Letters to the Editor

The mystery of the associate and the levy

I am interested to know if my performer levy to the local dental committee (LDC) is compulsory, or not? When I became an NHS associate in 2008, I was led to believe that the levy was a statutory requirement. However, it seems that I should have ‘opted in’, meaning that I may not be obliged to pay the levy. If this is the case, why, after numerous emails, am I unable to stop the levy?

The LDC Official's Guide implies that the levy is not a statutory requirement for me, an associate, and it is only compulsory for providers.¹ This letter discusses first, what the statutory levy is used for; secondly, my personal problems and concerns and finally, a different use for the associate levy.

The statutory levy pays for the local dental committee in supporting local practitioners, mainly providers, in NHS commissioning and governance. It seems that the levy is a statutory requirement for providers, but the LDC Official's Guide suggests that some GDS contracts may allow the providers to reclaim some of the costs of their own LDC provider levy by using their associates' levies payments.¹

In my experience, as a member of a committee, the majority of LDC members are either practice owners and providers or have connections with NHS foundation training. Significantly, with the increase of corporate practices, does the LDC need to expand its purpose to engage with and benefit more associates?

In June 2018, I attempted to stop the levy and I contacted the BSA, the LDC regional representative of the BDA and the LDC. Only the LDC responded and they told me that ‘the levy is extremely complex, as the BSA only gives it as a region’ and couldn't stop it. Hence, I have continued to pay the levy and instead taken the decision to write this letter.

Personally, I would like the LDC to evolve and support associates in new ways.² This could be through providing training in research skills needed to influence NHS commissioning, by conducting and supporting more practice-based research. This may also give associates a method of gaining higher degrees through the pure research route whilst improving the skills needed for dealing with complaints.

In brief, the LDC levy may not be a statutory requirement for associates and may not be serving associate dentists due to conflict of interest with providers. If this is the case, how do associates stop or transfer their levy to another organization better suited to supporting associates' needs, within the NHS system, or encourage the LDC to evolve?

Inferior dental blocks versus infiltration dentistry: is it time for change?

Thank you for your excellent recent article in the March issue of Dental Update. I wonder if you would be so kind as to answer the following questions please:

Author's response

Thank you for your kind words and detailed questions.

Tip of the iceberg – an unexpected finding

The objective of this letter is to highlight the importance of performing a comprehensive radiographic examination for all dental patients, especially when partially erupted teeth are present. As in our case, the intra-oral finding was only the ‘tip of the iceberg’.

Clinical presentation

A 37-year-old female patient, who was otherwise in good health, reported to our department for a routine dental check-up. During the intra-oral examination, a partially erupted anomalous tooth was identified in the right maxillary second premolar region (Figure 1). An intra-oral periapical radiograph was taken to confirm its status of eruption but, surprisingly, it revealed a large radio-opaque mass with a radiolucent interior, which was surrounding or attached to the impacted supernumerary tooth (Figure 2). This prompted us to take a standard maxillary occlusal radiograph which conveyed a circular radio-opaque tooth-like structure with a radiolucent centre, similar in appearance to that of a ‘doughnut’ (Figure 3). Finally, a panoramic radiograph was taken which showed the supernumerary tooth in its entirety, occupying a major portion of the right maxillary sinus (Figure 4). It also appeared to be associated with a large, well-defined cystic radiolucency surrounding the lesion. Figure 5 demonstrates the traced version of the outline of the cyst in the panoramic radiograph. In the ideal situation, advanced imaging such as cone-beam computed tomography (CBCT) should have been performed to assess the lesion's relationship with the maxillary sinus in three dimensions. However, unfortunately, despite repeated attempts, the patient did not respond and was lost to follow-up. Based upon the incidental radiographic findings, the definitive diagnosis was a huge cystic variant of dilated odontoma.

Although sometimes described as a type of odontoma, a dilated odontoma may actually represent the most severe expression of dens invaginatus.^{1, 2} Radiographically, the tooth is severely deformed, having a circular or oval shape with a radiolucent interior. Similar in appearance to complex odontoma, a dilated odontoma is a single calcified structure, however, it has a more radiolucent central portion, giving it an overall form like a ‘doughnut’.¹

Dilated odontoma are rare, with a prevalence ranging from 0.25% to 7.74%. They most commonly affect the maxillary permanent incisors and very rarely occur in the posterior region, let alone in a supernumerary tooth.² Spontaneous eruption of dilated odontoma is also an extremely rare occurrence which, to the best of our knowledge, has only been reported once in the literature.³ The present case is a rarity, as it is a partially erupted, supernumerary dilated odontoma located in the right maxillary posterior region and it is also remarkably large in size, being one of the largest reported cases in the literature to date. Furthermore, there has never been reference to a dilated odontoma being involved simultaneously with both the maxillary sinus and a cyst.

A rare dilated odontoma is of interest to a general dentist because of its clinical implications. If left untreated, it can impede the eruption of permanent teeth and may lead to cyst formation.² Furthermore, removal of such a tooth, especially so large, is a morbid procedure, and would likely be performed under general anaesthesia by an oral and maxillofacial surgeon. With our case, there is a high risk of creating an oro-antral communication (OAC)/oro-antral fistula (OAF), as it is in close proximity or almost occupying the maxillary sinus (which could be confirmed by a CBCT scan).