- Email: [email protected]
Response to criticism
received as the 1975 A D A prevention aw ard winner. T he conclusion, how ever, that these protocols for delivering and re porting the services to dental insurers will allow effective underw riting of com prehensive preventive care is flawed. T he problem rem ains. Preventive care is insurable not in how well doc um ented is the process, but how ef fective are the outcom es. T he dental insurance industry is still searching for the key to under writing the kind o f com prehensive preventive care D r. N izel describes. T he sad fact is that the task of moti vating the dental patient to learn a w hole new approach to maintaining his/her ow n oral health is probably effective (meaning a perm anent beha vior change) with no m ore than 20% o f the patients who are exposed to the inform ation. From the viewpoint of effective outcom es, an 80% failure rate will rem ain unacceptable to the u nderw riters, if it means that many dental services are reim bursed by the insurer with no observable change in the p atient’s health status. I t’s clear that the profession of den tistry and the dental insurers need to mutually support a wide range of oral health educational efforts in and out o f the dental office. Many people—at the tim e they becom e covered by den tal insurance—are very open to learn ing about w hat benefits they have. It may be at this moment that they are particularly susceptible to a persua sive m essage about preventive dental care. JA M E S B O U M A N B L U E CROSS O F W IS C O N S IN M IL W A U K E E
H a m h u n tin g
■ I would like to contact other prac ticing dentists who are also am ateur radio operators in order to engage in discussions of unusual or interesting clinical or practice m anagem ent prob lems via radio. My address is: RAY B A R N U M , D M D (W A 4 M F T ) L U L A RO A D H O M E R , GA 30547
C ritica l o f article
■ I agree fully with the sentim ents expressed in D r. H arold B ayne’s let ter to the editor in the June j a d a in w hich he criticizes the unscientific statem ents in the article by A llen, E verett, and Butler titled, “ H um an cardiorespiratory and analgesic ef fects of intravenous diazepam and local an esthesia,” w hich appeared in the April j a d a . I have em ployed diazepam , methohexital, and local in thousands of pa tients. If the doses of diazepam and m ethohexital are m aintained within the am nesic range and not within the anesthetic range, the entire content of the A llen-E verett-B utler article becom es misleading and unscientific (based on 12 patients). SY L V A N M . S H A N E , D D S B A L T IM O R E
R e s p o n s e to criticism m M y initial reaction to the letter by
D r. H arold Bayne in the June j a d a regarding the use of the anesthetic technique in which he uses diazepam , m ethohexital, together with local anesthesia, was one o f delight. H ow ever, it then turned to disappointm ent w hen I recalled a p art of th e pledge he m ade on joining the A m erican Society of Oral Surgeons, “ . . . and to render help willingly to my colleagues.” If, indeed, he had been following this pledge, rath er than utilizing time in unw arranted criticism of t h e j o u r n a l , he would have seen fit to sum m arize th e 50,000 cases w hich he has perform ed. It would have been of im m ense value to his colleagues to know w hat his m orbidity and com pli cations w ere. A review o f his tech nique, blood pressure and pulse changes, incidence of pain, and throm bophlebitis at the injection site would have given m ore help to his beginning colleagues. All drugs are no safer than their adm inistrator, but it is of little benefit to a beginner when he asks for the dosage o f a drug to reply with that well-worn truism o f experience,
516 ■ LETTERS TO THE EDITOR / JADA, Vol. 93, September 1976
“ enough.” With this vast store of clinical m aterial, it would perhaps be m ore in keeping with the concepts of the A m erican Society of O ral Sur geons for one to devote m ore o f his tim e to sharing his knowledge. GERALD D. A LL EN , MD PR O FE SSO R , U N IV O F C A L IF LOS A N G E L E S
Q u e stio n s C o u n c il rep o rt
■ T he Council on D ental M aterials and D evices is to be congratulated on adopting its new form at ( j a d a , M arch 1976) for reporting d o ’s and d o n ’ts in the use of com posites for the wet-fin gered dentist. H ow ever, in the M arch rep o rt there seem ed to be several dis crepancies. In the do category, the authors suggest to “ rem ove excess m aterial in contour and overextension” and to “ adjust contour and rem ove overex tension of material as req u ired .” In betw een these tw o sentences is, “ maintain glossy surface im parted by m atrix when contour is c o rrec t.” I have never seen an operator who could place a com posite with such precision as to not require rem oval of excess. It could be said th at he is lucky to n e e d to rem ove excess and adjust contour, because the “ glossy surface im parted by the m atrix” is the m ost transitory surface that he could leave —it is resin-rich and abrades away rapidly as suggested by the adm on ishm ent, “ don’t attem pt to ‘polish’ . . . by usual metallic or unfilled resin techniques.” This low-abrasionresistant surface, under the m atrix, has been reported to be so soft that even a few dozen brushing strokes will visibly dull its luster, and this sur face rapidly disappears as determ ined by scanning electron micrographs. A point of definition is perhaps all th at is necessary here: “ D o n ’t use a film-forming cavity varnish for pulp p ro tectio n .” Prim ate studies of our own have show n a calcium hydroxidefilled liner (hydroxyline) to protect the pulp. It perhaps isn’t quite a var nish but is too thin to be called a base. T h ere is no do rem onstrance to pro tect the dentin from acid etching; I feel that this should be considered as a “ m ust d o ” for the happy patient.
H a m h u n tin g
■ I would like to contact other prac ticing dentists who are also am ateur radio operators in order to engage in discussions of unusual or interesting clinical or practice m anagem ent prob lems via radio. My address is: RAY B A R N U M , D M D (W A 4 M F T ) L U L A RO A D H O M E R , GA 30547
C ritica l o f article
■ I agree fully with the sentim ents expressed in D r. H arold B ayne’s let ter to the editor in the June j a d a in w hich he criticizes the unscientific statem ents in the article by A llen, E verett, and Butler titled, “ H um an cardiorespiratory and analgesic ef fects of intravenous diazepam and local an esthesia,” w hich appeared in the April j a d a . I have em ployed diazepam , methohexital, and local in thousands of pa tients. If the doses of diazepam and m ethohexital are m aintained within the am nesic range and not within the anesthetic range, the entire content of the A llen-E verett-B utler article becom es misleading and unscientific (based on 12 patients). SY L V A N M . S H A N E , D D S B A L T IM O R E
R e s p o n s e to criticism m M y initial reaction to the letter by
D r. H arold Bayne in the June j a d a regarding the use of the anesthetic technique in which he uses diazepam , m ethohexital, together with local anesthesia, was one o f delight. H ow ever, it then turned to disappointm ent w hen I recalled a p art of th e pledge he m ade on joining the A m erican Society of Oral Surgeons, “ . . . and to render help willingly to my colleagues.” If, indeed, he had been following this pledge, rath er than utilizing time in unw arranted criticism of t h e j o u r n a l , he would have seen fit to sum m arize th e 50,000 cases w hich he has perform ed. It would have been of im m ense value to his colleagues to know w hat his m orbidity and com pli cations w ere. A review o f his tech nique, blood pressure and pulse changes, incidence of pain, and throm bophlebitis at the injection site would have given m ore help to his beginning colleagues. All drugs are no safer than their adm inistrator, but it is of little benefit to a beginner when he asks for the dosage o f a drug to reply with that well-worn truism o f experience,
516 ■ LETTERS TO THE EDITOR / JADA, Vol. 93, September 1976
“ enough.” With this vast store of clinical m aterial, it would perhaps be m ore in keeping with the concepts of the A m erican Society of O ral Sur geons for one to devote m ore o f his tim e to sharing his knowledge. GERALD D. A LL EN , MD PR O FE SSO R , U N IV O F C A L IF LOS A N G E L E S
Q u e stio n s C o u n c il rep o rt
■ T he Council on D ental M aterials and D evices is to be congratulated on adopting its new form at ( j a d a , M arch 1976) for reporting d o ’s and d o n ’ts in the use of com posites for the wet-fin gered dentist. H ow ever, in the M arch rep o rt there seem ed to be several dis crepancies. In the do category, the authors suggest to “ rem ove excess m aterial in contour and overextension” and to “ adjust contour and rem ove overex tension of material as req u ired .” In betw een these tw o sentences is, “ maintain glossy surface im parted by m atrix when contour is c o rrec t.” I have never seen an operator who could place a com posite with such precision as to not require rem oval of excess. It could be said th at he is lucky to n e e d to rem ove excess and adjust contour, because the “ glossy surface im parted by the m atrix” is the m ost transitory surface that he could leave —it is resin-rich and abrades away rapidly as suggested by the adm on ishm ent, “ don’t attem pt to ‘polish’ . . . by usual metallic or unfilled resin techniques.” This low-abrasionresistant surface, under the m atrix, has been reported to be so soft that even a few dozen brushing strokes will visibly dull its luster, and this sur face rapidly disappears as determ ined by scanning electron micrographs. A point of definition is perhaps all th at is necessary here: “ D o n ’t use a film-forming cavity varnish for pulp p ro tectio n .” Prim ate studies of our own have show n a calcium hydroxidefilled liner (hydroxyline) to protect the pulp. It perhaps isn’t quite a var nish but is too thin to be called a base. T h ere is no do rem onstrance to pro tect the dentin from acid etching; I feel that this should be considered as a “ m ust d o ” for the happy patient.