le sio n , and th e en larg ed n ode a re signs o f la te c a n cer. If w e a re to c u re oral c a n c e r w e m ust act m uch , m uch e a r lier— b ack to th e stag e w h e re th e su r face lesio n lo oks so in significant and b en ig n th a t o u r initial im pulse is to ig n o re it. W ith o u r p re se n t sta te o f k n o w led g e, this is w h ere w e m ust sta rt. T o d o this req u ire s th e care fu l, th o u g h tfu l, and sy stem atic ex am in a tio n o f th e h ard an d soft stru c tu re s o f th e oral c av ity by an e x p e rt, be h e d en tist o r p h y sician . A m o n g o u r tools fo r m aking an early diagnosis let us n o t fo rg et th e help th a t cy to lo g y can p ro v id e. A l m ost 15 y ears ago, H e n ry S an d le r d e m o n s tra te d in a d ram a tic w ay how c y to lo g y co u ld help in d iagnosing oral carc in o m a in situ; a first ste p in re d u c ing m o rta lity from this d isease. T h e c y to lo g ic m eth o d is e a sy , u su ally p a in le ss, w ell a c c e p te d by p a tie n ts, an d q u ite in ex p en siv e. W hile it is no t a s u b s titu te fo r b io p sy , its u se will trig g er b iopsy o f th o se lesions th at m ight o th e rw ise be ignored. I w ould urge all d e n tists to d isc u ss this w ith th e ir lo cal p ath o lo g ist an d m ake a r ra n g e m e n ts to utilize th is v alu ab le test. ROLA N D A. LOEB, M D CYTOLOGY LABORATORY, LT D . LA N C A ST E R , PA
‘Im p r a c tic a l’ sta te m e n t m In th e Ju n e j a d a , R ich ard T h o m a s G la ss a n d his co lleag u es d escrib ed “ T e a c h in g self-exam in atio n o f th e head and neck: a n o th e r a sp e c t o f p re v en tiv e d e n tis try ” (page 1265). T h e c o n c e p t o f self-ex am in atio n w as q u ite in terestin g an d I certain ly a p p la u d th e d esirab ility o f in creasin g th e p a tie n t’s a w a re n e ss o f a b n o rm al ities o f th e head an d n e c k regions. H o w e v e r, I sh o u ld like to ta k e issu e w ith a sta te m e n t e x p re sse d o n page 1266: “ T h e p a tie n t is told to o b se rv e any lesio n fo r tw o w eek s a n d if healing has n o t o c c u rre d w ithin this tim e sp an , to call th e d e n tist im m e d ia te ly .” It is o u r teac h in g , an d m y belief, th a t th e d e n tist is in a b e tte r p o sitio n to ex am in e th e p a tie n t a n d d eterm in e “ if healing h as n o t o c c u rre d .” T o ex p e c t th e naive p a tie n t to ex am in e su ch a reas as the p a late and la teral b o rd e rs
o f th e to n g u e is, in m y o p in io n , im p ra ctic a l. S u b tle a b n o rm a lities o r in c o m p le te healing easily could b e o v e r lo o k ed by th e p a tie n t. F u rth e r, th e p a tie n t w h o is a h e a v y u s e r o f alco h o l a n d a h ea v y sm o k e r is k n o w n to h a v e a h ig h er in c id e n c e o f o ral m alignancy. S om e au th o rs h av e su g g ested th e se p a tie n ts h av e a 15.5 tim es g re a te r risk o f oral c a n c e r. T h is p a tie n t w o uld be p a rtic u la rly u n reli ab le in self-ex am in atio n an d “ selfd ia g n o sis.” T h e re fo re , D r. G la s s ’s te c h n iq u e w o u ld h a v e lim ited u se fu l n e ss in this high risk p o p u latio n . I fo u n d th e a rtic le q u ite in terestin g , b u t w ould p re fe r th a t e m p h asis be g iv en to self-ex am in atio n an d n o t to self-diagnosis. S T U A R T L . F IS C H M A N , D M D
If th e ex a m in ers tre a te d th e ir p a tie n ts o r th e ir office sta ff th e w ay th e y tre a te d u s, th e y w o u ld n o lo n g er h a v e p ra c tic e s. I h a p p e n to b elieve th a t th e s e clinical ex a m in a tio n s d o no t a c c u ra te ly e v a lu a te a s tu d e n t’s clin ical ability o r ju d g m e n t. B u t if th e y m u st be g iv en , c a n ’t th e e x a m in e rs at le a st b e h a v e like g e n tle m e n ? T h e u su al a ttitu d e o f su c c e ssfu l b o a rd c a n d id a te s, o n c e th e ir a n g er su b sid e s, is “ I ’ve g o t m ine n o w , you fight y o u rs .” T ru e , this is w ritte n in a n g e r. B ut if th e re is e v e r a n y th in g I c a n d o to c o rre c t th is in ju stic e, I will d o it, an d I will jo in an y m o v e m e n t to se e th a t stu d e n ts are tre a te d a s I w ould like to be. JO S E P H C. S C O T T I, D M D BRONX, NY
PR O FE SSO R , ST A T E U N IV E R S IT Y O F N E W YORK A T B U F F A L O
E y e injuries in d e n ta l o ffice ‘H u m ilia tin g e x p e rie n c e ’ m I am w riting to you as a n ew co l league. M y e n tra n c e in to th e p ro fe ssio n , a fte r having been ta u g h t to c a re fo r th e p a tie n ts I tr e a t an d to em p a th ize w ith th e ir fe a rs, w as a hum iliating e x p e rie n c e . I a m referrin g to th e N o rth e a s t R eg io n al B o ard ex am in a tio n . B elieve m e, I d o n o t m e a n to b rag w hen I say th a t I w as a g o od stu d e n t. I w as priv ileg ed to re ce iv e sev eral d e p a rtm e n ta l a w a rd s, w as e le c t ed to O m ic ro n K a p p a U p silo n , and g ra d u a te d first in m y class o f 75. I am a little e m b a rra ss e d to sta te th is, b u t I d o so to show th a t this le tte r is n o t so u r g ra p e s, an d I am n o t b itte r a b o u t failing th e b o a rd s; I p assed . N o o n e sh o u ld b e su b je cte d to an e x p erie n c e like th is. A fte r fo u r y ears o f d en tal e d u c a tio n , to be fo rc e d to su b m it to th e sa rc a sm an d h a ra ssm e n t w e u n d e rw e n t is to b e d eg ra d e d as a p e rso n an d a s a p ro fessio n a l. A s one o f m y c la ssm a te s (also in O K U , and now in a p o stg ra d u a te o rth o d o n tic s p ro g ram ) said , “ It w as like pledging a fra te rn ity , a n d th is w as H ell W e e k .” S ev en o f m y c la ssm a te s failed th e b o a rd s. P e rh a p s o n e o r tw o d e se rv e d to fail. N o n e o f th e o th ers h a v e an y id e a o f w hy th e y faile d , an d th e b o a rd will n o t tell th e m w h y . T h is is ad ding in su lt to in ju ry .
502 ■ LETTERS TO THE EDITOR / JADA, Vol. 91, September 1975
m In re g ard to th e Ju n e j a d a a rtic le on a v o id a b le a d v e rs e e v e n ts in d e n tistry b y P e te r M ilgrom (page 1282), I w ish to a d d o n e a re a to his list o f av o id ab le a d v e rs e d en tal o u tc o m e s th a t I feel is e x tre m e ly im p o rta n t an d all to o o ften o v e rlo o k e d . I a m referrin g to ey e in ju ries in th e d e n ta l office. T o d a y w e a re p ra c ticin g sit-d o w n d e n tistry w ith th e p a tie n t in a h o rizo n ta l p o sitio n . W e c o n sta n tly h a v e sh arp in stru m e n ts h a n d e d to us o v e r th e p a tie n t’s fa c e , a n d re a c h fo r h a n d p iec es w ith sh a rp b u rs. W e c a rry c o tto n p elle ts lad en w ith ac id s, m ed ic am e n ts, v a rn ish e s, an d w h o k n ow s w h a t else to w ith in in ch e s o f th e e y es. W e rem o v e to o th stru c tu re a n d filling m aterials a t u ltra sp e e d , a n d th e s e p a rtic le s a re n o w p ro p e lle d v e rtically d u e to th e p a tie n ts h o riz o n ta l p o sitio n . F ro m m y o w n e x p e rie n c e I h a v e h a d am alg am land o n th e p a tie n t’s c o rn e a o n se v e ra l o c c a sio n s, a n d h a v e h a d to th en a tte m p t re m o v a l, a p ro c e d u re fo r w h ich w e a re n o t tra in e d . A sk a n y o p h th alm o lo g ist a b o u t th e healing o f a sc ra tc h e d co rn ea . A b o u t tw o y e a rs ag o , a s I w as re m oving a p a rticle o f am alg am fro m a p a tie n t’s e y e , I th o u g h t o f th e s e th in g s. I th o u g h t esp ecially o f th e fact th a t in m y d e n ta l train in g , a s late as 1969, w e w e re to ld to re m o v e p a tie n ts ’ g la sse s to “ a v o id b reak in g th e m .”
Y e t, w e w e re n o t allo w ed to o p e ra te w ith o u t glasses o f th e p re sc rip tio n o r sa fe ty ty p e on o u rselv e s. S u d d en ly , I re a liz e d th a t th e p a tie n t’s ey es a re a s im p o rta n t to him as m ine a re to me. F ro m th a t d ay on, n o p a tie n t in m y office h as b e e n p lace d in a reclining p o sitio n w ith o u t retain in g his ow n g la sse s, o r if h e h as n o n e , w earing th e safety g lasses I p ro v id e . I can h appily re p o rt n o t o n e case o f a foreig n o b je c t in a n ey e o f a p a tie n t o f m ine d u r ing th a t tim e; n e ith e r h av e I b ro k en a p a ir o f a p a tie n t’s glasses. I feel th a t w ith so m u ch em phasis p la c e d on p re v e n tio n in th e den tal office, an d rightly so , th is is o n e a re a so rely o v erlo o k ed . P a tie n ts should n o t be o p e ra te d on w ith o u t p ro te c tiv e e y e co v erin g s. D A V ID M . C A SE Y , D D S E. G R E E N B U S H , NY
Q u estio n resu lts o f stu d y • In th e S e p te m b e r 1974 j a d a (p 629) an artic le e n title d , “ p sy c h o th e ra p y fo r th e m y o fascial p ain -d y sfu n ctio n sy n d ro m e: a stu d y o f fa c to rs co in ciding w ith sy m p to m re m iss io n ,” by A . M a rtin P o m p re p o rts co m p lete re s o lu tio n o f all sy m p to m s in 15 out o f 23 p a in -d y sfu n ctio n sy n d ro m e (P D S ) p a tie n ts by u se o f p sy c h o th e r apy. A s fo rm e r m em b ers o f th e T M J c e n te r, w h e re th e stu d y w as d o n e, w e q u e stio n th e re su lts as rep o rte d . W e h elp ed ch o o se an d ad m in ister th e tre a tm e n ts te s te d w ith th e th re e differ e n t p sy ch o lo g ical g ro u p s re fe rre d to in th e a rtic le a n d , as p articip atin g clin ician s, w e w ere w ell a w a re o f th e re la tiv e effectiv en ess d e m o n stra ted by th e v ario u s tre a tm e n ts teste d (d ru g s, o cclu sal sp lin ts, m u scle ex e rc ise s, p s y c h o th e ra p y , an d so fo rth ). H o w e v e r, th e claim s o f su ccess w ith p s y c h o th e ra p y a re to tally in c o n sist e n t w ith w h a t w e k n o w to b e th e re su lts o b ta in e d a t th a t tim e. M an y o th e rs, beginning w ith M oul to n 20 y ears ag o , h a v e em ployed p sy c h o th e ra p y w ith P D S p a tien ts, bu t n o n e h as re p o rte d a ra te o f su ccess e v e n re m o tely ap p ro ach in g th at claim ed by P om p. W h at is th e b asis fo r th e claim th a t su ch a phen o m en a l ra te o f su c c e s s w as ach ie v ed ?
T h is u n b e lie v a b le su cc e ss ra te can n o t b e ju s tifie d m e rely b y poin tin g to th e s tu d y ’s “ s p e c ia l” P D S p o p u latio n . In fa c t, th e fa u lty ex p erim e n ta l de sign m a k e s m ean in g fu l e v alu a tio n o f th a t p o p u la tio n im p ro b ab le: p sy c h o n e u ro tic s w e re d ire c tly assig n ed to a g ro u p w h ich in c lu d e d o th e rs w h o had a lre a d y b e e n e x te n siv e ly tre a te d w ith “ c o n v e n tio n a l” m o d alities. N e v e r ag ain w e re th e se g ro u p s d istin g u ish ed o r w e re th e ir re s p o n se s. T h e a u th o r m ere ly m ad e a p o st h o c division o f all th e p a tie n ts in to fo u r n ew g ro u p s w h ich w e re lab eled : (1) reco g n ized n e e d fo r th e ra p y ; (2) d en ied p ro b lem s; (3) b iz a rre sy m p to m s; an d (4) o th e r. T h e m e th o d o f re p o rtin g su g g ests th a t th e a u th o r w as his ow n e v a lu a to r w hich ra ise s th e sp e c tre o f clinical b ia s, w ishful th ink in g , o r o f p a tie n ts try in g to p le a se an a u th o rity figure w ith fa v o ra b le re p o rts. (A ll p e rc e p tiv e clin ician s a re a w a re o f th is.) T h e a u th o r is a p sy ch o lo g ist, u n tra in e d in p h y sical ex am in a tio n o f th e sto m a to g n a th ic sy ste m a n d , th e re fo re , u n q u alified to p e rfo rm su ch ex am in a tio n s. A c c o rd in g to th e artic le, all o f th e p a tie n ts h ad m ultiple sy m p to m s. A n e x p e rie n c e d d ental e v a lu a to r w o u ld h av e re c o g n iz e d th a t in d iv id ual sy m p to m s re s p o n d selectiv ely . T h e re is n o m en tio n th a t p ain , th e m o st su b je ctiv e a n d re sp o n siv e sy m p to m , re s p o n d e d in an y w ay d iffe re n t ly th a n did o b jec tiv e sy m p to m s su ch as lim itatio n o f m o v e m e n t, m u scle te n d e rn e ss, a n d click in g , w hich are m o re re s iste n t a n d o ften p e rs ist to so m e d e g ree a fte r tre a tm e n t; n o m en tio n o f a n y su ch re sid u a l individual sy m p to m s; n o m e n tio n o f re c u rre n c e o f a n y in d iv id u al sy m p to m s in his p a tie n t fo llo w -up s. J u s t a flat sta te m en t o f “ c o m p le te re m iss io n ,” w h ich , u n su p p o rte d b y a d e q u a te clin ical d a ta , is su sp e c t. W e challenge th e a u th o r to s u b s ta n tia te his claim s w ith th e c o m p le te d a ta . W e d o u b t th a t he can . A n a rtic le su ch a s th is is d o u b ly u n fo rtu n a te w h e n it is in jec ted in to a c o n tro v e rsia l a re a su c h as th e T M J P D S . T h e c o n tro v e rsy b e tw e e n th e p ro p o n e n ts o f o cclu sal tre a tm e n t, on th e o n e h a n d , a n d th e m in o rity w ho fa v o r p sy ch o lo g ical tre a tm e n t, o n th e
o th e r, is fa r fro m re so lv e d . T h e re is v alid ity to som e o f th e claim s o f each g ro u p . I f th is c o n tro v e rsy is to be reso lv e d a n d a re a listic p e rs p e c tiv e o f th e P D S d e v e lo p e d , it is e sse n tia l th a t all o f th e e v id e n c e c o n sid e re d be valid and u n d is to rte d . T h is s tu d y ’s fa u lty ex p e rim e n ta l desig n a n d q u estio n ab le p ro c e d u re s h a v e p ro d u c e d re su lts w hich a re n e ith e r valid n o r cred ib le in o u r op in ion . U n fo rtu n a te ly , th ey n o w h a v e b e e n g iv en th a t illusion by h aving b e e n p u b lish e d . A s su c h , th e y w ill au to m a tic a lly h e lp d isru p t re so lu tio n o f th e P D S c o n tro v e rsy . In c id e n ta lly , th e a rtic le ’s a b stra c t in a d v e rte n tly m agnifies th e claim s e v e n m o re by statin g th a t th e e n tire p a tie n t p o p u la tio n p re v io u sly h ad b e e n tre a te d u n su c c e ssfu lly by c o n v e n tio n a l m e a n s, w hile th e article it se lf sta te s th a t th e m ajo rity , th e “ p sy c h o n e u ro tic s ,” w en t d ire c tly in to this stu d y o n c e th e y w e re so classified. T h e in fe re n c e w h ich em erg es is th a t p sy c h o th e ra p y is m o re effectiv e th a n th e s e u n n a m e d o th e r tre a tm e n ts. T h is is n o t th e ca se . W e sh o u ld n o te th a t th e su c c e ss c laim ed o c c u rre d p rim ar ily in th o s e w h o h ad n o t b een p re v io u sly tre a te d . T h e o b je c tio n s to this a rticle , ab o u t re s u lts startlin g ly o u t o f lin e, im p ro p e r e v a lu a tio n te c h n iq u e s, in co m p lete d a ta a b o u t th e p a tie n t p o p u la tio n , and so fo rth , sh o u ld h a v e b een raised long ag o, b e fo re p u b lic atio n . N o w , a fte r th e fa i t a c c o m p li o f p u b lic a tio n a n d th e u n ju stifie d sta tu s th is artic le will g ain , it will c o n tin u e its u n fo rtu n a te e ffe c t o f p a ssin g o ff p s y c h o th e ra p y as b eing fa r m o re e ffectiv e th a n it really is, a n d o f d isto rtin g th e p e rsp e c tiv e o f th e P D S , re g a rd le ss o f th e o b jec tio n s ra ise d h e re in th e “ L e tte rs to th e e d ito r” se c tio n . It will u n d o u b ted ly b e q u o te d as g o sp e l b y th o s e w h o se p u rp o s e s it se rv e s. I t will p ro b a b ly a lso in flu en ce th o s e clin ician s n o t k n o w led g ab le en o u g h to re je c t it o u t right. S a d ly , a n d m o re im p o rta n tly , th e u ltim ate v ictim s o f this m isin fo rm a tio n m ay b e th e p a tie n ts w h o se p a in a n d d isco m fo rt m ay b e p ro lo n g ed u n n ec e ssa rily . M A R T IN D . L E R M A N , D D S H O W A R D D. SU T C H E R , DDS U N IV E R S IT Y O F IL L IN O IS
LETTERS TO THE EDITOR / JADA, Vol. 91, September 1975 ■ 503
‘Im p r a c tic a l’ sta te m e n t m In th e Ju n e j a d a , R ich ard T h o m a s G la ss a n d his co lleag u es d escrib ed “ T e a c h in g self-exam in atio n o f th e head and neck: a n o th e r a sp e c t o f p re v en tiv e d e n tis try ” (page 1265). T h e c o n c e p t o f self-ex am in atio n w as q u ite in terestin g an d I certain ly a p p la u d th e d esirab ility o f in creasin g th e p a tie n t’s a w a re n e ss o f a b n o rm al ities o f th e head an d n e c k regions. H o w e v e r, I sh o u ld like to ta k e issu e w ith a sta te m e n t e x p re sse d o n page 1266: “ T h e p a tie n t is told to o b se rv e any lesio n fo r tw o w eek s a n d if healing has n o t o c c u rre d w ithin this tim e sp an , to call th e d e n tist im m e d ia te ly .” It is o u r teac h in g , an d m y belief, th a t th e d e n tist is in a b e tte r p o sitio n to ex am in e th e p a tie n t a n d d eterm in e “ if healing h as n o t o c c u rre d .” T o ex p e c t th e naive p a tie n t to ex am in e su ch a reas as the p a late and la teral b o rd e rs
o f th e to n g u e is, in m y o p in io n , im p ra ctic a l. S u b tle a b n o rm a lities o r in c o m p le te healing easily could b e o v e r lo o k ed by th e p a tie n t. F u rth e r, th e p a tie n t w h o is a h e a v y u s e r o f alco h o l a n d a h ea v y sm o k e r is k n o w n to h a v e a h ig h er in c id e n c e o f o ral m alignancy. S om e au th o rs h av e su g g ested th e se p a tie n ts h av e a 15.5 tim es g re a te r risk o f oral c a n c e r. T h is p a tie n t w o uld be p a rtic u la rly u n reli ab le in self-ex am in atio n an d “ selfd ia g n o sis.” T h e re fo re , D r. G la s s ’s te c h n iq u e w o u ld h a v e lim ited u se fu l n e ss in this high risk p o p u latio n . I fo u n d th e a rtic le q u ite in terestin g , b u t w ould p re fe r th a t e m p h asis be g iv en to self-ex am in atio n an d n o t to self-diagnosis. S T U A R T L . F IS C H M A N , D M D
If th e ex a m in ers tre a te d th e ir p a tie n ts o r th e ir office sta ff th e w ay th e y tre a te d u s, th e y w o u ld n o lo n g er h a v e p ra c tic e s. I h a p p e n to b elieve th a t th e s e clinical ex a m in a tio n s d o no t a c c u ra te ly e v a lu a te a s tu d e n t’s clin ical ability o r ju d g m e n t. B u t if th e y m u st be g iv en , c a n ’t th e e x a m in e rs at le a st b e h a v e like g e n tle m e n ? T h e u su al a ttitu d e o f su c c e ssfu l b o a rd c a n d id a te s, o n c e th e ir a n g er su b sid e s, is “ I ’ve g o t m ine n o w , you fight y o u rs .” T ru e , this is w ritte n in a n g e r. B ut if th e re is e v e r a n y th in g I c a n d o to c o rre c t th is in ju stic e, I will d o it, an d I will jo in an y m o v e m e n t to se e th a t stu d e n ts are tre a te d a s I w ould like to be. JO S E P H C. S C O T T I, D M D BRONX, NY
PR O FE SSO R , ST A T E U N IV E R S IT Y O F N E W YORK A T B U F F A L O
E y e injuries in d e n ta l o ffice ‘H u m ilia tin g e x p e rie n c e ’ m I am w riting to you as a n ew co l league. M y e n tra n c e in to th e p ro fe ssio n , a fte r having been ta u g h t to c a re fo r th e p a tie n ts I tr e a t an d to em p a th ize w ith th e ir fe a rs, w as a hum iliating e x p e rie n c e . I a m referrin g to th e N o rth e a s t R eg io n al B o ard ex am in a tio n . B elieve m e, I d o n o t m e a n to b rag w hen I say th a t I w as a g o od stu d e n t. I w as priv ileg ed to re ce iv e sev eral d e p a rtm e n ta l a w a rd s, w as e le c t ed to O m ic ro n K a p p a U p silo n , and g ra d u a te d first in m y class o f 75. I am a little e m b a rra ss e d to sta te th is, b u t I d o so to show th a t this le tte r is n o t so u r g ra p e s, an d I am n o t b itte r a b o u t failing th e b o a rd s; I p assed . N o o n e sh o u ld b e su b je cte d to an e x p erie n c e like th is. A fte r fo u r y ears o f d en tal e d u c a tio n , to be fo rc e d to su b m it to th e sa rc a sm an d h a ra ssm e n t w e u n d e rw e n t is to b e d eg ra d e d as a p e rso n an d a s a p ro fessio n a l. A s one o f m y c la ssm a te s (also in O K U , and now in a p o stg ra d u a te o rth o d o n tic s p ro g ram ) said , “ It w as like pledging a fra te rn ity , a n d th is w as H ell W e e k .” S ev en o f m y c la ssm a te s failed th e b o a rd s. P e rh a p s o n e o r tw o d e se rv e d to fail. N o n e o f th e o th ers h a v e an y id e a o f w hy th e y faile d , an d th e b o a rd will n o t tell th e m w h y . T h is is ad ding in su lt to in ju ry .
502 ■ LETTERS TO THE EDITOR / JADA, Vol. 91, September 1975
m In re g ard to th e Ju n e j a d a a rtic le on a v o id a b le a d v e rs e e v e n ts in d e n tistry b y P e te r M ilgrom (page 1282), I w ish to a d d o n e a re a to his list o f av o id ab le a d v e rs e d en tal o u tc o m e s th a t I feel is e x tre m e ly im p o rta n t an d all to o o ften o v e rlo o k e d . I a m referrin g to ey e in ju ries in th e d e n ta l office. T o d a y w e a re p ra c ticin g sit-d o w n d e n tistry w ith th e p a tie n t in a h o rizo n ta l p o sitio n . W e c o n sta n tly h a v e sh arp in stru m e n ts h a n d e d to us o v e r th e p a tie n t’s fa c e , a n d re a c h fo r h a n d p iec es w ith sh a rp b u rs. W e c a rry c o tto n p elle ts lad en w ith ac id s, m ed ic am e n ts, v a rn ish e s, an d w h o k n ow s w h a t else to w ith in in ch e s o f th e e y es. W e rem o v e to o th stru c tu re a n d filling m aterials a t u ltra sp e e d , a n d th e s e p a rtic le s a re n o w p ro p e lle d v e rtically d u e to th e p a tie n ts h o riz o n ta l p o sitio n . F ro m m y o w n e x p e rie n c e I h a v e h a d am alg am land o n th e p a tie n t’s c o rn e a o n se v e ra l o c c a sio n s, a n d h a v e h a d to th en a tte m p t re m o v a l, a p ro c e d u re fo r w h ich w e a re n o t tra in e d . A sk a n y o p h th alm o lo g ist a b o u t th e healing o f a sc ra tc h e d co rn ea . A b o u t tw o y e a rs ag o , a s I w as re m oving a p a rticle o f am alg am fro m a p a tie n t’s e y e , I th o u g h t o f th e s e th in g s. I th o u g h t esp ecially o f th e fact th a t in m y d e n ta l train in g , a s late as 1969, w e w e re to ld to re m o v e p a tie n ts ’ g la sse s to “ a v o id b reak in g th e m .”
Y e t, w e w e re n o t allo w ed to o p e ra te w ith o u t glasses o f th e p re sc rip tio n o r sa fe ty ty p e on o u rselv e s. S u d d en ly , I re a liz e d th a t th e p a tie n t’s ey es a re a s im p o rta n t to him as m ine a re to me. F ro m th a t d ay on, n o p a tie n t in m y office h as b e e n p lace d in a reclining p o sitio n w ith o u t retain in g his ow n g la sse s, o r if h e h as n o n e , w earing th e safety g lasses I p ro v id e . I can h appily re p o rt n o t o n e case o f a foreig n o b je c t in a n ey e o f a p a tie n t o f m ine d u r ing th a t tim e; n e ith e r h av e I b ro k en a p a ir o f a p a tie n t’s glasses. I feel th a t w ith so m u ch em phasis p la c e d on p re v e n tio n in th e den tal office, an d rightly so , th is is o n e a re a so rely o v erlo o k ed . P a tie n ts should n o t be o p e ra te d on w ith o u t p ro te c tiv e e y e co v erin g s. D A V ID M . C A SE Y , D D S E. G R E E N B U S H , NY
Q u estio n resu lts o f stu d y • In th e S e p te m b e r 1974 j a d a (p 629) an artic le e n title d , “ p sy c h o th e ra p y fo r th e m y o fascial p ain -d y sfu n ctio n sy n d ro m e: a stu d y o f fa c to rs co in ciding w ith sy m p to m re m iss io n ,” by A . M a rtin P o m p re p o rts co m p lete re s o lu tio n o f all sy m p to m s in 15 out o f 23 p a in -d y sfu n ctio n sy n d ro m e (P D S ) p a tie n ts by u se o f p sy c h o th e r apy. A s fo rm e r m em b ers o f th e T M J c e n te r, w h e re th e stu d y w as d o n e, w e q u e stio n th e re su lts as rep o rte d . W e h elp ed ch o o se an d ad m in ister th e tre a tm e n ts te s te d w ith th e th re e differ e n t p sy ch o lo g ical g ro u p s re fe rre d to in th e a rtic le a n d , as p articip atin g clin ician s, w e w ere w ell a w a re o f th e re la tiv e effectiv en ess d e m o n stra ted by th e v ario u s tre a tm e n ts teste d (d ru g s, o cclu sal sp lin ts, m u scle ex e rc ise s, p s y c h o th e ra p y , an d so fo rth ). H o w e v e r, th e claim s o f su ccess w ith p s y c h o th e ra p y a re to tally in c o n sist e n t w ith w h a t w e k n o w to b e th e re su lts o b ta in e d a t th a t tim e. M an y o th e rs, beginning w ith M oul to n 20 y ears ag o , h a v e em ployed p sy c h o th e ra p y w ith P D S p a tien ts, bu t n o n e h as re p o rte d a ra te o f su ccess e v e n re m o tely ap p ro ach in g th at claim ed by P om p. W h at is th e b asis fo r th e claim th a t su ch a phen o m en a l ra te o f su c c e s s w as ach ie v ed ?
T h is u n b e lie v a b le su cc e ss ra te can n o t b e ju s tifie d m e rely b y poin tin g to th e s tu d y ’s “ s p e c ia l” P D S p o p u latio n . In fa c t, th e fa u lty ex p erim e n ta l de sign m a k e s m ean in g fu l e v alu a tio n o f th a t p o p u la tio n im p ro b ab le: p sy c h o n e u ro tic s w e re d ire c tly assig n ed to a g ro u p w h ich in c lu d e d o th e rs w h o had a lre a d y b e e n e x te n siv e ly tre a te d w ith “ c o n v e n tio n a l” m o d alities. N e v e r ag ain w e re th e se g ro u p s d istin g u ish ed o r w e re th e ir re s p o n se s. T h e a u th o r m ere ly m ad e a p o st h o c division o f all th e p a tie n ts in to fo u r n ew g ro u p s w h ich w e re lab eled : (1) reco g n ized n e e d fo r th e ra p y ; (2) d en ied p ro b lem s; (3) b iz a rre sy m p to m s; an d (4) o th e r. T h e m e th o d o f re p o rtin g su g g ests th a t th e a u th o r w as his ow n e v a lu a to r w hich ra ise s th e sp e c tre o f clinical b ia s, w ishful th ink in g , o r o f p a tie n ts try in g to p le a se an a u th o rity figure w ith fa v o ra b le re p o rts. (A ll p e rc e p tiv e clin ician s a re a w a re o f th is.) T h e a u th o r is a p sy ch o lo g ist, u n tra in e d in p h y sical ex am in a tio n o f th e sto m a to g n a th ic sy ste m a n d , th e re fo re , u n q u alified to p e rfo rm su ch ex am in a tio n s. A c c o rd in g to th e artic le, all o f th e p a tie n ts h ad m ultiple sy m p to m s. A n e x p e rie n c e d d ental e v a lu a to r w o u ld h av e re c o g n iz e d th a t in d iv id ual sy m p to m s re s p o n d selectiv ely . T h e re is n o m en tio n th a t p ain , th e m o st su b je ctiv e a n d re sp o n siv e sy m p to m , re s p o n d e d in an y w ay d iffe re n t ly th a n did o b jec tiv e sy m p to m s su ch as lim itatio n o f m o v e m e n t, m u scle te n d e rn e ss, a n d click in g , w hich are m o re re s iste n t a n d o ften p e rs ist to so m e d e g ree a fte r tre a tm e n t; n o m en tio n o f a n y su ch re sid u a l individual sy m p to m s; n o m e n tio n o f re c u rre n c e o f a n y in d iv id u al sy m p to m s in his p a tie n t fo llo w -up s. J u s t a flat sta te m en t o f “ c o m p le te re m iss io n ,” w h ich , u n su p p o rte d b y a d e q u a te clin ical d a ta , is su sp e c t. W e challenge th e a u th o r to s u b s ta n tia te his claim s w ith th e c o m p le te d a ta . W e d o u b t th a t he can . A n a rtic le su ch a s th is is d o u b ly u n fo rtu n a te w h e n it is in jec ted in to a c o n tro v e rsia l a re a su c h as th e T M J P D S . T h e c o n tro v e rsy b e tw e e n th e p ro p o n e n ts o f o cclu sal tre a tm e n t, on th e o n e h a n d , a n d th e m in o rity w ho fa v o r p sy ch o lo g ical tre a tm e n t, o n th e
o th e r, is fa r fro m re so lv e d . T h e re is v alid ity to som e o f th e claim s o f each g ro u p . I f th is c o n tro v e rsy is to be reso lv e d a n d a re a listic p e rs p e c tiv e o f th e P D S d e v e lo p e d , it is e sse n tia l th a t all o f th e e v id e n c e c o n sid e re d be valid and u n d is to rte d . T h is s tu d y ’s fa u lty ex p e rim e n ta l desig n a n d q u estio n ab le p ro c e d u re s h a v e p ro d u c e d re su lts w hich a re n e ith e r valid n o r cred ib le in o u r op in ion . U n fo rtu n a te ly , th ey n o w h a v e b e e n g iv en th a t illusion by h aving b e e n p u b lish e d . A s su c h , th e y w ill au to m a tic a lly h e lp d isru p t re so lu tio n o f th e P D S c o n tro v e rsy . In c id e n ta lly , th e a rtic le ’s a b stra c t in a d v e rte n tly m agnifies th e claim s e v e n m o re by statin g th a t th e e n tire p a tie n t p o p u la tio n p re v io u sly h ad b e e n tre a te d u n su c c e ssfu lly by c o n v e n tio n a l m e a n s, w hile th e article it se lf sta te s th a t th e m ajo rity , th e “ p sy c h o n e u ro tic s ,” w en t d ire c tly in to this stu d y o n c e th e y w e re so classified. T h e in fe re n c e w h ich em erg es is th a t p sy c h o th e ra p y is m o re effectiv e th a n th e s e u n n a m e d o th e r tre a tm e n ts. T h is is n o t th e ca se . W e sh o u ld n o te th a t th e su c c e ss c laim ed o c c u rre d p rim ar ily in th o s e w h o h ad n o t b een p re v io u sly tre a te d . T h e o b je c tio n s to this a rticle , ab o u t re s u lts startlin g ly o u t o f lin e, im p ro p e r e v a lu a tio n te c h n iq u e s, in co m p lete d a ta a b o u t th e p a tie n t p o p u la tio n , and so fo rth , sh o u ld h a v e b een raised long ag o, b e fo re p u b lic atio n . N o w , a fte r th e fa i t a c c o m p li o f p u b lic a tio n a n d th e u n ju stifie d sta tu s th is artic le will g ain , it will c o n tin u e its u n fo rtu n a te e ffe c t o f p a ssin g o ff p s y c h o th e ra p y as b eing fa r m o re e ffectiv e th a n it really is, a n d o f d isto rtin g th e p e rsp e c tiv e o f th e P D S , re g a rd le ss o f th e o b jec tio n s ra ise d h e re in th e “ L e tte rs to th e e d ito r” se c tio n . It will u n d o u b ted ly b e q u o te d as g o sp e l b y th o s e w h o se p u rp o s e s it se rv e s. I t will p ro b a b ly a lso in flu en ce th o s e clin ician s n o t k n o w led g ab le en o u g h to re je c t it o u t right. S a d ly , a n d m o re im p o rta n tly , th e u ltim ate v ictim s o f this m isin fo rm a tio n m ay b e th e p a tie n ts w h o se p a in a n d d isco m fo rt m ay b e p ro lo n g ed u n n ec e ssa rily . M A R T IN D . L E R M A N , D D S H O W A R D D. SU T C H E R , DDS U N IV E R S IT Y O F IL L IN O IS
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