key: cord-0013181-yvp9rhg3 authors: Dobson, M. title: Teaching remote consultation date: 2020-10-09 journal: Br Dent J DOI: 10.1038/s41415-020-2236-9 sha: 4e0b639111c62b4549a51d06a2bab506225273d5 doc_id: 13181 cord_uid: yvp9rhg3 nan Sir, a 77-year-old male attended the Emergency Dental Clinic at the University Dental Hospital of Manchester (UDHM). The main complaint was an ongoing, nonspecific facial pain of the right face following extraction of the 16 two months previously. History revealed that the 17 had been removed four months prior to presentation due to similarly vague symptoms. The pain failed to settle so the 16 was subsequently removed. The patient reported both teeth to have become mobile prior to extraction. Ten days after the extraction of the 16 he presented at UDHM with ongoing persistent symptoms. He had already begun a course of antibiotics and was using chlorhexidine mouth rinses prescribed remotely via an urgent dental centre (UDC). Radiographs ruled out any retained root fragments but clinical examination revealed an area of exposed bone. Conservative management advice was reiterated and two weeks later, the patient was seen for a review. The pain had reduced but there was still discomfort in the area and the patient reported it to feel sharp on his tongue. The socket had epithelialised but a small fragment of bone was present and this was removed under local anaesthetic. He was advised to return to his GDP for review. The patient contacted UDHM six weeks later with ongoing pain and a face-to-face review was arranged. In that time he had not been offered a face-to-face review but rather been given a further two courses of antibiotics after remote UDC consultations. He presented with moderate discomfort, radiating around the right side of his face which he was able to manage with simple analgesia. He had no extra-oral swelling, temperature sensitivity or tenderness to chew. He reported no history of swellings. Examination revealed friable red and white speckled tissue fungating from the socket with adjacent ulceration extending around the 15 mesially and 17 region distally. There was an area of indurated tissue extending 1 cm into the hard palate with rolled borders. He had no risk factors in his medical or social history. A provisional diagnosis was made of squamous cell carcinoma and an urgent biopsy was taken. Histopathology confirmed moderately differentiated SCC and he has been referred via an urgent pathway to maxillofacial services. Reflecting back over this patient's history and clinical encounters there were signs that may have pointed towards a nonodontogenic diagnosis. Certainly, it would appear there was no indication for repeated courses of antibiotics. The picture is further complicated by the number of clinical and remote contacts with different clinicians. We hope this may serve as a timely reminder of the limitations of remote consultations and the possible consequences of a lack of continuity of care in any one setting. A. Srinivas, C. Moshkun, J. Darcey, Manchester, UK https://doi.org/10.1038/s41415-020-2226-y missing a serious diagnosis or misdiagnosing. This has also been noted by the medical profession, particularly around telephone consultation, where clinician experience and skill are deemed to reduce risk. 4 From my experience working in hospital oral surgery and oral medicine services during the pandemic, a multitude of factors inform a risk assessment that influences whether a patient is seen remotely or face-to-face, including: patient complaints/ concerns about their oral health, NHS trust policy, patient wishes, type of oral disease/problem (confirmed or suspected), patient's accessibility to a device for a remote consultation, distance a patient would travel to our clinic, prevalence of COVID-19, patient's general health and vulnerability to COVID-19. Furthermore, remote consultation requires a different communication approach and arguably more thorough history taking to triage those that require a face-to-face appointment. It seems inevitable that remote consultation will become a permanent and useful element of dentistry owing to the potential for improved efficiency and accessibility. With the start of the academic year upon us, as dental hospitals and schools, we will need to consider how to teach this new skill set to our students and trainees. Sir, were Dexamethasone to be included in the Dental Formulary, practitioners need to be aware of common and important physical and psychiatric side effects of this potent glucocorticoid (steroid), prior to prescribing for the control of pain related to root canal treatment. It is widely recognised that steroids can cause or worsen hyperglycaemia, and national guidelines recommend monitoring glucose levels in those with and at risk of diabetes. 1 Although much of the evidence concerns long term steroid use, hyperglycaemia has been frequently reported after short courses, for example in oncology practice. 2 Glucose levels can rise within hours of high dose steroids, with a disproportionate effect on afternoon and evening levels. 3, 4 Patients with or at risk of diabetes therefore need to be counselled to monitor their glucose levels after taking dexamethasone and may need to make short term adjustments of their diabetes therapy. Even short courses of Dexamethasone in the peri-operative period may have an impact on wound healing, 5 which would be relevant to the proposed use in endodontics. Another established side effect of Dexamethasone is that it can cause steroid induced psychiatric reactions, including psychosis, mood changes, behavioural disturbance and cognitive dysfunction. These symptoms can develop within days of a 5 mg single dose even in those who have no psychiatric history. 6, 7, 8, 9 The incidence of a psychiatric episode to steroids has been recorded at being between 13% and 62%. 8 Many of these are mild reactions such as euphoria and increased irritability and may not impact on functioning, but patients need to be warned about the severe reactions in up to 5-6% of patients, 8, 10 such as mania and suicidal thoughts. Severe and persistent symptoms will require treatment which is beyond the remit of the dentist. Whilst Dexamethasone may reduce pain related to endodontic procedures 11,12 it is not a drug to be used when other safer treatment options may be available. We would be opposed to it being more widely available. S Sir, I was surprised to read an article (BDJ 2020; 229: 15-18) reporting that dentists cannot prescribe co-codamol. I have been prescribing it for years on a private prescription in different practices and never had an issue with it, as well as other drugs that are not on the dental practitioners section of the BNF. After seeing the article, I checked the GDC website where it states: ' A dentist can prescribe any medicine from the British National Formulary (BNF) on a private prescription; however you must only prescribe medicines to meet the identified dental needs of your patients' . As for myself, I believe that many colleagues that deal with surgical procedures are prescribing it as it would be very counterproductive and difficult to seek medical advice every time you have procedures that are bound to cause moderate to severe pain. In that same light I believe that we may prescribe any medications that we judge to be beneficial and justifiable for the patient's dental condition. D. Silveira, London, UK https://doi.org/10.1038/s41415-020-2239-6   Teledentistry from a patient perspective during the coronavirus pandemic Joint British Diabetes Societies for inpatient care. Management of hyperglycaemia and steroid (glucocorticoid) therapy The effect of steroid pulse therapy on carbohydrate metabolism in multiple myeloma patients: a randomized crossover observational clinical study Continuous monitoring of circadian glycemic patterns in patients receiving prednisolone for COPD Diurnal profile of interstitial glucose following dexamethasone prophylaxis for chemotherapy treatment of gynaecological cancer Adverse side effects of dexamethasone in surgical patients Steroidinduced psychosis American Psychiatric Association aww. 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