Sir, please could someone explain why I am able to prescribe pethide, for which I cannot foresee a circumstance arising in which I would ever do so; yet I am unable to prescribe co-amoxiclav? A young patient recently presented with a severe dental infection, the tooth was opened, dressed and redressed with ledermix and amoxicillin but this failed to improve the situation. One of the indications for co-amoxiclav is severe dental infection. However, my attempt to do so resulted in my friendly local pharmacist kindly returning it to me after flashing lights and alarms were triggered on his computer by my audacious effort.

Professor David Wray, Chair, BNF Dental Advisory Group responds: Thank you for the opportunity to respond to Dr Cooper's letter. The BDA appreciates the frustration of practitioners at not being able to prescribe on the NHS some medications necessary for optimum patient care. We have been trying for some years to gain greater access to the BNF for dentists prescribing on the NHS, and whilst this is a bit of an uphill battle we hope that it may become a reality in the future. The BDA advises the authors of the BNF through the BNF Dental Advisory Group (BNF DAG) and we recently requested that a number of additional medications be added to the Dental Practitioners Formulary list in the BNF. We are hopeful that these will be included in the next issue of the BNF.

Most dental infections, even severe ones, are usually due to Streptococci or gram negative organisms and so are usually sensitive to penicillin. If patients do not respond to amoxicillin alone, in severe infections, most clinicians would prescribe metronidazole in addition and this is usually successful.

Occasionally, infections may arise due to Staphylococci and, in these circumstances, prescription of flucloxacillin or co-amoxiclav would be appropriate. These are not on the list of additional medications we have already requested. However, we consider that it would be reasonable to include these on the Dental List and the BNF DAG will request that they are added. Currently patients with severe, unresponsive dental infections need referral to secondary care which has its own health economic implications. Alternatively a prescription can be given privately.