Letters

Safety and cross infection

Sir;– In addition to my normal work, I run a part-time orthodontic clinic in someone else's surgery. I provide only removable appliances mostly to very young children.

The GDC expect me to spend several thousand pounds on emergency equipment and cross-infection control and train the entire dental team in their use (does this include the cleaner?)

While I entirely approve of the ethos, realities should not be ignored. My patients are more likely to stick a fork into themselves at a nearby restaurant than suffer harm in the surgery. Cross infection control sounds a great idea but even wise men sometimes fail to consider the long term consequences.

If all cross infection contacts were effectively sterilised, our immune system would quickly break down. We depend on constant contact with bacteria and viruses to maintain our natural resistance – this might even apply to Hepatitis B and AIDS, if they were introduced in small enough doses.

Deprived of this we would die from the first major assault from a range of normally benign diseases.

Bugs are good for you, think about it.

J. Mew

Heathfield

Warfarin and extractions

Sir;– Following the first successful public demonstration of general anaesthesia at Massachusetts General Hospital in 1846 the news of this momentous technique spread rapidly and was apparently in widespread use throughout the Western world within a matter of months.

Today it seems that more mundane but nevertheless important advances take much longer to become accepted in standard practice despite the improvements in communication. Repeated publication of the same results appears to be needed to get a message across and for practice to actually change.

A good example of this is the question of warfarin and dental extractions which has received yet further exposure recently in your letters column and your news pages (BDJ 2002; 193: 302–306).

I would not like your readers to think that the advice given, namely that there is no need to reduce or stop warfarin providing the INR is within the normal therapeutic range, is in some way new or revolutionary.

A paper published nearly 20 years ago in the BDJ demonstrated this point quite clearly and since that time I have never altered the warfarin dose for well controlled patients undergoing routine dental extractions.¹

In many ways the recent study reported by your correspondents from Morriston Hospital duplicates the findings of a similar study undertaken by colleagues in my own hospital which was published in 1998, although I was disappointed that this was not quoted in their letter.^2,3

Similarly, a comprehensive review of the relevant literature published in 2000 in the journal of your sister organisation from the USA concluded that 'dentists should recommend that therapeutic levels of anticoagulation be continued for patients undergoing dental surgery.'⁴

This advice is particularly relevant because many dentists seem reluctant to take responsibility in this area and bow to uninformed requests from medical practitioners to refer patients to hospital departments.

There are an increasing number of patients on warfarin in the community, often for atrial fibrillation.

It is not practicable to expect hospital oral and maxillofacial surgery departments to undertake routine dental extractions for all these patients, not only because it is not indicated but also because of the increasing pressure to meet Government performance targets for treatment of other cases.

I agree with your headline that there is no need to 'wage war on warfarin'. The disappointing aspect is that this is still considered newsworthy and that the previous studies have obviously not changed clinical practice in this area already.

The real scandal of course is the disgraceful level of remuneration for routine extractions under current NHS regulations which must result in a conscientious practitioner treating patients on wafarin according to current protocols at a loss.

A. E. Brown

East Grinstead

Shock waves

Sir;– We are taught that when oral surgery involves repair of an oro-antral fistuIa, the patient should be instructed to refrain from 'nose blowing' for two weeks.

The rationale being that shock waves of positive air pressure should be avoided. This advice I have followed over the years.

Recently, I closed an intelligent lady's chronic oro-antral fistula using a conventional buccal advancement flap, also lavaging the antrum, with temporary intra-nasal antrostomy.

At outpatient review, all was healing satisfactorily, though the patient did admit to a 'popping' sensation when drinking through a straw.

Perhaps, in addition to advice about positive pressure shock waves, we should also warn against negative pressure effects. Certainly I have never done so before and wonder whether my colleagues already do so.

B. Littler

Chelmsford

Premolar restoration

Sir;– I would be intrigued to know why the lower right second premolar in J. H. Harker's patient (BDJ 2002; 193: 428) needed restoring buccally while no other teeth needed attention for over sixty years?

L. J. Brinton

Suffolk

Antibiotic prophylaxis

Sir;– I was informed by a patient that she had recently undergone breast implant surgery and was told by her surgeon to make me aware that antibiotic prophylaxis was required prior to invasive dental procedures.

I subsequently wrote to her plastic surgeon who confirmed that he did indeed recommend antibiotic prophylaxis for such patients.

He felt that 'the catastrophic implications of an infected breast implant justifies handling breast implant patients in a similar way to those with prosthetic heart valves'. This in the absence of statistical scientific proof.

I wondered if anyone else in the profession has encountered this situation and indeed how they would manage such patients.

R. B. Pins

London

Professional opinion

Sir;– In the interesting article by Crossley and Mubarik, (BDJ 2002; 193: 471–473), some intriguing opinions emerge.

Perhaps the most surprising of these is that while three times as many budding doctors as dentists believe that their chosen profession requires the use of mental skills, (48% compared with 16%), only 48% of dental students, in comparison with 51% of medicals at Manchester, think manual skills are important.

It has been my long–held view that of all the professions, dentistry is the one which most requires manual skills. Inevitably, most of us who are not exceptionally talented, are destined for general practice, in both medicine and dentistry.

In the case of dental surgery, (by definition, the manipulation of teeth; ie by means of one's hands), adequate manual skills have surely always been a prime requisite.

Might this illuminating survey explain some of the failed conical crown preparations and the lop-sided floating dentures which new patients not in- frequently presented to me during 37 years in practice?

A. Sayburn

Durham

Hygienists using lasers

Sir;– In response to the letter from M. Prebble (BDJ 2002; 193: 365) as readers will know, dental hygienists' clinical duties are very tightly governed by law – most recently, on July 1st 2002 more duties were added to the remit for dental hygienists.

The proposals for these changes were first instigated in 1996, but we had to wait until this year for Parliamentary approval – we are very patient!

With the speed and constancy of changes in the dental world, this protracted mechanism for altering the way dental hygienists work proves to be unsatisfactory.

The BDHA are working with the GDC in its formidable reform programme to replace the current, outdated system with a new one in which hygienists and other professionals complementary to dentistry can be given new skills through changes to their curricula and top-up training, without the need to seek Parliamentary approval on each occasion.

The amendments to the Dentists Act, which will give us this new flexibility, are now being drafted.

We believe that this new framework will allow for sensible discussions leading to a consensus of opinion about clinical tasks and functions that a dental hygienist may undertake.

We then trust the GDC will be able to act swiftly to allow specific additions to our training.

C. Clitter

BDHA President