such a high percentage of their occlusal surfaces will rem ain caries-free w ithout the applica tion of sealants. W hen indi cated, it is preferable to place a very small (329 bur), wellcondensed silver am algam restoration th a t will last a lifetime. Plastic resins should not be painted in the grooves of teeth, a high percentage of which will never need a restoration. Once sealants are applied, grooves and pits cannot m ature (mineralize) and naturally seal themselves. While sealants are income-effective for m any dentists, these data strongly support th a t sealants are not cost-effective for patients. Sealants have gained ADA approval and are promoted by m anufacturers, clinical lecturers and practice m anagem ent “How-to-IncreaseYour-Bankroll” lectures. Then, why aren’t sealants recom mended by more dentists? The reason is clear. Many general dentists are conscientious and alert observers of the very good health of th eir non-sealant patients. D entists are seeing w hat these data support. Why perform (and charge the public for) a procedure th a t is unjustified? J o h n F. S in clair, D.M.D. S p rin gfield , Vt.
E d ito r’s comment: I would like to reiterate several points I m ade in the October editorial. These points are based on a nationwide study conducted by the N ational In stitu te for Dental Research. —“Evaluation of the clinical condition of lower left first m olars of 35- to 39-year-olds 14
JADA, Vol. 123, December 1992
counted 4 percent decayed, 29 governm ent agencies and percent m issing and 58 percent dental associations are simply filled—hardly a rem arkable a costly response to irrational dental health statu s for an age public fears. Recently, the ADA group considered to have had held a very useful workshop on favorable access to preventive the topic “Sterilizing Dental and restorative care. H andpieces” (October), and I —“For the 18- to 24-year-olds, would like to sum m arize some n urtured in an era character of th e comm ents I m ade there. F irst, we m ust realize th a t ized by fluoride and prevention, HIV transm ission cannot be the sam e study indicated th a t successfully m anaged by one of 10 young adults had applying old microbiological already lost th a t lower first paradigm s. We survive m ost molar. Additionally, low-dose exposures to invading 70 percent of those pathogens w ithout sustained m olars showed clinical infection prim arily because our evidence of restoration im m une system am asses or active decay. types of w hite blood — “In 1987, more th anvarious 50 cells against foreign m aterial. percent of children These cells can destroy m any between the ages of 5 to 17 hundreds or thousands of had no decay in their perm anent microbes entering the blood teeth. Yet, by the age 19, only 7 stream before disease ensues. percent were caries-free. That W hat happens however (as in percentage dropped below 2 the case w ith HIV), w hen the percent by age 35. Obviously, arm y of cells sent to the site of dental caries had not been invasion is exactly w hat the eradicated. . . . ” infectious agent needs to All dentists would like to replicate and cause have patients as healthy as Dr. disease? Sinclair’s b u t . . . “It’s not Introduce over yet. Not even close.” even Larry M eskin, D.D.S. m inute traces THE USE OF STUDENTS of u n treated blood from HIVWhy not allow third- and fourthinfected individuals year dental students to practice into the bloodstream hygiene? This would help with of others often enough and the hygienist shortage, m ake sooner or late r someone will be the student some much needed infected. Once in the income, help with patient bloodstream , HIV exposure is m anagem ent and technique and probably about as equal to possibly lead to associateships. infection as we can imagine. B ru ce C. G ronner, D.D.S. Most im portantly, the h a n d C hicago piece sterilization issue goes far HANDPIECE beyond sim ply preventing infec STERILIZATION tion in dentistry. W hen large segm ents of the population After reading comm ents about become infected w ith deadly handpiece sterilization in communicable diseases, should JADA, I wonder if most we be concerned only about the dentists really believe th a t new m ost efficient m eans of tra n s recom m endations by
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m ission? P erhaps current h epatitis B statistics suggest the answer. About a th ird of the several hundred thousand new cases now occurring each year in the U nited S tates are among people not reported to be a t high risk for contracting bloodborne pathogens. Those who w ant to take comfort in the fact th a t not one confirmed case of HBV transm ission by contam inated dental equip m ent has been reported m ust overlook the fact th a t it is impossible in retrospective studies to confirm th a t someone was infected via contam inated equipm ent. F urtherm ore, if contam inated dental devices were responsible for one HBV transm ission in every dental office in the country, no state or federal reporting system would link any of the cases to the profession. We’ve got to get away from the notion th a t bloodborne pathogens are eith er tra n s m itted by the most efficient m eans or not a t all. This is the m isleading conclusion from a reporting system capable only of linking clusters of infections w ith sources. It m akes no sense to argue th a t liquid chemical ste rila n ts are effective even th en applied to the outside of internally contam inated equipm ent, or for tre a tin g blood and bits of tissue covered w ith equipm ent lubri cants th a t repel chemical solutions. We cannot continue to rely on chemicals, all of which are ineffective at reaching pathogens shielded inside debris. Instead, we m ust continue to develop equipm ent
th a t can be cleaned adequately and subjected to h e a t tre a t m ent, which is more effective in reaching infectious microbes rem aining in any debris left behind. F ortunately for dentistry, equipm ent m anufacturers had the foresight, ingenuity and com m itm ent more th a n a dec ade ago to m ake delicate high speed dental handpieces and other equipm ent able to tolerate the m ost drastic sterilization tre a t m ent—autoclaving. W hat an accomplish m ent—and w hat an opportunity for d en tistry to lead the world in solving difficult cross-contam ination problems. For m any years to come, few areas of medical practice will be able to claim the stan d ard of practice being set by dentistry. If the public is informed of these changes, heightened p atien t confidence and an unprecedented level of esteem will be d en tistry ’s rew ard. I see countless d entists who have always p u t first the welfare of th eir patients. They are steadfastly m aking enorm ous and difficult changes and adm irably settin g the exam ple for medical practi tioners in every field to follow. But, it will be the ran k and file dentists of the future who will serve the public through even more troubled tim es, reaping the benefits of cu rren t policies and continuing to earn th eir p a tie n ts’ tru s t as predecessors in th e ir g reat profession have done before them . D avid L. L ew is, Ph.D . U n iv e r sity o f G eorgia A u gu sta, Ga.
E d ito r’s comment: I would like to reiterate several points I m ade in the October editorial. These points are based on a nationwide study conducted by the N ational In stitu te for Dental Research. —“Evaluation of the clinical condition of lower left first m olars of 35- to 39-year-olds 14
JADA, Vol. 123, December 1992
counted 4 percent decayed, 29 governm ent agencies and percent m issing and 58 percent dental associations are simply filled—hardly a rem arkable a costly response to irrational dental health statu s for an age public fears. Recently, the ADA group considered to have had held a very useful workshop on favorable access to preventive the topic “Sterilizing Dental and restorative care. H andpieces” (October), and I —“For the 18- to 24-year-olds, would like to sum m arize some n urtured in an era character of th e comm ents I m ade there. F irst, we m ust realize th a t ized by fluoride and prevention, HIV transm ission cannot be the sam e study indicated th a t successfully m anaged by one of 10 young adults had applying old microbiological already lost th a t lower first paradigm s. We survive m ost molar. Additionally, low-dose exposures to invading 70 percent of those pathogens w ithout sustained m olars showed clinical infection prim arily because our evidence of restoration im m une system am asses or active decay. types of w hite blood — “In 1987, more th anvarious 50 cells against foreign m aterial. percent of children These cells can destroy m any between the ages of 5 to 17 hundreds or thousands of had no decay in their perm anent microbes entering the blood teeth. Yet, by the age 19, only 7 stream before disease ensues. percent were caries-free. That W hat happens however (as in percentage dropped below 2 the case w ith HIV), w hen the percent by age 35. Obviously, arm y of cells sent to the site of dental caries had not been invasion is exactly w hat the eradicated. . . . ” infectious agent needs to All dentists would like to replicate and cause have patients as healthy as Dr. disease? Sinclair’s b u t . . . “It’s not Introduce over yet. Not even close.” even Larry M eskin, D.D.S. m inute traces THE USE OF STUDENTS of u n treated blood from HIVWhy not allow third- and fourthinfected individuals year dental students to practice into the bloodstream hygiene? This would help with of others often enough and the hygienist shortage, m ake sooner or late r someone will be the student some much needed infected. Once in the income, help with patient bloodstream , HIV exposure is m anagem ent and technique and probably about as equal to possibly lead to associateships. infection as we can imagine. B ru ce C. G ronner, D.D.S. Most im portantly, the h a n d C hicago piece sterilization issue goes far HANDPIECE beyond sim ply preventing infec STERILIZATION tion in dentistry. W hen large segm ents of the population After reading comm ents about become infected w ith deadly handpiece sterilization in communicable diseases, should JADA, I wonder if most we be concerned only about the dentists really believe th a t new m ost efficient m eans of tra n s recom m endations by
ZilaDent
Simply
Oral
Pain
M agic
Fast Oral PAIN Relief f fom
mak«rs of 2ilac«iA&
FAST P A IN RELIEF From
CUTS & SORES BRACES, DENTURES C au sed By
Long lasting, fa s t Acting
Zila Dent Film Forming G el »ilh B c n zntainc
ZilaDent™
• Treats Cuts & Sores inside the mouth caused by Braces, Dentures, toothbrushes, bites and other dental appliances.
ZilaDent"
• Forms a tenacious film which Secures against Braces & Denture cuts, sores and even hot beverages.
Z ila D e n r
• Fast, effective PAIN relief lasting up to six (6) hours.
ZilaD ent
• Your first line of defense against the pain caused by cuts and sores inside the mouth.
ZilaDent S im p ly O r a l Pain M a g ic
For FREE Samples please call
1- 8 0 0 -9 2 2 -7 8 8 7
m ission? P erhaps current h epatitis B statistics suggest the answer. About a th ird of the several hundred thousand new cases now occurring each year in the U nited S tates are among people not reported to be a t high risk for contracting bloodborne pathogens. Those who w ant to take comfort in the fact th a t not one confirmed case of HBV transm ission by contam inated dental equip m ent has been reported m ust overlook the fact th a t it is impossible in retrospective studies to confirm th a t someone was infected via contam inated equipm ent. F urtherm ore, if contam inated dental devices were responsible for one HBV transm ission in every dental office in the country, no state or federal reporting system would link any of the cases to the profession. We’ve got to get away from the notion th a t bloodborne pathogens are eith er tra n s m itted by the most efficient m eans or not a t all. This is the m isleading conclusion from a reporting system capable only of linking clusters of infections w ith sources. It m akes no sense to argue th a t liquid chemical ste rila n ts are effective even th en applied to the outside of internally contam inated equipm ent, or for tre a tin g blood and bits of tissue covered w ith equipm ent lubri cants th a t repel chemical solutions. We cannot continue to rely on chemicals, all of which are ineffective at reaching pathogens shielded inside debris. Instead, we m ust continue to develop equipm ent
th a t can be cleaned adequately and subjected to h e a t tre a t m ent, which is more effective in reaching infectious microbes rem aining in any debris left behind. F ortunately for dentistry, equipm ent m anufacturers had the foresight, ingenuity and com m itm ent more th a n a dec ade ago to m ake delicate high speed dental handpieces and other equipm ent able to tolerate the m ost drastic sterilization tre a t m ent—autoclaving. W hat an accomplish m ent—and w hat an opportunity for d en tistry to lead the world in solving difficult cross-contam ination problems. For m any years to come, few areas of medical practice will be able to claim the stan d ard of practice being set by dentistry. If the public is informed of these changes, heightened p atien t confidence and an unprecedented level of esteem will be d en tistry ’s rew ard. I see countless d entists who have always p u t first the welfare of th eir patients. They are steadfastly m aking enorm ous and difficult changes and adm irably settin g the exam ple for medical practi tioners in every field to follow. But, it will be the ran k and file dentists of the future who will serve the public through even more troubled tim es, reaping the benefits of cu rren t policies and continuing to earn th eir p a tie n ts’ tru s t as predecessors in th e ir g reat profession have done before them . D avid L. L ew is, Ph.D . U n iv e r sity o f G eorgia A u gu sta, Ga.
