Patterns from practice

LETTERS TO THE EDITOR

disk” without pain as long as the occlu­ sion is unlocked. Many clinicians indict only the disk and its various displace­ ments as the center of their treatment. Some carry this oversimplification into diagnosis and take short cuts by observ­ ing posterior condylar displacement on a TMJ radiograph and assuming the disk is anteriorly displaced or dislocated. The only time we must know the exact loca­ tion of the disk is when the patient does not respond to conservative o cclu sal treatment and surgery may be contem­ plated as a last resort. . . . I use lateral transcranial radiographs to d o c u m e n t c o n d y la r p o s it io n an d pathologic conditions only, and certainly agree that soft tissue such as the disk re­ quires special recording techniques when clinical conditions require them for suc­ cessful treatment.

methods of transcranial interpretation were evaluated for diagnosing disk dis­ placements, with arthrography serving as the control. Neither method was found to be particularly valid in assessing disk displacements. We believe our research is reported in sufficient detail to stand by itself and welcome further independent controlled studies in this critical area of diagnosis. Dr. Weinberg’s letter concludes that soft tissue pathology, such as disk displace­ ment, requires special recording tech­ niques. We obviously agree. Hopefully such agreem ent w ill help clarify the proper role of the transcranial radiograph in dentistry. D. CARL DIXON, DDS GAR S. GRAHAM, DDS ROBERT B. MAYHEW, DMD LARRY J. OESTERLE, DDS, MS DAVID SIMMS, MD WAYNE P. PIERSON, PhD LACKLAND AIR FORCE BASE, TX

P lan for the handicapped

□ On behalf of the board of directors of the Academy of Dentistry for the Handi­ capped, I would like to comment on the “ E m p h a s is ” a r t ic le on d e n t is t r y ’s strategic plan (January). Our concern re­ lates to the report’s failure to address the handicapped population as a major area LAWRENCE A. WEINBERG, DDS, M S of unmet need. We suggest that the pro­ NEW YORK fession consider the following: —The proportion of handicapped pa­ 1. Weinberg, L. A. An evaluation of duplicability of tem porom andibular joint radiographs. J Prosthet tients in both the indigent and elderly Dent 24:512-541, 1970. population represents a level well above 2. Weinberg, L.A. Temporomandibular joint func­ the population in general. tion and its effect on centric relation. J Prosthet Dent —Depending on definitions, the hand­ 30:176-195, 1973. 3. Weinberg, L.A. The role of condylar position in icapped constitute from 3% to 10% of our TM J dysfunction pain syndrome. J Prosthet Dent population. The ADA plan estimates that 4 1:636-643, 1979. the elderly will remain between 11% to 4. Weinberg, L.A. C linical report on the etiology 12% of the total population for the next 30 and diagnosis of TM J dysfunction-pain syndrome. J Prosthet Dent 4 4 :6 4 2 -6 5 3 ,1 9 8 0 . years. The size difference in these two 5. Weinberg, L.A. Posterior bilateral condylar dis­ underserved groups is not so great as to placem ent: its diagnosis and treatment. J Prosthet ignore the handicapped. Dent 36:426-440, 1976. — The financial obstacles to care that 6. W einberg, L.A. Posterior unilateral condylar displacem ent: its diagnosis and treatment. J Prosthet the elderly and indigent share are also Dent 37:559-569, 1977. shared by the handicapped— more than 7. W einberg, L.A. Superior condylar d isplace­ half of them. This obstacle is but one of ment: its diagnosis and treatment. J Prosthet Dent the many that include medical problems, 34:59-76, 1975. 8. W einberg, L.A. A nterior condylar disp lace­ physical inaccessibility, and prejudice. ment: its diagnosis and treatment. J Prosthet Dent We recognize that every interest group 34:195-207, 1975. cannot be represented in dentistry’s plan. 9. W e in b e rg , L .A . D e fin itiv e p ro s th o d o n tic therapy for TMJ patients. Anterior and posterior con­ However, our concern is that the handi­ dylar displacement. J Prosthet Dent 50(4):544-557, capped not be forgotten. 1983. It is too sim plistic to assume that the 10. W ein b erg , L.A . D efin itiv e p ro sth o d o n tic therapy for TMJ patients. Posterior and superior con­ burgeoning elderly population w ill be composed mainly of those with extensive dylar displacement. J Prosthet Dent 50(5):690-699, 1983. and unmet dental needs or inadequate re­ 11. Weinberg, L.A. The role o f stress, occlusion, sources. It is also too easy to assume that and condylar position in TM J dysfunction pain. J the limited dental care and educational Prosthet Dent 49:532-545, 1983. programs of the ’70s eliminated what was □ Comment: The article under discus­ once described as dentistry’s greatest sion is a retrospective radiographic as­ unmet need. PAUL S. CASAMASSIMO. DDS, MS sessment of the validity of transcranial PRESIDENT-ELECT radiography in diagnosing anterior disk ACADEMY OF DENTISTRY FOR THE HANDICAPPED displacement. In the reported study two 16 ■ JADA, Vol. 109, July 1984

Inhalers and periodontal symptom s □ We have noticed a series of patients whose mucosa and gingiva show abnor­ malities for no apparent reason. The tis­ sues seem to be mildly inflamed, with no stip p lin g , some m inor bleed in g, and some complaints about mild discomfort. These patients had generally been with the practice for some time and were con­ scientious, fastidious people whose oral hygiene was good to excellent. Calculus and plaque were generally minimal, and certainly not sufficient to explain the problem. Fortuitous inquiry showed that all of the patients were using an inhaler to pro­ vide relief from respiratory problems of an asthmatic nature, and generally as­ sociated with allergies. The drugs used were Proventil, Beclovent, and Brethine. The data sheet that accompanies Beclovent states: “Rinsing the mouth after in­ halation is advised.” The data sheet for Proventil includes “drying or irritation of the oropharynx,” in the list of adverse reactions. Because of our somewhat limited un­ derstanding of the pharm acology in ­ volved, and recognizing the priority of the inhaler problem, we simply advised our patients to rinse their mouths com­ pletely after using these inhalers. This solved the problem. We would suggest that, because this kind of medication is commonly used, especially in the seasons when allergies are prevalent it would seem wise to ex­ plore this area for patients with allergies, and the symptoms described. SUSAN ROSENMEIER, RDH WALTER KENT, DDS WYCKOFF, NJ

P atterns from practice □ I have been a general practitioner for 35 years and would like to offer a few in­ teresting observations from my clinical practice. All dentists are aware of the appearance of the aging tooth on p e ria p ica l ra ­ diographs; to oversim plify a com plex problem, the pulp appears reduced in size and volume, and appears to recede. I have noticed that, when the recession occurs prematurely in middle-aged pa­ tients with no apparent reason, there is a correlation between calcification of the pulp and high blood pressure. (I find it easier to detect the recession on periapi­ cal radiographs of the anterior teeth, maxillary or mandibular.) This condition occurs primarily in men and less fre­ quently in women. When I have reviewed radiographs of patients with coronary disease, I have also noticed that this same pattern exists, but not all of the time. I believe a study in a more controlled setting is necessary to

y

LETTERS TO TH E ED ITO R

T h is m andible o f an adult m ale from Germ any, ca 500,000 BP (before present), is know n as the “Heidelberg M an.” The m andible is the earliest evidence o f the a r­ ch aic form o f the species H o m o s a p ie n s . T he Heidel­ berg M an is a specim en in the A m erican Museum o f N atural H istory exhibition, A n c e s ­ tors: F o u r M illio n Y ea r s o f H u m an ity.

pursue this observation. If confirmed, possibly a new diagnostic tool can be de­ veloped for early detection of cardiovas­ cular disorders or calcium disturbances. LOUIS J. D’ERRICO, DDS SEAFORD, NY

MORA stats □ I would like to express my opinion concerning the issue of whether a MORA can increase strength. It is not the MORA, but rather the position obtained with the MORA that is important. This position is not universal and must be determined for each individual. Under this hypothesis, a study in w hich each MORA is co n ­ structed exactly the same could not prove a benefit of statistical significance. . . . EMIL M. VERBAN, IR., DDS BLOOMINGTON, IL

To err is hum an □ Those who write to correct the gram­ mar of o th ers (“ D e n ta le se ,” M arch) should be very careful. Although Dr. Weiss is correct in saying “No one in his right mind would say, ‘With he battling . . ” , he is not correct in suggesting “him ” as the correct word. The subject of a preposition takes the possessive case. Thus: “With his battling. . . . ” DERYCK G. NUCKTON, DDS MONTEREY, CA

□ Comment: Doctor Nuckton is right and I thank him for pointing out my error. The offending passage in the New York Times had read, “With both he and Teltscher battling the sudden gusts w ithin the Stadium Court.. . . ’’ Had I corrected it to, “With him and Teltscher on the Stadium Court, the sudden gusts were a problem . . . ” the pronoun, and Teltscher, would have been objects of a preposition, requir­ ing the accusative form. But I didn’t. Allan Buttrym, professor of English at Seton Hall University, has helped me to understand that battling, a noun form of a verb, or gerund, is the object of the prepo­ sition and that the pronoun and Teltscher modify it, and should take, as Dr. Nuckton points out, the possessive form. Thus, “ With his and Teltscher’s battling the sudden gusts . . . ” Sounds awkward, but it’s grammatically correct. In a recent article in Writer’s Digest, the grammarian Gary Provost predicted:

Ancestors □ The current exhibit at the American Museum of Natural History in New York City to Sept 9 ,1 9 8 4 , deserves to be called to the attention of the entire dental pro­ fession. It is an unprecedented gathering of original fossils— maxillas, mandibles, reconstructed heads and faces, and other sk e le ta l a rtifa c ts — from fam ou s a n ­ thropologic collections throughout the world. As such, this inspired display of the evolutionary growth and develop­ ment of our jaws and teeth conveys a pow erful stim u lu s to overall dental thought. First of all, the jawbones displayed are studded with almost whole complements of extremely well-preserved teeth. Keep­ ing in mind that most of these specimens date back thousands and thousands of years, we stand in awe of the state of pres­ ervation of the dentition. Even when speculating that the lifespan of these be­ ings might have been shorter than our own, we cannot help searching for rea­ sons. The most obvious is the optimal flatness of the occlusal surfaces of the mo­ lars. A much rougher, sandier diet of un­ refined grains probably was basic in pre­ historic times. Food processing had not yet been discovered. Chewing probably took longer. What is deduced is simply this: periodontal disease is imperatively correlated with cuspal tripping and with reflected radicular movement.

I am also dramatically impressed by the forward growth of the head and the back­ ward retreat of the mouth and chin in the course of hum an developm ent. There must have been many balancing shifts when the weight and position of the head changed. It is easy to assume that the den­ tists who are correlating overall bodily posture with faulty biting paths are on the right track, so to speak. And the forward stoop that so often comes with aging is surely to be faulted for the inevitable for­ ward thrust of the mandible. The en­ visioned skeletal musculature of mastica­ tion as it adapts to the more modern func­ tioning must also have been involved in the resulting asymmetries and m alocclu­ sions we see today. T h e p r o f e s s i o n a lis m o f th e a n ­ thropologists who have re-assem bled whole faces from shards of their finds is ingenious. The “lessons” for surgeons, as well as for all dentists practicing recon­ struction, are provocative. But most sur­ prising of all is our natural impulse to generalize over so few specimens. There are hardly more than 50 pieces in all, and they are enough. We quickly push aside all the classic rules of scientific method­ ology and allow our minds to connect, to add up.

During the next m onth I w ill receive at least 70 letters from readers, generously pointing out that in my article about gram mar I made five gram m atical mistakes. (The w ill instead of shall may be one of them.) . . . I know this will happen because it has h appened before. It happens to anybody w ho says anything about gram mar in public. .. .

to: “Lookback through this essay, and for certain you will find that I have again and again committed the very faults I am pro­ testing against.” So I am in good company when I make mistakes. I ’ll do it again. And I hope Dr. Nuckton and others w ill correct me when I do.

When I began the “Dentalese” essays, I commented that “all writers err” and quoted George Orwell, advising readers

JOSEPH GLAZER, DDS ATLANTA

JAY W EISS, DMD CALDWELL, NJ JADA, Vol. 109, July 1984 ■ 17