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Periodontal Therapy
LETTERS
TO
THE E D IT O R
pancuronium-aminophylline interac tion. A recent case report1 details this adverse interaction that resulted in the development of paroxsymal atrial ta ch y cardia and c a n c e lla tio n of surgery. GER.ALD T. MCAULIFFE, DMD DEPARTMENT OF ANESTHESIA BOSTON CITY HOSPITAL BOSTON 1. Belani, K.G., and others. Adverse drug in teraction involving pancuronium and aminophylline. Anesth Analg 61(5):473-474, 1982.
Ectopically erupting molars □ I have an alternative to the tech nique described in “Correction of ec topically erupting maxillary perma nent first molars” by Dr. Garcia-Godoy (August). In 27 years of practice, I have seen only three cases of ectopic eruption, so I am not an expert. However, my treatment for the cases was the same: I used a 170L carbide bur and, on the primary second molar, made a distal slice on an inclined plane, avoiding the contact area. In each case the permanent first molar erupted into its proper position by sliding along the inclined plane. The primary molar was retained long enough so that the second premolar erupted uneventfully. The entire pro cedure was done without an anesthetic and took about 60 seconds. RICHARD S. UPPGAARD, DDS MINNEAPOLIS
Keyes technique □ I think it is time all the mystery and noise about the “Keyes technique” of periodontal therapy are dispelled.. . . Despite the “gimmickry” of the use of the phase microscope as a motiva tional tool, Dr. Keyes is promoting the time-tested techniques I was taught in the 1940s while a student in dental school.. .. One of the essential and understated p illa rs of the w hole therapy is still “careful and meticu lous- removal of all deposits from the root surfaces of the teeth leaving a smooth, plaquefree, highly polished root.” If my colleagues in periodontics (I am a generalist) would spend a day with Dr. Keyes and see the color slides of the cases he has treated, I think even they would be impressed by the one 606 ■ JADA, Vol. 105, October 1982
aspect of Dr. Keyes about which he is unduly modest. He is a superb techni cian. He uses Orban scalers, and the photographs I saw showed beautifully scaled and root-planed dentitions. .. . Dr. Keyes also evinced no objection to periodontal surgery when deposits were inaccessible or tissue architec ture required correction. I realize that the fact that Dr. Keyes has not published any of his studies in a journal of scientific repute and his use of television and other media to promote his technique offends many members of our profession. But I find that, after every media outburst about Dr. Keyes, there is an upsurge in my patients’ application of home care plus an increase in awareness of periodon tal disease and requests for treat ment. . . . ALBERT ROLAND, DDS STATEN ISLAND, NY
Effects of epinephrine □ I read w ith interest “ A rte rial plasma epinephrine concentrations and hemodynam ic responses after dental injection of local anesthetic with epinephrine” by Dr. Tolas and others (January) and “Systemic effects of epinephrine-impregnated retrac tion cord in fixed partial denture prosthodontics” by Drs. Buchanan and Thayer (A pril).. . . In the article by Dr. Tolas and others, the following issues concern me. In general, the two groups of pa tients described were not treated sim i larly, at least as I understood the de sign of the study. In particular, no mention is made regarding the time of tooth extraction in both groups. The matched timing of this manipulation may be critical. It is unclear whether one or both groups received a second injection. The authors do cite a second injection in one group (paragraph 4), a local an esthetic with epinephrine. I am con cerned about a sim ilar treatment (placebo injection) in the other group. A lso, 2% lid o cain e is m uch less likely to produce profound local anes thesia compared with the preparation containing epinephrine, or compared w ith 3% mepivacaine or w ith 4% prilocaine (both without vasoconstric tors). Either one of the latter two agents may have been a better choice for the first injection. The lack of adequate
anesthesia could greatly influence the study. . . . In the Table, there is a very great dif ference between control values of plasma epinephrine in the two groups; . . . . If the reported palpitations were caused by excessive blood levels of epinephrine (endogenous or exogen ous), then the authors’ three- and five-minute time points for measure ment of plasma epinephrine concen tration may have been too late, espe cially because epinephrine has been reported to have a half-life of less than one minute.1,2 The fo llo w in g are my concerns about the article by Buchanan and Thayer. In Table 1, cardioacceleration is considered to be a beta-receptor effect, not an alpha-receptor effect.3 The enzymatic synthesis of epi nephrine has been well described, and it is not true that the exact mode of syn thesis of epinephrine is unknown. Adrenergic receptors are not located exclusively at myoneural junctions; for example, some are located at glan dular sites. Moreover, alpha and pos sibly beta receptors are also found on nerve endings and may influence the synthesis and release of the adrenergic neurotransmitter.3 T he e n z y m a t ic ste p s in th e metabolism of epinephrine are well characterized,3and it is untrue that the exact m echanism of e p inephrine metabolism is not fully known. . . . The authors have not convinced me that the use of racemic epinephrine is not dangerous and that in fact it is the preferred retraction system. Accepted Dental Therapeutics4 does not advise the use of this retraction system. . . . ALFRED E. CIARLONE, DDS, PhD AUGUSTA, GA 1. Lund, A. Elimination of adrenaline and noradrenaline from the organism. Acta Phar macol Toxicol 7:297,1951. 2. Lund, A. Release of adrenaline and norad renaline from the suprarenal gland. Acta Phar macol Toxicol 7:309, 1951. 3. Gilman, A.G.; Goodman, L.S.; and Gilman, A., eds. Goodman and Gilman’s the pharmacolog ical basis of therapeutics, ed 6. New York, Mac millan Publishing Co, Inc, 1980, pp 60, 72, 77. 4. Accepted Dental Therapeutics, ed 38. Chicago, American Dental Association, 1979, p 127.
Periodontal therapy □ In thé article “Changing concepts in periodontal therapy” (July), a ra-
LETTERS
TO
THE
E D IT O R
diograph (page 20) depicting occlusal trauma to a mandibular first molar with angular osseous defect and w id ened periodontal ligament space is presented. On closer inspection, the radiograph appears to be of a mandib ular second molar which occupies the space of a first molar; perhaps the an gular osseous defect could be from the incomplete uprighting of the second molar. No doubt occlusal trauma is occur ring, but let’s be accurate concerning the underlying cause.
zoster. The patient was a 75-year-old woman who came to the office one week after the onset of the painful le sion on her face. .. . Herpetic lesions were also present on the right side of her palate and upper lip and also noted on the right maxillary buccal gingival tissue. W ithin one month, healing had occurred w ith slight scarring and some slight residual pain. I realize it is difficult to accurately diagnose lesions from black and white reproduction of slides and apologize for any confusion this has caused.
E. WALTER WOLFORD, DDS, MPH ALBUQUERQUE
LAURENCE I. BARSH, DMD BOSTON
Jaw-closing muscles
Toothpaste component
□ In their interesting article, “Jaw d y s fu n c tio n in v io la and v io lin players” (June), Drs. Hirsch, McCall, and Bishop comment, “This finding of normal silent period durations of the jaw - closing m uscles was u n e x pected. . . . ” On the contrary, it ap pears to fit well with their other obser vations. Increased silent periods are found in those patients who overwork their jaw-closing muscles as they do in bruxing or clenching. In these instan ces, “the teeth were generally slightly apart” during playing. The burden of instrument support seems to be borne by the trapezius, sternocleidomastoid, lateral and medial pterygoids, and the digastric ipsilateral muscles. Their notable findings seem to be related to pressure on the right bilaminar zone, accounting for the pain, and to a possible change in form of the condyle, meniscus, or fossa (possibly all three) which would account for the clicking on the left side.
□ A n article in the August issue enti tled “Home treatment for dentinal hy persensitivity: a comparative study,” by Dr. Tarbet and others, referred to Thermodent toothpaste for sensitive teeth. In this article, it was indicated that Thermodent contains formaldehyde. Since January 1981, Thermodent has been marketed with 10% strontium chloride hexahydrate as the active in gredient. Thermodent does not now contain formaldehyde.
MILTON ARNOLD, DDS, MA DEPARTMENT OF ORAL MEDICINE NEW YORK UNIVERSITY DENTAL CENTER NEW YORK
Textbook review □ I was pleased with the review of my textbook, “Dental treatment planning for the adult patient,” that appeared in the July issue. However, I must comment on the statement: “It is virtually free of errors, with the exception of one mislabeled illustration, probably a basal cell car cinoma rather than herpes zoster.” This illustration, which appears on page 27 of the book, is indeed herpes 608 ■ JADA, Vol. 105, October 1982
JOHN A. DEVANEY, PhD TECHNICAL DIRECTOR MENTHOLATUM CO, INC BUFFALO, NY
Arm pain in dentist □ I read with interest the article by Drs. Adelman and Eisner, “Arm pain in a dentist: pronator syndrom e” (July). It was a good review of this syn drome and its differential diagnosis, pathogenesis, and treatment. Forearm pain is of special interest to dentists, and the authors explained its anatom ical basis w ell. This example of applied anatomy could have been en hanced if the reader were better oriented to their diagram. The case reported concerned a den tist with pronator syndrome in the right arm. What is shown in the dia gram is the left forearm. The interested reader would have been better served by the addition of three key words to the figure caption, “Anatomical rela tionship of the median nerve at the left elbow, anterior view.” This change and the correct spelling of “ulnar” would have improved the otherwise
excellent article. The authors are to be commended for their presentation of applied anatomy. SANDY C. MARKS, JR., DDS, PhD DEPARTMENT OF ANATOMY UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL WORCESTER, MASS
Pain of erupting teeth □ “There are 20 baby teeth. There are 28 adult teeth, not counting the four wisdom teeth. The 20 baby teeth hurt when they erupt. The four wisdom teeth hurt when they erupt. I’ve never heard any com plaint of pain with those other eight molars that just pop in. W hy do those other 24 teeth hurt when they erupt and not those other eight teeth?” One of my young patients, a mother for the first time, proposed these ques tions to me. Having been in practice for 52 years, I offered some explanation; however, I would appreciate a second or third opinion. IRVIN E. HENRY, DDS COLUMBUS, OHIO
□ There are no clear-cut answers to this series of questions. Several of our faculty members, two from pedodontics, two from oral diagnosis, and one from operative dentistry, helped to compile these replies. The 20 primary teeth do not all hurt when they erupt into the oral cavity. All agreed that the incisors and pri mary first molars usually cause pain when they erupt into the mouth, but the second molars and canines do not usually hurt. In regard to the third molars, it was agreed that they usually cause pain when they are partially erupted and mesially impacted. The consensus was that third molars with room to erupt into normal occlusion often do not hurt when they come into the mouth. It was also thought that the first and second molars occasionally cause pain when they erupt. They did not agree that “those other eight molars just pop in,” implying that they never cause pain. I hope that these observations and opinions would be shared by other ex perienced clinicians. JOSEPH M. GOWGIEL, DDS, PhD ASSOCIATE PROFESSOR AND CHAIRMAN, DEPARTMENT OF ANATOMY LOYOLA UNIVERSITY, CHICAGO
TO
THE E D IT O R
pancuronium-aminophylline interac tion. A recent case report1 details this adverse interaction that resulted in the development of paroxsymal atrial ta ch y cardia and c a n c e lla tio n of surgery. GER.ALD T. MCAULIFFE, DMD DEPARTMENT OF ANESTHESIA BOSTON CITY HOSPITAL BOSTON 1. Belani, K.G., and others. Adverse drug in teraction involving pancuronium and aminophylline. Anesth Analg 61(5):473-474, 1982.
Ectopically erupting molars □ I have an alternative to the tech nique described in “Correction of ec topically erupting maxillary perma nent first molars” by Dr. Garcia-Godoy (August). In 27 years of practice, I have seen only three cases of ectopic eruption, so I am not an expert. However, my treatment for the cases was the same: I used a 170L carbide bur and, on the primary second molar, made a distal slice on an inclined plane, avoiding the contact area. In each case the permanent first molar erupted into its proper position by sliding along the inclined plane. The primary molar was retained long enough so that the second premolar erupted uneventfully. The entire pro cedure was done without an anesthetic and took about 60 seconds. RICHARD S. UPPGAARD, DDS MINNEAPOLIS
Keyes technique □ I think it is time all the mystery and noise about the “Keyes technique” of periodontal therapy are dispelled.. . . Despite the “gimmickry” of the use of the phase microscope as a motiva tional tool, Dr. Keyes is promoting the time-tested techniques I was taught in the 1940s while a student in dental school.. .. One of the essential and understated p illa rs of the w hole therapy is still “careful and meticu lous- removal of all deposits from the root surfaces of the teeth leaving a smooth, plaquefree, highly polished root.” If my colleagues in periodontics (I am a generalist) would spend a day with Dr. Keyes and see the color slides of the cases he has treated, I think even they would be impressed by the one 606 ■ JADA, Vol. 105, October 1982
aspect of Dr. Keyes about which he is unduly modest. He is a superb techni cian. He uses Orban scalers, and the photographs I saw showed beautifully scaled and root-planed dentitions. .. . Dr. Keyes also evinced no objection to periodontal surgery when deposits were inaccessible or tissue architec ture required correction. I realize that the fact that Dr. Keyes has not published any of his studies in a journal of scientific repute and his use of television and other media to promote his technique offends many members of our profession. But I find that, after every media outburst about Dr. Keyes, there is an upsurge in my patients’ application of home care plus an increase in awareness of periodon tal disease and requests for treat ment. . . . ALBERT ROLAND, DDS STATEN ISLAND, NY
Effects of epinephrine □ I read w ith interest “ A rte rial plasma epinephrine concentrations and hemodynam ic responses after dental injection of local anesthetic with epinephrine” by Dr. Tolas and others (January) and “Systemic effects of epinephrine-impregnated retrac tion cord in fixed partial denture prosthodontics” by Drs. Buchanan and Thayer (A pril).. . . In the article by Dr. Tolas and others, the following issues concern me. In general, the two groups of pa tients described were not treated sim i larly, at least as I understood the de sign of the study. In particular, no mention is made regarding the time of tooth extraction in both groups. The matched timing of this manipulation may be critical. It is unclear whether one or both groups received a second injection. The authors do cite a second injection in one group (paragraph 4), a local an esthetic with epinephrine. I am con cerned about a sim ilar treatment (placebo injection) in the other group. A lso, 2% lid o cain e is m uch less likely to produce profound local anes thesia compared with the preparation containing epinephrine, or compared w ith 3% mepivacaine or w ith 4% prilocaine (both without vasoconstric tors). Either one of the latter two agents may have been a better choice for the first injection. The lack of adequate
anesthesia could greatly influence the study. . . . In the Table, there is a very great dif ference between control values of plasma epinephrine in the two groups; . . . . If the reported palpitations were caused by excessive blood levels of epinephrine (endogenous or exogen ous), then the authors’ three- and five-minute time points for measure ment of plasma epinephrine concen tration may have been too late, espe cially because epinephrine has been reported to have a half-life of less than one minute.1,2 The fo llo w in g are my concerns about the article by Buchanan and Thayer. In Table 1, cardioacceleration is considered to be a beta-receptor effect, not an alpha-receptor effect.3 The enzymatic synthesis of epi nephrine has been well described, and it is not true that the exact mode of syn thesis of epinephrine is unknown. Adrenergic receptors are not located exclusively at myoneural junctions; for example, some are located at glan dular sites. Moreover, alpha and pos sibly beta receptors are also found on nerve endings and may influence the synthesis and release of the adrenergic neurotransmitter.3 T he e n z y m a t ic ste p s in th e metabolism of epinephrine are well characterized,3and it is untrue that the exact m echanism of e p inephrine metabolism is not fully known. . . . The authors have not convinced me that the use of racemic epinephrine is not dangerous and that in fact it is the preferred retraction system. Accepted Dental Therapeutics4 does not advise the use of this retraction system. . . . ALFRED E. CIARLONE, DDS, PhD AUGUSTA, GA 1. Lund, A. Elimination of adrenaline and noradrenaline from the organism. Acta Phar macol Toxicol 7:297,1951. 2. Lund, A. Release of adrenaline and norad renaline from the suprarenal gland. Acta Phar macol Toxicol 7:309, 1951. 3. Gilman, A.G.; Goodman, L.S.; and Gilman, A., eds. Goodman and Gilman’s the pharmacolog ical basis of therapeutics, ed 6. New York, Mac millan Publishing Co, Inc, 1980, pp 60, 72, 77. 4. Accepted Dental Therapeutics, ed 38. Chicago, American Dental Association, 1979, p 127.
Periodontal therapy □ In thé article “Changing concepts in periodontal therapy” (July), a ra-
LETTERS
TO
THE
E D IT O R
diograph (page 20) depicting occlusal trauma to a mandibular first molar with angular osseous defect and w id ened periodontal ligament space is presented. On closer inspection, the radiograph appears to be of a mandib ular second molar which occupies the space of a first molar; perhaps the an gular osseous defect could be from the incomplete uprighting of the second molar. No doubt occlusal trauma is occur ring, but let’s be accurate concerning the underlying cause.
zoster. The patient was a 75-year-old woman who came to the office one week after the onset of the painful le sion on her face. .. . Herpetic lesions were also present on the right side of her palate and upper lip and also noted on the right maxillary buccal gingival tissue. W ithin one month, healing had occurred w ith slight scarring and some slight residual pain. I realize it is difficult to accurately diagnose lesions from black and white reproduction of slides and apologize for any confusion this has caused.
E. WALTER WOLFORD, DDS, MPH ALBUQUERQUE
LAURENCE I. BARSH, DMD BOSTON
Jaw-closing muscles
Toothpaste component
□ In their interesting article, “Jaw d y s fu n c tio n in v io la and v io lin players” (June), Drs. Hirsch, McCall, and Bishop comment, “This finding of normal silent period durations of the jaw - closing m uscles was u n e x pected. . . . ” On the contrary, it ap pears to fit well with their other obser vations. Increased silent periods are found in those patients who overwork their jaw-closing muscles as they do in bruxing or clenching. In these instan ces, “the teeth were generally slightly apart” during playing. The burden of instrument support seems to be borne by the trapezius, sternocleidomastoid, lateral and medial pterygoids, and the digastric ipsilateral muscles. Their notable findings seem to be related to pressure on the right bilaminar zone, accounting for the pain, and to a possible change in form of the condyle, meniscus, or fossa (possibly all three) which would account for the clicking on the left side.
□ A n article in the August issue enti tled “Home treatment for dentinal hy persensitivity: a comparative study,” by Dr. Tarbet and others, referred to Thermodent toothpaste for sensitive teeth. In this article, it was indicated that Thermodent contains formaldehyde. Since January 1981, Thermodent has been marketed with 10% strontium chloride hexahydrate as the active in gredient. Thermodent does not now contain formaldehyde.
MILTON ARNOLD, DDS, MA DEPARTMENT OF ORAL MEDICINE NEW YORK UNIVERSITY DENTAL CENTER NEW YORK
Textbook review □ I was pleased with the review of my textbook, “Dental treatment planning for the adult patient,” that appeared in the July issue. However, I must comment on the statement: “It is virtually free of errors, with the exception of one mislabeled illustration, probably a basal cell car cinoma rather than herpes zoster.” This illustration, which appears on page 27 of the book, is indeed herpes 608 ■ JADA, Vol. 105, October 1982
JOHN A. DEVANEY, PhD TECHNICAL DIRECTOR MENTHOLATUM CO, INC BUFFALO, NY
Arm pain in dentist □ I read with interest the article by Drs. Adelman and Eisner, “Arm pain in a dentist: pronator syndrom e” (July). It was a good review of this syn drome and its differential diagnosis, pathogenesis, and treatment. Forearm pain is of special interest to dentists, and the authors explained its anatom ical basis w ell. This example of applied anatomy could have been en hanced if the reader were better oriented to their diagram. The case reported concerned a den tist with pronator syndrome in the right arm. What is shown in the dia gram is the left forearm. The interested reader would have been better served by the addition of three key words to the figure caption, “Anatomical rela tionship of the median nerve at the left elbow, anterior view.” This change and the correct spelling of “ulnar” would have improved the otherwise
excellent article. The authors are to be commended for their presentation of applied anatomy. SANDY C. MARKS, JR., DDS, PhD DEPARTMENT OF ANATOMY UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL WORCESTER, MASS
Pain of erupting teeth □ “There are 20 baby teeth. There are 28 adult teeth, not counting the four wisdom teeth. The 20 baby teeth hurt when they erupt. The four wisdom teeth hurt when they erupt. I’ve never heard any com plaint of pain with those other eight molars that just pop in. W hy do those other 24 teeth hurt when they erupt and not those other eight teeth?” One of my young patients, a mother for the first time, proposed these ques tions to me. Having been in practice for 52 years, I offered some explanation; however, I would appreciate a second or third opinion. IRVIN E. HENRY, DDS COLUMBUS, OHIO
□ There are no clear-cut answers to this series of questions. Several of our faculty members, two from pedodontics, two from oral diagnosis, and one from operative dentistry, helped to compile these replies. The 20 primary teeth do not all hurt when they erupt into the oral cavity. All agreed that the incisors and pri mary first molars usually cause pain when they erupt into the mouth, but the second molars and canines do not usually hurt. In regard to the third molars, it was agreed that they usually cause pain when they are partially erupted and mesially impacted. The consensus was that third molars with room to erupt into normal occlusion often do not hurt when they come into the mouth. It was also thought that the first and second molars occasionally cause pain when they erupt. They did not agree that “those other eight molars just pop in,” implying that they never cause pain. I hope that these observations and opinions would be shared by other ex perienced clinicians. JOSEPH M. GOWGIEL, DDS, PhD ASSOCIATE PROFESSOR AND CHAIRMAN, DEPARTMENT OF ANATOMY LOYOLA UNIVERSITY, CHICAGO