Consent and capacity

Letters to the Editor LETTERS Send your letters to the Editor, British Dental Journal, 64 Wimpole Street, London W1G 8YS E-mail Priority will be given to letters less than 500 words long. Authors must sign the letter, which may be edited for reasons of space. MISSING THE CRUX Sir, I would like to challenge some of the statements made by Tomás et al. Confirm the efficacy (BDJ 2008; 205: 3). Given the problems with previously published guidelines on endocarditis prophylaxis where cardiac lesions were stratified according to risk, it was decided within the NICE Guideline Development Group (GDG) not to stratify risk groups. Hence in the NICE guideline we simply stated those at risk and those not at risk (isolated atrial septal defect, repaired patent duc tus arteriosus and repaired ventricular septal defects). From available evidence, it was concluded that those who have endocarditis have high rates of mortality and those with prosthetic valve endocar ditis have a higher rate of mortality com pared with native valve endocarditis. The message we were trying to portray was that all patients with known risk factors are at risk of developing endocarditis and should be regarded as such by dentists; this guideline does not change that. There is no doubt that antibiotics reduce levels of bacteraemias or else we would not prescribe them therapeutically, but with a single dose they do not universally elimi nate bacteraemia. There remains no evi dence that antibiotics are either effective or ineffective in preventing endocarditis. What Tomas et al. are missing is the main crux of the evidence and one of the pivotal factors which led the GDG to reach the published conclusions, namely that bacteraemia occurs following everyday activities which are never covered with prophylactic antibiotics. Although evidence was not found, it is likely that everyday activities other than those involving the oral mucosa produce a bacteraemia. Therefore, admittedly there is no evidence to support the statement but in those patients at risk of developing endocarditis achieving and maintaining a high level of oral health should be the aim of dentists as it is for all our patients. Whilst there are universal calls to increase the evidence base to inform our clinical decisions in this field, I remain sceptical that this is feasible or likely in the short term since the development of endocarditis is relatively rare compared to the large number of bacteraemias that are occurring on a daily basis. Crude evidence will come from the Hospital Episode Statistics whereby the diagno sis of all patients admitted to hospital is recorded; if a significant rise in cases of endocarditis is recorded in the light of the NICE guidance then an urgent rethink will have to take place. In the meantime, as a profession, den tists must ensure they continue to identify patients at risk of developing endocardi tis, ensure high levels of oral health are achieved in these patients and ensure patients are aware of the signs and symp toms of endocarditis to enable prompt investigation and treatment if required. R. Oliver, Manchester DOI: 10.1038/sj.bdj.2008.851 MAGIC WAND Sir, the experiences summarised in the paper by Versloot et al. (BDJ 2008; 205: E2) do not reflect our experience in NHS Highland. I have been using The Wand for over two years in my practice as senior dentist with special interest in children’s den tistry. I see a large number of patients referred into the anxious child service whose own dentists have been unable to provide treatment under local anaesthetic despite best efforts. Previously, a mixture of behaviour management, nitrous oxide sedation and general anaesthesia (GA) has been used. Many of these children can be acclimatised very quickly with The Wand to tolerate treatment with local anaesthesia. It has made treating the very anxious children who are referred to us a much quicker and simpler process, reduc ing the reliance on sedation and GA. The Wand allows the administration of very comfortable infi ltrations (buc cal, palatal and intra-ligamental) and ID blocks with a much less threaten ing appearance than a traditional den tal syringe. Lieberman1 expressed the importance of the change in patient per ception: ‘Since The Wand is so unique in appearance, the patients do not relate it to their previous experiences or pre conceived ideas. It has been our experi ence that an overwhelming percentage of patients who verbally express fear of the “shot”, seem greatly reassured that we will use The Wand instead.’ Held in a pen grip, the approach to the patient is much more relaxed, particularly when it is reduced in size by snapping the handle to its shorter length and it is also significantly less strain for the operator than giving a slow, controlled injection with a conventional syringe. The shape of the needle allows very easy introduction into tissue and the use of a pre-puncture technique to ensure comfortable pen etration. The reliability of inferior dental blocks is improved due to the ease of rota tion of the wand using the bi-rotational injection technique, reducing needle deflection as it passes through tissue.2 Performing pain free palatal infi ltra tions quickly and easily using a pre puncture technique enables orthodontic extractions with much less anxiety and comfortable PASA and AMSA tech niques produce reliable anaesthesia in BRITISH DENTAL JOURNAL VOLUME 205 NO. 7 OCT 11 2008 351 © 2008 Macmillan Publishers Limited. All rights reserved. LETTERS the maxilla with a greatly reduced dose and minimal labial anaesthesia. A significant advantage of The Wand is the very positive, reliable, simple aspiration facility. The cross infection control is simple and the re-sheathing is very effective, reducing the possibility of needlestick injury. It has proved very cost effective in reducing reliance on sedation and GA. We use two Wands which are in daily use for a large number of procedures. After two years we have suffered no reliability problems with little maintenance beyond periodic lubrication. There is a learning curve and a shift in perception when fi rst using the instrument and appropriate behaviour and anxiety management are still the cornerstone of treating children. However, my colleague in the depart ment is a vocational trainer and we have trained a number of FY2 dentists in its use. Their feedback has been very positive. In the words of one (formerly anxious) young patient: ‘It’s great now you don’t need to get the jag’! G. Jackson, Inverness 1. 2. Lieberman W H. The Wand. Pediatr Dent 1999; 21: 124. Malamed S E. Handbook of local anesthesia, 5th ed. Mosby, 2004. DOI: 10.1038/sj.bdj.2008.852 BETWEEN TWO STOOLS Sir, the adage ‘if it works don’t fi x it’, could have been applied to the system of remuneration to dentists prior to 2006. From 1948 till 1990 a fee per item of service was extant as the method of payment for dentists working in the NHS. The change to a capitation pay ment system prim (...truncated)