Sir, - It is an encouraging move for the BDJ to produce a series of articles that are designed to update the dental practitioner on those aspects of general medicine and surgery that are relevant to dentistry.

With so many of our patients on medication or a beneficiary of surgical advances, it is essential that we try to keep up-to-date with those aspects of medical advances that have any effect on our patients' care.

It is then such a pity that the first in the series, on cardiovascular disease, (British Dental Journal 2003, 194: 537) has two glaring omissions in what it covers. Firstly, despite listing hypercholesterolaemia as a risk factor for cardiovascular disease in Table 1, no mention is made of the statin drugs that are the first choice for controlling cholesterol levels, both as a treatment and as a preventative regime for susceptible patients. Surely, with ever increasing prescribing of these drugs, supported by evidence from several international collaborative studies and approved by NICE, an explanation of how they work on lowering cholesterol levels1 and the additional effects on arterial plaques would have been beneficial, especially when much has been written about the link between periodontal disease and the arterial diseases?

Secondly, there is a real likelihood that in all practices there will be patients attending who have had angiography and/or percutaneous coronary interventional procedures (stent placement, with or without drug coating) or even revasculation2,3,4. There is no mention of these procedures, nor of the need or otherwise for special precautions.

With early intervention by cardiologists now the norm and rapid advances in non-surgical techniques, there will be more of our patients who have benefited from these advances attending for dental care. Dentists should be aware of these procedures and be able to inform and reassure patients of their minimal impact on dental procedures. They are, unfortunately, not going to obtain this from their cardiologists! In particular patients who have undergone PCI do not require prophylaxis against endocarditis. They may be taking asprin and clopidogeral but not usually warfarin.

It is a pity that, what is potentially an important series for the dental practitioner, has started without being up-to-date in two of the most important and developing therapeutic areas in cardiovascular disease. Indeed, there is little in the article that could not have been written ten years ago! In a rapidly developing speciality, all but one reference is more than three years old.

Would it be possible to publish a supplement that contains both the details of modern therapeutic interventions, their impact on dental care and the evidence base to support what is included?

For those interested in up-to-date information on statins and angioplasty, the Medscape website (www.medscape.com) regularly provides informative overviews on these and similar subjects.

M. Greenwood and J.G. Meechan, authors of the paper respond:- We thank Dr Morganstein and Dr Mills for their letter. As mentioned in the introductory abstract, this series is limited to discussing those aspects of medicine and surgery which have a direct relevance to dental practitioners.

With regard to cholesterol lowering agents, we feel that these commonly prescribed drugs, whilst important to be aware of, do not impact directly on the practise of dentistry, sedation or anaesthesia. The intention of the drugs section of this paper was to deal with those therapeutic agents that affect dental management. The Dental Practitioners Formulary/British National Formulary will always provide easily accessible comprehensive advice and information with regard to the vast range of drugs on offer for the treatment of cardiovascular disease.

With regard to angiography and percutaneous coronary interventional procedures the 'minimal impact' they refer to on dental procedures is the main reason that these procedures were not alluded to. Going down this all-inclusive line one could easily cite investigations such as 24 hour tapes, exercise ECGs and echocardiography as well as others, but the line has to be drawn somewhere in a paper such as this.

The paper was intended to give an overall view of the assessment of a patient with cardiovascular disease from the perspective of a dental practitioner. History and examination are fundamental to this and we would suggest that the basics of this have not fundamentally changed in the last ten years.