MUNCHAUSEN SYNDROME

ETTERSI order for each bur and Macor block. Despite this, our variability, as expressed by the coefficients of variation, was below 20 percent and usually was less than 10 percent, suggesting viable and reproducible data. Regardless of the cutting substrate, this study was undertaken to determine whether disposable burs perform effectively. We do not, and certainly would not, suggest that disposable burs are superior to conventional dental diamond burs. What we have shown is that the lower-cost disposable bur, under fairly rigorous conditions, will perform very well and appears to match the performance of the conventional bur under the conditions of our study. As far as we were able to determine, disposable burs are not rejects from conventional bur manufacturing lines and appear to be reliable devices in their own right. An important facet of our study is the whole question of infection control. Increasing awareness and concern within the profession regarding the prevention of cross-infection is central to the use of disposable dental instruments. Efficient, low-cost, quality-controlled disposable diamond burs became available only recently and the profession needed an impartial and controlled evaluation of this essential component of the dental armamentarium. Our study showed that disposable burs perform well and the dentist, by using a new bur with each patient, always has a new, sharp cutting instrument and need not be concerned with the timeconsuming and essential sterilization required of conventional dental diamond burs. As scientists, we accept the fact that no study is perfect and 1152 JADA, Vol. 127, August 1996

peer review is essential to the progress of science. Although

the properties of Macor approach those of dental enamel, we should welcome any advice on effective substitutes for dental enamel that are superior to Macor. Our objective is to contribute to science and further the profession of dentistry as best we can. Sharon C. Siegel, D.D.S. J. Anthony von Fraunhofer, Ph.D. University of Maryland at Baltimore MUNCHAUSEN SYNDROME

I read your editorial highlighting Munchausen syndrome (April JADA) with much interest; however, I am deeply concerned that your focusing undue attention on this. rare dental entity might be doing our profession a disservice. We are often too quick to relegate a patient with bizarre and phantom pains to that category of "crazies." Nothing is worse for a dentist than having to interrupt a busy schedule to see a patient on consultation who comes with a sheaf of scribbled notes that in exquisite detail describe a myriad of inconsistent symptoms that have occurred over many years. After some perfunctory percussion and thermal tests, we are only too anxious to dismiss them. By legitimizing Munchausen syndrome in dentistry, you are giving validity to this behavior. There have been times when this type of consultation has presented when I was relaxed and unhurried and able to really listen to the patient. I can recall the personal gratification on a few of these occasions when I have come up with some

profound insight that subsequently led to the alleviation of the patient's symptoms. Last month a patient came to me with shooting pains on the right maxilla of 15 years' duration. Her first molar had been treated and retreated three times (once by me), and ultimately the mesio-buccal root was resected. Still the pain did not abate. She had visited several of our medical colleagues in different specialties. A psychiatrist suggested that the pain probably related to marital tensions. A neurologist subjected her to many sophisticated tests and elaborately named her many symptoms as causalgia, algodystrophy, traumatic vasospasm, hyperpathia, allodynia, etc., and then told her she had "reflex sympathetic dystrophy" due to traumatic maxillofacial injury such as a difficult extraction. Of course, this brought her no closer to the resolution of her pain. After listening carefully to the patient and examining her clinically and radiographically, my suspicions rose regarding the health of her upper right second molar. I instituted endodontic therapy on this tooth and her pain disappeared. I wonder how many other long-suffering patients are out there waiting for some patient dentist to carefully locate some degenerative pulp that is the source of all the distress. Let us remember that radiographs need not reveal pathology and if there is adequate drainage into some sinus or fascial space, acute local symptoms may not occur. My plea is that we be very wary of laying the Munchausen label on a dental patient. Since Munchausen patients thrive on their illness, they will focus on

LEk[TTIRSI[ medical maladies that have more of the life and death drama and that evoke greater sympathy from their nearest and dearest. Charles S. Solomon, D.D.S. New York CLINICAL DIRECTIONS

I would like to congratulate whoever came up with the idea of publishing "Clinical Directions" (JADA's new section to be introduced later this year). Since I have been in the field of dentistry, I have seen the evolution of printed matter go from techniques on how to be a better dentist to how to extract more money from patients with less effort and passable work quality. There is probably a wealth of information out in the private sector that remains with the individual practitioner for one simple reason: why should anyone go to the trouble to do otherwise? Except for the academic in school who must publish or perish, and others in similar institutional circumstances, there is no motivation for Dr. Average to go through the chore of following the rules and regulations of submitting a paper. Who is doing whom the favor? If an incentive can be found for Dr. A to break his routine and transfer his unique ideas with as little trouble as possible, I am sure there would be enough good gems to publish a telephone-book thick volume. Jack J. Tucker, D.D.S. San Antonio CLINICAL PRACTICE GUIDELINES

Regarding "Legal Implications of Clinical Practice Guidelines" (June JADA), by Gordon G. Keyes, to compare a treatment 1154 JADA, Vol. 127, August 1996

protocol for subacute bacterial endocarditis with guidelines promulgated by the ADA for the most basic procedures performed daily by the practicing dentist is like comparing apples and oranges. Not to follow the recommendation of the American Heart Association for preventing an often fatal disease is not the same as using clinical judgment, based on many years of experience, in the performance of a routine dental procedure. Should the result be perceived as unsatisfactory by the patient, the guidelines, unless followed precisely, will be used by the plaintiff's attorney and attested to by his hired gun (expert witness) as being the standard of care. To give the impression that the guidelines will assist the practitioner in his defense (having performed in a reasonable and prudent manner) is a giant, misguided leap of faith. John M. Sachs, D.D.S. Northfield, Ill. TMD FINDINGS

I am in complete agreement with the findings of the National Institutes of Health panel on temporomandibular disorders. And I am not surprised at the flurry of letters questioning those findings. There really has been very little scientific study of the disorders, treatment modalities and especially the outcomes. What I think most dentists fail to consider is that patients can get better on their own. In my experience, many of them do. John A. Cheek, D.D.S. Columbus, Ohio EXAMINING THE EXAM

Recently, I spent three. days

completing the board exam. The purpose of this exam is to ensure that only competent and caring dental practitioners become licensed. The exam is considered a rite of passage, a weekend of tension and endurance experienced by all dentists and patients. There is one aspect of the exam which I feel presents itself most profoundly: the abuse of the patient. Who among us would not agree that the licensure exam is incredibly difficult for the patients. As a dental student I was told on several occasions by my regular clinic patients, "I was a board patient once, never again." The memory of hours spent donning a rubber dam in true discomfort is obviously still vivid in their minds. The board of examiners provides a brochure for the patients, and there are legal waivers which the patients must sign. However, you simply cannot adequately warn someone about a day as horrendous as the one you are asking them to endure. If there were an adequate dental board patient training video, any patient who would take the time to view the contents would never, never become a board patient. At the end of day one of the board, I felt like the Attila of dentists. I placed the rubber dam on my patient and removed it five hours later. On day two of dental boards, my patient's jaw was fatigued and tender to palpation. He was more than simply uncomfortable. The purpose of an exam of this type is to ensure that only competent practitioners are licensed to practice dentistry. The board of examiners, I will assume, feels that the schools may not do an adequate job of