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Centuries with Amalgam
P"»LETTE«S
higher incidence of visits to the dispensary for respiratory illness for cohorts of dental students from 1957-62 th an non-dental students, and th a t dental students had an overall higher incidence of conversions to positive tuberculin tests than other students. One class showed a 42.8 percent conversion from their freshm en to senior year. (Proceedings, F irst International Symposium Aerobiol, Berkeley, Calif., 1963, page 88). A nother concern is for any unusually susceptible person who receives dental treatm ent after the tre a tm e n t of another infectious person. An HIVinfected person w ith a low CD4 cell count would have an in creased susceptibility to in fection, even by m outh, and even to TB bacteria aerosolized from spattered clinical clothing. This suggests the im portance of replacing gowns as well as m ak ing effective use of other infec tion control precautions when tre a tin g vulnerable patients. P erhaps th is explanation helps to clarify our observation th a t aerosol and spatter rem ain extensive and significant sources of contam ination for personnel, and in th e absence of adequate barriers, they present a hazard. O ur assertion is th a t additional ways of minimizing exposure to sp a tte r and aerosols deserve investigation. C arolyn B en tley, D.D.S. N a n cy B u rk hart, R.D.H., M.Ed. J a m e s C raw ford, M.A., Ph.D . T he U n iv ersity o f N orth C arolina C h apel H ill, N.C. MORE ABOUT QUACKERY
This le tte r is w ritten in refer ence to th e lette r to the editor in 1170
JADA, Vol. 125, September 1994
the May 1994 issue entitled “The Quackery Question,” by Dr. Jam es Garry. In his letter he indicates th a t according to a recent CNA risk m anagem ent sem inar in San Diego, there is no difference in the m alpractice susceptibility of dentists using, as Dr. G arry described the pro cedures, th e “Sargenti” approach to root canal therapy vs. the “conventional” therapy. Dr. G arry’s assertion related to this issue m ay be misleading to our fellow ADA mem bers, as it indicates th a t the substan tiation for his statem ent was provided a t one of the CNA D ental Risk M anagem ent Sem inars. As the coordinator of the CNA risk m anagem ent sem inars, I m ade an investiga tion of the inform ation present ed at th a t sem inar and found the following: ■■ Dr. G arry was not registered as in attendance a t any of the most recent California seminars. ■■ No inform ation was presented a t these sem inars in reference to the m alpractice susceptibility of dentists performing any specific endo dontic procedure. ■» O ur current statistics do not indicate w hether any particular endodontic m ethod creates more tre a tm e n t problems for patients or more liability for dentists. B ruce E. B loom , D.D.S., J.D . D irector D en tal a n d O ptom etric Loss C ontrol S erv ices CNA In su ra n ce C om panies C hicago, 111. ECONOMIC COMPRESSION
I ju st read Dr. Larry H. M eskin’s editorial “Economic Compression of the W orst Kind,” Ju ly JADA, in which he
paints a bleak economic future for dentistry. How can this be? I have on my desk m any promotions and brochures claiming to enable me to increase my earnings by 2550 percent. Some of these “profit centers” are TM J, bleaching, im plants, cosmetic dentistry, intraoral cam eras, soft tissue m anagem ent, computerization, increased p atien t load by PPO, practice m anagem ent, hygiene centers, etc. For a practice with a $200,000 gross, im plem enting these profit centers could generate up to 500 percent more income, or $1.2 million, so we should all soon be m ultim illionaires. I’m ju st sad th a t I don’t have another 25 years to practice. Lam ar V. K night, D.D.S., P.A. J a ck so n , M iss. CENTURIES WITH AMALGAM
I reread w ith great interest “Almost Two C enturies W ith Amalgam: W here Are We Today?” by Thomas G. Berry and others in the April JADA. I was dism ayed w ith the sta te m ent, “A significant problem, however, prevents the unquali fied endorsem ent of 4-META bonding agents (Amalgambond). Tests have shown th a t the bond undergoes breakdow n through hydrolization of the collagen peptides. For revision of my textbook, “Endodontics,” I recently com pleted an extensive survey of the literatu re of the adhesive bonding agents th a t I view as the solution to microleakage and subsequent pulpal inflam m ation and deaths. O ther th an a single abstract discussing bovine dentin’s greater tendency to dem ineralize relative to hum an
LEI 1ERS dentin, I could not recall any references to the “hydrolization of collagen peptides” leading to the breakdow n w ith Amalgambond. So I w ent back and reviewed the two articles referred to and nowhere in the article by Chang and others, nor the abstract by Ianzano and others, is hydroliz ation m entioned. The authors concluded th a t “the strength of the am algam restorations bene fited significantly from bonding. Since neither of the cited studies support the authors’ statem ent, the question re m ains: W hat tests are they re ferring to w hen they suggest th a t peptide hydrolysis is more of a problem w ith 4-META th an other adhesives? J o h n I. Ingle, D.D.S., M.S.D. San D iego A u th ors’ resp on se: Dr. Ingle has correctly identified a m istake in our references. Dr. Ianzano’s citation was m is placed. It does not support the statem ent th a t the bond under goes breakdow n and the rete n tion decreases, so it should not have been referenced for th a t statem ent. Dr. Chang’s article, however, does support the sta te m ent. It states “results obtained from this study indicated th a t subsequent thermocycling sign ificantly weakened shear bond strength values using the 4META adhesive.” Although not referenced in the paper, in an in vivo study of 4-META resin and the “hybrid layer,” N akabayashi and others stated th a t long-term imm ersion in w ater decreases bond strengths attributable to hydrol ysis of collagen peptides not protected by hydroxylapatite 1172
JADA, Vol. 125, September 1994
(N akabayashi and others. Q uin tessence Int;1992;23:135-41). Saiku and others supported these findings w ith th eir study (Saiku and others. Oper Dent:1993;18:172-8). They stated th a t “the increased microleakage seen in the aged Amalgambond-lined restora tions suggests th a t the resin undergoes hydrolytic degrad ation” and concurred th a t there was degradation of the exposed peptides. The statem ents in our paper were not m eant to imply th a t 4META products should not be considered for bonding am al gam, b u t ra th e r th a t unqualified endorsem ent was not w arranted a t this time. We th a n k Dr. Ingle for his in terest and the correction of the misreference. If all the read ers of the literatu re were as diligent, our articles would be more accurate and our science improved. T hom as G. B erry, D.D.S., M.A. K aren T roendle, D.D.S., M.P.H. J erry N ich olson , D.D.S., M.A. T he U n iv e r sity o f T exas San A n tonio, T exas DENTISTRY AS A CAREER
I have ju st finished reading Dr. Larry H. M eskin’s July editorial. As I write, my m alpractice and office liability prem ium is staring me in the face and beckoning my attention. I hear my office m anager on the phone w ith an insurance carrier trying to settle a claim for services I provided a patient last year. The new assistan t I hired didn’t show up today, and I’m still w aiting for a p a rt for my evacuation system. I ju st finished gaining access, through
a crown, on a non-vital tooth on a 90-year-old. She kept grabbing my h and and complaining, w ith the dam on, about lack of coverage and fees in general. (I give her a senior courtesy off my usual fees.) I have practiced dentistry for 29 years and have been most fortunate to have reaped the rew ards th a t our profession offers. Lately, I have been inundated w ith requests to provide dental care to select groups of patients in my community. It is often expected th a t I will provide free exam inations, prophylaxis and radiographs. If I should determ ine a need for fu rth er care, I am expected to provide it a t fees 30-50 percent below the fees I charge now. This would be comical if it were not for the increasing num bers of dentists in my area who are willing to accept these term s. It is difficult enough earning a living as a dentist. W hen you consider the cost of education, basic and continuing, setting up and m aintaining an office and the clinical dem ands of our profession our compensation should be increased 30-50 percent, not reduced! If th e insurance companies and the sta te of Tennessee th in k they can delivery quality dental care a t th eir proposed fees and not lose money, let them try. I certainly cannot. If th is tren d continues, and I feel it will, only a fool would choose dentistry as a career. Organized dentistry should indeed m ake Congress aw are of our needs. B ut more im portant, we should enlighten our own m em bers as to the folly of th eir short-sighted actions. F red D u b row sk y, D.D .S. P om on a, N.Y.
higher incidence of visits to the dispensary for respiratory illness for cohorts of dental students from 1957-62 th an non-dental students, and th a t dental students had an overall higher incidence of conversions to positive tuberculin tests than other students. One class showed a 42.8 percent conversion from their freshm en to senior year. (Proceedings, F irst International Symposium Aerobiol, Berkeley, Calif., 1963, page 88). A nother concern is for any unusually susceptible person who receives dental treatm ent after the tre a tm e n t of another infectious person. An HIVinfected person w ith a low CD4 cell count would have an in creased susceptibility to in fection, even by m outh, and even to TB bacteria aerosolized from spattered clinical clothing. This suggests the im portance of replacing gowns as well as m ak ing effective use of other infec tion control precautions when tre a tin g vulnerable patients. P erhaps th is explanation helps to clarify our observation th a t aerosol and spatter rem ain extensive and significant sources of contam ination for personnel, and in th e absence of adequate barriers, they present a hazard. O ur assertion is th a t additional ways of minimizing exposure to sp a tte r and aerosols deserve investigation. C arolyn B en tley, D.D.S. N a n cy B u rk hart, R.D.H., M.Ed. J a m e s C raw ford, M.A., Ph.D . T he U n iv ersity o f N orth C arolina C h apel H ill, N.C. MORE ABOUT QUACKERY
This le tte r is w ritten in refer ence to th e lette r to the editor in 1170
JADA, Vol. 125, September 1994
the May 1994 issue entitled “The Quackery Question,” by Dr. Jam es Garry. In his letter he indicates th a t according to a recent CNA risk m anagem ent sem inar in San Diego, there is no difference in the m alpractice susceptibility of dentists using, as Dr. G arry described the pro cedures, th e “Sargenti” approach to root canal therapy vs. the “conventional” therapy. Dr. G arry’s assertion related to this issue m ay be misleading to our fellow ADA mem bers, as it indicates th a t the substan tiation for his statem ent was provided a t one of the CNA D ental Risk M anagem ent Sem inars. As the coordinator of the CNA risk m anagem ent sem inars, I m ade an investiga tion of the inform ation present ed at th a t sem inar and found the following: ■■ Dr. G arry was not registered as in attendance a t any of the most recent California seminars. ■■ No inform ation was presented a t these sem inars in reference to the m alpractice susceptibility of dentists performing any specific endo dontic procedure. ■» O ur current statistics do not indicate w hether any particular endodontic m ethod creates more tre a tm e n t problems for patients or more liability for dentists. B ruce E. B loom , D.D.S., J.D . D irector D en tal a n d O ptom etric Loss C ontrol S erv ices CNA In su ra n ce C om panies C hicago, 111. ECONOMIC COMPRESSION
I ju st read Dr. Larry H. M eskin’s editorial “Economic Compression of the W orst Kind,” Ju ly JADA, in which he
paints a bleak economic future for dentistry. How can this be? I have on my desk m any promotions and brochures claiming to enable me to increase my earnings by 2550 percent. Some of these “profit centers” are TM J, bleaching, im plants, cosmetic dentistry, intraoral cam eras, soft tissue m anagem ent, computerization, increased p atien t load by PPO, practice m anagem ent, hygiene centers, etc. For a practice with a $200,000 gross, im plem enting these profit centers could generate up to 500 percent more income, or $1.2 million, so we should all soon be m ultim illionaires. I’m ju st sad th a t I don’t have another 25 years to practice. Lam ar V. K night, D.D.S., P.A. J a ck so n , M iss. CENTURIES WITH AMALGAM
I reread w ith great interest “Almost Two C enturies W ith Amalgam: W here Are We Today?” by Thomas G. Berry and others in the April JADA. I was dism ayed w ith the sta te m ent, “A significant problem, however, prevents the unquali fied endorsem ent of 4-META bonding agents (Amalgambond). Tests have shown th a t the bond undergoes breakdow n through hydrolization of the collagen peptides. For revision of my textbook, “Endodontics,” I recently com pleted an extensive survey of the literatu re of the adhesive bonding agents th a t I view as the solution to microleakage and subsequent pulpal inflam m ation and deaths. O ther th an a single abstract discussing bovine dentin’s greater tendency to dem ineralize relative to hum an
LEI 1ERS dentin, I could not recall any references to the “hydrolization of collagen peptides” leading to the breakdow n w ith Amalgambond. So I w ent back and reviewed the two articles referred to and nowhere in the article by Chang and others, nor the abstract by Ianzano and others, is hydroliz ation m entioned. The authors concluded th a t “the strength of the am algam restorations bene fited significantly from bonding. Since neither of the cited studies support the authors’ statem ent, the question re m ains: W hat tests are they re ferring to w hen they suggest th a t peptide hydrolysis is more of a problem w ith 4-META th an other adhesives? J o h n I. Ingle, D.D.S., M.S.D. San D iego A u th ors’ resp on se: Dr. Ingle has correctly identified a m istake in our references. Dr. Ianzano’s citation was m is placed. It does not support the statem ent th a t the bond under goes breakdow n and the rete n tion decreases, so it should not have been referenced for th a t statem ent. Dr. Chang’s article, however, does support the sta te m ent. It states “results obtained from this study indicated th a t subsequent thermocycling sign ificantly weakened shear bond strength values using the 4META adhesive.” Although not referenced in the paper, in an in vivo study of 4-META resin and the “hybrid layer,” N akabayashi and others stated th a t long-term imm ersion in w ater decreases bond strengths attributable to hydrol ysis of collagen peptides not protected by hydroxylapatite 1172
JADA, Vol. 125, September 1994
(N akabayashi and others. Q uin tessence Int;1992;23:135-41). Saiku and others supported these findings w ith th eir study (Saiku and others. Oper Dent:1993;18:172-8). They stated th a t “the increased microleakage seen in the aged Amalgambond-lined restora tions suggests th a t the resin undergoes hydrolytic degrad ation” and concurred th a t there was degradation of the exposed peptides. The statem ents in our paper were not m eant to imply th a t 4META products should not be considered for bonding am al gam, b u t ra th e r th a t unqualified endorsem ent was not w arranted a t this time. We th a n k Dr. Ingle for his in terest and the correction of the misreference. If all the read ers of the literatu re were as diligent, our articles would be more accurate and our science improved. T hom as G. B erry, D.D.S., M.A. K aren T roendle, D.D.S., M.P.H. J erry N ich olson , D.D.S., M.A. T he U n iv e r sity o f T exas San A n tonio, T exas DENTISTRY AS A CAREER
I have ju st finished reading Dr. Larry H. M eskin’s July editorial. As I write, my m alpractice and office liability prem ium is staring me in the face and beckoning my attention. I hear my office m anager on the phone w ith an insurance carrier trying to settle a claim for services I provided a patient last year. The new assistan t I hired didn’t show up today, and I’m still w aiting for a p a rt for my evacuation system. I ju st finished gaining access, through
a crown, on a non-vital tooth on a 90-year-old. She kept grabbing my h and and complaining, w ith the dam on, about lack of coverage and fees in general. (I give her a senior courtesy off my usual fees.) I have practiced dentistry for 29 years and have been most fortunate to have reaped the rew ards th a t our profession offers. Lately, I have been inundated w ith requests to provide dental care to select groups of patients in my community. It is often expected th a t I will provide free exam inations, prophylaxis and radiographs. If I should determ ine a need for fu rth er care, I am expected to provide it a t fees 30-50 percent below the fees I charge now. This would be comical if it were not for the increasing num bers of dentists in my area who are willing to accept these term s. It is difficult enough earning a living as a dentist. W hen you consider the cost of education, basic and continuing, setting up and m aintaining an office and the clinical dem ands of our profession our compensation should be increased 30-50 percent, not reduced! If th e insurance companies and the sta te of Tennessee th in k they can delivery quality dental care a t th eir proposed fees and not lose money, let them try. I certainly cannot. If th is tren d continues, and I feel it will, only a fool would choose dentistry as a career. Organized dentistry should indeed m ake Congress aw are of our needs. B ut more im portant, we should enlighten our own m em bers as to the folly of th eir short-sighted actions. F red D u b row sk y, D.D .S. P om on a, N.Y.