Australian Dental Journal
The official journal of the Australian Dental Association
Letters to the Editor essential there are some checks and balances on the profession from those remote from it, the pendulum has swung too far, and it is time it was reversed. Practical solutions include radically cutting red tape for appointments and consulting respected professionals (who are known not to have protectionist agendas) regarding teaching and public hospital appointments. Further, individuals should initially be placed on threemonth contracts to ensure inappropriate appointments can be avoided (and of course with watertight legal safeguards regarding their temporary nature to prevent the disgruntled from embarking on protracted actions re unfair dismissal etc). Students exposed to experienced teachers will emerge as better new graduates (let alone the peripheral benefit of instilling the appropriate ethical principles required for practice), and patients who genuinely cannot afford private treatment should be able to receive it without years on waiting lists. There should be a can-do approach consistent with traditional Australian culture, not the increasingly frequent obfuscation where there is a never-ending talkfest with no definitive progress. As the editorial points out, this is a healthcare issue about treating patients, not clients. As a postscript … three or four months ago, I admitted a 54-year-old female patient to hospital to excise a soft tissue lesion in the right buccal sulcus, adjacent to the premolar teeth. I have recently received a letter from the hospital asking for the reasons why the procedure was done in hospital. In other words, I was being asked to justify a clinical decision by an administrator (not the first time it has happened). For the record, the patient would have been unmanageable under local anaesthesia due to, first, a previous adverse experience in a dental practice; second, the lesion was close to a vital structure (the mental nerve); and third, I was not completely convinced preoperatively that the lesion was going to be benign. I had seen an almost identical presentation approximately two years previously which I was sure preoperatively was a mucocoele – it had collapsed during the excision which further convinced me before the histopathology report – and it proved to be a mucoepidermoid carcinoma. I am sure the administrator must comprehend all those clinical issues and deem them insignificant, hence asking me to justify my decision for hospital admission. It confirms the third point the Shepherd made to the NHS manager: ‘ … you don’t understand anything about the work I do, but interfere anyway…’ And is it any wonder why many clinicians do not want to enter academia/institutions (unless they have no alternative) when they are answerable to people who have disproportionate power, relative to the 538
knowledge they hold of the work done by those they dictate to? REFERENCES 1. Bartold PM. The Editor’s Top 10 Thoughts for Dentistry in Australia. Aust Dent J 2013;58:131–132.
ANGUS KINGON Oral Surgeon Pymble, New South Wales
(Received 1 July 2013.)
DEVELOPMENTAL ENAMEL DEFECTS IN THE PRIMARY DENTITION The comprehensive article Developmental enamel defects in the primary dentition: aetiology and clinical management,1 fails to include enamel lamellae as a developmental defect of enamel (DDE). This is understandable given the difficulty nowadays of obtaining data from apparently sound, extracted, deciduous or permanent teeth. As dental students in 1947, we were required to grind non-carious teeth to a translucent thickness in order to study the microscopic morphology of enamel and dentine without the distorting effect of decalcification. Sound teeth were available, because in those less enlightened times, dental clearance was the method of choice to treat so-called ‘focal sepsis’. Enamel lamellae were commonly seen in those ground teeth. Bernhard Gottlieb, in his book Dental Caries,2 regarded dental lamellae as the entry portals for bacteria causing dentinal caries at the dentino-enamel junction without any change being visible on the surface of the tooth. Walker et al., in Dental cracks. The role of enamel lamellae in caries initiation,3 used diamond discs to section teeth that had been soaked in dyes. They were also able to show dentinal caries connected to the surface by a lamella without enamel involvement being visible. Treatment planning for this type of caries still requires normal preventive measures, so one might well ask does it matter if the lamellae are there but are not identified? Given the current emphasis now being given to evidence based teaching, it is important that the evidence we see is supported by the theory we teach. I would suggest that anomalies, such as only one interproximal surface becoming carious, or biscuit eaters with poor oral hygiene remaining caries free throughout life, could be explained by the absence of lamellae in those protected teeth. We need reminding © 2013 Australian Dental Association
Letters to the Editor that dental caries is considered an infection in which the resistance of the host – in this case the tooth without lamellae – could play a part in the disease, and that surely warrants further attention.
REFERENCES 1. Salanitri S, Seow WK. Developmental enamel defects in the primary dentition: Clinical complications and management. Aust Dent J 2013;58:133–140. 2. Miller WD. The presence of bacterial plaques on the surface of the teeth and their significance. Dental Cosmos 1902;44:425–446.
REFERENCES 1. Salanitri S, Seow WK. Developmental enamel defects in the primary dentition: aetiology and clinical management. Aust Dent J 2013;58:133–140. 2. Gottlieb B. Dental caries. Philadelphia, Lea & Febiger: 1947. 3. Walker BN, Makinson OF, Peters MC. Enamel cracks. The role of enamel lamellae in caries initiation. Aust Dent J 1998; 43:110–116.
DR EDMOND A ADLER Mt Lawley, Western Australia
(Received 11 July 2013.)
DEVELOPMENTAL ENAMEL DEFECTS IN THE PRIMARY DENTITION: AUTHORS’ REPLY Thank you for your invitation to respond to the letter from Dr Adler who suggested that enamel lamella could be included as a type of developmental defect in our review paper, Developmental defects in the primary dentition: aetiology and clinical management, published recently in the ADJ.1 As our paper was written with a clinical focus, we did not delve into the histology of enamel defects. Thus, we did not include dental lamellae in the review because these defects are not visible clinically and are usually noted only in histological sections of the teeth seen under light microscopy. Furthermore, their aetiology and significance are still unclear. As mentioned in Dr Adler’s letter, the dental lamellae were first noted in histological sections of the enamel by Miller in 19022 and described as ‘lamellae’ by Bodecker in 1905.3 They are thought to be a form of developmental enamel defect due to their appearance under light microscopy, as areas of irregular ‘imperfections’ within the depth of enamel that are filled with organic material.2–5 The significance of dental lamellae is controversial.4 They have been suggested to be signs of enamel fractures or as channels for enamel metabolism.4,5 If dental lamellae are considered as areas of weaknesses within the enamel structure, it is quite possible that they act as convenient conduits for bacterial ingress into enamel and thus have a role in the aetiology of caries as suggested by Gottlieb6 and Walker et al.7 However, more research is required before the aetiology and significance of the dental lamellae can be established. We thank Dr Adler for his comments. © 2013 Australian Dental Association
3. Bodecker CF. A report of further investigations on the organic matrix in human enamel. Dent Res J 1924;6:117–130. 4. Lester KS. Some controversies concerning enamel histology. Aust Dent J 1964;9:82–89. 5. Awazawa Y. Optic and electron microscope observation of the tissue composition of enamel lamellae. J Nihon Univ School Dent 1959;2:23–34. 6. Gottlieb B. A new concept of the caries problem and its clinical applications. J Am Dent Assoc 1944;31:1588–1609. 7. Walker BN, Makinson OF, Peters MC. Enamel cracks–the role of lamellae in caries initiation. Aust Dent J 1998;43:110–116.
PROFESSOR W KIM SEOW Director, Centre for Paediatric Dentistry The University of Queensland DR STEPHANIE SALANITRI Metro-South Health District Queensland Health
(Received 12 July 2013.)
JAW NECROSIS AFTER HERPES ZOSTER INFECTION DUE TO HIV/AIDS AS UNDERLINING DISEASE A 43-year-old male was referred by his dentist to our department for a non-healing wound after extraction of upper and lower right third molars six months earlier (Fig. 1). The patient reported that the intraoral wound was initially healing well followed by wound breakdown in the lower right region. On examination, there was a wound dehiscence with exposed necrotic alveolar bone on the adjacent tooth, while the lower right 7 was still vital and immobile. The orthopantomogram revealed no healing of the alveolar cavity with diffuse irregular moth-eaten destructive radiolucencies extending to the region of lower right 7 (Fig. 2). Regarding his past medical history, the patient was receiving treatment for herpes zoster infection of the first, second and third trigeminal branch on the right side, two weeks before the extractions were performed. Additionally, the patient reported herpes infection in the genital region in the past, which was treated by his dermatologists. Otherwise his medical history was unremarkable. Considering his previous medical history, we initiated a blood test for Human Insufficiency Virus (HIV), which revealed to be positive for HIV. The patient was admitted to the Department of Infectious Diseases for 539
The official journal of the Australian Dental Association
Letters to the Editor essential there are some checks and balances on the profession from those remote from it, the pendulum has swung too far, and it is time it was reversed. Practical solutions include radically cutting red tape for appointments and consulting respected professionals (who are known not to have protectionist agendas) regarding teaching and public hospital appointments. Further, individuals should initially be placed on threemonth contracts to ensure inappropriate appointments can be avoided (and of course with watertight legal safeguards regarding their temporary nature to prevent the disgruntled from embarking on protracted actions re unfair dismissal etc). Students exposed to experienced teachers will emerge as better new graduates (let alone the peripheral benefit of instilling the appropriate ethical principles required for practice), and patients who genuinely cannot afford private treatment should be able to receive it without years on waiting lists. There should be a can-do approach consistent with traditional Australian culture, not the increasingly frequent obfuscation where there is a never-ending talkfest with no definitive progress. As the editorial points out, this is a healthcare issue about treating patients, not clients. As a postscript … three or four months ago, I admitted a 54-year-old female patient to hospital to excise a soft tissue lesion in the right buccal sulcus, adjacent to the premolar teeth. I have recently received a letter from the hospital asking for the reasons why the procedure was done in hospital. In other words, I was being asked to justify a clinical decision by an administrator (not the first time it has happened). For the record, the patient would have been unmanageable under local anaesthesia due to, first, a previous adverse experience in a dental practice; second, the lesion was close to a vital structure (the mental nerve); and third, I was not completely convinced preoperatively that the lesion was going to be benign. I had seen an almost identical presentation approximately two years previously which I was sure preoperatively was a mucocoele – it had collapsed during the excision which further convinced me before the histopathology report – and it proved to be a mucoepidermoid carcinoma. I am sure the administrator must comprehend all those clinical issues and deem them insignificant, hence asking me to justify my decision for hospital admission. It confirms the third point the Shepherd made to the NHS manager: ‘ … you don’t understand anything about the work I do, but interfere anyway…’ And is it any wonder why many clinicians do not want to enter academia/institutions (unless they have no alternative) when they are answerable to people who have disproportionate power, relative to the 538
knowledge they hold of the work done by those they dictate to? REFERENCES 1. Bartold PM. The Editor’s Top 10 Thoughts for Dentistry in Australia. Aust Dent J 2013;58:131–132.
ANGUS KINGON Oral Surgeon Pymble, New South Wales
(Received 1 July 2013.)
DEVELOPMENTAL ENAMEL DEFECTS IN THE PRIMARY DENTITION The comprehensive article Developmental enamel defects in the primary dentition: aetiology and clinical management,1 fails to include enamel lamellae as a developmental defect of enamel (DDE). This is understandable given the difficulty nowadays of obtaining data from apparently sound, extracted, deciduous or permanent teeth. As dental students in 1947, we were required to grind non-carious teeth to a translucent thickness in order to study the microscopic morphology of enamel and dentine without the distorting effect of decalcification. Sound teeth were available, because in those less enlightened times, dental clearance was the method of choice to treat so-called ‘focal sepsis’. Enamel lamellae were commonly seen in those ground teeth. Bernhard Gottlieb, in his book Dental Caries,2 regarded dental lamellae as the entry portals for bacteria causing dentinal caries at the dentino-enamel junction without any change being visible on the surface of the tooth. Walker et al., in Dental cracks. The role of enamel lamellae in caries initiation,3 used diamond discs to section teeth that had been soaked in dyes. They were also able to show dentinal caries connected to the surface by a lamella without enamel involvement being visible. Treatment planning for this type of caries still requires normal preventive measures, so one might well ask does it matter if the lamellae are there but are not identified? Given the current emphasis now being given to evidence based teaching, it is important that the evidence we see is supported by the theory we teach. I would suggest that anomalies, such as only one interproximal surface becoming carious, or biscuit eaters with poor oral hygiene remaining caries free throughout life, could be explained by the absence of lamellae in those protected teeth. We need reminding © 2013 Australian Dental Association
Letters to the Editor that dental caries is considered an infection in which the resistance of the host – in this case the tooth without lamellae – could play a part in the disease, and that surely warrants further attention.
REFERENCES 1. Salanitri S, Seow WK. Developmental enamel defects in the primary dentition: Clinical complications and management. Aust Dent J 2013;58:133–140. 2. Miller WD. The presence of bacterial plaques on the surface of the teeth and their significance. Dental Cosmos 1902;44:425–446.
REFERENCES 1. Salanitri S, Seow WK. Developmental enamel defects in the primary dentition: aetiology and clinical management. Aust Dent J 2013;58:133–140. 2. Gottlieb B. Dental caries. Philadelphia, Lea & Febiger: 1947. 3. Walker BN, Makinson OF, Peters MC. Enamel cracks. The role of enamel lamellae in caries initiation. Aust Dent J 1998; 43:110–116.
DR EDMOND A ADLER Mt Lawley, Western Australia
(Received 11 July 2013.)
DEVELOPMENTAL ENAMEL DEFECTS IN THE PRIMARY DENTITION: AUTHORS’ REPLY Thank you for your invitation to respond to the letter from Dr Adler who suggested that enamel lamella could be included as a type of developmental defect in our review paper, Developmental defects in the primary dentition: aetiology and clinical management, published recently in the ADJ.1 As our paper was written with a clinical focus, we did not delve into the histology of enamel defects. Thus, we did not include dental lamellae in the review because these defects are not visible clinically and are usually noted only in histological sections of the teeth seen under light microscopy. Furthermore, their aetiology and significance are still unclear. As mentioned in Dr Adler’s letter, the dental lamellae were first noted in histological sections of the enamel by Miller in 19022 and described as ‘lamellae’ by Bodecker in 1905.3 They are thought to be a form of developmental enamel defect due to their appearance under light microscopy, as areas of irregular ‘imperfections’ within the depth of enamel that are filled with organic material.2–5 The significance of dental lamellae is controversial.4 They have been suggested to be signs of enamel fractures or as channels for enamel metabolism.4,5 If dental lamellae are considered as areas of weaknesses within the enamel structure, it is quite possible that they act as convenient conduits for bacterial ingress into enamel and thus have a role in the aetiology of caries as suggested by Gottlieb6 and Walker et al.7 However, more research is required before the aetiology and significance of the dental lamellae can be established. We thank Dr Adler for his comments. © 2013 Australian Dental Association
3. Bodecker CF. A report of further investigations on the organic matrix in human enamel. Dent Res J 1924;6:117–130. 4. Lester KS. Some controversies concerning enamel histology. Aust Dent J 1964;9:82–89. 5. Awazawa Y. Optic and electron microscope observation of the tissue composition of enamel lamellae. J Nihon Univ School Dent 1959;2:23–34. 6. Gottlieb B. A new concept of the caries problem and its clinical applications. J Am Dent Assoc 1944;31:1588–1609. 7. Walker BN, Makinson OF, Peters MC. Enamel cracks–the role of lamellae in caries initiation. Aust Dent J 1998;43:110–116.
PROFESSOR W KIM SEOW Director, Centre for Paediatric Dentistry The University of Queensland DR STEPHANIE SALANITRI Metro-South Health District Queensland Health
(Received 12 July 2013.)
JAW NECROSIS AFTER HERPES ZOSTER INFECTION DUE TO HIV/AIDS AS UNDERLINING DISEASE A 43-year-old male was referred by his dentist to our department for a non-healing wound after extraction of upper and lower right third molars six months earlier (Fig. 1). The patient reported that the intraoral wound was initially healing well followed by wound breakdown in the lower right region. On examination, there was a wound dehiscence with exposed necrotic alveolar bone on the adjacent tooth, while the lower right 7 was still vital and immobile. The orthopantomogram revealed no healing of the alveolar cavity with diffuse irregular moth-eaten destructive radiolucencies extending to the region of lower right 7 (Fig. 2). Regarding his past medical history, the patient was receiving treatment for herpes zoster infection of the first, second and third trigeminal branch on the right side, two weeks before the extractions were performed. Additionally, the patient reported herpes infection in the genital region in the past, which was treated by his dermatologists. Otherwise his medical history was unremarkable. Considering his previous medical history, we initiated a blood test for Human Insufficiency Virus (HIV), which revealed to be positive for HIV. The patient was admitted to the Department of Infectious Diseases for 539
