Sir,- With reference to the letter by Roland Kitchen (BDJ 2003, 194: 119) I would like to take issue with several points he raises.

Firstly does he advocate only the use of “salt scrub” techniques in the treatment of periodontal disease in his patients? If so, could it not be said that they are being misinformed regarding the most efficacious treatments for periodontal disease?

My training advocates the following treatment. Firstly, establish consistent mechanical plaque control of high standard inclusive of interproximal hygiene, followed by supragingival scaling and subgingival root suface debridement. This is supplemented by maintenance scaling and monitoring of the indicators of periodontal disease. Antibiotics can be considered in refractory cases, though in my opinion refractory periodontitis is merely the failure to maintain oral hygiene in the majority of cases.

In reference to “commercial mouthwashes” I agree with him that mostly alcohol-based mouthwashes are indeed of little or no benefit in the treatment of periodontal disease. Though it is ambiguous, I sincerely hope that chlorhexidine gluconate mouthwash is not included in this category as it is well known as the gold-standard plaque control agent with which all new products are compared. Its use in periodontal disease is not proven though its ability to control supragingival plaque in patients who are unable to attain a high standard of mechanical plaque control is supported by a wealth of evidence. In the same vein I believe salt is unable to reach a high enough concentration in the periodontal pocket to have any beneficial effect on periodontal disease.

Has he considered that the benefit he perceives could be the result of an increase in mechanical plaque control in his patients during the use of the salt-scrub technique? Should interproximal cleaning not also be suggested?

Though I have had no experience in the use of salt in treating periodontal disease, I have experienced success using the methods stated above and will hopefully continue to do so unless a body of evidence suggests that the use of salt is more effective. In today's litigious climate I would suggest that patients be informed by their dental practitioner of the most successful evidence-based treatment available.

Sir,- I was most interested in Dr Kitchen's comments re. the prescription of hot salt mouthwashes (HSMs) in the letters column.

For all my 33 years practicing life I have prescribed the use of HSMs both post extraction and minor oral surgery and as a palliative in cases of septic socket and pericoronitis. Patients have invariably reported benefit from their use, by way of relief of symptoms and I have never had any reports of this treatment causing any aggravation of the condition. My advice is always to retain each mouthful of HSM around the area in question for as long as it remains hot and to repeat until the entire tumblerful has been used. I describe it to patients as more of a mouth 'bath' than a mouth 'wash'. In view of the benefit which patients report from this regime, it would take very strong evidence to convince me that I should discontinue this practice.

In the same issue, I was also interested to read details Dr Simons' Domiciliary Audit entitled 'Who will provide dental care for housebound people with oral problems' (BDJ 2003, 194: 137). I have recently been one of a small group of GDPs who undertook a similar audit of domiciliary cases. The place of residence of the 34 audit patients in our audit were 59% nursing/care home, 32% own home, 6% sheltered housing and 3% hospital. The vast majority of the cases involved full upper and/or lower dentures (28), while only three cases were for routine examination.

One of the recommendations of the audit was: -

'In view of the recommendation that all patients should undergo an oral screen on an annual basis, the relatively small number of cases seen under a recall arrangement would suggest that this is an area that should be addressed.'

As with all patients, requests for domiciliary care should not be looked at as 'one-off' courses of treatment, but should be followed up on a routine basis.

J. Watt

Coatbridge