LETTERS

ciate Dr. Bolands comments and observations. Yes, zinc phosphate cemented restorations are successful. Further, it is interesting to me that, from an historical standpoint, cast gold restorations cemented with zinc phosphate cement are among the longestlasting dental restorations. However, judgment of that clinical concept, based on the popular technique of microleakage, indicates that zinc phosphate leaks and should fail. Obviously, that is not true. Is microleakage really a negative factor? I doubt it. There are many unknowns in crown and fixed prosthesis cementation. Die spacers placed over the coronal portion of dies and ending about 1 millimeter from the margins provide an escapeway for the cement hydraulic forces involved during cementation. The spacers range from 30 mm to 55 mm thick on a short tooth preparation; up to 100 mm thick on a long tooth preparation. The cement layer is also an insulator, reducing hot and cold transfer to the tooth preparation, and potential postoperative tooth sensitivity. The newer cement category, hybrid ionomer, has almost completely eliminated postoperative tooth sensitivity while providing low solubility, high strength, increased retention, bond-to-tooth structure and fluoride release. Cements are getting better! Gordon J. Christensen, D.D.S., M.S.D., Ph.D. Provo, Utah
CLASS II COMPOSITE RESTORATIONS

LETTERS
JADA welcomes letters from
readers on topics of current interest in dentistry. The Journal reserves the right to edit all communications and requires that all letters be signed. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated.

TOOTH SENSITIVITY

I found Dr. Gordon Christensens article Resin Cements and Postoperative Sensitivity (August JADA) very interesting, as usual. I noticed that several cement types expand as they set. Apparently, zinc phosphate cement is not worth mentioning, as no one seems to know why it worked so well for years. Only one lecturer I have heard still uses it. What concerns me is the use of die spacers, an enamellike red or blue (usually) hard paint used by labs to cover dies. I know a smooth die makes waxing easier, but how significant is its use? Have any studies been done to determine the optimal thickness to be used for todays cements? To me, its use seems to decrease crown retention. I get tired of seeing cementation kits continue to rise in cost, but I also question just how much better they really are in reducing sensitivity and keeping crowns retained. Is this die spacer necessary? Thank you. Michael L. Boland, D.D.S. Alice, Texas Authors response: I appre-

I am writing in response to Establishing a Tight Contact in a Class II Resin-Based

Composite Restoration by Dr. Richard E. Derrick in the September JADA Clinical Directions section. His technique for obtaining a tight contact in a Class II composite restoration is, to say the least, interesting. In this rather complicated technique, Dr. Derrick places the composite only below the proximal contact with a band in place. He then places the remainder of the restoration after removing the band, and he sometimes lubricates the adjacent tooth with petroleum jelly. He then has the patient bite down into centric before contouring and curing the restoration. And all of this is done without a rubber dam. This technique would seem to have the following flaws: dafter the band is removed, it is likely that gingival bleeding would contaminate the prep; dpetroleum jelly could easily be incorporated into the composite, possibly compromising the margins; dhaving the patient bite into the uncured resin would likely contaminate the field with saliva, not to mention the possibility of the composite sticking to the opposing tooth and pulling as the patient opens; dfinishing and polishing of excess and overhangs will be much more time-consuming than other techniques; dthe literature clearly shows that rubber dam isolation is a must for composite restorations. JADA has an obligation to present sound clinical advice to practicing dentists. This technique is fraught with difficulty and potential problems that can easily undermine the success of the restoration. With the introduction of sectional matrix/ring systems
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(Composi-Tight, Palodent and others), establishing predictable, tight contacts has been made simple and reliable. Why JADA would choose to promote this dubious technique is beyond me. The editors should be much more careful in the future before publishing such a technique. Michael Kelliher, D.M.D. Longmeadow, Mass. Authors response: The band is removed, but not the wedge, which is tightened immediately. I dont usually see bleeding here. Petroleum jelly is only used on the adjacent composite contact area if it has just been placed. If used judiciously, you should be able to avoid contaminating the composite. It does not have to be used if the composite is 24 hours old, or if it is a natural tooth, porcelain inlay/crown, gold inlay/crown or an amalgam. Having the patient bite into the uncured resin shouldnt contaminate the field with saliva if you are working in a dry field, which is mandatory in curing procedures. I havent found sticking to the opposing tooth to be a problem. If you are finding this occurring, before biting into the uncured resin, trim the excess and place the occlusal anatomy, light-cure and then start to adjust the occlusion. There should be no or very little overhang if your band has been wedged at the gingival margin and the band is touching the adjacent tooth in the contact area. You have left only 1 millimeter to be filled after the band has been removed. The band has given you the contour. If you cannot achieve this, you should use an alternate technique. This technique is completely
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amenable to the rubber dam technique, which I highly recommend. The final curing would be done with the rubber dam in place, and the occlusion would be adjusted after the rubber dam is removed. I developed this technique after trying many of the commercial matrix systems on the market and not finding any that were completely satisfactory. Developing tight contacts in Class II resin-bonded composites is not a simple procedure. Employing my technique will give predictable tight contacts, but it does require some practice to master this method. Richard E. Derrick, D.M.D. Mendham, N.J.
SLEEP DISORDERED BREATHING

Kudos to Dr. Friedlander and his colleagues for their enlightening treatise on oral appliance therapy for the management of sleep disordered breathing (Diagnosing and Comanaging Patients With Obstructive Sleep Apnea Syndrome, August JADA). This timely topic deserves widespread exposure in all our journals since sleep disordered breathing, or SDB, adversely affects the lives of millions of people worldwide. With fewer than 95 percent of these cases being diagnosed and treated, the need is clear. Science has made the relationship between SDB and a host of medical conditions, in particular cardiovascular consequences. This provides an opportunity for dentists to impact not only the quality of patients lives, but, in some instances, the quantity. Dentistry is now evolving into a major component of the health care treat-

ment team in the management of SDB. This article creates an imperative awareness among dentists that SDB is a medical problem that can be life-threatening in severe cases. It also reinforces how important it is that dentists not act unilaterally in the treatment of these patients. As the title indicates, patients must be comanaged within the appropriate medical team. (In this arena, dentists are not medically or legally qualified to diagnose SDB, and physicians are not dentally qualified to manage oral appliances and their effect on the oral structures.) The comprehensive nature of the article serves the reader well, as many topics germane to dentistrys role in comanaging SDB are thoroughly presented. Dental sleep medicine, as it is now known, is vastly complex, and much more needs to be said that is beyond the scope of Dr. Friedlander and colleagues article. For example, the dentist treating sleep disorders has numerous appliances and multiple surgical procedures available to manage upper-airway patency during sleep. Knowing how and when to use each appliance, or when to opt for surgery or a proper referral (pulmonary, sleep, otolaryngological and so on) is both an art and a science. Patient referral protocol, trouble-shooting and managing individual appliances, insurance reimbursement issues, pharmacology, coexisting dental and medical conditions, morbidity and peer-reviewed research are but a few of the important areas needing attention in this new arena where medicine and dentistry coexist. At first glance, it may appear that this

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treatment is simple and straightforward. It is neither. As with any new treatment modality, proper training and education are essential. The increased awareness of sleep disorders by both physicians and the public is creating a demand for dentists who are proficient in dental sleep medicine. Don A. Pantino, D.D.S. President Robert R. Rogers, D.M.D. Immediate Past President Academy of Dental Sleep Medicine Wexford, Pa.
CLINICAL RESEARCH: LEARNING RIGHT FROM WRONG

Clinical observation is important because it remains the primary generator of hypotheses in the biomedical sciences. Dr. Edward F. Wrights article in September JADA (Referred Craniofacial Pain Patterns in Patients with Temporomandibular Disorder) illustrates many pitfalls encountered during the conduct of clinical research. Therefore, an examination of several of these potential problems should be instructive for clinicians and inexperienced researchers contemplating similar activity. It is to these individuals that this letter is directed, although a response from Dr. Wright is warmly welcomed. Start with a clearly defined hypothesis designed to increase knowledge in a particular area. This is harder than one may think at first. You should aim to show that all other cases not in your sample are fairly consistent with the initial hypothesis and that another hypothesis does not fit the data as well or

better. Additionally, the greater the degree of exposure, the higher the incidence rate. For example, in the case of chronic pain studies, variables such as greater pain intensity, more manual pressure on examination or greater chronicity should also lead to higher rates of the outcome variable. When stating the aims of your study, do not use phrases like I speculate that or patients with TMD may be quite similar. Speculation refers to reasoning often based on inconclusive evidence. Additionally, quite similar leaves too much room for maneuvering; it is an imprecise phrase, counter to rigorous (statistical) interpretation. When reading a study, begin by asking the following questions: Can the results be applied to my patient(s) care? To what extent do patients in the articles resemble my patient(s) in terms of symptoms, disorder severity and duration and demographic factors that may affect treatment outcome? (Marbach JJ, Raphael KG. Future directions in the treatment of chronic musculoskeletal facial pain: the role of evidencebased care. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83[1]:170-6). When recruiting research subjects, strive for diagnostic homogeneity. There is good reason why the National Institutes of Health recommended abandoning the term temporomandibular disorders, or TMD (National Institutes of Health Technology Assessment Conference on Management of Temporomandibular Disorders. Bethesda, Maryland, April 29May 1, 1996. Proceedings. Oral Surg Oral Med Oral Pathol Oral

Radiol Endod 1997;83[1]:49183). The well-recognized heterogeneity of TMD as identified in the NIH Technology Assessment Conference and even heterogeneity of disorder within the myofascial subtype (Greene CS, Lerman MD, Sutcher HD, Laskin DM. The TMJ pain-dysfunction syndrome: heterogeneity of the patient population. JADA 1969;79[11]:1168-72) make it virtually impossible to answer the questions posed in reference to the referred pain patterns reported. It seems unlikely that patterns would be identical for clinically different conditions unless they are the same for everyone. Moreover, the reader is furnished with no information about severity, duration or distribution of pain, any or all of which could have influenced the results. However, all of these issues pale before two major problems, namely blindness and the lack of a control group. Dr. Wright discusses the potential for subject bias and states: I was careful not to bias the subjects; only 29 percent of the subjects reported referred pain from the masseter muscle. Prior to this he reports: I asked subjects whether pain was developing or intensifying in a different location than that being palpated. Does anyone believe that the subjects were unaware of his goal to identify patterns of referred pain? This phenomenon is what researchers call subject bias. Subjects know what the investigator is looking for and frequently are willing to cooperate. The problem is that no one knows how frequently any particular sample of subjects complies. To help control for this,
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someone unfamiliar with the hypotheses of the study (blind), not the chief investigator, performs the clinical examination. While not a perfect or the only solution, this method is preferable to the one employed. Why is this so? Not primarily because the subject is biased but because of the inherent bias of the investigator (Cohen P, Cohen J. The clinicians illusion. Arch Gen Psychiatry 1984;41[12]:1178-82). Does anyone believe that Dr. Wright was unaware of his goal to identify referred pain patterns? In a recent popular movie, a youngster, and only he, sees ghosts. Since he is the only one who sees them, he is helpless to prove his unique power to anyone else. Finding referred pain patterns is analogous to identifying ghosts; only one person performed the examination and wrote the report. One cannot deny that Dr. Wright has special skills to identify referred pain patterns, but neither can he prove the validity of these skills. The study states that patients with TMD often report referred craniofacial pain generated from head and neck palpation ... . How does he know this without a control group? Perhaps anyone would respond with reports of pain at sites other than those palpated when Dr. Wright performs his examination. For example, maybe only depressed pain patients report referred pain. And since rates of depression, common in facial pain patients, were not reported, the reader just does not know. The list of absent variables is nearly endless, and one cannot expect Dr. Wright to include all of them. That is why researchers employ control groups.
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The appropriate selection of a control group, while not simple (Marbach JJ, Schwartz S, Link BG. The control group conundrum in chronic pain case/control studies. Clin J Pain 1992; 8[1]:39-43), is absolutely necessary in studies such as this one. Because no control group was used, we have, in fact, learned nothing about the relation between facial pain patients and referred pain patterns. The asymmetry makes it impossible to determine if differences detected are due to the presence of the disorder under investigation, or some other uncontrolled and unidentified variable. The lack of controls in the present study does not inform us about potential correlates of so-called TMD because the study did not compare patients with controls. One final point is important to mention. The paper includes a lengthy discussion of referred pain theories. Nevertheless, the data do not move forward our understanding of whether or not referred pain is a ghost or real. It does not tell us whether it is related to orif it exists is independent of facial pain. Remember, no hypothesis was presented, so it is not surprising that no problem was solved. For those who want to move knowledge forward, do not despair. However, before you undertake lengthy and time-consuming activities, spend some time thinking through the problem. Clinical researchers who are also child prodigies are rare indeed. Even among those who succeed, learning research techniques takes time. If you get stuck, find yourself a mentor; they are out there. Do the right thing. Joseph J. Marbach, D.D.S.

New Jersey Dental School, Department of Oral Pathology, Biology and Diagnostic Sciences New Jersey Medical School, Department of Psychiatry Newark, N.J. Authors response: The research design used in this study is classified as descriptive (Babbie ER. The practice of social research. 6th ed. Belmont, Calif.: Wadsworth Pub. Co.; 1992:91), and the intent of the study was to describe the potential referred pain patterns of this population. In a descriptive study, a second population (that is, a control or other group) is not utilized unless the researcher desires to compare the populations (Norman GR, Streiner DL. PDQ statistics. St. Louis: Mosby; 1986:159-62). If a research design utilizes an intervention, then I strongly recommend a control group be utilized so the intervention group can be compared with the control group in order to determine whether the intervention group had a significantly better effect than the control group. Unfortunately, there is no objective method to identify referred pain (that is, cervicogenic headaches and the like) other than through patient reports. TMD pain (intensity, frequency and character) is similarly based on patient perception, with no objective technique available to measure the perceived pain. Probably the closest procedure we have is pressure algometer pain thresholds, which is also based on patient perception. I concur with Dr. Marbach that researchers need to be cognizant of the tendency for subjects to distort their perceptions

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to please the examiner. During a study, subjects should observe an atmosphere in which the examiner is seeking the absolute truth and nothing less. I believe accurate study results are a product of the subjects integrity as well as the integrity of the individuals running the study. I disagree with Dr. Marbach that utilizing an examiner unfamiliar with the hypotheses makes the individual blinded nor does it necessarily enable him or her to obtain more honest subject perceptions. In this article, I tried to convey that the results were collected with the greatest subject honesty possible. In the environment this study was conducted, I cannot believe a subject would have reported he or she felt pain in a distant location when he or she had not, and then fabricated a mythical location. My belief is supported by the comparison of our results with the Branch et al. study (Branch MA, Carlson CR, Okeson JP. Influence of biased clinical statements on patient report of referred pain. J Orofac Pain 2000;14[2]:120-7). If only Dr. Marbach had the experience of working with me, he would know that my integrity is not an issue that needs to be challenged. My objective for donating my time to research is to provide myself and our colleagues with information that enables us to better diagnose and treat TMD patients, not to provide disingenuous information that would be refuted by future studies. I concur with many of the points Dr. Marbach made. One central thrust is that readers need to critically evaluate the research they read to determine whether the results can be generalized back to their patients. After reading Dr. Marbachs comment, in hindsight, it would have been nice to evaluate subgroups (that is, more depressed subjects, subjects with greater pain chronicity and others) of this population for referred pain differences. I appreciate Dr. Marbachs taking his time to review the important subject of research design. Edward F. Wright, D.D.S., M.S. San Antonio
OCCLUSAL VS. NONOCCLUSAL ETIOLOGY

conditions causes a decrease in patient parafunctional activity, show me these studies. C. R. Hoopingarner, D.D.S. Houston Authors response: I wholeheartedly agree that proper research and a fair forum, along with well-defined diagnoses, would go a long way toward resolving the differences that seem to cloud the TMD issue. I agree with Dr. Hoopingarner that occlusal prematurities do not cause bruxism. However, I believe working and balancing interferences starts a chain reaction that can cause muscular hyperactivity, which leads to excess force on teeth, bone, ligaments and temporomandibular joints as well as muscle fatigue and pain. That excess force is either mitigated by or exacerbated by host resistance and adaptability, behavior issues and a variety of other factors such as bruxism. Some of the original research demonstrating that occlusal discrepancies directly affect muscle activity was done by Ramfjord almost 40 years ago. Muscular activity has been repeatedly linked to occlusion. Dr. Sig Ramfjords EMG studies showed that a meticulous occlusal equilibration quelled disharmonious muscle activity patterns. When the teeth can be brought together with no deflection from centric relation to centric occlusion, muscle activity is harmonious (Ramfjord SP. Dysfunctional temporomandibular joint and muscle pain. J Prosthet Dent 1961;11[3-4]:353-74). Williamson and Lundquist proved that posterior disclusion is a solid scientific tenet. They
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I read with interest Dr. Ronald Gilligans letter to the editor in March JADA, as well as Dr. Jeremy Shulmans letter and Dr. Gilligans response in August JADA. Certainly, the occlusal vs. nonocclusal etiology of temporomandibular disorder and bruxism has raged on for years and will continue to do so until it is addressed in a fair forum by members of both sides of the issue and researched properly. What I find interesting and lacking in Dr. Gilligans response is the scientific evidence to show that introducing a slight prematurity into the dentition creates a change in a patients baseline muscle activity reading. To my knowledge, no research has shown this. To the contrary, what research is available was done in the past by doctors such as John Rugh, Chuck Green and Dan Laskin, showing that this has no effect. If occlusal prematurities are the cause of bruxism, then we should be able to create bruxism in a nonbruxist population by introducing them. If creating strong cuspid rise or deep bite

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showed the relationship between decreased muscle activity/EMG activity and anterior guidance (Williamson EH, Lundquist DO. Anterior guidance: its effect on electromyographic activity of the temporal and masseter muscles. J Prosthet Dent 1983;49[6]:816-23). Further, the following research also addresses the correlation between occlusal and muscular disharmonies: Riise C, Sheikholeslam A. The influence of experimental interfering occlusal contacts on the postural activity of the anterior temporal and masseter muscles in young adults. J Oral Rehabil 1982;9(5):419-25. Belser UC, Hannam AG. The influence of altered workingside occlusal guidance on masticatory muscles and related jaw movement. J Prosthet Dent 1985;53(3):406-13. Kirveskari P, Le Bell Y, Salonen M, Forssell H, Grans L. Effect of elimination of occlusal interferences on signs and symptoms of craniomandibular disorder in young adults. J Oral Rehabil 1989;16(1):21-6. Kerstein RB, Farrell S. Treatment of myofascial paindysfunction syndrome with occlusal equilibration. J Prosthet Dent 1990;63(6):695-700. These studies represent just the tip of the scientific iceberg. I am surprised that Dr. Hoopingarner has no knowledge of this research, particularly in light of the fact that he provides comprehensive dentistry and craniomandibular orthopedics. It is extremely difficult to stay abreast of the dental literature. It is also complicated by our tendency to look for simple cause-and-effect relationships rather than multifactorial answers that more closely fit the multifactorial nature of TMD. It is not a single disease. There is no single cause nor can there be a single solution. Our challenge is to specifically diagnose our patients problems, understand the causes of the problems as well as possible, and then treat them appropriately and specifically. In my opinion, the majority of problems seen in general practice can be definitely diagnosed as occlusomuscle disharmonies. Fortunately, occlusal equilibration provides a direct solution for most of these clinical challenges. Unfortunately, occlusal equilibration is extremely exacting. Many of us tend to base our opinions and clinical practices on the teaching and expertise of respected mentors and educators. The ongoing controversy surrounding TMD is a healthy one if we open-mindedly examine those teachings along with the clinical research available and avoid the exclusionary thinking that tends to stifle us all. Ronald M. Gilligan, D.D.S. Frisco, Colo.
DENTISTRY IN THE 21st CENTURY

I want to congratulate JADA for the special supplement, Dentistry in the 21st Century, that was published with the June issue. It gives you a short and excellent update on the main areas of dentistry and an idea of new treatment and materials for the future. JADA has improved to the point that it is probably number 1 in the worlda must-read for the general practitioner and the specialist. Dr. Pedro Olavarrieta Doctor en Odontologia Santo Domingo, Dominican Republic

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JADA, Vol. 131, November 2000 Copyright 1998-2001 American Dental Association. All rights reserved.