severe to minimal in reference to clinical manifestations. The lowest degree of expressivity would be one which does not produce any clinically apparent defect detectable by conventional means, and is referred to as nonpene trance. It is the factor of nonpene trance which may result in a distor tion of the expected inheritance pat tern with fewer than one in two affect ed siblings and children. The above may be helpful in the etiology of amelogenesis and other in herited autosomal dominant Mendelian characteristics. GEORGE H. MATSUMOTO, DDS LINCOLN STATE SCHOOL LINCOLN, ILL
A birthday present m I ’d like to make a suggestion to ward a campaign comparable to those which encourage visits to the dentist. As many dentists have experienced, people do forget when they last saw a dentist. When you ask them they say, “ I think it was two years ago.” You look up their records and it’s frequent ly three or four years ago. My suggestion is this. “ Give your self a birthday present. Visit your den tist on your birthday.” In this way, only a year can pass before an auto matic reminder arises. “ Give yourself a birthday present. ’’ What nicer gift could you get than healthy teeth and gums? WALTER BELLER, DDS MINEOLA, NY
Referral rapport
■ To keep pace with our professions,
increased specialization guidelines should be established to avoid redun dant procedures, coordinate treat ment planning, and establish respon sibility for maintenance. In medical practice, it would be rare to refer a patient outside your hospital staff. To facilitate care, physicians use this one facility, the hospital, to main tain supervision. Dentistry’s health care delivery system is unique. Imag ine the dental patient with surgical, endodontic, periodontal, and pros thetic considerations; for them there is no one facility. The dentist is faced with an increasingly complicating sys tem of referral and recall, each inde pendent to individual offices. The purposes of recall are triadic: early recognition of disease, mainten ance of unaffected or restored tissues, and record. Our patients see a confus ing delineation of these responsibil ities and are presently involved in an anachronistic system. Recall should be assigned to one office and staff and, as a general guideline, should be the responsibility of the dentist initiating the referral. The area which presents the most confusing and complicating referral recall is the periodontal prosthetic pa tient. I have found the following pat tern of referral to be the most advan tageous to patient and doctor. First, treatment should be initiated in the generalist’s office—gross debride ment, home care instructions, and mo tivation. This will provide the dentist with a better understanding of the oral health, give a clearer indication of the resulting prosthetic service, and establish the patient’s motivational level. An improperly motivated peri odontal patient is a failure to periodon tist and prosthodontist. Second, teeth which obviously are hopeless or present an impossible re storative problem should be extract ed. Third, temporary stabilization of teeth—occlusal equilibration, remov al of carious lesions, and other imme diate dental needs—should be met pri or to initiating surgical periodontal therapy. When periodontal therapy has been completed to the surgeon’s satisfac tion, the patient is returned and the case completed as rapidly as possible
LETTERS TO THE EDITOR / JADA, Vol. 86, June 1973 ■ 1229
—especially when transitional splint ing is utilized. Recall is the sole re sponsibility of the dentist initiating the referral, and in most cases would be the general dentist. This system of re ferral recall can eliminate confusion and will place control in the hands of one office and staff. Restoratively speaking, periodontally treated patients present the great est challenge. Avoid treating these pa tients with procedures that are unfa miliar, even if requested. You are go ing to be more successful and achieve a better result with techniques you have used before. Continue attending bona-fide post graduate education courses; it is this knowledge which will enable you to better manage these difficult cases. Strive to maintain the key position in treatment planning and maintenance. No man is better qualified to take the long view than the man who has the broadest scope. J. C. MORGANELLI, DDS CHICAGO
On unionization m In the March ja d a , Reuben Feltman comments on the problems of malpractice actions (page 541). At one point he labels suits against dentists as “ legal blackmail.” He continues with a discussion of the unfairness of the legal entanglement in which in dividual dentists sometimes find them selves snared. He concludes with a statement about equal application of constitutional law. Dr. Feltman is certainly correct. He is correct in asking for equal rights, and he is correct in addressing the en tire dental profession about the prob lem because the situations of which he speaks are quite prevalent. However, talking about rights and obtaining them are two different things. The dental profession has far too long neglected to try to do any thing about this problem. Therefore, there isn’t any real machinery to go in to action and right this wrong. On the other hand, the legal profession has for years been at the task of defending its own. Any real reform for dentists would
have to come through the legislatures of the individual states. But what do you find when you get to the state leg islature? Mostly you find a bunch of lawyers who have found it easier to get on the soap box and con the public than to hang out a shingle and earn a living at being an attorney. They are not about to give up a good thing with out a fight. A few progressive states, where in dividual representatives have man aged to wrestle away the collusion of lawyers, have taken notice of these suits against dentists and other busi ness people. These states have insti tuted a system requiring a deposit (as much as $500) in civil law suits. Should a person filing a civil suit lose, then the deposit goes to paying the cost of court and legal fees of the party being sued. This has cleared the courts of a lot of vindictive and annoyance-type of suits. However, to hope that all states suddenly will take such a progressive step isn’t in the present realism. There is something on the horizon, though, and if we would all support it, it would give the dental profession a lot more leverage in dealing with gov ernment on all levels. This something is a professional peoples’ union—the American Federation of Physicians and Dentists. With large numbers of physicians and dentists in this union, the local unions would have the fi nancial and political power to right some of the wrongs in the legislatures, and to keep liberal-minded bureau crats from sticking their noses into the doctor-patient relationship and ruin ing the health professions. Not everyone agrees, though, that a union is the answer. For instance, Louis A. Saporito, ADA president, said he does “ not believe a union is either necessary or appropriate for members of the health professions.” Dr. Saporito’s idea of service to in dividuals is to send out a brochure la beled Index to A D A M em ber S er vices. Most of these so-called services are as useless to the real individual needs of dentists as the “ teats on a boar hog.” The only service of any merit at all to individual needs is the one concerning financial aid to indi viduals of unfortunate circumstances. Most of the other services are just
1230 ■ LETTERS TO THE EDITOR I JADA, Vol. 86, June 1973
bureaucratic “ built-ins” to create a job and make a showing of concern. They rarely touch on the real prob lems facing individuals today. A union would also serve in other capacities. For instance, we could have a retirement program. We could elect a board to manage and invest monies for this purpose. The retire ment programs based on insurance are very poor and give a poor return. We could have a collective legal depart ment for advice and defense. We could have a credit union for loans at a lower interest rate. There are many pluses to a union, but most of all we could stop begging and start demanding—demand equal rights in the courts as mentioned by Dr. Feltman, demand fluoridation as a national health policy, demand that a dental hygiene educational program be instituted in public school systems, demand there be a justification for ex pansion of dental manpower, and de mand that patients have the right to choose their own doctor. Also, we could demand and be recognized as a first class citizen and not a back door ^beggar as Dr. Saporito suggests. A beggar, a coward, and a serf to the bu reaucracy of the ADA is what our lot has been until now. So, if you want some changes, Reu ben, join the union movement. Sup port Donald C. Meyer, Gerald W. Lustig, the American Federation of Physicians and Dentists, Vern S. Boddicker, the National Committee for Freedom of Choice in Dentistry, and national reciprocity. Changes are possible—for the bet ter or the worst. The worst is to leave your future in the hands of the ADA officials, most of whom are not elect ed but appointed. If you want it for the better, you are going to have to pitch in and work. The opposition isn’t go ing to hand it to you on a silver platter. JOHN B. SANDERS, DDS WEST ORANGE, TEXAS ■ In reference to your editorial on unionization in the February jada , I would like to make a suggestion that might not only help the dental profes sion but also the nation as a whole. I wonder if it wouldn’t be better if our whole nation was unionized. La bor unions would negotiate with man
C om m ents on article m I have read with interest J. S. Giansanti’s article on “ A kindred showing hypocalcified amelogenesis imper fecta.” Dr. Giansanti’s propositus was de scribed as being autosomal dominant, while C. Schulze’s proband was in the classification of sex-linked dominant (March jada). Due to the confusion regarding the etiology of amelogenesis imperfecta, the following might be applicable: —the three common inheritance patterns all may be involved as etio logical factors by inspection of the pedigree.
—since in amelogenesis imperfecta various gradations of hypomaturation are observed, the factor of expressiv ity comes into play. The patients with amelogenesis in the pedigree may pre sent the same genotype, but the ap pearance of the phenotypes would dif fer due to the genome interacting with a multitude of environmental factors. —or, the phenomenon of nonpene trance may result in the expressivity of a mutant gene varying from severe to minimal in reference to clinical manifestations. The lowest degree of expressivity would be one which does not produce any clinically apparent defect detectable by conventional means, and is referred to as nonpene trance. It is the factor of nonpene trance which may result in a distor tion of the expected inheritance pat tern with fewer than one in two affect ed siblings and children. The above may be helpful in the etiology of amelogenesis and other in herited autosomal dominant Mendelian characteristics. GEORGE H. MATSUMOTO, DDS LINCOLN STATE SCHOOL LINCOLN, ILL
A birthday present m I ’d like to make a suggestion to ward a campaign comparable to those which encourage visits to the dentist. As many dentists have experienced, people do forget when they last saw a dentist. When you ask them they say, “ I think it was two years ago.” You look up their records and it’s frequent ly three or four years ago. My suggestion is this. “ Give your self a birthday present. Visit your den tist on your birthday.” In this way, only a year can pass before an auto matic reminder arises. “ Give yourself a birthday present. ’’ What nicer gift could you get than healthy teeth and gums? WALTER BELLER, DDS MINEOLA, NY
Referral rapport
■ To keep pace with our professions,
increased specialization guidelines should be established to avoid redun dant procedures, coordinate treat ment planning, and establish respon sibility for maintenance. In medical practice, it would be rare to refer a patient outside your hospital staff. To facilitate care, physicians use this one facility, the hospital, to main tain supervision. Dentistry’s health care delivery system is unique. Imag ine the dental patient with surgical, endodontic, periodontal, and pros thetic considerations; for them there is no one facility. The dentist is faced with an increasingly complicating sys tem of referral and recall, each inde pendent to individual offices. The purposes of recall are triadic: early recognition of disease, mainten ance of unaffected or restored tissues, and record. Our patients see a confus ing delineation of these responsibil ities and are presently involved in an anachronistic system. Recall should be assigned to one office and staff and, as a general guideline, should be the responsibility of the dentist initiating the referral. The area which presents the most confusing and complicating referral recall is the periodontal prosthetic pa tient. I have found the following pat tern of referral to be the most advan tageous to patient and doctor. First, treatment should be initiated in the generalist’s office—gross debride ment, home care instructions, and mo tivation. This will provide the dentist with a better understanding of the oral health, give a clearer indication of the resulting prosthetic service, and establish the patient’s motivational level. An improperly motivated peri odontal patient is a failure to periodon tist and prosthodontist. Second, teeth which obviously are hopeless or present an impossible re storative problem should be extract ed. Third, temporary stabilization of teeth—occlusal equilibration, remov al of carious lesions, and other imme diate dental needs—should be met pri or to initiating surgical periodontal therapy. When periodontal therapy has been completed to the surgeon’s satisfac tion, the patient is returned and the case completed as rapidly as possible
LETTERS TO THE EDITOR / JADA, Vol. 86, June 1973 ■ 1229
—especially when transitional splint ing is utilized. Recall is the sole re sponsibility of the dentist initiating the referral, and in most cases would be the general dentist. This system of re ferral recall can eliminate confusion and will place control in the hands of one office and staff. Restoratively speaking, periodontally treated patients present the great est challenge. Avoid treating these pa tients with procedures that are unfa miliar, even if requested. You are go ing to be more successful and achieve a better result with techniques you have used before. Continue attending bona-fide post graduate education courses; it is this knowledge which will enable you to better manage these difficult cases. Strive to maintain the key position in treatment planning and maintenance. No man is better qualified to take the long view than the man who has the broadest scope. J. C. MORGANELLI, DDS CHICAGO
On unionization m In the March ja d a , Reuben Feltman comments on the problems of malpractice actions (page 541). At one point he labels suits against dentists as “ legal blackmail.” He continues with a discussion of the unfairness of the legal entanglement in which in dividual dentists sometimes find them selves snared. He concludes with a statement about equal application of constitutional law. Dr. Feltman is certainly correct. He is correct in asking for equal rights, and he is correct in addressing the en tire dental profession about the prob lem because the situations of which he speaks are quite prevalent. However, talking about rights and obtaining them are two different things. The dental profession has far too long neglected to try to do any thing about this problem. Therefore, there isn’t any real machinery to go in to action and right this wrong. On the other hand, the legal profession has for years been at the task of defending its own. Any real reform for dentists would
have to come through the legislatures of the individual states. But what do you find when you get to the state leg islature? Mostly you find a bunch of lawyers who have found it easier to get on the soap box and con the public than to hang out a shingle and earn a living at being an attorney. They are not about to give up a good thing with out a fight. A few progressive states, where in dividual representatives have man aged to wrestle away the collusion of lawyers, have taken notice of these suits against dentists and other busi ness people. These states have insti tuted a system requiring a deposit (as much as $500) in civil law suits. Should a person filing a civil suit lose, then the deposit goes to paying the cost of court and legal fees of the party being sued. This has cleared the courts of a lot of vindictive and annoyance-type of suits. However, to hope that all states suddenly will take such a progressive step isn’t in the present realism. There is something on the horizon, though, and if we would all support it, it would give the dental profession a lot more leverage in dealing with gov ernment on all levels. This something is a professional peoples’ union—the American Federation of Physicians and Dentists. With large numbers of physicians and dentists in this union, the local unions would have the fi nancial and political power to right some of the wrongs in the legislatures, and to keep liberal-minded bureau crats from sticking their noses into the doctor-patient relationship and ruin ing the health professions. Not everyone agrees, though, that a union is the answer. For instance, Louis A. Saporito, ADA president, said he does “ not believe a union is either necessary or appropriate for members of the health professions.” Dr. Saporito’s idea of service to in dividuals is to send out a brochure la beled Index to A D A M em ber S er vices. Most of these so-called services are as useless to the real individual needs of dentists as the “ teats on a boar hog.” The only service of any merit at all to individual needs is the one concerning financial aid to indi viduals of unfortunate circumstances. Most of the other services are just
1230 ■ LETTERS TO THE EDITOR I JADA, Vol. 86, June 1973
bureaucratic “ built-ins” to create a job and make a showing of concern. They rarely touch on the real prob lems facing individuals today. A union would also serve in other capacities. For instance, we could have a retirement program. We could elect a board to manage and invest monies for this purpose. The retire ment programs based on insurance are very poor and give a poor return. We could have a collective legal depart ment for advice and defense. We could have a credit union for loans at a lower interest rate. There are many pluses to a union, but most of all we could stop begging and start demanding—demand equal rights in the courts as mentioned by Dr. Feltman, demand fluoridation as a national health policy, demand that a dental hygiene educational program be instituted in public school systems, demand there be a justification for ex pansion of dental manpower, and de mand that patients have the right to choose their own doctor. Also, we could demand and be recognized as a first class citizen and not a back door ^beggar as Dr. Saporito suggests. A beggar, a coward, and a serf to the bu reaucracy of the ADA is what our lot has been until now. So, if you want some changes, Reu ben, join the union movement. Sup port Donald C. Meyer, Gerald W. Lustig, the American Federation of Physicians and Dentists, Vern S. Boddicker, the National Committee for Freedom of Choice in Dentistry, and national reciprocity. Changes are possible—for the bet ter or the worst. The worst is to leave your future in the hands of the ADA officials, most of whom are not elect ed but appointed. If you want it for the better, you are going to have to pitch in and work. The opposition isn’t go ing to hand it to you on a silver platter. JOHN B. SANDERS, DDS WEST ORANGE, TEXAS ■ In reference to your editorial on unionization in the February jada , I would like to make a suggestion that might not only help the dental profes sion but also the nation as a whole. I wonder if it wouldn’t be better if our whole nation was unionized. La bor unions would negotiate with man