LETTERS
TO
THE
E D IT O R
Should trauma occur, a fixed appliance would probably stabilize an abutment tooth better than would a removable one. The clasp of a re movable appliance might be snapped off by facial injury and then aspi rated. Singleton5 provides a review of the literature on the dangers of small removable appliances. MORTIMER LORBER, DMD, MD WASHINGTON, DC 1. Coman, W.B. The partial denture— a dangerous foreign body. Med J Aust 2:1126, 1972. 2. Donaldson, D.; Eccles, C.N.; and Smith, G.A. Partial dentures as a hazard to the airway. Br Dent J 131:546, 1971. 3. White H. Risks of small dentures. BrMed ] 3:694, 1973. 4. Wright, F.W., and Ramsden, P.D. Chronic foreign body in the oesophagus. Br J Clin Pract 28:413, 1974. 5. Singleton, J. McL., and Richards, S. A c quired tracheo-oesophageal fistula. Br Dent J 123:434, 1967. 6. Sejdinaj, I., and Powers, R.C. Enterocolonic fistula from swallowed denture. J Am Med Assoc 225:994, 1973.
Fractured orthodontics □ A book has come to my attention that could mislead or at least confuse readers regarding certain fundamen tals of orthodontic diagnosis and treatment. Entitled So You’re Get ting Braces, the book is the parents’ recounting of their three children’s experiences with orthodontic treat ment. Although it does succeed in con veying the “ braces” experience, the book contains a number of factual er rors. The authors, Alvin and Virginia B. Silverstein, do not have an adequate understanding of growth and development of the human face and jaws, nor do they understand or adequately explain a number of den tal terms they use in the text, such as periodontal ligament, periodontal membrane, crossbite, overbite, and closed bite. The drawings, which ap pear to have been copied from dental textbooks, are well done. However, some of them have been reduced so much that they are ineffective illus trations. Photographs of the children, though attractive, are of little real value in depicting orthodontic 18 ■ JADA, Vol. 98, January 1979
treatment even when the children’s teeth can be seen. There are no in traoral photographs. In general, the book is charming but inadequate for orthodontic patients and their par ents. GLENDON J. BOGDON, DDS WEST ALLIS, WIS
Pain control for the mentally disabled □ The article “ An interdisciplinary approach to the dental care of the mentally disabled” (The Journal, September 1978) contains statements and implications which I feel are at variance with current standards of dental and anesthetic training and practice. The authors say “ . . . it is not con sidered . . . safe to place patients under general anesthesia; thus pre medication is desirable.” The case presented concerns a retarded epileptic with a history of aggressive behavior, who was receiving phéno barbital 30 mg three times a day, Di lantin 100 mg three times a day, Teg retol 100 mg twice a day, and Mellaril 150 mg at bedtime. This patient was given an oral dose of 40 mg diazepam before dental treatment. Such a massive dose of Valium, es pecially in view of the other obtundants being administered, would have to be considered as inhibitive of protective gag and cough reflex es. Why should it be considered in herently “ safer” than . . . intrave nous sedation and anesthesia, or general endotracheal anesthesia? The advantage of an intravenous sedative-anesthetic combination is that the dose can be constantly tit rated; also, any medication required for treatment of an emergency situa tion could be administered im mediately in the patent vein. Moreover, if you have a cuffed endo tracheal tube there is the additional benefit of a controlled airway that can be sealed off from possible aspi ration of foreign matter. . . . The authors go on to say, “ As den tists are generally unfamiliar with treating mentally disabled persons, the pharmacist was consulted about
the use of premedications.” Are we to infer that pharmacists are qualified to prescribe for and treat patients? On the sample chart, moreover, there is the cryptic line, “ Physician’s Com ment: OK - Dr. A ble.” In sum, we have an article which tells us that anesthesia is unsafe, that dentists don’t know how to premed icate, sedate, and anesthetize, and that treatment should be OK’d by a physician. . . . The authors should have qualified their statements with the information that there are many dentists who have had postgraduate training that enables them to treat handicapped patients in a manner at least as safe and efficient as the one described. THOMAS RENNIE, DDS BENNINGTON, VT
Author’s com m ent: The primary point of our article is the utiliza tion of the skills of appropriate professions— the dentist, the phar macist, and the physician— in a health problem common in institu tions for the mentally ill___The team approach would not be needed if there were one professional who had additional training in all the other specialized disciplines, for example, if dentists with anesthesiology train ing were available who had addi tional training in medicine and clini cal pharmacy and who were experi enced in dealing with the mentally retarded. . . . Although Dr. Rennie obviously has expertise in dental anesthesiology, the average dental course does not generally include clinical anesthesiology. Also, the number of dentists with such train ing varies from state to state and be tween rural and urban areas. In addi tion, most dentists are not conversant with the often complex drug regi mens of patients in mental health facilities. The pharmacist can and should be helpful in providing in formation about the patient’s drug therapy. . . . his role was not to pre scribe treatment for the patient but to serve as a consultant. The ultimate role of prescribing remains with the dentist. We apologize for using the sugges tive name of Dr. Able as our physi
TO
THE
E D IT O R
Should trauma occur, a fixed appliance would probably stabilize an abutment tooth better than would a removable one. The clasp of a re movable appliance might be snapped off by facial injury and then aspi rated. Singleton5 provides a review of the literature on the dangers of small removable appliances. MORTIMER LORBER, DMD, MD WASHINGTON, DC 1. Coman, W.B. The partial denture— a dangerous foreign body. Med J Aust 2:1126, 1972. 2. Donaldson, D.; Eccles, C.N.; and Smith, G.A. Partial dentures as a hazard to the airway. Br Dent J 131:546, 1971. 3. White H. Risks of small dentures. BrMed ] 3:694, 1973. 4. Wright, F.W., and Ramsden, P.D. Chronic foreign body in the oesophagus. Br J Clin Pract 28:413, 1974. 5. Singleton, J. McL., and Richards, S. A c quired tracheo-oesophageal fistula. Br Dent J 123:434, 1967. 6. Sejdinaj, I., and Powers, R.C. Enterocolonic fistula from swallowed denture. J Am Med Assoc 225:994, 1973.
Fractured orthodontics □ A book has come to my attention that could mislead or at least confuse readers regarding certain fundamen tals of orthodontic diagnosis and treatment. Entitled So You’re Get ting Braces, the book is the parents’ recounting of their three children’s experiences with orthodontic treat ment. Although it does succeed in con veying the “ braces” experience, the book contains a number of factual er rors. The authors, Alvin and Virginia B. Silverstein, do not have an adequate understanding of growth and development of the human face and jaws, nor do they understand or adequately explain a number of den tal terms they use in the text, such as periodontal ligament, periodontal membrane, crossbite, overbite, and closed bite. The drawings, which ap pear to have been copied from dental textbooks, are well done. However, some of them have been reduced so much that they are ineffective illus trations. Photographs of the children, though attractive, are of little real value in depicting orthodontic 18 ■ JADA, Vol. 98, January 1979
treatment even when the children’s teeth can be seen. There are no in traoral photographs. In general, the book is charming but inadequate for orthodontic patients and their par ents. GLENDON J. BOGDON, DDS WEST ALLIS, WIS
Pain control for the mentally disabled □ The article “ An interdisciplinary approach to the dental care of the mentally disabled” (The Journal, September 1978) contains statements and implications which I feel are at variance with current standards of dental and anesthetic training and practice. The authors say “ . . . it is not con sidered . . . safe to place patients under general anesthesia; thus pre medication is desirable.” The case presented concerns a retarded epileptic with a history of aggressive behavior, who was receiving phéno barbital 30 mg three times a day, Di lantin 100 mg three times a day, Teg retol 100 mg twice a day, and Mellaril 150 mg at bedtime. This patient was given an oral dose of 40 mg diazepam before dental treatment. Such a massive dose of Valium, es pecially in view of the other obtundants being administered, would have to be considered as inhibitive of protective gag and cough reflex es. Why should it be considered in herently “ safer” than . . . intrave nous sedation and anesthesia, or general endotracheal anesthesia? The advantage of an intravenous sedative-anesthetic combination is that the dose can be constantly tit rated; also, any medication required for treatment of an emergency situa tion could be administered im mediately in the patent vein. Moreover, if you have a cuffed endo tracheal tube there is the additional benefit of a controlled airway that can be sealed off from possible aspi ration of foreign matter. . . . The authors go on to say, “ As den tists are generally unfamiliar with treating mentally disabled persons, the pharmacist was consulted about
the use of premedications.” Are we to infer that pharmacists are qualified to prescribe for and treat patients? On the sample chart, moreover, there is the cryptic line, “ Physician’s Com ment: OK - Dr. A ble.” In sum, we have an article which tells us that anesthesia is unsafe, that dentists don’t know how to premed icate, sedate, and anesthetize, and that treatment should be OK’d by a physician. . . . The authors should have qualified their statements with the information that there are many dentists who have had postgraduate training that enables them to treat handicapped patients in a manner at least as safe and efficient as the one described. THOMAS RENNIE, DDS BENNINGTON, VT
Author’s com m ent: The primary point of our article is the utiliza tion of the skills of appropriate professions— the dentist, the phar macist, and the physician— in a health problem common in institu tions for the mentally ill___The team approach would not be needed if there were one professional who had additional training in all the other specialized disciplines, for example, if dentists with anesthesiology train ing were available who had addi tional training in medicine and clini cal pharmacy and who were experi enced in dealing with the mentally retarded. . . . Although Dr. Rennie obviously has expertise in dental anesthesiology, the average dental course does not generally include clinical anesthesiology. Also, the number of dentists with such train ing varies from state to state and be tween rural and urban areas. In addi tion, most dentists are not conversant with the often complex drug regi mens of patients in mental health facilities. The pharmacist can and should be helpful in providing in formation about the patient’s drug therapy. . . . his role was not to pre scribe treatment for the patient but to serve as a consultant. The ultimate role of prescribing remains with the dentist. We apologize for using the sugges tive name of Dr. Able as our physi
