- Email: [email protected]
Temporary teeth?
they contacted. As cities grew , man established the reservoir w ater sup ply. R eservoirs are essentially rain w ater collected from short runoffs and devoid of minerals. D uring the process of supplying this “ b etter” source of w ater, it was 50 years before chlorination was intro duced to eliminate disease carried by the water. A bout ten years later, alum was added to clear the sediment. Both events w ere accom panied by public uproar. Man and his reservoirs inadvert ently took fluoride out of w ater. F luo ride is an essential elem ent, as is io dine. Leave iodine out of one’s diet and the result is endem ic goiter. Chlo rine, iodine, and fluorine all are essen tial to life. T he hard tissues of bone and teeth are basically mineral in con tent, as much as 99% mineral. F luo ride as found in natural w ater is one of the essential elem ents that assists form ation of hard tissues. In recent years, research has shown a direct relationship betw een the in gestion of fluoride and dental disease. W hen fluoride was taken from birth on, dental disease was 60% less evi dent than w hen fluoride was absent. A n ideal am ount has been determ ined, and m ost m ajor cities in the U nited States have adjusted their w ater sup plies to m eet this recom m ended am ount. N ine states have enacted legislation mandating the fluoride ad ju stm ent of m ajor w ater supplies. Countries such as Chile and Ireland also have made adjustm ents. The World H ealth O rganization endorses fluoridation of public w ater supplies. G od put fluoride into the w ater and man inadvertently took it out. T here are sins of om ission and sins of com mission. O rganized dentistry has for many years recom m ended the “ ad ju sted fluoridation” of com munal wa te r supplies as intended by nature. Know the truth, and the truth shall make you free. L E E A . K R IM M E R , D D S O R A D E L L , NJ
On high b lo o d pressu re m We desire to com m ent on Louis M.
A b b ey’s article, “ Screening for hy
pertension in the dental office,” in the M arch j a d a (page 563). D r. A bbey is to be congratulated for his tim ely and provocative contribution to our litera ture on high blood pressure detection. T he following com m ents, how ever, seem appropriate: 1. It is now widely recognized that the criteria used for classifying a sus pected hypertensive will vary with age and h istory.1A blood pressu re reading could be pathological in an 18-year-old and not in a 75-year-old. E xperts do not use ope fixed criterion for defining high blood pressure in individuals. N o r should we, regardless of w hether our goal is a study or a referral. It is true that we and many others have made this m istake in the p ast.2-3 H ow ever, in the future, researchers should adopt variable criteria by age and his tory. This w ould reduce our falsepositive and false-negative rates, a very necessary objective. 2. O ur data also hint that some re ferral m ethods may be handicapping the execution of otherw ise effective screening program s. H aving been trained in blood pressure detection, dentists who had indicated th at they would participate in the H B P program were asked to choose which of the fol lowing statem ents m ost closely de scribed their contem plated referral procedure: — I would be inclined to inform the patient of his sustained blood pressure elevation and recom m end a medical consultation; or —I would be inclined to inform the patient of his sustained blood pressure elevation, obtain the p atien t’s consent to phone his physician, and then dis cuss my readings with his medical doc tor. Should the physician wish to see the patient, an appointm ent would be arranged. They voted in a ratio of seven to one for the first statem ent. We suggest that should dentists per sist in this attitude, they may refer many patients inaccurately, possibly provoke the w rath of some normotensive patients and their physicians, and have a low er follow-through rate for medical consultations than would have occurred if appointm ents were arranged. This issue of referral procedures
1242 ■ LETTER S TO THE EDITOR / JADA, V ol. 88, J u n e 1974
should be studied u n d er carefully con trolled conditions. Several dentists have left our program because of “ flack” they received from patients and physicians. H ow ever, they all were referring patients in accordance with the first statem ent, despite our repeated requests th at they follow the other procedure. T o o u r knowledge, all who have followed th e second pro cedure are still with the program. D rs. Stokes, Payne, and Cooper from the N ational H ea rt and Lung In stitute recently suggested “ the use of every health care facility to screen every patient (for H B P ), together with conscientious education, referral, and followup study. . . . ” 4 We m ust realize th at calling the p a tien t’s physician is an essential fea ture of this screening procedure which dentists have been called on to p er form. F urtherm ore, consultation de notes a caring attitude arid a desire to heal. In our opinion, this w as largely responsible for the high level of refer ral success and patient receptiveness we experienced in o u r stu d y .2 CHARLES L. BER M A N , DDS M IC H A E L A. G U A R IN O SH IR L E Y M . G IQ V A N N E L L I, RN H A C K E N SA C K , NJ
1. Finnerty, F. Rem arks prepared for the New Jersey C onference on High Blood Pres sure, March 20, 1974. T h e C itizens for the Treatm ent
of
High
B loofi
Pressure,
Inc.,
Chevy Chase, Md. 2. Guarino, M.A.; Giovannelli, S.M .; Ber man, C.L. Hypertension detection by den tists. H ea lth S erv Rep 88:291 April 1973. 3. United States N ational C en ter for Health Statistics. Heart disease
in adults: United
States, 1960-1962. (PHS Pub No. 1000, Series 11, No. 6) W ashington, Govt Print Off, 1964. 4. Stokes, J.B.; Payne, G.H.; Cooper, T. Hypertension control— the challenge of pa tient education, N ew E n g l J M e d 289:1369 D ec 20, 1973.
T em porary teeth ?
■ It is a m ost unusual coterie of den tists that R obert O. N ara associates with (M arch j a d a , page 465). F o rtu nately, I have not m et any dentist who would fit his statem ent, “ 95% of den tists presum e that teeth are tem po ra ry .” I doubt that 95% of D r. N a ra ’s
class at the U niversity of M ichigan dental school was taught that. If th e object of his letter w as to cam paign for reciprocity as in his opening paragraph, his statem ents give strong evidence for the usefulness of state boards. C ertainly, any dentist who feels “ teeth are tem porary” is not desirable to serve the public o f my state. T he printed report of the T ask F o rce on N ational H ealth Program s of the A D A (Sept 1971 j a d a ) contains none of the statistical m aterial referred to by D r. N ara. H is com m ents on de livery of care and dental licensure al luding to th e T ask F orce report stand in p o or alignm ent with the direct quotes from the report: “ W e believe the m ost damaging policy would be to focus attention and funds solely on the delivery of care while at the same tim e neglecting pre ventive m easures, m anpow er, and re search. “ We could find no evidence that in dividual state licensure exam inations significantly affect the distribution of dental m anpow er in the U nited S tates, although w e are aw are of instances in w hich individual dentists have regis tered prejudicial com plaints after their failure to pass such exam inations. We believe th at the integrity of state boards of dental exam iners should be p reserved, but we think state boards should give m ore attention than they now do to their responsibility for con tinually evaluating the qualifications of licensed personnel. In ou r view, the initial licensure of applicants to prac tice is no m ore im portant than is cred ible recertification.” In regard to com m ents on the Brit ish system and “ the grass is greener” syndrom e, there is an interesting quote from the British D en ta l Journal in the M arch 1974 issue o f D e n ta l S u r vey:
“ A further possibility,” he said, “ is w orth attention by authority, never slow to consider new and better ways to control the profession. This is in spired by conditions for practicing in m any states of the U S A . A dentist qualified in one state cannot, in most cases, practice in another w ithout tak ing an exam ination there. . . . W hat could be m ore simple than to intro
duce a like system here, and so supply the N o rth with an adequate num ber of dentists. . . . ” J. H A L D A N E SO U T A R , D D S M IA M I SH O R E S, FL A
■ In answ er to R obert O. N a ra ’s let ter, you simply cannot com pare our “ m arvelous” health care delivery sys tem with N ew Z ealand’s without also com paring life style and diet. If you com pared all socialized pro grams of health care delivery system s, as well as dietary intake and social and cultural habits, our health delivery system may come out better than you think. Y ou also may w onder why statistics not only show that the average num ber of missing teeth is increasing with age, but also that there are m ore people with diabetes, arthritis, and arterio sclerotic heart disease. I t’s not the health care delivery sys tem th a t’s at fault. If we d o n ’t recognize the problem , it will never be solved—no m atter w hat health care delivery system you use—and a lot of valuable tim e will be wasted. j K EV IN W . T O A L , D D S JE N N IN G S , MO
Fine editorial
■ Y ou are to be com m ended for the fine editorial in the M arch j a d a (page 449) entitled “ Include me o u t?” W hy c a n ’t we have more articles as well as editorials pertaining to the subject of third party and govern m ent intervention in dentistry? We need to have m ore discussion on these m atters fo r the sake of our patients as well as the profession. T he profession can and will “ help it w ork,” as your editorial adm on ished, if more leadership and know l edge is m ade available. G L E N N C. M cG O U IR K , D D S FO R T W O R T H , TE X
C are o f the sick m L et’s call sick care w hat it is— sick. We get people who need help because health has failed. M aybe everybody
1244 ■ LETTER S TO TH E EDITOR / JAD A, V o l. 88, J u n e 1974
could look at a big, broad picture of w hy health fails, and point fingers and assum e responses so th at it w on’t fail. H ealth m aintenance should be based o n a balance of nutrition (social ized farming), good shelter (socialized housing), and exercise (socialized rec reation). We are only a m icrodot in th at pic ture, so stop expecting the sick pro viders to solve the problem s of the uni verse; nobody else has. W e do a darn good jo b at patching up the products of the nonhealth m aintenance of the system . We ain’t the system . W e are prisoners of it like everyone else. L E O N B R O D IS , D D S B R A D F O R D , PA
S u g a r a t b reakfast • T he article on cariogenicity of reg ular and presw eetened cereals (April j a d a , page 807) was w elcom e and valuable. H ow ever, I think it is still wise to discourage consum ption of sugar at breakfast, despite the rep o rt ed lack of an association betw een p re sw eetened cereal and caries. If a relatively sugarfree breakfast is eaten, a person will not only reduce his frequency of exposure to sugar but will avoid an initial high blood sugar level followed by a sharp decrease. T his avoids a craving for a mid-moming sugary snack, fu rth er reducing the frequency of exposure to sucrose. O bviously, carbohydrates are im p o rtan t for good nutrition, but they should be in the form of starch which provides energy and vitamins rather than sugar. M IC H A E L C. W O L F , D D S F A IR L E IG H D IC K IN S O N U N IV E R S IT Y D E N T A L SC H O O L
D e n tistry a n d the A D A m Solom on H olland’s letter (April , page 691) was brief, but many may have picked up som e deeply felt vibrations about the A D A . D entistry, obviously, needs an or ganization, and calling it the A m erican D ental A ssociation is appropriate enough. But, dentistry does not need the A D A that exists today. This group
ja d a
On high b lo o d pressu re m We desire to com m ent on Louis M.
A b b ey’s article, “ Screening for hy
pertension in the dental office,” in the M arch j a d a (page 563). D r. A bbey is to be congratulated for his tim ely and provocative contribution to our litera ture on high blood pressure detection. T he following com m ents, how ever, seem appropriate: 1. It is now widely recognized that the criteria used for classifying a sus pected hypertensive will vary with age and h istory.1A blood pressu re reading could be pathological in an 18-year-old and not in a 75-year-old. E xperts do not use ope fixed criterion for defining high blood pressure in individuals. N o r should we, regardless of w hether our goal is a study or a referral. It is true that we and many others have made this m istake in the p ast.2-3 H ow ever, in the future, researchers should adopt variable criteria by age and his tory. This w ould reduce our falsepositive and false-negative rates, a very necessary objective. 2. O ur data also hint that some re ferral m ethods may be handicapping the execution of otherw ise effective screening program s. H aving been trained in blood pressure detection, dentists who had indicated th at they would participate in the H B P program were asked to choose which of the fol lowing statem ents m ost closely de scribed their contem plated referral procedure: — I would be inclined to inform the patient of his sustained blood pressure elevation and recom m end a medical consultation; or —I would be inclined to inform the patient of his sustained blood pressure elevation, obtain the p atien t’s consent to phone his physician, and then dis cuss my readings with his medical doc tor. Should the physician wish to see the patient, an appointm ent would be arranged. They voted in a ratio of seven to one for the first statem ent. We suggest that should dentists per sist in this attitude, they may refer many patients inaccurately, possibly provoke the w rath of some normotensive patients and their physicians, and have a low er follow-through rate for medical consultations than would have occurred if appointm ents were arranged. This issue of referral procedures
1242 ■ LETTER S TO THE EDITOR / JADA, V ol. 88, J u n e 1974
should be studied u n d er carefully con trolled conditions. Several dentists have left our program because of “ flack” they received from patients and physicians. H ow ever, they all were referring patients in accordance with the first statem ent, despite our repeated requests th at they follow the other procedure. T o o u r knowledge, all who have followed th e second pro cedure are still with the program. D rs. Stokes, Payne, and Cooper from the N ational H ea rt and Lung In stitute recently suggested “ the use of every health care facility to screen every patient (for H B P ), together with conscientious education, referral, and followup study. . . . ” 4 We m ust realize th at calling the p a tien t’s physician is an essential fea ture of this screening procedure which dentists have been called on to p er form. F urtherm ore, consultation de notes a caring attitude arid a desire to heal. In our opinion, this w as largely responsible for the high level of refer ral success and patient receptiveness we experienced in o u r stu d y .2 CHARLES L. BER M A N , DDS M IC H A E L A. G U A R IN O SH IR L E Y M . G IQ V A N N E L L I, RN H A C K E N SA C K , NJ
1. Finnerty, F. Rem arks prepared for the New Jersey C onference on High Blood Pres sure, March 20, 1974. T h e C itizens for the Treatm ent
of
High
B loofi
Pressure,
Inc.,
Chevy Chase, Md. 2. Guarino, M.A.; Giovannelli, S.M .; Ber man, C.L. Hypertension detection by den tists. H ea lth S erv Rep 88:291 April 1973. 3. United States N ational C en ter for Health Statistics. Heart disease
in adults: United
States, 1960-1962. (PHS Pub No. 1000, Series 11, No. 6) W ashington, Govt Print Off, 1964. 4. Stokes, J.B.; Payne, G.H.; Cooper, T. Hypertension control— the challenge of pa tient education, N ew E n g l J M e d 289:1369 D ec 20, 1973.
T em porary teeth ?
■ It is a m ost unusual coterie of den tists that R obert O. N ara associates with (M arch j a d a , page 465). F o rtu nately, I have not m et any dentist who would fit his statem ent, “ 95% of den tists presum e that teeth are tem po ra ry .” I doubt that 95% of D r. N a ra ’s
class at the U niversity of M ichigan dental school was taught that. If th e object of his letter w as to cam paign for reciprocity as in his opening paragraph, his statem ents give strong evidence for the usefulness of state boards. C ertainly, any dentist who feels “ teeth are tem porary” is not desirable to serve the public o f my state. T he printed report of the T ask F o rce on N ational H ealth Program s of the A D A (Sept 1971 j a d a ) contains none of the statistical m aterial referred to by D r. N ara. H is com m ents on de livery of care and dental licensure al luding to th e T ask F orce report stand in p o or alignm ent with the direct quotes from the report: “ W e believe the m ost damaging policy would be to focus attention and funds solely on the delivery of care while at the same tim e neglecting pre ventive m easures, m anpow er, and re search. “ We could find no evidence that in dividual state licensure exam inations significantly affect the distribution of dental m anpow er in the U nited S tates, although w e are aw are of instances in w hich individual dentists have regis tered prejudicial com plaints after their failure to pass such exam inations. We believe th at the integrity of state boards of dental exam iners should be p reserved, but we think state boards should give m ore attention than they now do to their responsibility for con tinually evaluating the qualifications of licensed personnel. In ou r view, the initial licensure of applicants to prac tice is no m ore im portant than is cred ible recertification.” In regard to com m ents on the Brit ish system and “ the grass is greener” syndrom e, there is an interesting quote from the British D en ta l Journal in the M arch 1974 issue o f D e n ta l S u r vey:
“ A further possibility,” he said, “ is w orth attention by authority, never slow to consider new and better ways to control the profession. This is in spired by conditions for practicing in m any states of the U S A . A dentist qualified in one state cannot, in most cases, practice in another w ithout tak ing an exam ination there. . . . W hat could be m ore simple than to intro
duce a like system here, and so supply the N o rth with an adequate num ber of dentists. . . . ” J. H A L D A N E SO U T A R , D D S M IA M I SH O R E S, FL A
■ In answ er to R obert O. N a ra ’s let ter, you simply cannot com pare our “ m arvelous” health care delivery sys tem with N ew Z ealand’s without also com paring life style and diet. If you com pared all socialized pro grams of health care delivery system s, as well as dietary intake and social and cultural habits, our health delivery system may come out better than you think. Y ou also may w onder why statistics not only show that the average num ber of missing teeth is increasing with age, but also that there are m ore people with diabetes, arthritis, and arterio sclerotic heart disease. I t’s not the health care delivery sys tem th a t’s at fault. If we d o n ’t recognize the problem , it will never be solved—no m atter w hat health care delivery system you use—and a lot of valuable tim e will be wasted. j K EV IN W . T O A L , D D S JE N N IN G S , MO
Fine editorial
■ Y ou are to be com m ended for the fine editorial in the M arch j a d a (page 449) entitled “ Include me o u t?” W hy c a n ’t we have more articles as well as editorials pertaining to the subject of third party and govern m ent intervention in dentistry? We need to have m ore discussion on these m atters fo r the sake of our patients as well as the profession. T he profession can and will “ help it w ork,” as your editorial adm on ished, if more leadership and know l edge is m ade available. G L E N N C. M cG O U IR K , D D S FO R T W O R T H , TE X
C are o f the sick m L et’s call sick care w hat it is— sick. We get people who need help because health has failed. M aybe everybody
1244 ■ LETTER S TO TH E EDITOR / JAD A, V o l. 88, J u n e 1974
could look at a big, broad picture of w hy health fails, and point fingers and assum e responses so th at it w on’t fail. H ealth m aintenance should be based o n a balance of nutrition (social ized farming), good shelter (socialized housing), and exercise (socialized rec reation). We are only a m icrodot in th at pic ture, so stop expecting the sick pro viders to solve the problem s of the uni verse; nobody else has. W e do a darn good jo b at patching up the products of the nonhealth m aintenance of the system . We ain’t the system . W e are prisoners of it like everyone else. L E O N B R O D IS , D D S B R A D F O R D , PA
S u g a r a t b reakfast • T he article on cariogenicity of reg ular and presw eetened cereals (April j a d a , page 807) was w elcom e and valuable. H ow ever, I think it is still wise to discourage consum ption of sugar at breakfast, despite the rep o rt ed lack of an association betw een p re sw eetened cereal and caries. If a relatively sugarfree breakfast is eaten, a person will not only reduce his frequency of exposure to sugar but will avoid an initial high blood sugar level followed by a sharp decrease. T his avoids a craving for a mid-moming sugary snack, fu rth er reducing the frequency of exposure to sucrose. O bviously, carbohydrates are im p o rtan t for good nutrition, but they should be in the form of starch which provides energy and vitamins rather than sugar. M IC H A E L C. W O L F , D D S F A IR L E IG H D IC K IN S O N U N IV E R S IT Y D E N T A L SC H O O L
D e n tistry a n d the A D A m Solom on H olland’s letter (April , page 691) was brief, but many may have picked up som e deeply felt vibrations about the A D A . D entistry, obviously, needs an or ganization, and calling it the A m erican D ental A ssociation is appropriate enough. But, dentistry does not need the A D A that exists today. This group
ja d a