Letters

Dental general anaesthetics

Sir, — Given the imminent publication of the CMO/CDO Working Party report on dental general anaesthetics, readers may be interested in research that has been carried out in Lincolnshire with regard to the views of practitioners and patients on dental GA since the publication of the GDC guidelines in November 1998.

There is very little published research on the choice of general anaesthesia for pain and anxiety management in dentistry. We have been attempting to find out if it is possible to elicit the views of referring dentists, patients/parents and dentists working at referral centres. A questionnaire methodology has been developed and the key points that have emerged from the results of the various elements of this audit are:

• 1 In an area of relatively low use of dental GA such as Lincolnshire, the views and referral patterns of GDPs changed very little following the GDC guidelines and indicated that changes were already being made before November 1998.

• 2 A majority of respondents were not supportive of the guidelines and their views ranged from mildly critical to complete disagreement, both in content and application. A significant minority emphasised the need for better services for the small number of cases needing dental GA. The majority of respondents thought that dental GA should be provided in hospital.

• 3 The views and experiences of those who had been referred showed that the referring practitioner was the major influence on the choice of dental GA. Half of the patients/parents felt that GA was very important to them or their child.

• 4 Alternatives to GA and possible risks were not universally explained to patients at referral, but was universal at referral centres, as reported by the patients.

• 5 A comparatively small number of GDPs provided a sedation service while an increased number referred for sedation. However, only one fifth of respondents replying to the questionnaire expressed interest in the provision of sedation if resources were to be made available.

The views of patients, parents and the profession expressed in this audit have emphasized that a small residual need for GA exists that will be difficult to provide if future arrangements are not carefully planned and funded.

I. Middlemass and J. Green

Lincoln

Medical emergencies

Sir, — In response to articles on medical emergencies in dental practice^1,2,3 and the General Dental Council's guidelines,⁴ Barnet Community Dental Service recently reviewed their drug policy and provided retraining for all clinical staff. Training was provided by a registrar in oral medicine and the Trust's resuscitation nurse in an interactive three hour session. Protocols for the management of medical emergencies were reviewed and interspersed with practical sessions including basic life support and intramuscular drug administration. All material presented was reproduced as a document and given to all participants.

The participants' knowledge was evaluated by pre and post course questionnaires. A significant improvement in knowledge scores occurred following the course (mean score increasing from 67 per cent to 86 per cent.) All participants felt confident in managing the acutely unwell patient in the dental setting after retraining compared with 20 per cent at the start of the session. The combination of theory and practical skills was generally thought to have made the course more stimulating and successful. Regular updates were thought to be necessary to reinforce the material.

We suggest that a half day course on the management of medical emergencies in the dental practice is sufficient to increase the confidence of the dental team and forms an important part of continuing education.

J. M. Iceton, T. A. Hodgson and J. Teasdale

London

Rare artefact

Sir, — Identification of artefacts in radiographs and avoiding unnecessary interventions is very important in quality dental care. I work as a senior house officer in oral and maxillofacial surgery at the Luton and Dunstable Hospital. Recently, we received a referral letter from one of the local dental practitioners regarding an 85 year old gentleman who needed removal of both left and right lower wisdom teeth. An OPG was provided along with the referral letter (Figure 1), apparently showing wisdom teeth on both sides. The patient complained of pain in the right lower quadrant. On examination there was a partly erupted lower right wisdom tooth but no tooth was visible on the left side. The OPG provided by the practitioner showed some irregularities of the left side of the mandible. We thought that it could be an artefact and we decided to take a new OPG.

Figure 1

An apparent LL8 on the OPG.

The new radiograph (Figure 2), showed clear evidence that the lower left wisdom tooth was absent. It was understood that the tooth image on the left side of the OPG was due to a secondary image from the right side. It is extremely rare for an OPG to have this type of artefact and this will increase the chance of it going unnoticed. The suspicion of an artefact and the decision to take a new OPG helped us not to make a hasty decision, avoiding the possibility of an unnecessary surgical intervention. I wonder if anyone else has seen a similar artefact?

Figure 2

No LL8 on the OPG.

A. A. Sharafuddin

Luton

Radiographic protocols

Sir, — Recently, on attempting to remove a crown from the lower second molar of a patient, the coronal section of the tooth 'disappeared' and was assumed to be aspirated or swallowed. The patient was informed and sent to the local hospital A&E department for a chest X-ray. After being kept waiting for over five hours he was notified by the consultant that a radiograph was not necessary and he returned to my practice somewhat perplexed and irritated that I had referred him there.

We thought it appropriate to telephone some A&E departments and check what their recommendations were regarding a suspected aspirated foreign body. We randomly selected ten major A&E radiographic departments within the greater London area and spoke to the radiographic superintendent or equivalent. Interestingly, only one of the departments referred to their protocol book and two others had written recommendations following those of the Royal College of Radiologists which recommends chest and soft tissue of neck radiographs in these cases. Four respondents stated that they did not have set protocols but would generally chest radiograph the patient if the foreign body was thought to be radio opaque and three stated that they would only recommend a radiograph if the patient was having breathing difficulties.

This highlights a significant disparity of views on radiographic protocols for aspirated foreign bodies and perhaps it is necessary for the general dental practitioner to telephone the A&E department on referral of a patient to ensure that a radiograph is recommended. We have notified the Royal College of Radiologists of our findings and felt it important to notify our colleagues.

C. Sale and T. Renton

London

Dental notations

Sir, — It is remarkable that for so many years the dental profession has been unable to agree on a system of tooth notation which would be readily acceptable. In this computer age it is truly surprising that the dental schools are still teaching the Palmer Notation. Although it is easily understood it cannot be typed, either on a typewriter or a computer, and it is really quite a nuisance. The alternative of giving each quadrant its own number and each tooth a number within the quadrant (the FDI Notation) is clumsy and as a previous correspondent (BDJ 2000, 189: 64) has pointed out, is easily misprinted or misinterpreted. It is even less clear when describing the primary dentition e.g. 55 or 73.

The most elegant solution to the problem would appear to be the Scandinavian Notation, in which upper teeth are denoted by a plus sign and lower teeth by a minus sign. The centre line is represented by the position of the plus or minus sign e.g. 4 + 4 or

5 - 5. Deciduous teeth are denoted as in the Palmer Notation by letters of the alphabet. This notation is precise, accurate, not in the least misleading and easily typed. Why do we need to wait for computers to adapt to the Palmer Notation, why cannot we simply take advantage of the Scandinavian system with all its advantages and, as far as I can see, no disadvantages whatsoever?

N. M. Bass

London

Natural nylon!

Sir, — Can anyone please tell me where to obtain natural bristle tooth brushes — the old fashioned ones — for a lady who thinks her gums are allergic to nylon?

A. G. Bairstow

Torquay

Retirement

Sir, — I had my list number within the National Health Service withdrawn due to my age when I was 65 years old. I have continued to practice privately as I still find it a satisfying part of my life, and my patients are not just patients. Certainly the object is not financial for the practice is so small as to be barely sustainable as many of my patients had been exempt from payment under the NHS. During the last few years, I have sought to discover why this regulation exists, and various people have suggested:

• 1 Problems associated with superannuation. If this is the case, one could opt out of superannuation.

• 2 That problems have arisen with domiciliary visits GMPs have to make when they are older. This is not paralleled among GDPs.

• 3 Ability to satisfactorily perform duties as GDPs. There are other regulations under the NHS which monitor one's performance at any age.

• 4 A suggestion that employers can always freely make any decisions they choose. Strictly speaking GDPs are not employees but even if they were, this is manifestly untrue if one considers government laws on matters such as sex discrimination.

• 5 It is rare for a dental practitioners to express dissatisfaction in this regard. Any dissatisfaction is unacceptable even though only a few are affected.

J. W. Russell

West Lothian

Unnecessary amalgam replacements

Sir, — I refer to the BBC Radio Four programme 'You and Yours' on Monday 22nd November 1999. Dr Geoffrey Craig, chair of the BDA's Health and Science Policy Group confidently assured listeners that there was no evidence to support my finding that new amalgam can be bonded directly to old amalgam. The repair of amalgam with amalgam was 'just not possible' with strength. Do his statements sustain examination? Surely, if a joined amalgam laboratory test sample fails other than at the repair interface, it indicates that the repair bond was stronger than the parts which failed. This result has been reported by the authors listed below.^5,6,7,8 Dr Craig challenged me for published evidence: all are available in the BDA Library. Negatives cannot disprove those positives. I agree that many authors have produced, at best, weak repair bonds in their studies: they used laboratory methods which did not work. In a clinical study,⁹ 44 out of 45 amalgam repairs were considered satisfactory after two years. In a 15 year review,¹⁰ 67 out of 1117 vibration condensed amalgams had been refinished or repaired (using unspecified methods) and only 25% failed after unspecified periods. Had Dr Craig considered these?

Figure 3 (below), presented at a Bristol conference in 1996,⁸ is a micrograph of a reassembled joined sample after 3 point loading to fracture which I prepared using vibration condensation in the School of Engineering, City University, London. The method simulated the clinical repair procedure I published in 1981.⁵ The 4 mm diameter cylindrical sample was notched in the parent material adjacent to the joint (tip radius 0.2 mm) and the central load applied opposite on the added amalgam 0.2 mm from the interface. Is there any doubt that there was 'no weakness at all' at the bond since the fracture path traversed the joint interface from parent to added amalgam? This occurrence is inconsistent with bond weakness where the crack path would have deviated to follow the joint. Where could this interpretation be in error? Has any similar fracture path been reported using bonding agents? Additionally, in the study reported at that conference, out of 769 joined samples prepared using vibration assisted condensation, 241 (31 per cent) failed in the parent and 72 (9 per cent) failed in the added amalgam after three point bend testing with the joint interface at span centre. How could this happen if the amalgam bonds were weak?

Figure 3

Reassembled joined high copper admixed amalgam after 3-point loading to fracture

Dentists who have been taught that amalgam repair is impossible may replace amalgams which could have been repaired, advantageously. Typical examples include cases with an otherwise satisfactory amalgam restoration where a piece of tooth or amalgam has fractured or there is a localised area of caries. Complete removal of such amalgams inevitably enlarges the dental cavity, weakens the remaining tooth, incurs more time, expense and need for analgesia and risks introduction of new faults. These patients are sent further down the 'restorative spiral' because the replacement restoration has a shorter life expectancy. Dr Craig's statements do not allay my fears that many amalgams are being replaced unnecessarily as the result of dentists' teaching. I agree with Osborne and Summitt that the dental education system promotes premature removal of amalgam restorations.

A. H. Cook

London

Dr Geoff Craig responds: From my recollection of the interview I suspect Dr Cook may have misinterpreted some of my comments. When discussing his claims I said that I was unaware of any evidence from longitudinal clinical trials in support of his experimental findings. I did suggest in the interview that I thought it would be helpful if he published the findings from his PhD thesis in a peer-reviewed journal so that colleagues could judge for themselves.

Scleroderma presents as facial hypoaesthesia

Sir, — Dr N. S. Matthews reports an interesting patient with scleroderma and facial hypoaesthesia who had to cope with a year's delay in diagnosis and four speciality referrals. This highlights one of our main problems in dentistry and medicine and the health services — the huge gap between the published literature and clinical and research findings, and the knowledge of clinicians or, perhaps more seriously, their failure to access data. The association is well-recognised and published in standard readily available recent textbooks^13,14 and readily available recent journals^15,16 let alone on a simple free computer search.

We was there first!

Sir, — Having seen the picture of Heckmondwike Dental Centre receiving the Investor in People award, I was a little disappointed at their claim to be the first dental practice in Yorkshire to be recognised as such. We at STAN Dental Care in Sheffield received the Investor in People award in February 1999. At the time I made extensive enquiries through Sheffield TEC to find out which other dental practices in our region had achieved the award. I was informed that we were the first dental practice in South Yorkshire and the second in the whole of Yorkshire at that time. While wholeheartedly congratulating Heckmondwike Dental Centre on achieving this prestigious award, I, on behalf of STAN Dental Care, claim that we were there first!

N. D. Sheehan

Sheffield

Dental school entrants

Sir, — I was interested to read about the necessary and timely drive of the BDA to encourage wider ethnic minority entrance to the profession. Indeed, in a diverse world, one would hope that dental students would reflect the community they serve, and be male, female, black, white, straight, gay and from every social class. To do this, however, we must ensure that dental schools are open and welcoming and operate in a way which respects this diversity, enabling all students, irrespective of their personal characteristics and background, to fuflfil their full potential. This must also be the case in terms of the way we treat our colleagues. There should be no place for racism, sexism or homophobia in the dental profession.

We need, also, to be aware that many of those we treat are from working-class, lower income environments. This cannot be said of dental school intake, where public school education still appears to be somewhat over-represented. Perhaps the BDA should also be thinking of ways to attract state school pupils, from working class backgrounds, who will be able to empathise and relate to the everyday lives of their patients. This will improve and enhance the service we are able to provide.

D. Fairclough

Leigh

Xylotox labelling

Sir, — Are you aware that Astra are producing Xylotox 2% with new labelling. The cartridges now have black printing, and contain 1:80000 adrenaline. Unfortunately they no longer state this on the cartridge, nor that it contains lignocaine (but they feel it is necessary to write it on the cardboard box they come in!). Cartridges frequently do not remain in the carton they come in as the blister packs will be distributed to different areas, e.g. A&E, the ward and out–patients in a hospital setting and different surgeries within a dental practice. This unnecessary alteration is causing confusion as previously the adrenaline concentration has always been stated on the cartridge, and serves a useful reminder to the operator as to what is being injected into a possibly medically compromised patient.

Xylotox cartridge labels have been printed in red, green and now black, with reduced information. I have contacted Astra and they assure me that the formulation has not changed, unfortunately they have made a retrograde step.

M. G. Perini

Preston

(We apologize that the above letter was published unfinished in the last issue)