LETTERS TO THE EDITOR
private practitioners a few mechanical ideas that might be useful. (All of the authors are private practitioners who volunteer their services to the university, and all are appreciative of clinical dentistry in the literature.) Today, some three years after treatment, our patient is happy and free from dental disease. She has a centrically related occlusion and proper disclusion. We ask for no more. CLAUDE R. WOOD , JR. , DDS KNOXVILLE, TENN
The practitioner-scientist
Upper left and right: Frontal and lateral photographs of patient published in "Coordination of the goals of orthodontic, surgical, and prosthetic dentistry: anterior maxillary osteotomy" (The Journal, October). Lower left and right: unpublished frontal and lateral photographs of same patient.
submitting the upper left and right photographs with our article, we had submitted the lower left and right set, Dr. Gross would not have thought that our patient had lip incompetence or long-face syndrome. We are sorry. A Le Fort I osteotomy could have been performed, but in view of the vast amount of reconstruction that would have to be performed regardless of the surgical approach , we wonder why? Le Fort I procedures require more operating room time , intermaxillary fixation, and longer hospitalization than do maxillary osteotomies with use of the splint we
described. This patient's operation took 45 minutes; she required no postoperative pain medication , and she performed in a dance recital 48 hours postoperatively. With regard to the temporomandibular joint symptoms, total elimination of the symptoms by splint therapy or bite adjustment is diagnostic of a muscular problem, and we did not think it necessary to elaborate on the obvious. Dr. Gross was critical of the mechanical aspects of treatment that were demonstrated in the report. It was our intent to share with other
D An intriguing aspect of "Direct pulp capping treatment: a long-term follow-up (The Journal, October 1978) is the concept that important clinical research can be conducted by the private practitioner in the dental office. The concept of a practitionerscientist adds new dimensions to private practice. Not only would it be stimulating for the practitioner and beneficial for the profession as a whole , but it would encourage more precise record-keeping and it would surpass most continuing education courses in keeping the practitioner abreast of findings in his field of interest. The questions would probably be pragmatic ones such as that addressed in the Haskell article, "What is the rate of success in pulp capping procedures?" But general practitioners . need answers to just such basic questions , and often there are no good clinical studies that address them. Studies of this type are unlikely to come from established dental research centers because of the difficulties of long-term recordkeeping and recall, of obtaining grants and grant renewals, and the prohibitive cost of paying the scientists and maintaining the data. The answers almost have to come from practitioner-scientists who have the interest, the patient information, and the ability to do long-term follow-up. Problems relating to human experimentation could arise in certain studies, and these would probably JADA, Vol. 98, January 1979 • 13
LETTERS
have to be dealt with in institutions. But studies evaluating the superior ity of one accepted clinical method over another, or long-term follow-up of the results of diagnostic and treat ment methods would not be likely to raise these problems, and would therefore be ideal subjects for study by private practitioners. Many of the questions most often asked by dental practitioners are answered in their own practices. Information from pa tient records, objectively evaluated and passed on to the profession, would help refine many current techniques and add vitality to the dental profession. PETER L. JACOBSEN, DDS, PhD SAN FRANCISCO
Peripheral ameloblastoma □ Birkholz, Sills, and Reid reported on a case of peripheral ameloblas toma (The Journal, October 1978.) Citing a case report of mine that was published in the Journal o f Oral Surgery in July 1973, they say, “ the foci of the tumor were identified as being within the bone.” This is not a correct interpretation. Let me quote from the histopathological discussion in my case report: “ Of considerable interest was the un expected discovery of a small focus of ameloblastoma on the deep (periosteal) surface of the tissue re moved from the clinically unrelated buccal surface (Fig 8). Figure 9 shows shows the presence of tumor super ficially invading the underlying bone. Thus there were two discrete foci of tumor and no connection be tween them could be demonstrated. A diagnosis of acanthoameloblastoma was made.” Since two separate and discrete foci were seen, with apparent super ficial bone invasion from one focus, we felt that two primary sites were involved. We did not feel that the primary site was bone, but rather that it was gingiva. ROBERT S. BALFOUR, DDS GLEN BURNIE, MD
Author’s comment: We did not mean to imply that Dr. Balfour’s case was
not a true peripheral ameloblastoma. In fact, Gardner, whose article in Cancer (April 1977) we also cited, says that Balfour’s case was an exam ple of peripheral ameloblastoma. We specifically singled Dr. Bal four’s article out as it was the only case of a peripheral ameloblastoma that demonstrated histologic in volvement of the underlying bone. A case reported by Peters and others in the Journal o f Oral Surgery (30:63-66, 1972) described bone invasion by basal cell carcinoma of the oral cav ity. Several other authors referred to a “ depression” or “ cupping” of the underlying bone, but no invasion. If our choice of words suggested that Dr. Balfour’s case was inter preted as a bony, or intraosseous ameloblastoma, we apologize. That meaning was not intended. HOWARD BIRKHOLZ, DDS TEMPLE, TEX
Dentures for convulsive patients □ I read with interest Dr. Mortimer Lorber’s “ Lectures on dentistry in medical schools” (The Journal, November 1978). His statement, “ For example, removable appliances should not be made for patients with convulsive disorders; such appli ances may be dislodged and even aspirated during a seizure,” com pels me to solicit his comment. As an institutional dentist, I pro vide dental care for mentally re tarded people. Many of the patients I treat have convulsive disorders. These patients usually have close supervision, and their seizure activ ity is well controlled. I have found that satisfactory partial dentures for improved masticatory function, maintenance of arch integrity, and prevention of supraeruption of un opposed teeth can be constructed for them. For these patients, quality crown and bridge restoration with out the use of general anesthesia would probably be difficult and im practical. I believe that removable partial dentures are less hazardous to abutment teeth than fixed appliances where the potential for dental and facial trauma exists.
TO
THE
E D IT O R
In view of these problems, is there still strong opinion that risk of dislodgment and aspiration precludes fabrication of removable partial and complete dentures for patients with convulsive disorders? J. BOYD CAMAK, JR., DMD CLINTON, SC
Author’s comment: The satisfactory use of partial dentures in institution alized mentally retarded patients, many of whom have convulsive dis orders and would require general anesthesia for fixed prosthodontic appliances, cannot be denied. The risk may be minimal in medicated patients who live in a highly con trolled environment where they are continually observed by a competent staff who are expert at managing convulsive patients and who min ister to them at the onset of the seizures. For the numerous individuals of normal intelligence who, despite a convulsive disorder, are integrated into society, the situation may be dif ferent. Such people are often likely to be alone or with individuals who do not know how to manage seizures. Furthermore, they can cooperate with a dentist to receive fixed restora tions that are not likely to be aspi rated, swallowed, or dislodged if dental supervision of the restorations is maintained. Complete dentures would proba bly not be hazardous, and, except for implants, there is no alternative for edentulous patients. But even large partial dentures replacing posterior teeth in both quadrants of a jaw can be dislodged and have been swallowed1 and aspirated2 by normal individuals. Smaller re movable prosthodontic appliances that replace one or several teeth in a quadrant are more hazardous. . . . They have been aspirated and im pacted in the larynx,1-3 swallowed,3-6 and impacted in the esophagus4; they have perforated the tissue from there to the trachea, forming a tracheo-esophageal fistula,5 and have even perforated the tissue from the small to the large intestine, forming a granulomatous mass.6 JADA, Vol. 98, January 1979 ■ 15
private practitioners a few mechanical ideas that might be useful. (All of the authors are private practitioners who volunteer their services to the university, and all are appreciative of clinical dentistry in the literature.) Today, some three years after treatment, our patient is happy and free from dental disease. She has a centrically related occlusion and proper disclusion. We ask for no more. CLAUDE R. WOOD , JR. , DDS KNOXVILLE, TENN
The practitioner-scientist
Upper left and right: Frontal and lateral photographs of patient published in "Coordination of the goals of orthodontic, surgical, and prosthetic dentistry: anterior maxillary osteotomy" (The Journal, October). Lower left and right: unpublished frontal and lateral photographs of same patient.
submitting the upper left and right photographs with our article, we had submitted the lower left and right set, Dr. Gross would not have thought that our patient had lip incompetence or long-face syndrome. We are sorry. A Le Fort I osteotomy could have been performed, but in view of the vast amount of reconstruction that would have to be performed regardless of the surgical approach , we wonder why? Le Fort I procedures require more operating room time , intermaxillary fixation, and longer hospitalization than do maxillary osteotomies with use of the splint we
described. This patient's operation took 45 minutes; she required no postoperative pain medication , and she performed in a dance recital 48 hours postoperatively. With regard to the temporomandibular joint symptoms, total elimination of the symptoms by splint therapy or bite adjustment is diagnostic of a muscular problem, and we did not think it necessary to elaborate on the obvious. Dr. Gross was critical of the mechanical aspects of treatment that were demonstrated in the report. It was our intent to share with other
D An intriguing aspect of "Direct pulp capping treatment: a long-term follow-up (The Journal, October 1978) is the concept that important clinical research can be conducted by the private practitioner in the dental office. The concept of a practitionerscientist adds new dimensions to private practice. Not only would it be stimulating for the practitioner and beneficial for the profession as a whole , but it would encourage more precise record-keeping and it would surpass most continuing education courses in keeping the practitioner abreast of findings in his field of interest. The questions would probably be pragmatic ones such as that addressed in the Haskell article, "What is the rate of success in pulp capping procedures?" But general practitioners . need answers to just such basic questions , and often there are no good clinical studies that address them. Studies of this type are unlikely to come from established dental research centers because of the difficulties of long-term recordkeeping and recall, of obtaining grants and grant renewals, and the prohibitive cost of paying the scientists and maintaining the data. The answers almost have to come from practitioner-scientists who have the interest, the patient information, and the ability to do long-term follow-up. Problems relating to human experimentation could arise in certain studies, and these would probably JADA, Vol. 98, January 1979 • 13
LETTERS
have to be dealt with in institutions. But studies evaluating the superior ity of one accepted clinical method over another, or long-term follow-up of the results of diagnostic and treat ment methods would not be likely to raise these problems, and would therefore be ideal subjects for study by private practitioners. Many of the questions most often asked by dental practitioners are answered in their own practices. Information from pa tient records, objectively evaluated and passed on to the profession, would help refine many current techniques and add vitality to the dental profession. PETER L. JACOBSEN, DDS, PhD SAN FRANCISCO
Peripheral ameloblastoma □ Birkholz, Sills, and Reid reported on a case of peripheral ameloblas toma (The Journal, October 1978.) Citing a case report of mine that was published in the Journal o f Oral Surgery in July 1973, they say, “ the foci of the tumor were identified as being within the bone.” This is not a correct interpretation. Let me quote from the histopathological discussion in my case report: “ Of considerable interest was the un expected discovery of a small focus of ameloblastoma on the deep (periosteal) surface of the tissue re moved from the clinically unrelated buccal surface (Fig 8). Figure 9 shows shows the presence of tumor super ficially invading the underlying bone. Thus there were two discrete foci of tumor and no connection be tween them could be demonstrated. A diagnosis of acanthoameloblastoma was made.” Since two separate and discrete foci were seen, with apparent super ficial bone invasion from one focus, we felt that two primary sites were involved. We did not feel that the primary site was bone, but rather that it was gingiva. ROBERT S. BALFOUR, DDS GLEN BURNIE, MD
Author’s comment: We did not mean to imply that Dr. Balfour’s case was
not a true peripheral ameloblastoma. In fact, Gardner, whose article in Cancer (April 1977) we also cited, says that Balfour’s case was an exam ple of peripheral ameloblastoma. We specifically singled Dr. Bal four’s article out as it was the only case of a peripheral ameloblastoma that demonstrated histologic in volvement of the underlying bone. A case reported by Peters and others in the Journal o f Oral Surgery (30:63-66, 1972) described bone invasion by basal cell carcinoma of the oral cav ity. Several other authors referred to a “ depression” or “ cupping” of the underlying bone, but no invasion. If our choice of words suggested that Dr. Balfour’s case was inter preted as a bony, or intraosseous ameloblastoma, we apologize. That meaning was not intended. HOWARD BIRKHOLZ, DDS TEMPLE, TEX
Dentures for convulsive patients □ I read with interest Dr. Mortimer Lorber’s “ Lectures on dentistry in medical schools” (The Journal, November 1978). His statement, “ For example, removable appliances should not be made for patients with convulsive disorders; such appli ances may be dislodged and even aspirated during a seizure,” com pels me to solicit his comment. As an institutional dentist, I pro vide dental care for mentally re tarded people. Many of the patients I treat have convulsive disorders. These patients usually have close supervision, and their seizure activ ity is well controlled. I have found that satisfactory partial dentures for improved masticatory function, maintenance of arch integrity, and prevention of supraeruption of un opposed teeth can be constructed for them. For these patients, quality crown and bridge restoration with out the use of general anesthesia would probably be difficult and im practical. I believe that removable partial dentures are less hazardous to abutment teeth than fixed appliances where the potential for dental and facial trauma exists.
TO
THE
E D IT O R
In view of these problems, is there still strong opinion that risk of dislodgment and aspiration precludes fabrication of removable partial and complete dentures for patients with convulsive disorders? J. BOYD CAMAK, JR., DMD CLINTON, SC
Author’s comment: The satisfactory use of partial dentures in institution alized mentally retarded patients, many of whom have convulsive dis orders and would require general anesthesia for fixed prosthodontic appliances, cannot be denied. The risk may be minimal in medicated patients who live in a highly con trolled environment where they are continually observed by a competent staff who are expert at managing convulsive patients and who min ister to them at the onset of the seizures. For the numerous individuals of normal intelligence who, despite a convulsive disorder, are integrated into society, the situation may be dif ferent. Such people are often likely to be alone or with individuals who do not know how to manage seizures. Furthermore, they can cooperate with a dentist to receive fixed restora tions that are not likely to be aspi rated, swallowed, or dislodged if dental supervision of the restorations is maintained. Complete dentures would proba bly not be hazardous, and, except for implants, there is no alternative for edentulous patients. But even large partial dentures replacing posterior teeth in both quadrants of a jaw can be dislodged and have been swallowed1 and aspirated2 by normal individuals. Smaller re movable prosthodontic appliances that replace one or several teeth in a quadrant are more hazardous. . . . They have been aspirated and im pacted in the larynx,1-3 swallowed,3-6 and impacted in the esophagus4; they have perforated the tissue from there to the trachea, forming a tracheo-esophageal fistula,5 and have even perforated the tissue from the small to the large intestine, forming a granulomatous mass.6 JADA, Vol. 98, January 1979 ■ 15
