UNUSUAL GINGIVITIS Result in a Sub-Optimal Outcome

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MANAGING EMERGENCIES encounter such problems in practice In August 2002 the Department of Sir, I was interested in the observations later in their careers they are able to put Health (DoH) published ‘NHS den- by Shelley et al. (BDJ 2009; 206: 449) this training to use. tistry: options for change’.2 This report, on the management of potential airway It is therefore unfortunate that some accepted by the then Secretary of State, obstruction in the dental surgery. postgraduate dental deans do not seem was the result of months of discussions The authors are right to raise con- to understand how useful the experience and debates between all the principal cerns, but not about the ability to treat gained as an SHO in a hospital post can stakeholders (including the DoH and the emergencies such as the sublingual be, especially as much of this experience GDSC), ably chaired by Dame Margaret haematoma. Their concerns should be is gained when ‘on-call’. Some of these Seward, the then Chief Dental Offi cer for directed at the inability to recognise deans have publicly stated that they do England. The report embraced the con- and arrange appropriate management not want ‘dental’ SHOs to be on call as it clusions of three task groups. of such patients. This includes diag- has no relevance to general dental prac- One of these task groups examined nosing the problem and seeking help tice. I beg to differ. Perhaps a period of ‘Systems of delivery of dental care’. from the most appropriate source in a time spent in an on-call post should be Amongst their conclusions was ‘No one timely manner. a compulsory part of the proposed ‘F2’ system of remuneration suits everybody, Intubation in the conscious patient year in order to ensure all graduates practices and patients are different and requires the use of muscle relaxants and, have exposure to the management of there must be some accommodation for in the event of developing obstruction, patients with potentially life threaten- this in any new system’. The task group can be challenging even for anaesthet- ing emergencies. was chaired by Dr Barry Cockcroft, ists with extensive experience. It would P. Ramsay-Baggs who is the current Chief Dental Offi cer be inappropriate for a practitioner to By email for England. attempt to intubate in the circumstances DOI: 10.1038/sj.bdj.2009.768 The respective governments chose to described. What will the practitioner do ignore their own report when introduc- with a paralysed patient after a failed IGNORED REPORT ing the April 2006 contract in England intubation? Perhaps ring his or her Sir, when I left offi ce as the chairman of and Wales. defence organisation. the General Dental Services Committee A. S. Kravitz OBE In the example of a developing sub- (GDSC) in January 2003 I resolved not London lingual haematoma an urgent phone call to make public utterances in the future 1. Dentistry’s future debated. Br Dent J 2009; 206: 565. to the local Maxillofacial or ENT Unit is on matters relating to the General Den- 2. Department of Health. NHS dentistry: options for probably the best way to get the patient tal Services. change. London: Department of Health, 2002. seen and treated quickly. Attempts to However, I cannot let your report of the DOI: 10.1038/sj.bdj.2009.769 treat the condition in the surgery will Westminster Health Forum keynote sem- delay defi nitive treatment and may inar entitled ‘The Future of Dentistry’1 UNUSUAL GINGIVITIS result in a sub-optimal outcome. pass without comment – in particular the Sir, as per the photograph enclosed (Fig. The authors state that the training to conclusions of Professor Watt. 1), I am writing this letter to bring this manage these emergencies does not seem You reported that he said ‘…there was unusual form of gingivitis to the atten- to exist. This is not true. SHO posts in no perfect system of the remuneration tion of our colleagues. I have only seen maxillofacial units do exactly this, they of dentists ... around the world different this condition twice in this form and I expose the practitioners to patients with systems have been tried, no system will have not seen it written up in the litera- compromised health and developing be satisfactory to the three stakeholders, ture or any specifi c reference to it. In the emergencies, the sublingual haematoma the public, the profession or the govern- absence of any other name for it I refer being just one of these. In a structured ment’. He called for tests and pilots of to it as post-cancer lichenoid gingivitis. clinical environment they learn how to different models of care, stating that one The two cases that I have seen had the manage these emergencies and if they system would not fi t all. following characteristics:

• Post-menopausal females While one of the patients was taking a non-rigorous methodology (simultane- (both patients) Fosamax (alendronate)-based tablet (an ous use of other products eg qât, ciga- • Breast cancer (one full single anti-osteoporosis bisphosphonate drug), rettes, bidis, pan, etc; strongly neglected mastectomy, the other partial and these are known to create a variety hygiene; unclear current profi le and past single mastectomy) of side effects including urticaria and smoking career).8 This applies to the few • Clearance of local lymph nodes rashes, the other patient was not taking cases of oral squamous cell carcinoma (one case and not the other) this medication and developed similar studied by El-Hakim et al. who, surpris- • Post-surgical chemotherapy oral lesions. I have therefore concluded ingly, also mention ‘the heat generated (both patients) that this condition arises from some from the smoke’ and the ‘irritation by • Post-surgical radiotherapy aspect of the cancer treatment that both tobacco juice products’.9 This is not pos- (in one case but not the other) of these ladies had received rather than sible because the inhaled hookah smoke • Concurrent hormone replacement being due to this medication. temperature is below that of the ambient therapy (Fosamax: one case and I look forward to receiving comments air and, unlike a cigarette, pipe or cigar, not the other). from other colleagues who may have no ‘tobacco juice’ can reach the smok- observed similar lesions and their views er’s mouth further to a trip of up to 200 on what the causative agents may be. to 300 cm on average (not to mention P. Galgut the bath). London Dar-Odeh and Abu-Hammad1 warn DOI: 10.1038/sj.bdj.2009.770 against the great amount of ‘tar’. How- ever, cigarette ‘tar’ and hookah tar are HOOKAH EPIDEMIC completely different. Narghile smoke is Sir, I would like to add some further mainly made up of water and glycerol useful references to Drs Dar-Odeh and (no biological activity) and is far less Abu-Hammad’s interesting paper on concentrated in chemicals (hundreds vs narghile (hookah, shisha) smoking.1 For thousands) than cigarette smoke.8 As Fig. 1 Post-cancer lichenoid gingivitis instance, Indian cancer specialists have for the great amounts of aldehydes and earlier noted that the South-East Asian polycyclic aromatic hydrocarbons, these The clinical features of the oral con- water pipe ‘does not appear to produce are not those of human ‘smoking ses- dition present as a characteristic pain- precancerous oral lesions’.2 Regarding sions’ but those artifi cially produced by less marginal atrophic gingivitis with a smokeless tobacco, the important fact an unrealistic narghile smoking machine straight and clearly defi ned demarca- that tobacco smoking and chewing act (one puff every 17 s for a full hour…) tion line about 2-3 mm from the gin- synergistically is indeed noteworthy.3 supposed to mimic the average narghile gival margin. Other red patches are Also, an impressive study about leuko- smoker. Amazingly, the only hot debate sometimes seen in the mucosa adjacent plakia showed that hookah smoking ‘did has been about the international stand- to the molar regions, reminiscent of not lead to any appreciable number of ard smoking machine for cigarettes physical trauma during function. Char- lesions, because neither the smoke nor which draws only but a few puffs every acteristically there are no Whickham’s the pipe are too warm’.4 60 s. Hookah smoking machines set striae or other white lines/areas or other As for the study on bronchogenic with different parameters revealed com- bullous lesions present either intra- carcinoma,5 not only were 14 of the pletely different toxicant yields.8,10-12 orally or extra-orally. On close ques- 17 smokers heavy users (>110 g, ie the As a conclusion, the main clearly and tioning one of these patients described weight equivalent of 110 cigarettes) early identifi ed public health problem a skin rash which presented as crops and the hygienic conditions unknown is carbon monoxide.8,13 Unfortunately, of ulcers 1-3 mm in diameter on her but also in the same region, Jindal et tobacco harm reduction policies are still forearms. She could not recall these al. showed that almost one third of all taboo so the hookah epidemic has been ulcers being preceded with blisters prior patients with bronchogenic carcinoma worsening for a decade now.14 to forming. and 94.4% of the 54 women had never K. Chaouachi In both cases the condition seemed to smoked.6 Pollution, kerosene, and even By email fade with time, taking approximately 18 radon are important. In fact, about two 1. Dar-Odeh N S, Abu-Hammad O A. Narghile months to disappear completely. dozen publications point in the other smoking and its adverse health consequences: Management has included reassurance direction, including the fi rst aetiological a literature review. Br Dent J 2009; 206: 571-573. 2. Pindborg J J, Murti P R, Bhonsle R B, Gupta P C. that it was not a new manifestation of the study ever carried out on this issue with Global aspects of tobacco use and its implications original cancer, regular reviews includ- exclusive/ever hookah smokers.7 As for for oral health. In Gupta P C, Hamner J E, Murti P R (eds). Control of tobacco-related cancers and other ing palpating the head and neck regions the other scarcely reported cases of other diseases. International Symposium, 1990. Bombay: types of cancer (oesophageal, bladder, Oxford University Press, 1992. for enlarged lymph nodes and checking 3. Jayant K, Balakrishnan V, Sanghvi L D, Jussawalla intra-orally for any abnormalities in the pancreatic) and other diseases (contact D J. Quantifi cation of the role of smoking and eczema, tuberculosis or aspergillosis, chewing tobacco in oral, pharyngeal, and soft tissues or any asymmetric enlarge- oesophageal cancers. Br J Cancer 1977; ments of the peri-oral bone. etc), the attention was often drawn to a 35: 232-235.

4. Mehta F S, Pindborg J J, Gupta P C, Daftary D K. The exact mechanism of the effective- are able to recruit dental nurses capable Epidemiologic and historic study of oral cancer and leukoplakia among 50,915 villagers in India. ness of this procedure is not known, but of qualifi cation. Cancer 1969; 24: 832-849. it is said that it heals cells, tissue and all Education providers should endeavour 5. Nafae A, Misra S P, Dhar S N, Shah S N. Broncho- genic carcinoma in Kashmir Valley. Indian J Chest organs simultaneously. It activates the to overcome problems of lack of employer Dis 1973; 15: 285-295. enzymes of the body and these enzymes support through a learning agreement 6. Jindal S K, Malik S K, Dhand R, Gujral J S et al. Bronchogenic carcinoma in Northern India. Thorax draw toxins out of the blood. Also, dur- which all three parties commit to prior to 1982; 37: 343-347. ing the swishing of the oil, the person’s commencement of the course. It is impor- 7. Sajid K M, Chaouachi K, Mahmood R. Hookah smoking and cancer. Carcinoembryonic Antigen metabolism is intensifi ed. In India, peo- tant that the dental profession works (CEA) levels in exclusive/ever hookah smokers. ple perform this procedure early in the cohesively to ensure that we have highly Harm Reduct J 2008; 19. 8. Chaouachi K. Hookah (shisha, narghile) smoking morning with an empty stomach. I feel trained, highly able dental nurses. and environmental tobacco smoke (ets). A critical that further research is warranted to P. Hughes review of the relevant literature and the public health consequences. Int J Environ Res Public know exactly how this procedure works Chief Executive, NEBDN Health 2009; 6: 798-843. in the case of odontogenic problems. DOI: 10.1038/sj.bdj.2009.773 9. El-Hakim I E, Uthman M A E. Squamous cell carcinoma and keratoacanthoma of the lower V. Ballal lip associated with ‘goza’ and ‘shisha’ smoking. Manipal HUMILIATION Int J Dermatol 1999; 38: 108-110. 10. Chaouachi K. Public health intervention about DOI: 10.1038/sj.bdj.2009.772 Sir, I have just had the humiliating expe- narghile (hookah, shisha) entails a radical critique rience of applying for registration under of the related ‘standardised’ smoking machine. WORK COHESIVELY J Public Health 2009; in press. the Private Dentistry Wales Regulations. 11. Rakower J, Fatal B. Study of narghile smoking in Sir, in response to the letter from L. C. Not only was I subjected to a criminal relation to cancer of the lung. Br J Cancer 1962; 16: 1-6. Hampshire entitled Set up to fail (BDJ record check, I also had to provide two 12. Sanghvi L D. Cancer epidemiology: the Indian 2009; 206: 507-508) I would like to referees who could vouch for my clinical scene. J Cancer Res Clin Oncol 1981; 99: 1-14. 13. Salameh P, Aoun Bacha Z, Waked M. Saliva highlight the following. competence. Thirty years of NHS service cotinine and exhaled carbon monoxide in real life The National Examining Board for Den- apparently counted for nothing. I wasn’t waterpipe smokers: a post hoc analysis. Tobacco Use Insights 2009; 2: 1-10. tal Nurses (NEBDN) has a robust Quality even trusted to give my own name and 14. Chaouachi K. Harm reduction techniques for Assurance process in place whereby only address but had to submit proof in the hookah (shisha, narghile, ‘water pipe’) smoking of tobacco based products. Med Hypotheses 2009; training centres accredited by NEBDN form of a birth certifi cate, domestic util- in press. can offer training. Although this ensures ity bill and verifi ed passport photograph. DOI: 10.1038/sj.bdj.2009.771 a standardised approach to the delivery If the Government really wants to of the training programme, it would be improve the standard of private den- OIL THERAPY unrealistic to include selection criteria tistry it should encourage and support Sir, I would like to share with your read- as part of the accreditation process. Edu- dental professionals rather than abuse ers the concept of ‘oil pulling’ which cational providers should be responsible and demean them. is regularly performed in the southern for accepting students on their courses, G. E. Swan part of India. It is an ancient Ayurvedic and many would resent interference from Rhondda Cynon Taff procedure in which a tablespoon of external agencies such as NEBDN. DOI: 10.1038/sj.bdj.2009.774 oil (preferably sunfl ower or sesame or Education providers do ‘take on’ the other cold pressed refi ned oil) is rinsed students when they accept them on to RIGHTS REGAINED or swished around the mouth, pulling the course. They have a responsibility to Sir, may I via the courtesy of your col- it through the teeth. This procedure is provide training of an adequate standard umns express my thanks to the numerous carried out for about 15 to 20 minutes for students in preparation for examina- friends and colleagues who responded to until the oil gets thinner and turns white tions. NEBDN accreditation is an impor- my recent letter in which I outlined the in colour. The oil is then spat from the tant indicator that a range of quality anomalous and restrictive measures that mouth and the mouth is thoroughly measures are in place, but courses will had been imposed on dentists who need rinsed with warm water or tap water and not be identical. As there is no strong to order prescription only medicines cleaned with the fi ngers. People perform evidence that previous academic quali- in emergency. this procedure saying that it is a good fi cations are a reliable indicator of an It is with pleasure that I wr ite to infor m exercise for oral musculature, reduces ability to learn, course leaders should my fellow dentists that as a result of tooth pain, secures mobile teeth and be able to use their own judgement and our efforts we have now regained our eliminates bleeding gums. The literature ensure that students will be competent former rights of prescription. None of has reported that it has been also used to sit the examination. the bodies mentioned in my original to effectively treat various disorders NEBDN agrees wholeheartedly that letter communicated with me to show like bronchitis, eczema, migraine head- employers should consider a trainee their acknowledgement of responsibility aches, nerve paralysis, arthritis, blood dental nurse’s educational needs when but as we have regained our rights we disorders, gastroenteritis, peritonitis, recruiting. With mandatory registra- must be content with the outcome. meningitis, heart and kidney disor- tion, such oversight is likely to become M. B. Rothschild ders, women’s hormonal disorders, and more uncommon as employers will London chronic diseases like cancer, AIDS etc. have a constant problem unless they DOI: 10.1038/sj.bdj.2009.775

X-RAY BURN OUT the range of treatments available in spe- but because they don’t believe they work. Sir, with reference to the article The cialist units and also limit employment This should be for the patient to decide mesio-angular third molar - to extract of DCPs within hospital practice. One not the orthodontist. Patients waiting or not to extract (BDJ 2009; 206: E23), can imagine a scenario where a general for surgery are likely to want any infor- I do thank R. T. Allen et al. for their dental practitioner refers a patient to mation about non-surgical methods, extremely helpful paper which certainly his/her local hospital only to have the regardless of their effectiveness. refi nes established NICE guidance. referral returned on the grounds that the The General Dental Council takes There is, however, that phenomenon of consultant cannot accept responsibility a stern attitude to any clinician who X-ray ‘burn out’, artifactually suggest- for the case; similarly a patient who sus- fails to mention all alternatives ‘that ing dista l car ies in t he second molar. T h is tains traumatic injuries may not be able the patient might wish to know about’. paper does not differentiate between such to benefi t from temporary restoration Currently about half the patients who a possibility and an actual second molar of any damaged teeth but could have a are offered surgery subsequently have cavity. Perhaps a second clinical/radio- fractured mandible reduced and fi xed. compromise treatment or accept their graphic examination following wisdom If the British Association of Oral and condition, never knowing that a full tooth removal to determine ‘burn out’, Maxillofacial Surgeons wish to advise correction might have been achieved arrested caries or a frank cavity requir- their fellows to de-register with the GDC without surgery. ing restoration, would further ‘fi ne tune’ then perhaps they would consider mak- Because the orthodontists speak with the NICE Guidelines. ing a case for the appointment of more one voice their opinions are often accepted B. Littler consultants in oral surgery to care for without question, even by august bodies Chelmsford those patients for whom maxfac con- such as the GDC. Over the years I have DOI: 10.1038/sj.bdj.2009.776 sultants could potentially no longer frequently voiced these concerns and as assume responsibility? a result I have been labelled an ‘unsci- DENTAL DECISIONS I. Brook entifi c maverick’, my character has been Sir, we read with interest the letter C. Freeman impugned to a point where established Another hiccup by S. Laverick of Dundee Sheffi eld fi gures will not reply to my letters, my (BDJ 2009; 206: 509), a consultant oral DOI: 10.1038/sj.bdj.2009.777 efforts to apply logic to orthodontic treat- and maxillofacial surgeon, with refer- ment have been ridiculed and I have now ence to having to pay registration fees to ACCEPTING RESPONSIBILITY been thrown out of the British Orthodon- both the GDC and GMC. Given that oral Sir, your readers may be interested to tic Society. I accept all this as the lot of and maxillofacial surgery includes some know that I have laid a formal com- those who challenge the establishment aspects of dentistry and that only regis- plaint with the General Dental Coun- but sometimes it has to be done. tered dentists can carry out the practice cil, because I believe the trustees of the I have many good friends in ortho- of dentistry it follows then that de-reg- British Orthodontic Society ‘are failing dontics and I hope they will forgive this istration with the GDC might restrict to provide the general public with fully transgression but the specialty must this practice. For example, it is accepted informed consent about orthodontic become more self critical if we are to that removal of a tooth is a maxillofacial treatment’. maintain the public’s faith. It is no good procedure, but the decision as to whether There is no doubt that: saying ‘this is as good as it gets’. a tooth needs removal or can be restored • Most orthodontic treatment increases J. Mew is clearly a dental decision. vertical growth By email Much of the routine day to day care • Those with vertical growth tend to DOI: 10.1038/sj.bdj.2009.778 of patients in ‘maxfac’ units can be del- look less attractive egated to dentally registered junior and • Vertical growers tend to develop SLOGAN STANDARDS middle grade staff, but those individu- long-term crowding. Sir, I ver y much agree with Dr Marshall’s als work under the authority of a named letter (BDJ 2009; 207: 53). The GDC slo- consultant and unless the consultant This is not the place for a detailed gan is a bit negative and now out-of-date. is appropriately registered it would be critique but the specialty must accept Could I suggest something like ‘The Gen- inappropriate for him/her to assume responsibility for these and other adverse eral Dental Council - Setting the Stand- responsibility for those patients; the side effects of modern fi xed appliances. ards in UK Dental Healthcare, on behalf non-consultant staff would have to act Sadly our patients are often quite una- of all patients’. This would encompass its as independent practitioners; this is not ware that they exist. role in monitoring education and train- in line with current hospital practice Lack of informed consent particularly ing, CPD, overseas applicants etc as well where patients are under the care and applies to orthognathic surgery where as disciplinary. The whole dental team responsibility of a named consultant. patients are rarely told about alterna- supports the GDC fi nancially and we Furthermore, dental care profession- tives such as ‘Natural Growth Guidance’ want to live up to its standards. als can take prescriptions for treatment which claim to achieve a full correc- J. Fenwick only from registered dentists, therefore tion without surgery. This is not because Newport de-registration from the GDC could limit orthodontists do not know about them, DOI: 10.1038/sj.bdj.2009.779