LETTERS

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Opportunistic and hospital practice, as well as in the They witness the challenges we face and teaching of undergraduates and it is difficult to paint a rosy picture in reprehensible postgraduates, we find the balance of this today’s environment. The resolution of Sir, the article by Macluskey, Slevin, Curran paper suspect and are concerned that it manpower issues, resource funding, and Nesbitt (BDJ 2005; 199: 671-675) has been independently reviewed and realistic expectations and autonomy are raised more questions than it answered. accepted as a scientific analysis. The desperately needed in academia. I believe Having stated within the introductory suggestion that a practice such as this if these are sorted then perhaps we can paragraphs that the usual referral centre could be a more proper place to train save the plight of the academic in currently is the nearest ‘District General students is patently opportunistic and . Hospital’, the paper then went on to review professionally reprehensible. R. McAndrew the differences between a teaching hospital N. Ali, J. Carter, L. Cheng, K. Coghlan, P. By email in Scotland and a specialist surgical dental Hardee, S. Holmes, I. Hutchinson doi: 10.1038/sj.bdj.4813434 practice in Northern Ireland! London The first identified flaw is that there is doi: 10.1038/sj.bdj.4813433 Propolis: a background no evidence whatsoever that the pattern of Sir, Dr T. A. Parr reported a patient who referral of patients with third molar disease Academic plight developed oral ulceration as a was in any way comparable between the Sir, recruitment and retention has been an consequence of exposure to a fungicide, two centres. By definition, dental teaching issue in clinical academia for many years who was then treated with propolis (BDJ hospitals with oral and maxillofacial and while this has never been fully 2006; 200: 64). However, before clinicians surgery units tend to attract a referral of addressed, any article which highlights the consider using propolis, a little more complex cases whereas, by their own plight of clinical academics within dentistry background might be worth considering. admission, the surgical dental practice has to be applauded (BDJ 2006; 200: 73- Propolis (bee glue, or royal jelly) is a surveyed attracted over 30% of patients 74). Despite the rosy picture painted by natural substance based on the resin of for third molar surgery who required only O’Brien and Kay, the shortages remain and pines, collected by bees. The term ‘simple extractions’. Even if it is accepted we need to ask ourselves: why is it suitable ‘propolis’ derives from ‘pro’ (Greek = that the case mix was not too disparate, people are not queuing up to join us? before), and ‘polis’ (city) based on the fact the second question is the degree of To fly high in academia, which is what I that honeybees use propolis to narrow the discrimination being exercised in believe O’Brien and Kay are advocating, opening to their hives. submitting patients to surgery. The dental you need to be able to get airborne and Propolis is a complex entity, containing hospital consultation process resulted in you cannot do this if you are laden down, about 55% resinous compounds and balsam, more than a quarter of the 50 patients tied or restricted. Unfortunately this is the 30% beeswax, 10% ethereal and aromatic examined being advised that they did not stark reality of academia. There are oils, and 5% bee pollen. Contained chemicals require a surgical procedure. In contrast several issues not least of which are the include amino acids; flavanoids including the practice submitted every one of their competing agendas of research, teaching, flavones, flavonols and flavanones; terpenes; 250 patients to a surgical episode. training and service provision. vanillin; tetochrysin; isalpinin pinocembrin It also seems remarkable that a dental Research governance becomes ever chrysin galangin; ferulic acid; caffeic acid; hospital should choose to put 42% of their more burdensome and as GDPs are caffeic acid phenethyl ester; cinnamic acid patients through local anaesthetic required to undertake CPD we are and cinnamyl alcohol. treatments compared to only 30% in the increasingly called upon to provide Propolis has a degree of antimicrobial surgical dental practice, whereas 70% of Section 63 courses. Add to that chronic action against fungi such as C. albicans, and the surgical dental practice patients are understaffing, increases in student some bacteria1 including a range of oral subject to local anaesthetic with IV numbers and lack of administrative microorganisms2 and viruses, and may be as sedation – for which, in that setting, an support and the reasons behind a lack of effective as aciclovir against additional fee is payable. manpower become clear. Opportunities to virus.3 It also has immunomodulatory Finally, the surgical dental practice is to partake in the so called more attractive activity with augmentation of non-specific be commended upon the 0% complication pursuits are in reality accepted less and antitumour resistance.4 rate which was achieved. However it is less as to do so often places an unbearable Not surprisingly therefore, many claims, interesting that within the hospital setting burden on colleagues left behind to hold not always substantiated, have been made where all surgical practitioners are subject to the fort. The academic masters, like Oliver for the general beneficial effects of propolis. peer review and continuous peer scrutiny, Twist, want more. Additionally, it is a In dentistry, propolis has been used in the comparable morbidity was 13%. stark reality that no matter how hard we dentifrices,5 as a storage medium for teeth As a group of practitioners of oral and try in our jobs, our activity and indeed our after evulsion,6 in periodontal therapy7 and maxillofacial surgery, involved both in plights are always on show to the people in endodontics.8 Propolis ethanolic individual practice, National Health we want to attract: our students and our solutions are the most used propolis Service district general and teaching junior colleagues. products on the market for assisting the

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treatment of ulcers in the mouth, thrush or doi: 10.1038/sj.bdj.4813436 are very hard to achieve and inevitably skin infections: there is little evidence base. there is a high rate of failure but if we do While I am a great supporter of holistic Courage for debate not try, then extractions and/or dentistry and complementary medicine, the Sir, I was sad to see that the letters orthognathic surgery become inevitable. fact is that as well as the fact that there is criticising my opinion article, Science Some children improve their oral posture little evidence base for efficacy, versus empiricism (BDJ 2005 199: 495-497) spontaneously and this, as Dr McIntyre phytomedicines such as propolis, though tended to be personal rather that scientific. reminds us, may be the group that grow natural, cannot necessarily always be Empiricism essentially means favourably regardless of treatment. Mr regarded as safe.9 Propolis is, for example, experiment, and if one thing does not Pearson recommends a double blind well recognised as causing hypersensitivity work, try something else (trial and error) clinical trial but how does one assess the and anaphylaxis,10 and as occasionally but it is valueless without scientific logic. It changes in oral posture? No one has yet causing untoward reactions such as allergic is empiricism which has led the specialty developed a means of measuring tongue ,11 and oral ulceration.12,13 around the houses on the extraction issue. posture, so it would prove nothing. C. Scully CBE Angle tried without and it did not work so I know of only one way. Select a number By email Tweed tried with it and that failed too. Now of good responses to each treatment and no one knows. My critics would do better if compare them. The most ‘effective’ method 1. Kosalec I, Pepeljnjak S et al. Flavonoid analysis and they analysed people with naturally will have a higher ratio of satisfactory antimicrobial activity of commercially available propolis products. Acta Pharm 2005; 55: 423-430. straight teeth and used scientific logic to results but if one method is more 2. Park Y K, Koo M H et al. Antimicrobial activity of propolis work out why, but they do not do this. ‘efficacious’ it is likely to have a higher on oral microorganisms. Curr Microbiol 1998; 36: 24- Dr Horobin agrees with me that our ratio of excellent results. I would be happy 28. 3. Vynograd N, Vynograd I et al. A comparative multi- modern lifestyle is the obvious cause of to present 10 of my good cases so that they centre study of the efficacy of propolis, acyclovir and malocclusion, but Dr Di Biase believes could be matched against those of any placebo in the treatment of genital herpes (HSV). that ‘the aetiology of malocclusion is other orthodontist in the UK. Because I Phytomedicine 2000; 7: 1-6. poorly understood’. Is it ethical to treat a have been in practice longer than most, it 4. Orsolic N, Saranovic A B, Basic I. Direct and indirect mechanism(s) of antitumour activity of propolis and its disease that you do not understand? might be fair to increase this to three other polyphenolic compounds. Planta Med 2006; 72: 20-27. Twenty-five years ago I first put forward orthodontists. My only condition would be 5. Botushanov P I, Grigorov G I, Aleksandrov G A. A clinical an explanation for the aetiology of that they are assessed by lay judges. Sadly, study of a silicate toothpaste with extract from propolis. 1 2 Folia Med (Plovdiv) 2001; 43: 28-30. malocclusion and again in 2004; no one many will see this as provocative but I can 6. Martin M P, Pileggi R. A quantitative analysis of propolis: has ever challenged it scientifically and I see no other way to settle this debate. a promising new storage media following avulsion. Dent know of no rational alternative. It is just I have made similar offers in the past, Traumatol 2004; 20: 85-89. ignored as it does not slot in with even to pay the cost (substantial) of an 7. Gebaraa E C, Pustiglioni A N, de Lima L A et al. Propolis extract as an adjuvant to periodontal treatment. Oral mechanical/surgical thinking. independent scientific enquiry to assess the Health Prev Dent 2003; 1: 29-35. Dr McIntyre quotes 1,915 articles which science supporting orthotropics versus 8. Sabir A, Tabbu C R, Agustiono P et al. Histological failed to show that functional appliances orthodontics. I also offered to pay the analysis of rat dental pulp tissue capped with propolis. J Oral Sci 2005; 47: 135-138. had a significant effect on mandibular individual orthodontists for attending to 9. Cuzzolin L, Zaffani S, Benoni G. Safety implications growth, a finding that may be true, but give evidence. It seems that no orthodontist regarding use of phytomedicines. Eur J Clin Pharmacol negative evidence is dangerous. I have not has the courage to show their cases or 2006; 62: 37-42. 10. Thien F C, Leung R, Baldo B A et al. Asthma and seen one article that shows that growth debate this issue on a purely scientific basis. anaphylaxis induced by royal jelly. Clinical and guidance appliances do not produce a J. Mew Experimental Allergy 1996; 26: 216-222. change, or for that matter that orthodontic By email 11. Lombardi C, Bottello M, Caruso A et al. Allergy and skin treatment has any long-term benefit at all. diseases in musicians. Allerg Immunol 2003; 35: 52-55. Too few orthodontists pay attention to the 1. Mew J R C. The aetiology of malocclusion: can the 12. Hay K D, Greig D E. Propolis allergy: a cause of oral Tropic Premise assist our understanding. Br Dent J mucositis with ulceration. Oral Surg Oral Med Oral Pathol direction of facial growth or are aware of the 1981; 151: 296-302. 1990; 70: 584-586. overwhelming influence of oral posture. 2. Mew J R C. The Postural Basis of Malocclusion: A 13. Kiderman A, Torten R, Furst A L et al. Bi-lateral philosophical overview. Am J Orthod Dentofacial eosinophilic ulcers in an infant treated with propolis. How can one correct a mandible when the maxilla has dropped half an inch? No one Orthop 2004; 126: 729-738. J Dermatolog Treat 2001; 12: 29-31. 3. Peck H, Peck S. A concept of facial aesthetics. Angle who rests their tongue against the palate Orthodontist 1970; 40: 119-127. doi: 10.1038/sj.bdj.4813435 with their lips sealed will have a 4. Soh J, Chew M T, Wong H B. Professional assessment malocclusion, despite what Mr Pearson says. of facial profile attractiveness. Am J Orthod Dentofacial Orthop 2005; 128: 201-205. Ozone or hot air? My own research on identical twins has 5. Tedesco L A, Albino J E, Cunat J J et al. A dental-facial Sir, I write to you concerning my alarm that, convinced me that a substantial ratio of attractiveness scale. Amer J Orthodont 1983; 83: 38-43. in the twenty-first century, it would appear patients receiving conventional treatment that some of your correspondents can suffer some facial damage and that the doi: 10.1038/sj.bdj.4813437 provide controversial lines of therapy for teeth of most patients need to be held their patients without obtaining informed straight for ever, hardly an optimal result. Political motives consent from their patients. If the Orthodontists are poorly placed to refute Sir, I would like to reply to L. Westcott’s practitioner, whom some may think has a this as they prefer the flat faces they letter (BDJ 2006; 200: 125) No honours for monopoly of information, cannot provide create,3-5 while the general public prefer a dentists. I sympathise entirely with an evidence base for such proposed forward (horizontally) growing face. I do L. Westcott. I suppose the idea of not procedures, it would therefore follow that not say this to annoy people but to grading a BDS is not really to show any the patient cannot make an informed encourage reasoned debate. differentiation; you either pass or fail or decision therefrom. The burden for We have to balance the merits of fixed get honours and sometimes distinctions. informing the patient lies with the appliances that we know are ‘clinically However it does seem rather senseless that practitioner; the patient has no burden to effective’ (in the short-term anyway) you cannot get a place in medical school enquire. against other methods that may be more with a BDS, considering how closely B. Karet ‘clinically efficacious’. Postural changes related the subjects are, and the length of

360 BRITISH DENTAL JOURNAL VOLUME 200 NO. 7 APR 8 2006 LETTERS the courses for medicine and dentistry are the London Deanery. For further factual the same. In my view the BDS degree accuracy RITA stands for Record of In- should be ‘honours’ anyway, because of Training Assessment,1 not ‘Registrar In the five year period to do a bachelor’s Training Assessment’ as quoted by L. W. degree. In addition dental students have to McArdle. pass each and every professional exam 1-5 Specialist Registrars (SpR) accepted on to in order to proceed; they cannot just OMFS training programmes typically have scrape through with a pass or 3rd of 40%: had significant experience of dentoalveolar the pass mark is 50 and above. There are a surgery even prior to entry on to a second lot of courses such as Hygiene and Therapy degree course and often continue such work converting to degree, BSc etc (three years); during their studies as a necessity of being perhaps it is time the BDS degree is self financing students (most, if not all, have promoted to honours, masters or DDS like held Surgical Royal College approved OMFS in the States and Canada. I get the feeling SHO training posts prior to reading for said there could be smatterings of underlying second degree). Add to this the validated political motives going on perhaps. exposure during SpR training and it M. Parsons becomes readily apparent that senior OMFS Sheffield trainees are well beyond ‘acquiring the doi: 10.1038/sj.bdj.4813438 necessary skills in surgical dentistry required for inclusion on the GDC’s specialist lists’. Stamping our feet Furthermore, as far as we are aware, Sir, is it just me or do others feel the need within the London Deanery no OMFS for a Mission Statement for our profession? trainee has failed to pass through the final Fashions change all the time. For a while RITA interview as a consequence of not we all wanted to be called Doctor, so we being exposed to adequate training in changed the name of tartar to calculus and surgical dentistry. Successfully stamped our feet. Finally the GDC agreed completing annual RITA interviews is just not to prosecute us for using the coveted one element of the requirements necessary title (although I believe anyone else could) to obtain a CCT in Oral and Maxillofacial and now we have reached a satisfactory Surgery which is recognised by the GDC muddle. Some of us are Doctor, some of us for inclusion on its Oral Surgery and are not. Some organisations insist on the Surgical Dentistry Specialist lists. title; others deny that we are anything The suggestion that we will become other than Mr/Mrs/Ms. So that is settled ‘consultants lacking proficiency in this and clearly it is time to move on. clinical field’ is clearly incorrect and Now we want to be like Richard Branson damaging to our professional reputation and we spend our time fussing about both within the dental community and the management, marketing and public at large and we therefore request salesmanship. Ethical selling, of course. the author retract his comments. Although what I really mean is Treatment M. Cameron, B. Visavadia, M. Heliotis, M. Acceptance. A mission statement is a basic Shelley, L. Cascarini, M. Kumar, K. Fan, C. requirement for any self-respecting Mills, B. Swinson, S. Hodges, C. Bridle, S. business and we really cannot go on much Walsh, C. Leiw, D. Coombes, N. Shah, P. longer without one. It could be something Norris, J. McKenzie, J. Collyer, J. Antscherl, B. like: ‘We aim to improve the quality of Bisase, D. Chin-Shong people’s lives by using our special knowledge and skills.’ Could it please NOT Mr McArdle replies: As a trainer in be, ‘We try to fix it as cheaply as possible’? surgical dentistry, I consider that it is N. Cole reasonable for me to comment on training Isles of Scilly in this specialty for all who should be doi: 10.1038/sj.bdj.4813439 undertaking it. I believe that the OMFS SpRs have OMFS training revisited missed my point as my comments are not Sir, as a group of London based trainees directed at any specific group of in Oral and Maxillofacial Surgery individuals. A significant number of the (OMFS), we would like to register our signatories and other OMFS trainees are deep concern regarding the comments by already on the GDC’s specialist list for L. W. McArdle (BDJ 2006; 200: 2) who is surgical dentistry. I have always been fully not an OMFS trainer. aware of this and my concerns have never We unreservedly reject the assertion been directed at those who have that OMFS trainees lack the ‘appropriate demonstrated competencies in this way. training and clinical experience’ because My opinion, however, remains the same. OMFS units are ‘failing to deliver’ It is my observation that competency in training opportunities. This is factually surgical dentistry is assumed and my incorrect as demonstrated by the RITA concern therefore is one of complacency. It process which is rigorously executed by cannot be presumed that OMFS trainees

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will have achieved competency in surgical Caries before concrescence? Twin Block appliances. A randomised controlled trial. dentistry skills before entering OMFS Sir, the case report involving concrescence AJDO 2003; 124: 128-137. training and it cannot be presumed that of the mandibular molars (BDJ 2006; 200: doi: 10.1038/sj.bdj.4813441 these skills will be a by-product of OMFS 141–142) was of some concern. The training. It is my opinion and, in my patient is reported as having several Climbing every mountain experience, the opinion of other oral episodes of pain from the lower right third Sir, I write in response to the article by Kay surgeons and OMFS surgeons, that surgical molar region. There is no mention of and O’Brien (BDJ 2006; 200: 73-74) on dentistry training for OMFS trainees needs treatment of the grossly carious second academic dentistry. As a young clinician to be emphasised if they are to continue to molar in this quadrant prior to being listed wishing to pursue a career in academic provide these skills when consultants. for a significant surgical procedure. restorative dentistry I was encouraged by The assessment of OMFS training M. Forde their enthusiastic advertisement of an programmes is under the mandate of the St Helens academic career. SAC in OMFS and, based upon G. D. In response to their title question ‘where Wood’s comments (BDJ 2005; 199: 249), Dr Kaan Gunduz, the author of the case is everybody?’ I believe the answer lies they too have noted the importance of this report, responds: A clinical diagnosis of partly in the ‘hurdles’ mentioned in the issue. As I stated in my original letter: pulpitis of the second lower right molar tooth article. I would like to highlight these deficiencies in surgical dentistry training caused by caries was made. The patient was hurdles further. will have implications for future anaesthetised with local anaesthetic, and the A young clinician will usually first consultant led services. teeth were isolated with rubber dam. A complete Vocational Training, and then be pulpotomy was performed. Also, the caries required to undertake Senior House Office L. W. McArdle is senior specialist clinical on the first lower right molar was excavated (SHO) posts in order to sit the MFDS exam. teacher and honorary associate specialist without evidence of pulp exposure and The SHO posts (which are themselves very in oral surgery at Guy’s Hospital. He is restorated with amalgam. competitive) will be expected to cover a programme director for the MClinDent doi: 10.1038/sj.bdj.4813440 variety of disciplines, usually at least oral (Surgical Dentistry) degree at Kings and maxillofacial surgery and the clinician’s College London and Hon Secretary of the Worthwhile projects chosen specialty. Upon completing the British Association of Oral Surgeons based Sir, Hedger and colleagues (BDJ 2006; necessary SHO posts and MFDS the clinician in Edinburgh. 199: 754) are looking for a scientific is then required to undertake a PhD and gain enquiry to establish the truth about a National Training Number (NTN) leading to Editor’s note: The postscript from Mr functional appliances. There is extensive a Certificate of Completion of Specialist McArdle makes clear his reason for writing literature about functional appliances and Training (CCST). During this time, the to the Editor from an address in Edinburgh. perhaps the most significant studies are pressure to produce high quality publications We quote the name of the correspondent and those of Tulloch1 and O’Brien.2 and attract research grants, not to mention the city/town as given in the address from As a member of the BOS and of the teaching commitments, is a further strain on which the letter originates as a reference at Establishment I should like to refute the the clinician’s time. Even after completing all the foot of each letter we publish (or ‘by suggestion that we do not use functional of the above, the clinician may still have to email’ if received electronically). In the appliances. I have been using them for 40 wait a number of years before being eligible instance of Mr McArdle’s previous letter years and have recently carried out a for a senior lecturer position. (BDJ 2006 200: 2), we received a complaint prospective trial, of twin blocks and I am sure you may appreciate that from about this practice with the accusation that activators. The preliminary results which my perspective the above ‘hurdles’ we were negligent in not pointing out the have been analysed by my colleague are sometimes look more like mountains! location in which Mr McArdle worked, disappointing – of the 60 patients However, having undertaken the necessary rather the location and position from which included in the trial only 27 achieved SHO posts, MFDS and with publications he sent his letter. We are therefore grateful satisfactory resolution of their underway, I am not deterred. I am currently to Mr McArdle for clarifying the matter. malocclusion with functional appliances considering self-funding a PhD in order to The correspondence over this subject has alone. Fifteen achieved partial overjet make myself eligible for a lecturer position clearly touched on important issues reduction and required completion of and NTN. This does however mean that I affecting the profession and I believe that treatment with fixed appliances and in am going to be at least in my mid-thirties the BDJ is the appropriate place for such nearly half of the cases (28) functional before completing all of the above – and I topics to be debated. However, on this appliances failed to achieve any have focussed my career towards this goal matter and on others which readers have satisfactory reduction of overjet. This poor since qualifying, which I presume is already raised and will wish to raise in the success rate may partially explain why relatively rare. Senior lectureship is still a future, I would put forward a reminder that they represent only 3% of NHS treatment. distant goal, far away on the horizon. I the BDJ is a journal which represents us as I am sure that the British Orthodontic wonder how many of my colleagues are a profession and that part of the privilege of Society Foundation would be delighted to understandably put off by the above being a profession involves being respectful receive financial contributions as these hurdles, especially given that any clinician of the opinions and standing of others. I funds are used to support worthwhile with the above experience would be able to would therefore urge future correspondents orthodontic research projects. pursue a career in private practice or as an to be mindful of this and to guard carefully K. G. Isaacson NHS consultant much sooner and with against making remarks that may be, R. Walker more immediate financial gain. rightly or wrongly, construed as personal or Basingstoke Until more dedicated career pathways are derogatory to individuals, specific fields of created which allow time for completion of a practice or the profession in general. 1. Tulloch J F C, Proffit W R, Phillips C. Outcomes in a 2- PhD and CCST, and are given to candidates phase randomised clinical trial of early Class II treatment. who are dedicated to academia, I fear the Amj Orthod Dentof Orthop 2004; 125: 657-667. doi: 10.1038/sj.bdj.4813448 2. O’Brien K, Wright J, Confoy F et al. Effectiveness of problems of recruiting new academics will treatment of Class II malocclusion with Herbst and not only persist, but may even worsen.

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M. W. Barber N. Palmer undergraduate degree (albeit not in Sheffield L. Longman medicine) there following a first doi: 10.1038/sj.bdj.4813442 By email qualification in dentistry, and my college accepted without question that my dental Multi vs. single dose 1. Standing Medical Advisory Committee. The path of degree entitled me to a waiver of one out least resistance. London: Department of Health, 1998. Sir, I was heartened to read the letter from 2. Houvinen P, Cars O. Control of antimicrobial of the three years of the course. P. Williams (BDJ 2006; 200: 124) with resistance: time for action. The essentials of control B. Soper regard to his success with a single tablet of are already well known. Br Med J 1998; 317: 613-614. doi: 10.1038/sj.bdj.4813446 200mg metronidazole as a post-operative 3. Hill M. No benefit from prophylactic antibiotics in third molar surgery. Evid Based Dent 2005; 6: 10. preventative of infection. This concurs 4. Jaafar N, Nor G M. The prevalence of post- Paying to park with my own experience, published in the extraction complications in an outpatient dental Sir, is it reasonable to expect NHS staff to BDJ in February 2004, where a single dose clinic in Kuala Lumpur Malaysis – a retrospective pay to come to work? More and more surgery. Singapore Dent J 2000; 23: 24-28. 200mg metronidazole has (so far!) stopped 5. Poeschl P W, Eckel D, Poeschl E. Postoperative hospitals are asking hospital staff to pay all incidences of post-operative infection prophylactic antibiotic treatment in third molar surgery car parking fees in order to gain extra irrespective of surgical difficulty. – a necessity? J Oral Maxillofac Surg 2004; 62: 3-8. funds. In some hospitals the amount paid 6. Faculty of General Dental Practitioners (UK) Royal At a recent antibiotics course however, I College of Surgeons, England. Adult antimicrobial is proportional to the amount one earns, was surprised to note that a centre of prescribing in primary care for general dental but in others (such as mine) a set fee is excellence still made no reference to small practitioners. 2000. payable per day, regardless of income. single dose therapy as being a reportedly 7. Faculty of Dental Surgery. National Clinical For those lower down the pay scale, such Guidelines. London: Royal College of Surgeons of good way to treat our patients, and that England, 1997. as domestic and ancillary staff, this may anything between five and 10 day courses 8. Oginni F O, Fatusi O A, Alagbe A O. A clinical be a considerable chunk of their wages. It of postoperative antibiotics are still being evaluation of dry socket in a Nigerian teaching might be acceptable if one could actually hospital. J Oral Maxillofac Surg 2003; 61: 871-876. taught as the norm. This is despite the 9. Larsen P E. The effect of a chlorhexidine rinse on the find a parking space without having to evidence from Professor Martin1 and incidence of following the surgical hunt for a spot for half an hour. experiential evidence from oral surgeon removal of impacted mandibular third molars. J In addition, surely there should be practitioners such as Mr Williams or others. Oral Maxillofac Surg1991; 49: 932-937. some concession for very ill individuals As Mr Williams states, it really is time doi: 10.1038/sj.bdj.4813444 (eg cancer patients) and their immediate GDPs tried to cut down on the numbers of families, who, at present, are running up multi-dose courses of antibiotics in favour Surprising advice hefty car parking bills. I understand of single dose regimes, if only because Sir, like L. Westcott (BDJ 2006: 200: 125) hospitals want to discourage people who although controversial, it appears to work. I, too, applied to Cambridge University to are not attending hospital from using Consequently, I also urge colleagues to try further the education provided by GKT their car parks but maybe the Department it as part of their own regime. (although it was still Guy’s when I gained of Health could set a limit for the R. Kitchen my BDS in 1978). Cambridge is well- maximum car parking charges individual Bristol known for a certain lack of cohesion and NHS trusts can impose. Perhaps they uniformity when it comes to decision- could also specify that if staff do have to 1. Longman L P, Martin M V. The use of antibiotics in the making, and I am a little surprised that pay parking fees, it should be in line with prevention of post-operative infection: a reappraisal. Br Dent J 1991; 170: 257-262. advice appears to have been taken from what they earn, and they should be one college admissions tutor only. guaranteed a parking space. doi: 10.1038/sj.bdj.4813443 In 1992 I applied to Cambridge for Z. Shrivastva enrolment on an M.Phil degree course, to Liverpool Follow the guidelines be told the same thing by the head of the doi: 10.1038/sj.bdj.4813447 Sir, we refer to a recent letter from department I was applying to: that is, that P. Williams on this subject (BDJ 2006; the equivalent of an upper second degree Immediate referral 200: 124). With the increasing problem of was required, and that dentistry was not a Sir, I feel I must strongly support antimicrobial resistance and the potential classified degree. I was, however, also told Professor Thomson's view (BDJ 2006; serious side effects of antibiotics dentists that this was not a problem — I would 200: 242) on the need for specialist have a moral and ethical duty to prescribe simply need to get two academic references referral and biopsy and find the reply of appropriately.1,2 To prescribe even a single relating to my time as a BDS student. This I Professors Scully and Felix alarming if dose of 200mg of metronidazole duly did, supported most enthusiastically not slightly arrogant. I work in hospital immediately after the majority of adult by the delightful A. H. R. Rowe, and gained practice as an oral surgeon and extractions, in our opinion, is an entry to my chosen college (Sidney Sussex) occasionally in ‘High Street' specialist inappropriate use of antibiotics. with no problem at all. My postgraduate practice also. If someone presents to me We would point the author to the education, which became a Doctorate and a in the latter I organise an immediate scientific evidence which shows that the pathway to writing, was admittedly within referral to my local oral surgery incidence of postoperative infections the History Faculty, not the Faculty of colleagues and I do not mess around with following extractions is extremely low (4%) Medicine. But as far as admission to the biopsy in this setting. I also feel that and also to the evidence and guidelines that University goes, I can’t see how this would charging a patient either on a GDS basis support our view.3-8 The clinical make any difference. or a private basis for this is experiences of one practitioner undertaking R. King inappropriate. Do Professors Scully and a relatively small number of extractions Cambridge Felix have to cope with the surgical does not constitute good scientific evidence. doi: 10.1038/sj.bdj.4813445 problems that such a delay could We would urge practitioners to follow the potentially cause? existing guidelines and consider using a Try Oxford A. R. J. Curtis local application of chlorhexidine rather Sir, L. Westcott (BDJ 2006; 200: 125) By email than systemic antibiotics.9 should try Oxford. I took a second doi: 10.1038/sj.bdj.4813490

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