British Dental Journal V204 N4

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POSTURE TECHNIQUE 1. Sitting for long periods with the is tilted posteriorly, and the body is tilted Sir, I compliment A. Gandavani et al. thighs widely splayed seems to away from the work surface, which is (BDJ 2007; 203: 601-605) for highlight put pressure on the hip joints. compensated by increasing the fl exion of ing the importance of correct posture in I have met two dentists recently the lumbar spine (slumped sitting). This preventing back pain. I am concerned who have had to cease using a posture was frequently observed in the about some aspects of the study. BSS due to hip pain study and we consider this to be a prin For example Figures 3 and 4 are not 2. This thigh splay prevents the nurse cipal contributory factor to the result truly comparable. The student in Figure from sitting close enough to the ant musculoskeletal problems reported 3 on the BSS has the ‘patient’s head’ at patient forcing her to lean over both by the dental community in this and the correct working height (as shown by forwards and sideways (nurses also previous studies. her upward-sloping forearms). However, have backs) Regarding Dr Paul’s comment about the the one on the CS in Figure 4 has the 3. Some dental chairs do not go high positioning of the back rest: we consider patient’s head far too low; his stool is enough to put the mouth at a den that the back rest may not be an impor not high enough (so producing the 90 tist’s focal distance causing him or tant factor influencing posture in this degree flexion of knees and hips rightly her to overfl ex study. In the observation of 21 dentists condemned in the article); his stool seat 4. Nurses cannot sit high enough across the West Midlands and around slopes down backwards and the stool when the dentist sits at the 200 students in the School of Dentistry back is tilted so far back as to make it height required by a BSS. Many – University of Birmingham, all using useless. Little wonder he is in such dis have to stand. a CS, none of them were actively using torted posture. their back rests while treating patients. Any one of these errors would produce In conclusion – even the most perfect The BS used in this study does not have the kyphosis and slumping referred to in stool will not be totally effective if all a back rest; however, the design is such the study. Combined in one dentist they the other techniques needed to work in that it promotes good posture. are a disaster. perfect posture are not applied. In response to the comment about sit On the other hand I can guarantee E. Paul ting with thighs widely splayed on the BS: that if this student’s stool was raised to a By email the BS allows the hips to fall into a sup correct height and its seat tilted slightly ported abducted position and the angle forward, this would produce the correct Dr Amar Gandavani responds: We wish adopted by each user will vary slightly, knee and femur/trunk angles of more to thank Dr Paul for his interest and but will be within the ‘normal range of than 90 degrees. The dental chair should for his positive and helpful comments. movement’. This position is encouraged then be raised to place the patient’s In response to his comment about fi g for increasing the blood supply to the mouth at the correct height at the stu ures: the students were initially trained head of the femur and for maintaining dent’s mid-sternal level. Finally if the in properly adjusting and using their the length of the piriformis muscle. Sit stool back rest were brought forward respective seats (Bambach Seat [BS] and ting with slight abduction and external into firm contact with his lower back to Conventional Seat [CS]) with the correct rotation of the hips is a natural position reciprocate his lumbar lordosis, his pos operating posture before the commence and seen as the position adopted by many ture would be as good as the student on ment of the study. The students using the when sitting. the BSS. No equipment will work if not BS developed healthy posture, whereas Finally in response to the comment used correctly! the students using the CS developed a about seat height: we agree that seat Excellent though this study is one less ideal posture. height is an important factor infl uencing must also look at stools in a general Regarding CS producing 90 degree the working posture. Dr Paul has sug practice context. flexion of the knees: Mandal (1984) has gested that the CS has to be high enough In my experience there are some dis clearly identified that using a CS keeps for a dentist to put the mouth in his/her advantages of the BSS: the knees in 90 degree flexion, the pelvis focal distance. The BS, like conventional

LETTERS

seats, may readily be adjusted to the of the FSA’s ‘8 tips for eating well’, and The patient was in considerable pain. correct height, but the dental chair also so should be kept in mind by health pro- There was a palpable deformity and the needs to be adjusted relative to the den fessionals. If dental care professionals TMJ was low on the same side. tal seat height in order to obtain optimal remain in any doubt about what to say Two millilitres of local anaesthetic vision of the tooth being operated on. to their patients in the surgery, Deliver was infiltrated around the right TMJ This lack of sufficient raise may occur ing better oral health3 recommends that and the dislocation was reduced with in a minority of older chairs but was not everyone is advised to reduce the fre considerable effort using a combined seen in this study. quency and amount of sugary foods and intraoral and extra oral technique. No We again thank Dr Paul for his com drinks consumed. sedation was required. The patient was ments regarding this article. C. Stillman-Lowe advised not to open his mouth wide and DOI: 10.1038/bdj.2008.110 Independent Oral Health Promotion Adviser to support his jaw. He was subsequently discharged with an analgesic prescrip 1. Kay E J, Locker D. Effectiveness of oral health SWEET NOTHINGS promotion: a review. London: Health Education tion and warned about further risk Sir, I must take issue with R. Cottrell’s Authority, 1997. of dislocations. 2. http://www.eatwell.gov.uk/healthydiet/ letter on sugar and health (BDJ 2007; eighttipssection/8tips/ Non-traumatic dislocations of the TMJ 203: 560-561). He is incorrect to refer to 3. Department of Health and the British Association for the Study of Community Dentistry. Delivering occur most commonly while yawning, ‘the review of evidence of effectiveness better oral health: an evidence-based toolkit for eating, dental treatment, endoscopy1 of oral health promotion methods by prevention. London: Department of Health, 2007. and oral intubation.2 Most dental treat Professor Liz Kay for the Health Devel DOI: 10.1038/bdj.2008.111 ments require the patient to open his or opment Agency’, which he then refer her mouth wide for a long period of time, ences to an article in the BDJ. The report, TMJ DISLOCATION which makes it likely for the dislocation published in 1997,1 was in fact commis Sir, we would like to report a case to occur in the dental surgery. The risk sioned by the Health Education Author of temporomandibular joint (TMJ) of dislocation can be minimised by ask ity and was co-authored by Dr Elizabeth dislocation which occurred during ing the patient to bite on a mouth prop Kay and Professor David Locker. Both Dr administration of an inferior alveolar and ensuring adequate rest during pro Richard Watt and I wrote commentaries. nerve block. longed treatment. The exact statement that the book con A 28-year-old male patient was being In this particular patient, four hours tains on sugar (in the executive sum administered inferior alveolar nerve had elapsed since the dislocation dur mary) runs as follows: block by his dentist for a class II fi lling ing which time the patient had been in ‘Attempts to control individuals’ con in the 36, when the patient felt a click a lot of discomfort. Spasm of the mas sumption of sweet foods and drinks in the right TMJ, with associated pain seter and pterygoid muscles worsens as are generally not satisfactorily evalu and inability to close his mouth. A diag time progresses, rendering reduction ated. However, when such interventions nosis of unilateral TMJ dislocation was difficult. In addition, complications of are directed towards individuals, they made, however, no attempt was made to reduction such as fracture of the con appear to be of limited value.’ reduce the dislocation and the patient dyle and the articular eminence are rare The authors conclude that the most was referred to the Accident and Emer if reduction is achieved early using the cost-effective means of delivering fl u gency department. correct techniques. oride to the population should be the The dislocation was spontaneous. The All the tools that are required to method of choice for promoting oral patient did not have any previous his reduce a non-traumatic dislocation health through caries reduction. tory of clicking, subluxation, trauma or which occurs in the dental surgery are However, looking at the broader issue dislocation of the TMJ. within easy reach of a general dental of food and health today, the advice of An orthopantogram was performed practitioners ie local anaesthetic, pano the Food Standards Agency (FSA) is to (Fig. 1) and the patient was referred on rex and if necessary sedation. It is far cut down on sugar:2 to the maxillofacial team. Clinical his easier to relocate it immediately and the ‘Most people in the UK are eating too tory and examination was not sugges morbidity is much reduced if the dislo much sugar. We should all be trying to eat tive of connective tissue disorders like cation is reduced as soon as possible. If fewer foods containing added sugar, such Ehler danlos or Marfan’s syndrome. needed, the patient may then be referred as sweets, cakes and biscuits, and drink on to a maxillofacial unit. ing fewer sugary soft and fi zzy drinks. Reduction of dislocated TMJ is being ‘Having sugary foods and drinks too taught as a mandatory skill for phy often can cause tooth decay, especially sicians working in the emergency if you have them between meals. Many department. During dental school, the foods that contain added sugar can also theoretical management of TMJ disloca be high in calories so cutting down could tion is covered in the curriculum. How help you control your weight.’ ever, no attempt is made to train using Irrespective of whether this advice is mannequins or simulators to teach prac endorsed by the Sugar Bureau, it is part Fig. 1 Dislocated right condyle tical skills at reduction.

We would like to emphasise the need to include teaching practical techniques in undergraduate dental education. M. A. Nusrath, J. R. Adams, D. R. Farr, D. G. Bryant Middlesbrough

1. Mangi Q, Ridgway P F, Ibrahim Z, Evoy D. Dislocation of the mandible. Surg Endosc 2004; 18: 554-556. 2. Ting J. Temporomandibular joint dislocation after use of a laryngeal mask airway. Anaesthesia 2006; 61: 201. DOI: 10.1038/bdj.2008.112

RIGA-FEDE DISEASE Sir, we would like to report an unusual case of sublingual and ventral tongue ulceration, which was present for two weeks, in a six-week-old female Cau Fig. 1 Ulcer on the ventral surface/fl oor of the mouth casian baby. The mother was concerned about her baby’s intraoral discomfort and difficulty with feeding. Examination ulcerative granuloma (with stromal revealed a distressed baby with a lower eosinophilia)5 (Fig. 1). Such ulceration right mandibular tooth of whitish colour can also be seen in infants with primary and shape resembling a primary incisor, teeth and a tongue thrusting habit and with grade II mobility. The tongue was in children with familial dysautonomia slightly raised at rest with an 8 x 10 mm (insensitivity to pain).6 Recognition of indurated and tender ulcer on the ven these clinical signs may also be an indi tral surface/floor of the mouth extend cator of neurological disorders. ing from the tip to the lingual fraenum Treatment of Riga-Fede disease has (Fig. 1). The medical history was clear. varied from excision of the lesion, to As the tooth was the suspected cause of smoothening of the sharp incisal edges the ulceration and pain it was extracted or rounding of the sharp edges of the and this was completed using topical tooth with composite increments, the anaesthetic. On review ten days later, latter being where mild to moderate examination revealed complete healing ulceration occurs.4 Where the ulceration of the ulcer and the extraction socket. is large and interfering with feeding, The baby appeared to be much more removal of the tooth can be benefi cial, content and the mother reported that her as in this case. baby was feeding normally. D. Jariwala, R. M. Graham, T. Lewis Ulceration of the ventral surface of the By email tongue in newborn babies or infants is 1. Goho C. Neonatal sublingual traumatic ulceration most commonly related to natal or neo (Riga-Fede disease): reports of cases. J Dent Child natal teeth, as illustrated in this case.1,2 1996; 63: 362-364. 2. Hedge R J. Sublingual traumatic ulceration due to We believe this particular type of ulcer neonatal teeth. J Indian Soc Pedod Prev Dent 2005; ation to be a case of Riga-Fede disease;3 23: 51-52. 3. Baghdadi Z D. Riga-Fede disease: report of this was initially described by Riga in a case and review. J Clin Pediatr Dent 2001; 1881 and Fede in 18904 and has been 25: 209-213. 4. Slayton R. Treatment alternatives for sublingual reported since, but not widely in the traumatic ulceration (Riga-Fede disease). Pediatr British literature. Typically, the benign Dent 2000; 22: 413-414. 5. Elzay R P. Traumatic ulcerative granuloma with lesion begins as an ulcerated area on the stromal eosinophilia (Riga-Fede disease and ventral surface of the tongue exposed traumatic eosinophilic granuloma). Oral Surg Oral Med Oral Pathol 1983; 55: 497-506. to repeated trauma from a natal tooth.2 6. Rakocz M, Frand M, Brand N. Familial dysatonomia It may progress to an enlarged fi brous with Riga-Fede’s disease: report of case. ASDC J Dent Child 1987; 54: 57-59. mass and has appearances that have been described as those of a traumatic DOI: 10.1038/bdj.2008.113