Oral Health Group

Letters (March 01, 2003)

March 1, 2003
by Oral Health

Re: Endodontic Standard of Care, Oral Health, December 2002.

Very well put, Dr. Ruddle. ‘Standard of Care’ is a legal term. It derives from settlement of an official court proceeding and is becoming less and less a regional variable. Nonetheless, it still equates with average rather than excellence. What is the best method of bringing the dental profession’s level of excellence to an acceptable level?


Continuing education is surely a must but my experience tells me that in endodontics excellence in planning and treatment can be taught in undergraduate programs. It is expensive and labor intensive but surely not as expensive or hard as having patients lose confidence in endodontics because over one in 10 treatments do not bring about the desired result. If we are willing to stand up to the task of sharing the new knowledge and technology with undergraduate students, they readily adopt it. It’s some practicing dentists and tenured “teachers” who are difficult to budge from the “good enough” mentality. Once again, you usually get what you expect. Thanks again for pushing us all toward excellence.

G. Merritt, DDS

Leawood, KS

I have read with interest the continuing discussion about the paucity of teachers of dentistry. My first instinct was to write something satirical. I thought I could have a good deal of fun and at the same time make the points I wished to make. Upon more sober reflection I decided the discussion was too serious to trivialize with humour.

The great American violinist Isaac Stern once said, “People will look everywhere for the reason they don’t have a career, except in the mirror.” This whole discussion strikes a personal note of resonance with me. I went to the University of Toronto to study dentistry in 1960 with the avowed intention not of being a general practitioner but of becoming a teacher of dentistry. I have spent the last 37 years as a general practitioner– a career I’ve enjoyed greatly. The question is; what happened along the way?

What happened was dental school. Without dwelling on my personal experiences I would raise two points: first there has been a regrettable tendency on the part of dental schools to move away from clinical instruction by practicing dentists to “professional teachers.” Professional teachers are certainly invaluable in some areas, but nothing replaces the one-to-one interaction on the clinic floor between the student and the active practitioner. Indeed, one of my teachers, the revered C.H.M. Williams told us, to use his words, “As long as I am standing in front of the classroom telling you what to do I have a responsibility to be on the firing line myself.” Good advice then — good advice now.

The second and somewhat more difficult point is best stated this way: when you were a student, how humanely were you treated? Were you treated like the professional colleague you were from the day you stepped into the Faculty of Dentistry? Were your problems resolved with the sort of sympathy, compassion, and understanding that as a practitioner you are supposed to show your patients, staff and colleagues? In the way your instructors treated you did they lead by example — did they show a humane compassion for sensitive, bright young people undergoing a very demanding course of study? Were these instructors the sort of people with which you would wish to associate professionally? Were you proud to know them?

These were questions I had asked myself and answer for myself. The great German theologian Reinhold Neibur one said, “The lost dimension in religion is the earnestly asking for man’s place in the universe even if the answer hurts.”

We do ourselves and our profession less than justice unless we take a similar attitude.

P.C. Bradely, DDS

Saanichton, BC

Re: January, 2003 Oral Health

I find it difficult to believe that there is so much negativity regarding the use of bonded composite restorations in your January 2003 issue of Oral Health.

Once I learned how to correctly bond to dentin and not overetch and under prime using self-etching primers (Kuraray’s Clearfil S.E.) my post-operative sensitivity has plunged to almost zero. I am having far less post-operative sensitivity now than when I was using amalgam. Thirty months ago I would have read these articles and would have been nodding my head in agreement. Not so now. Bonded posterior composite restorations have reduced the number of endodontic procedures in my practice by 40% — and the same with the number of full coverage crowns.

The use of magnification, Diagnodent, fissurotomy burs, and bonded composite restorations allow me to be so much more conservative of tooth structure.

I received my dental training in the late ’60s and learned all the G.V. Black’s tenets. The catch phrase then was “extension for prevention,” it is now “prevention of extension.” I plugged amalgam for 30 years and it was a good old workhorse. Amalgam has been around since the 1830s when two French men by the name of Crawcour came to America with their crude amalgam of silver shavings cut from coins and mixed with enough mercury to make a sloppy paste. This was the start of the Amalgam War. A campaign was mounted against the use of amalgam and this campaign soon assumed the fervor of a religious crusade.

Every member of the newly-formed American Society of Dental Surgeons was required to sign a pledge that it was “his opinion and firm conviction that any amalgam whatever is unfit for the plugging of teeth or fangs and I pledge myself never under any circumstance to make use of it in my practice.” Those who refused to sign the pledge were summarily expelled.

But progress cannot be so easily impeded and improvements in techniques and materials over the next 170 years provided the material that is being emotionally defended in these articles. As I said before, progress cannot be easily impeded and, as user friendly as amalgam is, the new kid on the block (bonded composites both direct and indirect) are here to stay.

We need to embrace these changes and learn how to bond to dentin properly. Our ability to bond a tooth-coloured material to enamel as well as dentin is changing the face of dentistry. It is going to fix more problems that it will create.

It is going to take our profession to a new level.

Howard Horsman, DDS

Riverview, NB

Re: January, 2003 Oral Health

I look forward to each issue of “Oral Health,” which I consider to be one of the last independent non-biased publications. I found the January paediatric issue to have little paediatric content at all. I was however amazed to read an issue devoted to the “Joy of Amalgam.”

A review of the ADA mercury hygiene recommendations includes:

1. “Train all personnel involved in the handling of mercury or dental amalgam regarding the potential hazard of mercury vapour.”

2. Make personnel aware of environmental issues.

3. Work in well ventilated spaces.

4. Periodically check dental atmosphere for mercury vapour.

5. Use proper work area to facilitate spill contamination and clean up.

6. Discontinue use of bulk mercury and alloy.

7. Use an enclosed amalgamator mixing arm.

8. Avoid skin contact with mercury or amalgam.

9. Recap and dispose of single use capsules according to applicable waste disposal laws.

10. Use high volume evacuation.

11. Salvage and store scrap amalgam in airtight containers or under radiographic fixer solution.

12. Remove professional clothing before leaving the work place.

My question is why would anyone want to be near the hazardous material described above? Does anyone in academia really believe that a patient in the real world would want mercury in his or her mouth? The hay day of amalgam is over. Let us move on.

Dale A. Schisler, DDS

Oakville, ON

P.S. I did’t enjoy Dr. Kurtzman, Jones, and Lopez’ article on fiber reinforced post system.

Re: The Perils of Ignoring Scientific Method, January, 2003

This article is SO biased against composite. Since when does composite restoration make the local endodontist prosper? This is pure fiction, no scientific data there. Ama
lgam makes teeth crack all the time… and composites are not perfect either. Indirect restoration should be use in many cases instead of direct restoration. This will save more root canal compare to over drill and over fill teeth. I do most of my root canals on bad amalgam that other dentists were only watching, waiting too long before they do something about it, or on simply bad dentistry. Yes, composites are more difficult to do…so what? Just learn to do them the right way! It is like root canal… we do not do them the same way we did five years ago. Anybody can do an amalgam with his/her eyes closed.

Alain Gagnon, DMD

Montreal, PQ

Re: The Perils of Ignoring Scientific Method, January, 2003

One needs only to read the introductory paragraphs of Dr. Applebaum’s editorial to sense the theme of his discussion. His comments are of significant value to all dental professionals. For the seasoned clinician, Applebaum’s opinions are logical truths of day-to-day clinical dentistry. For young dentists, especially those struggling with the temptation to dabble with new technology, his comments deserve careful attention.

Dentists have always been somewhat vulnerable to the lure of CDE. Experienced clinicians understand the challenges of dentistry and every imaginable clinical obstacle has potential on the lecture circuit; manufacturers understand this all too well. Armed with financial momentum and refined marketing tactics, they have utilized outspoken practitioners to promote techniques which diametrically oppose those of conventional dentistry. To date, the majority of CE courses still advocate philosophies, which don’t exactly jive with those accepted by major universities.

It is unfortunate, and arguably disheartening, that in publications which preach conservative dentistry, we see case reports on the management of orthodontic problems by veneering, or the replacement of “defective alloys” with chairside milled ceramics which ultimately look like costly provisionals with virtually zero anatomical appeal.

A very small percentage of the general population may be prepared to undergo elective procedures, having full knowledge of the risks and benefits of current treatment modalities. For the vast majority of patients, however, the “don’t fix what is not broken” approach generates more appreciation than even the prettiest elective rehabilitation case.

Continuing dental education must be left in the hands of educators. Universities have the facilities and manpower necessary to formulate sound treatment principles based on unbiased research. Logic should direct us to abandon courses that promote or even suggest outrageous treatment philosophies. Supporting research-oriented education will preserve the reputation that dentistry has worked so diligently to achieve.

R. Del Zotto, BSc., DDS

Woodbridge, ON

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