It was m ost deplorable to note that in their survey, 6 out of 18 patients receiving dental treatment (patients with prosthetic heart valves) did not receive any antibiotic coverage by the dentist for the prevention of endocar ditis. From these figures, it is obvious that dentists are still unaware of the need for antibiotic chemoprophylaxis in patients with cardiovascular dis orders undergoing dental procedures. Dentists should be aware of the fact that planned dental and oral surgi cal procedures may result in a transi tory bacteremia, which in turn initi ates a bacterial endocarditis. The oral cavity is the primary source of poten tially pathogenic organisms for all patients with structural heart disease (congenital or rheumatic). The highest level of oral health possible should be maintained in these patients, with periodontal and carious pathosis avoided by professional dental care. Antibiotic prophylaxis should be the sine qua non for all dental procedures in these individuals. My colleagues again are reminded that the organisms most likely to be the culprits in orally engendered en docarditis are the notorious S trepto cocci viridans against which penicil lin is the drug of choice at this time. In conclusion, all dentists, physi cians, and patients are reminded that any device or cardiovascular disease that the patient has (eg, valvular heart disease, previous episodes of endo carditis, shunts for hemodialysis, in tracardiac prosthesis, or pacemaker) may predispose to endocarditis. In these patients, antibiotic chemopro phylaxis is the most reasonable ap proach for the prevention of transient bacteremia and bacterial endocarditis. GEORGE M. MATSUMOTO, DDS CHIEF, DENTAL SERVICE COTY HOSPITAL LINCOLN DEVELOPMENT CENTER LINCOLN, ILL
■ Hopefully, those who read the arti cle on antibiotic prophylaxis in the Novem ber j a d a will read more than the little green box. It is unfortunate that with only 11 cases of endocarditis the authors are willing to recommend a definitive reg imen for prophylaxis. N one of the 11 cases even involved a patient with a
gram-negative organism which, un fortunately, is found in the endocar ditis patient with prosthetic heart valves. From their own statistics, they show that only 5 of 8 (62.5%) of the organisms in these patients were sensitive to penicillin. Without even getting into the com plexities of prophylaxis for prosthetic heart valve patients, I certainly would include an antibiotic that covers peni cillin-resistant organisms.
sonnel. The dentist who treats this patient must have a similar degree of knowledge in his special area of health care. A s the authors state, the combin ation o f penicillin and streptomycin appears to be most effective in pre venting this potentially lethal compli cation. The patient should not be denied this treatment simply because the dentist may not have the partic ular drug in his office.
JOHN M. ALEXANDER, DDS VIRGINIA COMMONWEALTH UNIV
LARRY J. PETERSON, DDS
RICHMOND
■ The paper entitled, “ Antibiotic prophylaxis for endocarditis in pa tients with a prosthetic heart valve” is a timely one indeed. Many pros thetic heart valves are successfully placed each year, and most of these patients now survive and thus require dental care following cardiac rehabil itation. In view of the fact that an infec ted prosthetic valve results in death in the majority of cases, recommen dations for prophylaxis of prosthetic valve endocarditis should be clear and unequivocal. However, the guidelines proposed by Dr. J. T. Santinga and associates for antibiotic prophylaxis seem inconsistent and contradictory. Using information gathered from an experimental model and, in fact, from their own group of patients with prosthetic valve endocarditis, the authors state that penicillin and streptomycin may be a more effective prophylactic regimen than penicillin alone. Surprisingly, they do not rec ommend this drug combination for outpatient dental procedures “ be cause it (streptomycin) is not avail able in most dentist’s offices . . . ” H owever, they do recommend both drugs for hospitalized patients. The patient with a prosthetic heart valve is clearly a high-risk patient who must receive excellent dental care if he is to avoid cardiac compli cations. If the dentist from whom the patient requests treatment is not pre pared to deliver it, (i.e. to use proper antibiotic prophylaxis) then the pa tient should be referred elsewhere. A prosthetic valve is placed by a team of highly trained, highly skilled per
24 ■ LETTERS TO THE EDITOR / JADA, Vol. 94, January 1977
UNIV OF CONNECTICUT FARMINGTON
‘Critical’ o f techniques ■ With reference to “ Evaluation of alternative alloys to type III gold for use in fixed prosthodontics,” Drs. D . A. Nitkin and K. Asgar, Septem ber j a d a (page 622), we offer the fol lowing comments. The article proved to be very in formative in pointing out that basic differences do exist in the behavior of the types of alloys that were tested— gold-based, semiprecious, and non precious. We agree with the stated conclu sion that the gold-based alloys repre sent a standard for comparison in terms o f the ease of casting and ob taining accurate fit. We also agree with the observation that the semi precious alloys do behave in a more gold-like manner in these respects than do the nonprecious crown and bridge alloys. We wish to note, however, that the “ optimum conditions for waxing, melting, investing, and casting” re ferred to in the publication were, in fact, not optimum in regard to the processing of Howmedica III alloy. We are critical o f several points of the techniques employed in casting the Howmedica III alloy. In particu lar, the use of 10- and 12-gauge sprues is contrary to the recommendation of the Howmedica III technique which describes the use of 8-gauge sprues. A lso, the length of the sprues used for Howmedica III alloy appears to be excessive in terms of our own rec ommendations . . . at least, by com parison with the sprues remaining on
the Type III and Forticast alloys as shown in Figure 3. The use of larger diameter (8-gauge) sprues of shorter length than those recommended in the “gold alloy” spruing technique is necessary due to the lower density o f the nonprec ious alloys, and also due to the greater differential between metal and invest ment mold temperatures which exists with the nonprecious alloys versus gold-based or semiprecious alloys. If smaller sprues are used, filling of the mold becom es difficult and the alloy also is chilled during its entry into the mold, making the attainment of a com plete and sharp margin difficult. We also wish to note that the article does not adequately describe the in vesting and burnout processes which were utilized. For example, the H ow medica III technique relates to the use o f split rings or a double layer of asbestos to obtain proper expansion; no mention of this is made in the article. We believe it important to observe that the nonprecious alloys do, in fact, behave differently than the gold-based alloys, and it is the realization of this fact which sometimes necessitates technique modifications similar to those mentioned. The results of Nitkin and Asgar confirm this and we find the publication of the article to be valuable in making this distinction. RONALD P. DUDEK JOHN A. TESK,PHD HOWMEDICA, INC. CHICAGO
D entistry and hepatitis m The Seattle-King County Health Department routinely administers a standard questionnaire developed by the Center for D isease Control to each person with a reported case of
viral hepatitis. Reporting of cases, though incomplete, is considered to be quite good as compared with other United States metropolitan areas. Since October 1975, those persons indicating dental services during the six-month period prior to develop ment of hepatitis have been ques tioned in greater detail about these services. Through August 1976, there have been 380 case reports of which 191 were type A , 97 were type B, and 92 were type unspecified. Among them were one dentist with type B and two dental hygienists, one with type A and one with type B. A dentist was seen by 21% of the type A cases, 145& of the type B cases, and 15% o f the type unspecified cases. These persons (68 cases of viral hep atitis) were treated by 66 different dentists. Only two dentists were named twice by the cases, but three of these four involved better possible sources for their hepatitis and none had hepatitis B. The time interval between the den tal visits and the onset of illness in 33 cases (48%) was outside the common ly accepted incubation period ranges for the type of hepatitis involved (type A , 15 to 50 days; type B, 45 to 160 days; type unspecified, 15 to 160 days), and the intervals for 22 of the remaining 35 were at the fringes of these incubation periods. N o cases were reported in patients treated by the dentist or the two dental hygien ists and there was no association be tween those three persons. In this metropolitan area of 1,200,000 people, 93% of the 900 practicing dentists were not named by a reported hepatitis patient. Since the back ground rate of hepatitis among people receiving dental care is low, occur rence of viral hepatitis transmission through the dentists’ offices should be readily apparent if case reports are followed up.
On the basis of our experience, the dentists’ offices do not appear to be a significant source of hepatitis transmission. The small number of case reports indicating dental care at the appropriate incubation interval prior to illness onset is not beyond the level which might be expected on a purely statistical basis. JEAN SPEARMAN MAX BADER. MD SEATTLE-KING COUNTY HEALTH DEPARTMENT SEATTLE
Evaluating dental radiographs m I read with great interest the article titled, “ A study to develop a rating system and evaluate dental radio graphs submitted to a third party car rier,” in the N ovem ber j a d a (page 1010). I fully accept the need to develop a means of evaluating the quality of all services rendered by our profession. I believe the intent of this article is long overdue; however, I do not be lieve this to be the duty of third party reviewers and third party dental con sultants. I think this duty belongs in the realm of the profession’s peer re view system. All cases involving a question by a third party of possible substandard quality of any procedure, including radiographic technique, should be forwarded to the appropri ate peer review committee. I also object, in the strongest terms, to any lay person reviewing dental X rays for any reason. This is a func tion of the dental consultant, a lic ensed dentist. In my office, X rays will only be sent directly to the dental consultant w hose name and address must be supplied by the carrier. PHILIP R. BARBELL, DDS PENNSAUKEN, NJ
LETTERS TO THE EDITOR / JADA, Vol. 94, January 1977 ■ 25
■ Hopefully, those who read the arti cle on antibiotic prophylaxis in the Novem ber j a d a will read more than the little green box. It is unfortunate that with only 11 cases of endocarditis the authors are willing to recommend a definitive reg imen for prophylaxis. N one of the 11 cases even involved a patient with a
gram-negative organism which, un fortunately, is found in the endocar ditis patient with prosthetic heart valves. From their own statistics, they show that only 5 of 8 (62.5%) of the organisms in these patients were sensitive to penicillin. Without even getting into the com plexities of prophylaxis for prosthetic heart valve patients, I certainly would include an antibiotic that covers peni cillin-resistant organisms.
sonnel. The dentist who treats this patient must have a similar degree of knowledge in his special area of health care. A s the authors state, the combin ation o f penicillin and streptomycin appears to be most effective in pre venting this potentially lethal compli cation. The patient should not be denied this treatment simply because the dentist may not have the partic ular drug in his office.
JOHN M. ALEXANDER, DDS VIRGINIA COMMONWEALTH UNIV
LARRY J. PETERSON, DDS
RICHMOND
■ The paper entitled, “ Antibiotic prophylaxis for endocarditis in pa tients with a prosthetic heart valve” is a timely one indeed. Many pros thetic heart valves are successfully placed each year, and most of these patients now survive and thus require dental care following cardiac rehabil itation. In view of the fact that an infec ted prosthetic valve results in death in the majority of cases, recommen dations for prophylaxis of prosthetic valve endocarditis should be clear and unequivocal. However, the guidelines proposed by Dr. J. T. Santinga and associates for antibiotic prophylaxis seem inconsistent and contradictory. Using information gathered from an experimental model and, in fact, from their own group of patients with prosthetic valve endocarditis, the authors state that penicillin and streptomycin may be a more effective prophylactic regimen than penicillin alone. Surprisingly, they do not rec ommend this drug combination for outpatient dental procedures “ be cause it (streptomycin) is not avail able in most dentist’s offices . . . ” H owever, they do recommend both drugs for hospitalized patients. The patient with a prosthetic heart valve is clearly a high-risk patient who must receive excellent dental care if he is to avoid cardiac compli cations. If the dentist from whom the patient requests treatment is not pre pared to deliver it, (i.e. to use proper antibiotic prophylaxis) then the pa tient should be referred elsewhere. A prosthetic valve is placed by a team of highly trained, highly skilled per
24 ■ LETTERS TO THE EDITOR / JADA, Vol. 94, January 1977
UNIV OF CONNECTICUT FARMINGTON
‘Critical’ o f techniques ■ With reference to “ Evaluation of alternative alloys to type III gold for use in fixed prosthodontics,” Drs. D . A. Nitkin and K. Asgar, Septem ber j a d a (page 622), we offer the fol lowing comments. The article proved to be very in formative in pointing out that basic differences do exist in the behavior of the types of alloys that were tested— gold-based, semiprecious, and non precious. We agree with the stated conclu sion that the gold-based alloys repre sent a standard for comparison in terms o f the ease of casting and ob taining accurate fit. We also agree with the observation that the semi precious alloys do behave in a more gold-like manner in these respects than do the nonprecious crown and bridge alloys. We wish to note, however, that the “ optimum conditions for waxing, melting, investing, and casting” re ferred to in the publication were, in fact, not optimum in regard to the processing of Howmedica III alloy. We are critical o f several points of the techniques employed in casting the Howmedica III alloy. In particu lar, the use of 10- and 12-gauge sprues is contrary to the recommendation of the Howmedica III technique which describes the use of 8-gauge sprues. A lso, the length of the sprues used for Howmedica III alloy appears to be excessive in terms of our own rec ommendations . . . at least, by com parison with the sprues remaining on
the Type III and Forticast alloys as shown in Figure 3. The use of larger diameter (8-gauge) sprues of shorter length than those recommended in the “gold alloy” spruing technique is necessary due to the lower density o f the nonprec ious alloys, and also due to the greater differential between metal and invest ment mold temperatures which exists with the nonprecious alloys versus gold-based or semiprecious alloys. If smaller sprues are used, filling of the mold becom es difficult and the alloy also is chilled during its entry into the mold, making the attainment of a com plete and sharp margin difficult. We also wish to note that the article does not adequately describe the in vesting and burnout processes which were utilized. For example, the H ow medica III technique relates to the use o f split rings or a double layer of asbestos to obtain proper expansion; no mention of this is made in the article. We believe it important to observe that the nonprecious alloys do, in fact, behave differently than the gold-based alloys, and it is the realization of this fact which sometimes necessitates technique modifications similar to those mentioned. The results of Nitkin and Asgar confirm this and we find the publication of the article to be valuable in making this distinction. RONALD P. DUDEK JOHN A. TESK,PHD HOWMEDICA, INC. CHICAGO
D entistry and hepatitis m The Seattle-King County Health Department routinely administers a standard questionnaire developed by the Center for D isease Control to each person with a reported case of
viral hepatitis. Reporting of cases, though incomplete, is considered to be quite good as compared with other United States metropolitan areas. Since October 1975, those persons indicating dental services during the six-month period prior to develop ment of hepatitis have been ques tioned in greater detail about these services. Through August 1976, there have been 380 case reports of which 191 were type A , 97 were type B, and 92 were type unspecified. Among them were one dentist with type B and two dental hygienists, one with type A and one with type B. A dentist was seen by 21% of the type A cases, 145& of the type B cases, and 15% o f the type unspecified cases. These persons (68 cases of viral hep atitis) were treated by 66 different dentists. Only two dentists were named twice by the cases, but three of these four involved better possible sources for their hepatitis and none had hepatitis B. The time interval between the den tal visits and the onset of illness in 33 cases (48%) was outside the common ly accepted incubation period ranges for the type of hepatitis involved (type A , 15 to 50 days; type B, 45 to 160 days; type unspecified, 15 to 160 days), and the intervals for 22 of the remaining 35 were at the fringes of these incubation periods. N o cases were reported in patients treated by the dentist or the two dental hygien ists and there was no association be tween those three persons. In this metropolitan area of 1,200,000 people, 93% of the 900 practicing dentists were not named by a reported hepatitis patient. Since the back ground rate of hepatitis among people receiving dental care is low, occur rence of viral hepatitis transmission through the dentists’ offices should be readily apparent if case reports are followed up.
On the basis of our experience, the dentists’ offices do not appear to be a significant source of hepatitis transmission. The small number of case reports indicating dental care at the appropriate incubation interval prior to illness onset is not beyond the level which might be expected on a purely statistical basis. JEAN SPEARMAN MAX BADER. MD SEATTLE-KING COUNTY HEALTH DEPARTMENT SEATTLE
Evaluating dental radiographs m I read with great interest the article titled, “ A study to develop a rating system and evaluate dental radio graphs submitted to a third party car rier,” in the N ovem ber j a d a (page 1010). I fully accept the need to develop a means of evaluating the quality of all services rendered by our profession. I believe the intent of this article is long overdue; however, I do not be lieve this to be the duty of third party reviewers and third party dental con sultants. I think this duty belongs in the realm of the profession’s peer re view system. All cases involving a question by a third party of possible substandard quality of any procedure, including radiographic technique, should be forwarded to the appropri ate peer review committee. I also object, in the strongest terms, to any lay person reviewing dental X rays for any reason. This is a func tion of the dental consultant, a lic ensed dentist. In my office, X rays will only be sent directly to the dental consultant w hose name and address must be supplied by the carrier. PHILIP R. BARBELL, DDS PENNSAUKEN, NJ
LETTERS TO THE EDITOR / JADA, Vol. 94, January 1977 ■ 25
