Questions over GA

Sir, – The article titled 'Links between anaesthetic morbidity and nerve damage during lower third molar surgery' (BDJ2002;  193: 43–45) published recently suggests a lack of appreciation of current clinical guidelines. The authors report that 273 (69.8%) of patients in their study had their third molars extracted under general anaesthesia. They also suggest that the main criterion for the selection of GA is the patient's preference.

This selection technique is in clear contradiction to guidelines by the Royal College of Anaesthetists and the recommendations for General Anaesthesia by the General Dental Council. In addition, these guidelines reinforce the desire to shift away from using general anaesthesia to using sedation techniques in conjunction with LA for patient management. This reflects both risk benefit analysis and cost effectiveness of GA in comparison with sedation plus LA, and LA alone. As a consequence of these and other guidelines, and with a desire to reflect good patient management and clinical governance, our oral surgery unit has seen a dramatic change in practice with respect to general anaesthesia over the last five years, in that approximately 5% undergo GA, 20-25% have sedation and LA and the remaining 70-75% have third molar extractions under LA.

Secondly, the authors report that 27.2% of the third molars extracted were unerupted. How could these teeth be symptomatic? Were they all associated with pathology? This seems to substantiate NICE's comments that almost 30% of third molars are being removed unnecessarily in the UK. Several previous reports have highlighted the association between difficulty of surgery and depth of impaction of third molars with lingual nerve injury, reinforcing that removal of these buried teeth places many patients at unnecessary risk of lingual nerve injury.

T. Renton and L. McArdle

London

The authors K. Rehman and K. Webster respond:

We are grateful for the interest Dr's Renton and McArdle showed in our paper.

At University Hospital Birmingham, the proximity of a dental hospital dealing with the majority of dentoalveolar surgery means that most patients having a general anaesthetic for removal of wisdom teeth in our unit are medically compromised, or have social reasons for general anaesthesia. We would agree that treatment under local anaesthesia +/- sedation should be offered where appropriate. However the evidence for risk or cost benefit for LA over GA is at best sparse. Renton and McArdle were also concerned that 27.2% of teeth removed were unerupted and were not likely to be symptomatic and therefore did not fulfill NICE criteria for removal.

NICE guidelines were followed during this study and an internal departmental audit has shown that compliance with NICE guidelines was high. Eruption status (although an indicator for problems) is not the main indicator for need for removal of wisdom teeth. However, our study did show that eruption status was a predictor for nerve injury. Rather than utilizing a knee jerk: 'local anaesthesia good, general anaesthesia bad' reaction, readers are advised to take all the relevant factors into account before deciding on the appropriate form of anaesthesia.

Disability Discrimination

Sir, – While we are pleased by the publication of a paper examining the impact of the Disability Discrimination Act on dentists (BDJ2002;  193: 199–201), we found the contents disappointing and prejudicial to disabled people. The social model of disability was accepted many years ago, and within this model a person with a disability may be handicapped in terms of their ability to carry out normal day to day activities.

Throughout the article there is continual confusion in the use of the words 'disability' and 'handicapped'. We fully support the concept that the language around disability is changing. However, we do not support the listing of jargon that is so out of date that it would now be considered offensive if used, and which implies that the majority of dentists are ill-informed.

The authors quite rightly point out that it is unacceptable to label people with a spectrum of disabilities ranging from sensory impairment to mental illness within one group. Yet, throughout the article, that is exactly what the authors proceed to do. It is simply not acceptable to come out with statements such as: 'Disabled people are less likely to have qualifications than non-disabled people. In the working population, 30% of disabled people have no qualifications (compared with 14% of non-disabled people), and only 7% have a degree level qualification (compared with 14% of non-disabled people).'

These sentences take no account whatsoever of the wide spectrum of disability. The comments are not supported with either evidence or discussion around what barriers may be in place for individuals with different types of disabilities. Examples of how the term 'reasonableness' is likely to be interpreted are equally flawed. What justification is there for stating that it is reasonable to expect one member of staff to have Deaf Equality Training while then stating that it may not be reasonable to expect a practice to routinely provide leaflets in Braille.

Finally, while it may well be likely that disabled people will increasingly demand the same access to dental care as non-disabled people, surely the whole philosophy of removing discrimination against disability means that disabled people are entitled to the same access to health care as non-disabled people, and they are entitled to that now.

C. Mander and S. Read

Leicester

The authors A. Merry and D. Edwards respond:

We would like to thank Dr Mander and Dr Read for their interest in our paper and are sorry that they felt disappointed by it. The fact that they felt strongly enough to write underlines the fact that this issue is important and that there are sensitivities around the area of disability.

The papers come out of a two-year period of intensive work on disability with dental practices across Merseyside.

Local disabled activists and Disability Equality Officers in the Liverpool Primary Care Trusts read and approved the contents of the papers. They did not feel the contents were prejudicial to disabled people but dealt with the issues in a positive way. We agree that the social model of disability is not a new concept in disability circles but our experience in running several Disability Awareness Training workshops is that it has not been universally understood or accepted in healthcare or dental settings.

With respect to the comments about our paper labelling people with a spectrum of disabilities within one group, we would respectfully point out that it is accepted practice to refer to 'disabled people'. Indeed, the Disability Discrimination Act, 1995 (DDA)¹, and Disability Rights Commission (DRC) both routinely refer to 'disabled people' (for examples see the Disability Rights Commission website²). As we mention in Table I, it is reference to 'the disabled' as a homogenous group rather than 'disabled people' which is considered offensive as it denies people's individuality.

As regards the other terms in Table 1, we have found from the Disability Awareness Training workshops that we have organised, that dental teams have valued the opportunity to discuss the changes in language around disability and this is why we felt it appropriate to include some discussion of this in the paper. Our experience is that some of the outdated terms are unfortunately still very much in use. The overriding message is that language can cause offence and needs to be handled sensitively as demonstrated by the letter from Drs Mander and Read. If any offence was inadvertently caused we apologise.

Our reasons for quoting the statistics in the section entitled 'Who is disabled' were simply to illustrate how many people are covered by the DDA and to show how widespread discrimination against disabled people is, as many people think that a very small minority of people are affected. Regarding the examples given and the interpretation of 'reasonableness', it is impossible at this time to know exactly how Part III of the DDA will be interpreted in law³. The examples are provided to help dentists to think through how they can reduce barriers and are not intended to be prescriptive. Many are based on examples given by the DRC in advice issued to small businesses that we have taken the liberty of adapting for a dental practice setting⁴.

We agree wholeheartedly that disabled people are entitled to the same access to health care as non-disabled people and that they are entitled to that now. However, the reality is that many disabled people are presently denied this when trying to access a range of services including dental care⁵.

The Disability Rights Commission recognise that full access will not be achieved overnight⁶. With Part III of the DDA due to come into effect in 2004, our aim in writing this paper was to bring the implications of the DDA to the attention of dentists, especially those in general practice, so that they can plan for any changes that might be necessary in order for them to comply with the Act. Anecdotal feedback from local general dental practitioners suggests that it has been successful in doing this.

We hope that this has answered the questions raised and that we can work together across the country to improve awareness and access.

Blood pressure monitoring

Sir, – In the Government's new proposals for primary care 'Option's for Change', I was interested to note the suggestion that dentists should consider monitoring the blood pressure of their patients as part of lifestyle advices and checks.⁷

The sentiment behind this screening service appears to be that since hypertension is often asymptomatic, detecting it in the 'well' patient may identify problems earlier and reduce the morbidity and mortality from myocardial infarctions and strokes. However one great concern with monitoring blood pressure is the so-called 'white coat effect'. This occurs whereby some subjects with apparent elevation of blood pressure have normal, or reduced, blood pressures when the measurement is repeated away from the medical environment.⁸

In a study in Southampton, researchers found readings made by doctors using conventional Riva-Rocci/Korotkoff techniques were much higher than systolic ambulatory pressure (difference=18.9mmHg).⁹

The patients were apparently tenser when seeing the doctor and this raised their pressure artificially, in some cases, putting them into the risk category requiring medication. The study concluded, 'it is time to stop using high blood pressure readings documented by general practitioners to make treatment decisions'.

I would suggest that patients attending the dentist are more likely to be stressed and anxious and this 'white coat effect' is likely to be more pronounced. Even if PCDs were to administer the screening service at the patient's oral health assessment check, the false positives may well outweigh the benefit of the service.

If an ambulatory service is to be introduced, which is more accurate at predicting target organ damage¹⁰, the costs for the machine (£2000) and the training required to offer advice, counselling and information would need to be considered since the service on its own would doubtless generate questions from patients.

As a general practitioner I would not feel confident running and managing such a service and would imagine GPs would not welcome a flood of referrals and self referrals from the worried well and the extremely worried and uninformed unwell. The implications are enormous and unless the service is thought through carefully and funded properly, the only raised blood pressures will be that of the dentist and the practice staff.

L. T. D'Cruz

Chigwell

Rubber dam

Sir, – The proof of negligence does not require that the technique used is proven to be inferior (BDJ2002;  193: 126–127). It is only necessary to depart from those measures which a prudent operator might be expected to use and that harm occurred as a result. 'Res ipse loquitur'. Removing a file from the bronchus leaves a large and disfiguring scar. Our patients put their trust in us and deserve to have that trust respected.

Nevertheless, Dr Mackay very accurately specifies a criticism that might be levelled not only at the current guidelines for endodontic treatment, but also for most operative procedures in clinical dentistry. If, by 'clinically proven as more successful', we are asked for a statistically significant difference in measured success of clinical outcome as judged in multi-centre, prospective, randomised clinical trials yielding Cochrane A type evidence, almost nothing we do in clinical dentistry could be justified.

So if Dr Mackay asks for proof that any procedure carried out under rubber dam is more successful he may expect the answer no. However he neatly summarises most of the reasons why the use of rubber dam is advisable.

Most of our 'best clinical practice' remains a distillation of conventional wisdom, the clinical experience of mentors, and of laboratory based science, sometimes supported by small and often relatively poorly designed clinical trials. The teaching of Black's cavity designs, extension for prevention, Ante's law and much other nonsense decorated our textbooks for decades.

It is necessary for endodontists, and indeed for all clinicians, to take up their obligation to engage in clinical audit. It is also necessary for the profession to find ways to channel that improved flow of quality evidence such that we become able to reevaluate the 'conventional wisdom' approaches which have not always been justifiable in the past, in evolving a system of statistically demonstrable best clinical practice, which our patients have the right to expect in the future.

A. T. Hyatt

London

Sir, – I read J. R. Mackay's spirited defence of not using rubber dam in endodontics with great interest.

He is clearly a caring practitioner (who uses sodium hydrochloride) and a thoughtful one (hence the letter). I am full of dismay at the lengths that some of our colleagues will go to, to avoid using a technique which will make their practice of dentistry easier, better and faster.

I am delighted that this letter has been published as it challenges established teaching and best practice. This is always a healthy thing to do and hopefully it will encourage further discussion of the issue.

This letter represents a considerable degree of thinking amongst our colleagues in general practice, and it is sad to think that while students are taught to use rubber dam at dental school, few continue to do so in practice.

I have given 'hands on' courses in endodontics for a number of years and the results of questionnaires that participants are given indicate that the principle reason for not using rubber dam are: too difficult; never been taught; do not have the time

If we are to encourage the routine use of rubber dam in dentistry then dental students have to not only be taught the technique, but have to come to an understanding themselves of the advantages of the use of rubber dam.

This can only be achieved by repeated practice. If dental schools could be persuaded to teach students to use rubber dam for operative dentistry as well as endodontics, then this aim could be achieved, while improving the quality of their operative dentistry as well.

Finally I would like to take issue with Mr Mackay's points regarding his perceived disadvantages of rubber dam. If the technique is used correctly, with the careful choice of the correct clamp then soft tissues are minimally affected.

In many years of both general practice and as an endodontist, I have never fractured a tooth with a rubber dam clamp that was not going to suffer fracture anyway. Patients often tell me that they think it is a great technique, and if you want to know if dental nurses like working with rubber dam, ask mine.

A. C. S. Druttman

London

We would like to thank all the other correspondents on this topic who confirmed the main points made above. The subject is now closed.

Lost in trousers

Sir, – I wonder whether my collegues would like to read about an incident that has happened to me? The wife of a patient rang the surgery on a Monday to say that over the weekend her husband had lost his upper denture. I saw him the same day; he told me that, after a very agreeable night out, he had fallen asleep in his armchair and, on waking, could not find his dentures. He was confused since he was adamant that he had arrived home with them, and was certain that he had not taken them out!

We constructed a replacement for him and nothing more was heard from him. Today we received a telephone call from his wife to say that they had just found his old denture (about two months after losing it).

It transpires that whilst he was asleep in his armshair his denture must have fallen out and landed upon his trousers. He had awoken and gone to bed obviously slightly worse for wear and hung up his clothes in his wardrobe with his denture stuck to the trouser leg due to his liberal use of denture fixative! I'm not sure whether he will ever be able to live this one down.

M. Neeld

Newcastle-upon-Tyne