Chu, FCS

Samaranayake, LP

Tsang, PCS

HKU Scholars Hub

Title Staphylococci may indeed cause acute dental infections [7]Author(s) Tsang, PCS; Chu, FCS; Samaranayake, LPCitation British Medical Journal, 2002, v. 325 n. 7364, p. 599Issued Date 2002URL http://hdl.handle.net/10722/42611Rights B M J. Copyright © B M J Publishing Group.Fear has basis in reasonEditor—A deep seated fear may yet berational. The fear of being declared deadwhile still alive, in the case of “brain dead”patients, is a fear with a basis in reason.1 Ifsuch patients are not dead, they certainly willbe after unpaired vital organs are removedfor transplantation. Rather than being“settled,” the acceptability of criteria forbrain death is the subject of intenseinternational debate.As early as 1974, the philosopher HansJonas wrote in opposition to brain deathcriteria2; a lengthy article by Byrne et alfollowed nine years later (reprinted in ananthology by Potts et al3). More recently, theneurologist Alan Shewmon reversed hisprevious support for brain death criteria.4In 2000, the anthology Beyond Brain Deathwas published, with contributors from theUnited States, the United Kingdom, Japan,and Liechtenstein.3There are many reasons for this growingopposition. Shewmon’s accounts of longterm survivors of whole brain death empiri›cally falsify the claim that whole brain deathmarks the end of a unified humanorganism.4 Even if Shewmon’s claims areunfounded, a prognosis that brain death willlead to immanent somatic death (in thesense of the loss of a unified functioningorganism) is not the same thing as a diagno›sis that somatic death has occurred (Byrne etal3). Evans, among others, discusses themounting evidence that brain activity per›sists in a number of patients declared braindead.3 Coimbra identifies the dangers in akey test used to diagnose brain death, theapnoea test.5 Philosophers, such as HansJonas and Josef Seifert, have attacked thedualism of brain and body (Jonas’ term) thatis inherent in criteria for brain death.3 4This debate should raise serious doubtsconcerning whether brain dead people aredead and lead to a rethinking of the entireenterprise of removing vital organs fromsuch patients. A fundamental goal of medi›cine is to do no harm (non›maleficence). Anyaction that directly causes the death of apatient, even if it is for the good of others,opposes the goal of medicine not to harmthat individual patient. Any attempt to down›play the importance of the brain death debatein the interests of organ transplantation istherefore fundamentally wrong. It is preciselywhether transplantation kills the donor that isthe key issue that cuts to the heart of the goalsof medicine.Michael Potts headPhilosophy and Religion Department, MethodistCollege, 5400 Ramsey Street, Fayetteville, NC28311›1420, USAmpotts20@hotmail.com1 Editor’s choice. Deep fears. BMJ 2002;324(7348). (8 June.)2 Jonas H. Against the stream. In: Philosophical essays: fromancient creed to technological man. Englewood Cliffs, NJ:Prentice›Hall, 1974.3 Potts M, Byrne PA, Nilges RG, eds. Beyond brain death: thecase against brain based criteria for human death. Dordrecht:Kluwer, 2000.4 Shewmon DA. “Brain stem death,” “brain death” anddeath: a critical reevaluation of the purported evidence.Issues Law Med 1998;14:125›45.5 Coimbra CG. Implications of ischemic penumbra for thediagnosis of brain death. Braz J Med Bio Res 1999;32:1479›87.Staphylococci may indeedcause acute dental infectionsEditor—In their letter Ribeiro and Cousincontend the likelihood of a causal relationbetween the development of an epiduralabscess after root canal treatment and theisolation of Staphylococcus aureus in thereport by O’Rourke et al.1 2We disagree and support the originalproposal of O’Rourke et al because recentstudies using both molecular technologyand conventional culture techniques indi›cate conclusively that Staphylococcus spp arenot uncommon in dental root canalinfections.3 4 Furthermore, in a stringent andcomprehensive investigation that we arecurrently conducting on the microflora ofendodontically involved teeth, staphylococciwere isolated from root canals in eight out of86 patients (unpublished data). Indeed intwo cases, staphylococci were the sole andmajor isolate from the aseptically opened,infected root canals.We emphasise, however, that mostendodontic infections are polymicrobial innature. Using the polymerase chain reac›tion, Munson et al recently found a mean of17 taxa in endodontic samples and a total of30 new phylotypes.5 Therefore, acute dentalinfections are still best treated by anti›microbial agents such as penicillin, amoxi›cillin, clindamycin, and metronidazole, butthe possibility of staphylococci causingacute exacerbations or bacteraemias shouldnot be overlooked.Peter C S Tsang clinical assistant professorFederick C S Chu clinical assistant professorLakshman P Samaranayake professor of oralmicrobiologyFaculty of Dentistry, University of Hong Kong, 34Hospital Road, Hong Kong, Chinacsptsang@hku.hk1 Ribeiro N, Cousin G. Staphylococci are unlikely to causeacute dental infections. BMJ 2002;324:1457. (15 June.)2 O’Rourke F, Barker R, Khan S. Minerva. BMJ2002;324:686. (16 March.)3 Kitaura H, Ohara N, Matsuo T, Kobayashi K, Yamada T.PCR amplication of 16S ribosomal RNA gene fordetection of bacterial infection in root canal. Dent Jap1997;34:21›3.4 Gomes BPFA, Lilley JD, Drucker DB. Clinical significanceof dental root canal microflora. J Dent 1996;24:47›55.5 Munson MA, Pitt Ford T, Mcnish A, Chong B, WeightmanAJ, Wade WG. Molecular analysis of microflora associatedwith endodontic infections. J Dent Res 2001;80:767.Children are still seen but notheardEditor—Kroenke and Gask and Underwooddescribe in some detail the multiplicity ofpsychological presentations in patients.1 2 Nomention is made, however, of the manychildren seen in general practice and by pae›diatricians who have primarily mental healthproblems, psychological factors associatedwith their physical illness (such as diabetesmanagement), or medically unexplainedsymptoms (such as recurrent abdominalpain). The best estimate of the prevalence ofpsychiatric disorders in young people in theUnited Kingdom is the Office for NationalStatistics figure of 10% of all children.3 Thisfigure increases appreciably in inner citiesand when chronic ill health, and particularlyneurological disorders, are present. But onlyone in five of these attend mental health serv›ices for children and adolescents. Someevidence exists that family doctors canprovide effective treatment for this group.4Children are in the unique position ofbeing presented to their family doctors byparents, rather than seeking help them›selves. They are therefore vulnerable in “theconsultation” to the effects of mental illnessand personality disturbance in their parents,which can range from the genuinely (over›)anxious to the homicidal.Quite apart from the genetic transmis›sion, the psychosocial impact of parentalmental illness, separation, and divorce isconsiderable and may well present aspsychosomatic symptoms in vulnerable chil›dren. At the other end of the scale, a fewparents and carers actively harm childrenand then seek help for their illness.Patterns of help seeking behaviour areestablished in childhood. Practising psycho›logical medicine in children may well reduceundesirable adult patterns of health careuse. If it is to truly encompass the whole per›son, child and adult, psychological medicinemust consider all members of the family, notonly adult patients.Sean P Maskey consultant child and adolescentpsychiatristGreat Ormond Street Hospital, LondonWC1N 3JHmaskes@gosh.nhs.uk1 Kroenke K. Psychological medicine. BMJ 2002;324:1536›7.2 Gask L, Usherwood T. ABC of psychological medicine: theconsultation. BMJ 2002;324:1567›9.3 Meltzer H. Mental health of children and adolescents in GreatBritain. London: Stationery Office, 2000.4 Bower P, Garralda E, Kramer T, Harrington R, Sibbald B.The treatment of child and adolescent mental healthproblems in primary care: a systematic review. Fam Pract2001;18:373›82.Recommendations from qualityof life scales are not simpleEditor—As someone who is guilty ofadding to the large number of diseasespecific quality of life (QOL) scales, let meadd a note of caution to the pleas made byGarratt et al for guidance and recommenda›tions for the users of these scales—howeverunderstandable that plea is.1 QOL scales arenot like thermometers or spirometers,where the reading is independent of thetype of patient.A QOL scale is just a shopping bag ofexperiences (or questions) that are puttogether to form a scale, rather like the retailprice index. The retail price index is a shop›ping bag of goods for an “average” shopper,even though most people are not that aver›age shopper. The scale value obtained froma QOL scale depends on the overlapbetween the items in a scale and the patient’sown experience of disease. So, for example,if there is a generic QOL scale and there aremany pain items but no items on sleepdisturbance, then arthritis will come outworse than asthma. The same logic appliesto disease specific scales. If there areLetters599BMJ VOLUME 325 14 SEPTEMBER 2002 bmj.com

Staphylococci may indeed cause acute dental infections [7]

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Staphylococci may indeed cause acute dental infections [7]

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