Australian Dental Journal

The official journal of the Australian Dental Association

Letters to the Editor conditions in an experienced general dental practice. Certainly the extraction clinic is co-located within the Oral and Maxillofacial Surgery Unit so consultants and advanced trainees in oral and maxillofacial surgery and registered nurses are readily available. No patient in our reported study required such back-up expertise. We agree that insulin dependent Type 1 and unstable Type 2 diabetics on insulin require different care. Indeed, one could make good arguments that this is a separate disease which involves a small minority of diabetics. There is an unfortunate tendency to lump all ‘diabetics’ into one category. This should not be the case. Currently readers of the Australian Dental Journal should be aware that we are doing a similar study on insulin dependent diabetics which we will report in the Journal. Watch this space. REFERENCE 1. Huang S, Dang H, Huynh W, Sambrook PJ, Goss AN. The healing of dental extraction sockets in patients with Type 2 diabetes on oral hypoglycaemics: a prospective cohort. Aust Dent J 2013;58:89–93.

PROFESSOR ALASTAIR N GOSS Emeritus Consultant and Director of Research Oral and Maxillofacial Surgery The University of Adelaide Emeritus Consultant Surgeon The Royal Adelaide Hospital Adelaide, South Australia PROFESSOR PAUL J SAMBROOK Director, Oral and Maxillofacial Surgery Faculty of Health Sciences Adelaide, South Australia

(Received 17 July 2013.)

TOP 10 THOUGHTS FOR DENTISTRY IN AUSTRALIA Your Top 10 Thoughts for Dentistry in Australia1 was timely, and two of them have prompted this response. Not only do there seem to be few incentives for individuals to enter academia (editorial point 7), but my experience is that an excellent source of expertise from which I benefited when young is encouraged far less than in previous years: senior dental practitioners coming in a session or two a week to teach. This provides for students being exposed to diverse approaches/techniques to their work, and a potential network for practice succession with what should be the collateral benefit of having a mentor. Anecdotally, I have been informed for many © 2013 Australian Dental Association

years that, in some faculties at least, much teaching is being done by relatively new graduates. I am also aware of experienced people who have an interest in providing public clinical services (for no significant financial reward) but are ultimately deterred by the box-ticking and bureaucratic hoop-jumping imposed by non-clinicians, as well as, on occasion, not being encouraged when indicating a readiness to contribute. Overall, it might be best summed up by the following which was sent to me by a recently-retired friend from student years (who was a senior academic and clinician in the UK): Once upon a time there was a shepherd looking after his sheep on the side of a deserted road in the Highlands. Suddenly, a brand new bright red Porsche 911 appears and screeches to a halt beside him. The driver, a woman wearing a Chanel suit, Ray Bans and a Cartier watch, steps out and asks the shepherd, ‘If I can guess how many sheep you have can I keep one?’. The shepherd looks at the large flock and says ‘Okay’. The woman connects a laptop to a mobile phone fax, enters the NASA website, scans the field using GPS, opens a database linked to 60 Excel files with logarithms and pivot tables, then prints out a 150 page report on a high tech mini printer. She studies the report and says to the shepherd, ‘You have exactly 1586 sheep’. The shepherd replies, ‘That’s correct. You can have the pick of my flock’. The woman packs away her equipment, looks at the flock and puts an animal in the boot of her Porsche. As she is about to leave, the shepherd says, ‘If I can guess your profession will you return the animal to me?’. The woman thinks for a moment, then agrees. The shepherd says, ‘You are a National Health Service (NHS) Manager’. ‘Correct’, responds the woman, ‘but how did you know?’. The shepherd replied, ‘Simple, first you came without being invited. Second, you wasted a lot of time telling me something I already knew. Third, you don’t understand anything about the work I do, but interfere anyway. Now, can I have my dog back?’. Whether it seems frivolous or not (and the gender of this particular NHS manager is irrelevant, and a distraction), people are not disposed to create such satirical pieces unless something provokes them to do so. There are parallels in Australia; some people who wish to put a bit back into the system without personal reward can find it difficult. In other words, (editorial point 9), many are interested in doing things which are not purely for financial gain, or indeed any personal gain, but do so out of a sense of professionalism. While it is 537

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

Top 10 thoughts for dentistry in Australia.

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