LETTERS TO THE EDITOR Send your letters to the Editor, British Dental Journal, 64 Wimpole Street, London, W1G 8YS Email [email protected]
Priority will be given to letters less than 500 words long. Authors must sign the letter, which may be edited for reasons of space. Readers may now comment on letters via the BDJ website (www.bdj.co.uk). A 'Readers' Comments' section appears at the end of the full text of each letter online.
PERIODONTOLOGY A little caution Sir, I was interested to read the correspondence provoked by Dr Batchelor’s recent opinion piece (BDJ 2014; 217: 405–409). There is now good evidence that proper periodontal therapy followed by assiduous supportive therapy is effective in treating and maintaining the dentitions of patients with chronic periodontitis. If it turns out that chronic infection and inflammation affecting a substantial area of soft tissue persisting over many years does indeed contribute significantly to systemic ill-health and morbidity, would this then become a public health issue? Many diabetic patients do not comply with health and lifestyle recommendations, but we would still regard it as appropriate to offer the best treatment we can to maintain health. Perhaps we should be a little cautious in judging the value or otherwise of periodontal therapy? R. Saravanamuttu By email DOI: 10.1038/sj.bdj.2015.299
PREVENTIVE DENTISTRY Early childhood caries in infants Sir, following recent publicity dealing with early childhood caries (ECC) in the press and the screening of the Channel 4 programme ‘Junk food kids’, I am very concerned that, despite much research and knowledge about this problem, it is still as bad as it was 50 years ago when I first became involved in paediatric dentistry. The problem is a behavioural one involving a lack of knowledge and education among inner city parents with children at risk. We know that very early diagnosis and the implementation of preventive care stops any early manifestations of ECC or, indeed, prevents it. The answer for many years has been that all children should be seen and under the care of a dentist by the first year of life, ‘A dental visit by one’. This rubric has become established in paediatric dentistry but has not been effectively introduced in Great Britain.
ACIDIC SALIVA SUBSTITUTES Sir, the articles by Jawad et al., A review of dental treatment of head and neck cancer patients before, during and after radiotherapy: parts 1 and 2 (BDJ 2015; 218: 65–68 and 69–74), provide a useful overview of the management of patients receiving radiotherapy in the head and neck region. The papers highlighted how the management of these patients can be challenging and a team approach is most effective. The authors discuss xerostomia and its management, and detail various saliva substitutes. They explain that some preparations are acidic and should be avoided in dentate patients. We feel it would be useful to further expand on this point. For patients attending our oncology support service we have identified several inappropriate prescriptions, mainly from some of our medical colleagues, and feel it would be useful to raise awareness of this issue. A UK Medicines Information (UKMi) document1 is a good reference and details three preparations as acidic and best avoided in dentate patients: Glandosane synthetic saliva, SST tablets
Outreach research studies, in the UK, Australia and Brazil, have all shown a substantial and significant prevention, as high as 95%, of ECC when preventive advice for mothers is started as soon as the first primary teeth erupt. When infants are under the care of dentists with repeated dental visits, if necessary at four-month intervals if there is any sign of enamel demineralisation, ECC can be eliminated. It follows that every general dentist should now be ensuring that children born to mothers within their practice area should be seen soon after the primary incisors erupt and by the first birthday at the latest. The examination of infants is extremely easy, requiring infants to be wrapped in a favourite blanket on their mother’s lap with their head cradled on a dentist’s lap. Any
(although it is formulated with a calcium phosphate dibasic buffer to prevent demineralisation) and Biotene Oralbalance gel (although a reformulated version with a pH closer to neutral is now available). Glandosane has been shown, in many in vitro studies, to have detrimental demineralising effects on enamel and dentine.2-4 As alternatives are available it would seem appropriate to avoid these preparations in dentate patients. R. Holliday, S. Barclay, M. Garnett, F. Stacey, Newcastle Upon Tyne 1. Henderson S. Saliva substitutes: Choosing and prescribing the right product. UK Medicines Information (UKMi), 2013. Available online at: www.ukmi.nhs.uk/filestore/ukmias/ NWQA190.6Salivasubstitutes.doc (accessed April 2015). 2. Kielbassa A M, Shohadai S P, Schulte-Mönting J. Effect of saliva substitutes on mineral content of demineralized and sound dental enamel. Support Care Cancer 2001; 9: 40–47. 3. Meyer-Lueckel H, Schulte-Mönting J, Kielbassa A M. The effect of commercially available saliva substitutes on predemineralized bovine dentin in vitro. Oral Dis 2002; 8: 192–198. 4. Zandim-Barcelos D L, Kielbassa A M, Sampaio J E, Tschoppe P. Saliva substitutes in combination with high-fluoride gel on dentin remineralization. Clin Oral Investig 2015; 19: 289–297.
sign of demineralisation can be demonstrated to the infant’s mother and preventive advice given. By doing so not only is ECC largely prevented but the oral health knowledge of the mothers also increases. Mothers from high-risk, low-socioeconomic backgrounds pose an additional problem of often not being registered with an NHS dentist but this can be solved by dentists working with the home visitors who follow up all births in the local community. By dentists working with the post-natal visitors a referral system should then ensure that these at-risk infants are seen before ECC becomes established. A major national campaign is needed lead by the dental profession in co-operation with the NHS. It has been long established that when children’s primary dentitions are kept free BRITISH DENTAL JOURNAL VOLUME 218 NO. 8 APR 24 2015
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of dental caries it follows that there is every likelihood that it continues into the permanent dentition and adulthood. M. E. J. Curzon Northallerton, North Yorkshire DOI: 10.1038/sj.bdj.2015.300
ORAL CANCER Two cancer cases in a career? Sir, it used to be an anecdote that a dentist might only see two cases of oral cancer in their entire career. But was, or is, that true? Recalculation may be needed because, although there are many more dentists (40,000), the incidence of oral cancer has risen sharply (three-fold) in the last 30 years without a marked increase in population size. Factoring in potentially malignant, possibly pre-cancerous lesions, we will all be seeing clinically significant cases each year. Approximately 60% of the population attend the dentist regularly (38.4 million people).1 If we reflect this attendance pattern in the 6,767 cases of mouth cancer per year, then 4,060 patients would have attended their dentist; approximately one oral cancer per ten dentists or conversely, one case per 9,500 patients seen. If we then add in potentially malignant lesions (erythroplakia, leukoplakia, submucous fibrosis, lichenoid lesions) at a population rate of 2.5%,2,3 then we might expect to see 24 premalignant lesions per year (960,000 amongst 40,000 dentists), which is two a month. Where cancer is suspected, the patient should be urgently referred to be seen within two weeks.4 Furthermore, with an increase in oropharyngeal lesions that may spread to cervical lymph nodes, dentists should carefully check for swellings in the neck every time a patient attends, as well as a careful clinical examination of the entire oral mucosa. This may be particularly important in irregular attenders, as that may be the one chance for early
detection, which could quite literally save that person’s life. G. R. Ogden, Dundee C. Scully, S. Warnakulasuriya, London P. Speight, Sheffield 1. Health and Social Care Information. Adult Dental Health Survey 2009 - Summary report and thematic series [NS]. 2011, Available online at: http:// www.hscic.gov.uk/pubs/dentalsurveyfullreport09 (accessed April 2015). 2. Lim K, Moles D R, Speight P M. Opportunistic screening for oral cancer and precancer in general dental practice: results of a demonstration study. Br Dent J 2003; 194: 497–502. 3. Warnakulasuriya S, Kovacevic T, Madden P et al. Factors predicting malignant transformation in oral potentially malignant disorders among patients accrued over a 10-year period in South East England. J Oral Pathol Med 2011; 40: 677–683. 4. National Institute for Health and Care Excellence (NICE). Referral guidelines for suspected cancer. 2005. Available online at: https://www.nice.org.uk/ guidance/cg27/chapter/referral-timelines (accessed April 2015).
DENTAL REGULATION In conflict with the GMC Sir, in fear of being accused of ‘hitting a man when he is down’, I do believe the General Dental Council (GDC) needs to clarify its position with respect to patient confidentiality. The regulation/advice of the GDC appears to be in conflict with that of the General Medical Council (GMC) on this matter.1,2 The GMC’s advice to its registrants clearly states that any information given to a medical practitioner is assumed eligible to be disclosed to other healthcare professionals involved in the patient’s care unless the patient declares otherwise. The GDC’s advice appears to read that the patient must give their stated permission for this information to be disclosed. It would appear the only secure way that a GDC registrant can claim they have that permission is to have written consent for that disclosure from the patient. Clearly, any practitioner in secondary care replying to a healthcare professional
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who has referred the patient to them could be challenged on the information given in their reply unless the patient gives their specific authority to disclose any information. Surely, the GDC should reconsider its advice, and do as the GMC have advised, and clearly state that implied consent for information disclosure to other healthcare professionals is assumed unless otherwise stated by the patient. Should my interpretation of the regulation be correct where does it place those colleagues who hold both GDC and GMC registration? A ridiculous situation could arise where a joint GMC and GDC registrant satisfies one of their regulatory authorities and not the other. How can such a situation be both fair to a patient and the registrant? G. D. Wood Wirral 1. General Dental Council. Standards for the Dental Team. Paragraph 4.25. London: GDC, 2013. 2. General Medical Council. Confidentiality guidance: Disclosing information with consent. Paragraphs 24-26. Manchester: GMC, 2009.
The overriding objective Sir, readers may be interested in my recent experience in front of the GDC’s Registration Appeals Committee for a deficiency of 48 hours of non-verifiable continuing professional development (CPD) which would seem to contradict Council’s professed policy of proportionality. There is no legal compulsion for any of the health regulatory bodies to act proportionally. However, for the GDC to publicise at every possible occasion their policy of proportionality leading dentists to expect them to act proportionally is a commitment, which if not met, is flawed and unlawful. Only two months ago the Council’s Chairman wrote a ‘Dear Registrant’ letter which finished – ‘We all have a common objective, a high quality