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Beverly Hills, Calif.

HE SUBJECT OF HIGH-SPEED operative instruments requires a critical review. With the present state of anesthesia and the general acceptance of anesthesia on the part of the public for all operative procedures causing appreciable discomfort, it has seemed paradoxical that so much emphasis has been placed upon reduction of patient pain in the sales promotion of these newer instruments. If this lessening of pain in operative procedure is intended to imply lessened trauma to the dental pulp, then it is more understandable. There has been so much written, so much demonstrated, and so much lectured on these new instruments that there is no reason to go into any detail about them here other than to identify them. One thing, however, which has become evident as common to them all is the requirement for new skills and judgment, with ever vigilant caution. The first of these newer instruments to become available to the dental profession was the Airbrasive. The hazards inherent in this equipment were such that the manufacturer wisely stipulated that the equipment would be sold only to those dentists who took a course in its use at one of several established training centers. Some dentists, particularly those with a bent toward research, developed an amazing skill with the Airbrasive. In general, however, the complications involved in its use and its certain limitations militated against increasing popularity. Today, relatively little is heard of the Airbrasive, and it is noted that Journals from time to time carry offers of sale of it as used equipment. The Cavitron, an instrument utilizing ultrasonic vibrations through what might be described as preformed cavity formers and a slurry of abrasives, was introduced to the market perhaps before adequate research upon its effect on the dental pulp had been completed. This equipment, for various reasons of complexity, messiness, etc., has not achieved great popularity




The following discussion will deal entirely with high-speed rotary instruments used in operative dentistry procedures. It is these which have caught and retained the interest of the profession. The commercial exhibitors of these rapid rotary instruments at every dental convention monopolize the attention of dentists. It is exceedingly unfortunate that the term high speed was applied to these rotating instruments in the beginning. Granted that it is hard to think of a more descriptive term, nevertheless, the term itself has been applied to the operating process in such a way that it implies hvry to the uninstructed many. The sad connotation
Read before the American Academy of Restorative Received for publication Feb. 20, 1958. 1031 Dentistry, Chicago, Ill., Feb. 2, 1958.

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Den. 1958

is high-speed dentistry. A glaring example was in an advertisement in one of the free commercial Journals which goes to virtually every dentist in the United States. This advertiser, who had shown such discretion in bringing forth the Airbrasive equipment, referred to the Airotor with speeds of 100,000 r.p.m. up to 250,000 r.p.m. as a great contribution to highpeed dentistry. To realize the seriousness of this connotation high-speed, it is onlv necessary to mingle in the crowd about one of the commercial exhibits demonstrating one of these iiistruments and listen to the discussion. The concern seems to be almost exclusivel> in how short a time a preparation may be completed, not how well. ,4 number of highly competent dentists have admitted to a sense of necessar) haste when first using more rapidly rotatin g cutting instruments for operative procedures. In most instances, these experiences were with belt-driven, more or less conventional equipment. If such operators can be affected in this way, what may we expect from less expert and possibly careless dentists, thoroughly confused by the application of the term high speed ?

Some consideration of the characteristics of the various rotating instruments is indicated. Kilpatrick divides them into three methods : ( 1) gear-driven equipment including straight handpieces and contra-angle handpieces, (2) belt-driven contra-angle handpieces, and (3 ) turbine-driven contra-angle handpieces. It is recognized that there will always be a need for a dental handpiece usable at formerly conventional speeds upon occasion. For this reason, ball-bearing handpieces developed by several manufacturers meet a dual need in that they may be opera.ted at speeds, varying from the usual 6,000 r.p.m. peak achievable with standard equipment, up through perhaps 24,000 r.p.m. with relatively simple adjustments. Such a handpiece, through the use of an oversize driving pulley on the unit motor, may perhaps be stepped up to 12,000 r.p.m. A switch arrangement allowing the cutting out of resistance to the motor will usually double the speed to 24,000 r.p.m. \arious types of double-belt arrangements and, in some, gears, likewise, have been used with varying degrees of satisfaction, according to the dentists desires. The development of ball-bearing handpieces, both for straight and contra-angle, has been a great boon to operative dentistry, even if used without increased rotating speeds, Among other improvements, it has required manufacturers to develop more accurately balanced cutting points.

The purpose of increased speed of the rotating instrument is to increase cutting efficiency. This should mean to cut more rapidly, with less vibration, and to cut with less pressure, with resultant lower heat production, for the safety of the dental pulp. With each increase in rotating speed has come a corresponding reduction in torque. This is a decided safety factor and soon teaches the desirability of light pressure application, since excessive pressure Lvill stall the revolving point. With the realization of the safety of the low stalling pressure, due to lowered torque, and the relatively lower frictional temperatures developed, it is

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startling to recall that in a recent article in Life Magazine, devoted entirely to one of the high-speed mechanical handpieces and its inventor, the inventor is quoted as beavailing the loss of torque in his equipment and promising a future development \vhich will produce a torque value similar to that of the conventional equipment rotating at 1,000 to 6,000 r.p.m. It would appear that this inventor should be an early candidate for some instruction in operative technique. The deplorable effects of such misinformation in lay publications will be obvious. The hydraulically driven instrument now manufactured as Turbojet appears to have been the first departure from the mechanical drive principle in rotary cutting instruments. It has the desirable quality of very low torque, as well as supplying its own coolant to the revolving point. The torque on this instrument is so low that, running at better than 50,000 r.p.m., it has been demonstrated to be possible to stall a small diamond wheel on the wrist without laceration. A more recent instrument available to the profession is the Airotor, which as its name implies is an air-driven turbine. This instrument has even lower torque than the hydraulically driven one. This equipment possesses certain advantages in size over the hydraulic turbine, but it brings in the complication of variable air pressures in most professional buildings. The turbine type cutting instruments definitely are adjuncts to the standard belt-driven type of handpiece. They undoubtedly supply the most effective cutting of tooth substance now known, and in capable hands, they have a strong safety factor in their low torque. The rapidit) of their cutting action, however, presents a distinct hazard, especially in areas of difficult access. Control is dependent upon visibility- alone. since the tactile sense is missing.

1Yhat has the phrase high speed meant to the practice of dentistry? To skillful and studious dentists, it has brought reduced fatigue, increased efficiency, and economy of time. To their patients, it has meant increased comfort, chiefly through reduced irritating noise and shorter operation periods. It will be noted that nothing is said here of reduced pain. Dentists of the type described have long years ago eliminated the pain of operative dentistry for their patients through standard, accepted methods of analgesia or anesthesia. To them, time has always been of importance, but always subordinate to patient comfort and welfare. In the hands of the dentist lvho has depended for his knowledge upon advertising, the detail man, and the throw-away publicationst it is to be feared that the term high speed has increased his vulnerability to malpractice actions. While superficially it appears to have increased his production, it has nevertheless laid upon him some headaches and worries that would make a migraine sufferer gloat in his freedom from pain. For the patients of this latter type of dentist, it has meant catastrophies to an innumerable host of dental pulps and a rapid approach to complete dentures.

A trend which has appeared to permeate the profession with the introduction of high-speed rotary equipment is the increased application of so-called full cover-

J. Pros. Den. Nov.-Dec., 1958

age operative procedure. This is most notable when fixed prosthodontics are involved. Possibly in days of greater operative difficulty, full crown restorations were avoided at times when they might have been the indication of protective choice. Today, however, it appears that the rapid and easy reduction of tooth substance and contour has led many dentists into unwarranted destruction of tooth substance. An example is a man recently examined, approximately 30 years of age, an actor, who within the year had had twenty-eight crowns placed on his teeth. This work had been done in a large New York clinic. It was quite well done. The occlusion and color were good. The hinge axis had been determined, and proper jaw relations had been established to produce a very creditable result. The porcelain on the mandibular right second molar had fractured, leaving a troublesome sharp place. This patient had applied for treatment in New York originally to correct a diastema and somewhat protruded maxillary incisors. By his report, dental decay had not been excessive. He was persuaded to have the entire twenty-eight teeth treated in this manner in order to prevent any further tooth decay. The improved appearance was a factor, of course, but it was minimized, in the opinion given supporting the full mouth reconstruction, as being secondary to the preservation from future tooth decay. The gingival tissues about most of the teeth showed passive congestion, hypertrophy, and a flabby tone. Ko effort whatsoever had been made to educate the patient to proper daily maintenance. It was pointed out to the patient that, unless he undertook vigorous personal hygiene measures, he would soon experience further bony absorption with the exposure of all of the cervical margins of the restorations. It is a very rare instance when one sees this many crowns in a mouth, without finding gingival inflammatory conditions about some of them. There is no artificial material tolerated by the gingival tissues as well as is natural tooth substance. Undoubtedly, gold foil, correctlq- inserted, is the best tolerated of the artificial materials. It seems highly probable that had preparation of these twenty-eight teeth been as difficult in 1957 as it was in 1937, the patient would not have had twenty-eight full crowns in his mouth.

Unless steps are taken to bring adequate instruction to the vast majority of dentists who are influenced to use high-speed rotary instruments, it may be anticipated that an era of slovenly cavity preparation will plague dentistry for some time to come. The effect on the public esteem for high quality operative dentistry, which we have all striven to establish, is unpleasant to contemplate.
REFERENCE 1. Kilpatrick, H. C.: An Evaluation of Rotational Speeds up to 200,000 R.P.M. A Progress 1957. 409 N. CAMDEN DR. BEVERLY HILLS, CALIF. High Speed and Coolant Report III. Bul. Alabama Equipment for D. A. 41:7-16,