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L E T T E R S procedure is absolutely critical to achieving adequate margin integrity, and I insist on use of the dam when placing those restorations.

Class V restorations (abra-sion, erosion or abfraction) are a different story, and I seldom use the dam to place these. Al-though I try to use the ultimate in moisture control, I am fully aware that I am not successful. My clinical impression is that these composites deteriorate at a more rapid rate than the Class I, II, III and IV restora-tions placed using the rub- ber dam.

I realize that a study pre-sented with multiple variables and many different practition-ers will result in varying sta-tistics as there is no ultimate control. I think the authors did a very respectable job in their study, but I would hope that any future studies such as this would include the use or non-use of the rubber dam in evalu-ating the results.

Please, fellow dentists, be-come rubber dam aficionados; both you and your patients will be better served.

George A. Kirchner, DDSAllentown, Pa.

Authors’ response: We would like to thank Dr. Kirch-ner for his interest in our ar-ticle and for finding it informa-tive. We agree with him that clarifying the use of rubber dam by participating dentists would have enriched our article.

We actually did conduct a statistical analysis that took into account whether or not a rubber dam was used during the restoration placement. Den-

JADA welcomes letters from readers on articles that have appeared in The Journal. The

Journal reserves the right to edit all communications and requires that all letters be signed. Letters must be no more than 550 words and must cite no more than five references. No illustrations will be accepted. A letter concerning a recent JADA article will have the best chance of acceptance if it is received within two months of the article’s publication. For instance, a letter about an article that appeared in April JADA usu-ally will be considered for accep-tance only until the end of June. You may submit your letter via e-mail to jadaletters@ada.org; by fax to 1-312-440-3538; or by mail to 211 E. Chicago Ave., Chicago, Ill. 60611-2678. By sending a letter to the editor, the author acknowl-edges and agrees that the letter and all rights of the author in the letter sent become the property of The Journal. Letter writers are asked to disclose any personal or professional affiliations or conflicts of interest that readers may wish to take into consideration in as-sessing their stated opinions. The views expressed are those of the letter writer and do not necessar-ily reflect the opinion or official policy of the Association. Brevity is appreciated.

RUBBER DAM I read with interest Dr. Michael McCracken and colleagues’ June JADA cover story, “A 24-Month Evaluation of Amal-gam and Resin-based Compos-ite Restorations” (McCracken MS, Gordan VV, Litaker MS, et al. JADA 2013;144[6]:583-593). This certainly was an extensive study, comparing our two pri-

mary restorative materials and their success rates over several years.

As a general dentist for over 40 years, I have always been intrigued by the longevity of various restorative materials, and I completely agree that there are multiple factors that affect the eventual outcome of our placed restorations. These numerous factors were included in the study, and their effect upon our efforts is apparent. These variations have been duly noted in my practice over the years.

However, one glaring omis-sion from the authors’ study was the use, or nonuse, of the rubber dam in compiling the results of the study.

All dentists have been taught the importance of using the rubber dam during restor-ative procedures and I realized, early in my professional career, the benefits it provides for the patient, the dentist and the of-fice support staff. Although I have no documentation for a clinical study, my years of prac-tice experience have demon-strated the value of rubber dam usage as restorative procedures are accomplished.

My nondocumented study in-dicates that restorations placed using the rubber dam survive far better than those placed without the dam being used. I find this to be especially critical when using resin-based com-posites. Moisture is always our enemy in restorative dentistry. I will admit that amalgam is somewhat forgiving if placed without a dam, but composites are a different story. With com-posite use on Class I, II, III and IV restorations, the bonding

System, United States, 2005-2008. MMWR Morb Mortal Wkly Rep 2012;61(supple-ment):57-64.

Accessed Sept. 29, 2013.16. Chen M, Rhodes PH, Hall HI, Kilmarx

PH, Branson BM, Valleroy LA. Prevalence of undiagnosed HIV infection among persons aged ≥ 13 years: National HIV Surveillance

15. Centers for Disease Control and Prevention. Smoking and tobacco use: adult cigarette smoking in the United States— current estimate. www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/.

Copyright © 2013 American Dental Association. All Rights Reserved.

1222 JADA 144(11) http://jada.ada.org November 2013

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that the preamble of the American Dental Association Principles of Ethics and Code of Professional Conduct states that the “qualities of honesty, compassion, kindness, integ-rity, fairness and charity are part of the ethical education of a dentist and the practice of dentistry and help to define the true professional.”1 Later, Dr. Auld stated that “[t]he fee is for the service provided and not for the means of payment, and, thus, the charge should be the same across the board.”

How does this admonish-ment impact the practice of dental offices’ having mul-tiple fee schedules granting discounted fees to preferred provider organizations and se-lected insurance companies?

I have always been un-comfortable with the concept of having discounted fees for patients enrolled in special pro-

Operative Dentistry DivisionCollege of Dentistry

University of FloridaGainesville

FEE SCHEDULES I have a concern prompted by Dr. Douglas Auld’s response in his May JADA Ethical Moment column. The question posed (in fact, the title of the article itself) dealt with “… The Ethi-cal Implications of Having More Than One Fee Schedule” (JADA 2013;144[5]:536-537).

The question arose from a dentist’s becoming aware that two of his colleagues were con-sidering having “multiple fee schedules based on the source of reimbursement.” In this in-stance, the proposed plan was to have a separate schedule of (higher) fees for patients cov-ered by insurance.

Dr. Auld began his response by reminding the questioner

tists reported not using rubber dams on 87 percent of the res-torations (n = 6,218). We found no significant differences in res-toration longevity between res-torations placed with a rubber dam as compared with those placed without a rubber dam.

However, given that rubber dam use was relatively rare in this sample (n = 765), we have to approach the results with caution, as we had little power to evaluate possible differences in rates between restorations placed with and without rubber dams.

In retrospect, we wish that we had included the rubber dam data in the article itself.

Valeria V. Gordan, DDS,MS, MS-CI

for The National Dental PBRN Collaborative Group

ProfessorDepartment of Restorative Dental

Sciences

Copyright © 2013 American Dental Association. All Rights Reserved.