LETTERS

Send your letters to the editor, British Dental Journal, 64 Wimpole Street, London W1G 8YS. E-mail bdj@bda dentistry.org.uk Priority will be given to letters less than 500 words long. Authors must sign the letter, which may be edited for reasons of space.

Illicit drugs for toothache use of illicit drugs for toothache explains patient is currently well, is highly why, in Sheridan’s study, fewer than 29 % educated and her interpersonal Sir,— I read with interest the article by of the drug users experiencing oral health presentation and interactions are such J. Sheridan et al (BDJ 2001; 192: 453-457) problems had consulted a dentist. that she would be taken as you or I. When about self-reported oral health problems I. Madinier, Nice, France asked about her medical history she by illicit drug users. Actually, I wondered reported that she had a diagnosis of why drug users suffering from extensive schizophrenia and was on a monthly dental caries did not seek dental care Stigma knows no bounds depot medication. She also reported that earlier, and how they controlled toothache. Sir,— It is well recognised that sufferers of her last admission had been January of In our hospital drug-addicts clinic, mental illness are often stigmatised in their this year but that she was currently well dental examination and treatment day to day life. Such stigma can be present and under ourselves at the CMHT. The including prosthetic rehabilitation are and affect patients in all walks of life. So dentist promptly informed her that the proposed to the patients attempting a significant is this problem that it was practice did not have the facilities to treat withdrawal programme. Thus, during acknowledged within the National Service her and before being considered for routine dental examination I asked them Framework (NSF) as a key area for strategy treatment she would need a letter from her whether: 1) they had experienced acute and action. The Royal College of GP and psychiatrist. pulpitis, 2) they had taken illicit drugs as Psychiatrists has spent thousands of Understandably our patient was an analgesic for toothache, and 3) pounds on the anti-stigma ‘Changing distressed by this and could not cannabis smoking had analgesic Minds’ campaign, targeting both health comprehend what the problem or properties regarding toothache. From professionals and the public. Members of difference was in respect of her case to April to July 2001, fifty long-term the college and fellow mental health any others, and indeed had we not parenteral drug-addicts were examined professionals have been tasked with encouraged her to attend? She (12 females, 38 males, mean age 35). All educating and changing attitudes of both subsequently telephoned the CMHT to ask these patients exhibited severe carious our medical colleagues and the public and if we could explain what the problem was. destruction with a mean number of 10 promoting mental health awareness. It is The dentist was contacted, and it became missing and 10 decayed teeth. 83.3% of easy for complacency to slip into day-to- evident that she had no appreciable females (10/12) and 89.5% of males day practice, especially assuming that the understanding of mental illness and was (34/38) had experienced at least once main area our patients experience stigma relying purely on stereotypes of the acute pulpitis. 25.0% of females (3/12) is in the social and not health forum. ‘schizophrenic’. The dentist explained her and 60.5% of males (23/38) reported the A recent experience served to quickly concern that the patient might suddenly use of illicit drugs for their toothache. re-awaken me to the fact that stigma become ‘unwell’ in the surgery, not For this purpose, the most efficient remains a very real issue in accessing comply with treatment, and they would be molecules were intravenous heroin and/or healthcare services. The South Stockton unable to contain the situation. She felt cocaine, locally applied cocaine, and to a Community Mental Health Team (CMHT) larger premises eg. the health centre, lesser extent cannabis smoking. These last has a service for patients with chronic and would be more appropriate. Asked why two methods were generally combined enduring mental health problems, which she thought the patient might become ill with one or more licit analgesics such as looks at the whole health of the patient; she could not answer. Asked how the paracetamol with codeine, ibuprofen and psychiatric, physical and social. This patient had presented she said, ‘Well, but other non steroidal antiflammatory includes health promotion and she could've just been saying that’. Asked agents. Interestingly, 58.3% of females encouraging patients to access health if they would treat any other category of (7/12) and 47.4% of males (18/38) screening, primary care services and patient in the same manner, a long reported pulpitis induction during dentistry, as these are areas often convoluted answer clearly illustrated not. cannabis smoking. Perhaps pulpitis could neglected. We actively encourage Asked whether she had any experience of be added to the list of vascular adverse registration and regular check ups with a patients with mental illness the answer effects linked to cannabis use already dentist; indeed, we are looking to have a was no. reported (conjunctivitis, tachycardia, local dentist present to the service interest The dentist was imparted with some hypotension, angina pectoris and session on the importance of oral health. psycho-education about mental health paroxysmal atrial fibrillation), in patients It was with much dismay therefore when I problems and informed how her handling already suffering from deep cavities. was involved in the following experience. of the case had caused distress. She agreed Anyway, this unexpected effect of a One of our patients had attended a local to re-contact the patient to inform her substance considered to have analgesic non–NHS dental practice to register and that she would be happy to treat her and properties deserves attention. obtain a check-up that was overdue. would apologise for any distress caused. In conclusion, it is likely that the hidden Worthy of note is that this particular She did indeed inform the patient she

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would treat her, but did not apologise or where we have to disclose our success acknowledge the unnecessary distress rates for each item of treatment and caused. She also declined our invitation to compare it with national and local attend one of the well–being sessions to averages. In many ways this may be a meet other patients which might have good thing, but, as we have seen with helped inform her views. school and hospital tables, it can lead to How can we as professionals expect the all sorts of problems and greater general public to be impartial and non- dissatisfaction if you are in the ‘losing’ judgemental in their approach to people team. Being a professional is about trust, with mental illness when some among us honesty and putting the client interests are still riddled with stereotypes that are first. imposed upon patients rightly accessing We, along with many other ‘professions’ services? How can CMHTs countrywide have had to compromise over the years, actively promote health issues such as mainly due to financial restrictions dentistry when patients come up against imposed by third parties. The real issue this sort of treatment and barriers to care? here is not simply the cost of treatment At what level do we need to tackle the but ‘value for money’ — consumers want lack of understanding and knowledge that to know that they are not being ‘ripped surrounds mental illness and so damages off’. The challenge facing the profession is our patients? how to communicate this information I am unaware of what training and without it degenerating into a slanging teaching, dentistry and other allied match. medical professions receive in mental P. S. Mike must know some good health, but this experience from a fairly plumbers; I have never known one give an recently qualified practitioner raises estimate and stick to it! concerns. Medical, dental, and other allied D. Meacher, Anglesey schools/courses are often changing and re-organising the content and structure of Mike Grace responds: teaching programmes, I would suggest I would like to thank David for his letter that mental health is an area that needs which raises the issue of quality and over- particular attention if we are to improve charging. While this is obviously important the experience of our patients. I do not think this is what the Consumers M. J. Temple, Stockton-on-Tees Association is mostly concerned about with regard to the content of my leader. The concern is simply that many Private dentistry pricing professionals (not just dentists) seem very Sir,— I read with interest your editorial shy about admitting the actual cost to the regarding the Consumers Association's client/patient. To my mind this is what the request to the Office of Fair Trading that issue is about, and I was trying to point they investigate private dentistry pricing out the illogicality that dentists think one (BDJ 2001; 191: 535). While I agree way when they are buying (I like to know wholeheartedly that ‘consumers’ should be how much it costs) and when they are given an accurate idea of the likely cost ot selling (I am not so happy about telling treatment, how do we ethically people how much it will cost.) differentiate between justifiable costs and Incidentally, I do have a good plumber! over charging? While it is relatively easy to differentiate between an NHS and private denture on technical rather than Questions, questions professional grounds, it is extremely Sir,— Being involved with the survey on difficult to make a differentiation cavity liners I would like to thank between, say, root treatment — one M. R. Yewe-Dyer for completing the practitioner may make do with a quick questionnaire (BDJ 2001; 191: 595). scrape and a single GP point while The problem with many such surveys is another may have invested in the latest that they are usually carried out by final imaging equipment, apex locator, NiTi year students as part of their final BDS rotary files (and handpiece), ultrasonic examination. Once the BDS hurdle has canal preparation systems and thermal GP been overcome the students are subsumed condensing equipment, not to mention the into vocational training and valuable courses to make it all work. All the patient research is never published. knows is that they have had a root filling The cavity liner survey has been and paid privately for it. presented for publication but if the results At present, we are not in a position to from the hairline recession survey are say one is ‘better’ than the other, but to known then please advise me as to my mind it all bears as much relevance as whether being follicullarly challenged the basic cost of the treatment. Perhaps affects my dentistry. ‘league tables’ are around the corner, S. A. Bhatti, Crumpsall

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