Supporting staff through menopause

CGDent recorded webinar, Thursday 16 February 2023

In 2022, the British Association of Dental Nurses (BADN) published a menopause policy and advice outlining the challenges faced by menopausal women in the workplace, with suggestions for how employers can support menopausal employees. 

In the UK, 99% of dental nurses, 96% of orthodontic therapists, 94% of dental hygienists,  92% of dental therapists, 52% of dentists and 27% of dental technicians are female – 78% of the regulated dental profession as a whole.

This CGDent-hosted webinar will explore the BADN’s recent menopause policy and consider the ways menopausal staff can be supported in the workplace.

    Speaker:

    • Anita Stanforth, BADN Education Representative and Chair of the Education Committee

    GDC development outcomes: A, B, D

    CPD approx 1.5 hours

    This webinar is hosted by the College of General Dentistry and powered by our CPD delivery partner, ProDental CPD – watch the recording below.

    It was free to view live for all dental professionals, and College members also have free access to the recorded webinar and can claim CPD hours for free.  A £20 fee will apply for non-members who wish to claim CPD.

    Membership of the College of General Dentistry is open to all registered dental professionals. Membership for dentists is available from £94, and for other registered dental professionals from £33. The full list of CGDent membership rates is at https://cgdent.uk/membership-fees/

    Sign up to the College’s monthly newsletter

    Vice Presidents and dental team representatives 2022-23

    Tashfeen Kholasi and Patricia Thomson have been elected as the College of General Dentistry’s Vice Presidents for 2022-23, and Louise Belfield, John Stanfield, Bill Sharpling and Sarah Hill have been re-appointed to their roles providing representation of the wider dental team on the College Council.

    Top row (l-r): Tashfeen Kholasi, Patricia Thomson, Louise Belfield
    Bottom row (l-r): Bill Sharpling, John Stanfield, Sarah Hill

    Patricia Thomson FCGDent, Council representative for the West and North of Scotland, graduated from Glasgow Dental School in 1983 and has worked in general dental practice ever since. She became a principal in 1985, sold her practice in 2017, and now works as a part-time associate. She has provided mixed NHS and private care and has an interest in orthodontics. She has tutored colleagues for entry exams for the Royal Colleges, presented teaching sessions on orthodontics to vocational trainees, and delivers postgraduate lectures at RCPS Glasgow. She served on the National Board of the Faculty of General Dental Practice UK (FGDP) from 2016-21, and is Chair of the College of General Dentistry’s Regional Funding Panel. She is a Fellow of the International College of Dentists and a Past President of the West of Scotland branch of the British Dental Association.

    Tashfeen Kholasi FCGDent, Council representative for the North East and North West Thames region, was re-elected after serving as one of the College’s inaugural Vice Presidents in 2021-22. She is an associate dentist and Chief Clinical Information Officer in general dental practice, as well as a Clinical Tutor in Special Care and Sedation at King’s College London, from where she qualified. With a strong interest in digital health, she is a Fellow of the Faculty of Clinical Informatics, and a former health informatics clinical lead at NHS Digital. She has a Diploma in Conscious Sedation and a Master’s in Legal Aspects of Medical Practice, and is currently completing a Master’s in Healthcare Leadership and Commissioning. She was elected to the FGDP’s board in 2020 and serves on the College’s Membership Affairs Committee, Professional Affairs Committee and Membership Admissions Panel.

    The Vice Presidents support the College President in the delivery of the strategy and policy agreed by the Council, from which they are elected.

    Roshni Karia MCGDent stood down as a Vice President after completing the maximum two years’ service in the role, having previously been Vice Dean of the FGDP in 2019-20. During her tenure, she has been instrumental in the development of the College’s soon-to-be-launched Certified Membership scheme, and has been appointed Chair of the College’s Professional Affairs Committee for 2022-23.

    Louise Belfield, John Stanfield and Bill Sharpling have been re-appointed to the College Council for a further year as the respective voting representatives of dental nursing & orthodontic therapy, dental hygiene & therapy, and dental technology & clinical dental technology. It is intended that these positions will become elected in 2023 following the formation of professional faculties within the College. Sarah Hill has also been re-appointed to provide additional non-voting representation of dental professionals other than dentists.

    Louise Belfield AssocFCGDent is a dental nurse, research scientist, lecturer, Health Education England Dental Clinical Fellow, and National Examination Board for Dental Nurses Trustee. Louise trained as a dental nurse in Devon, qualifying in 2001. She has worked across a range of dental specialties at Torbay and South Devon NHS Foundation Trust including community, special care, and emergency dentistry, as well as in general dental practice. She holds a BSc (Hons) in Human Biosciences, a doctorate in immunology, and a postgraduate certificate in clinical education. She was awarded Senior Fellowship of the Higher Education Academy in 2019 in recognition of her continued contributions to dental education. She is a member of the College’s Professional Affairs Committee and Membership Admissions Panel.

    Bill Sharpling FCGDent is Associate Dean (CPD) and Director of the London Dental Education Centre (LonDEC) at the Faculty of Dentistry, Oral & Craniofacial Sciences, King’s College London. Previously, he was Head of Dental Technology at Guy’s, King’s College and St Thomas’ Hospitals. He is also the External Examiner for the BSc(Hons) Clinical Dental Technology programme at the University of Central Lancashire. After qualifying in 1986, Bill spent the next 10 years working as a Dental Technician, gaining advanced qualifications in fixed and removable prosthodontics. He has worked in commercial dental laboratories, the Armed Forces and as the Chief Instructor in Conservative Dental Technology at Guy’s Hospital Dental School. He is a member of the College’s Careers and Training Committee.

    John Stanfield AssocFCGDent has over 40 years’ experience as a dental hygienist, and works in private dental practice in Cheshire. He was Editor of the FGDP’s Team in Practice journal and Vice-Chair of its DCP Committee, and now serves on the College’s Membership Affairs Committee. Originally qualifying in the Army in 1980, he has experience of hospital, NHS, teaching establishments and private practice. He has studied learning and teaching, with a special interest in the use of technology and media, was a clinical lead for NHS Test & Trace, and is a trustee for the dental charity Maasai Molar, enabling the education of children of the Maasai region towards better dental health.

    Sarah Hill AssocFCGDent qualified as a dental hygienist from the University of Bristol with distinction in 2012, and holds a BSc (Hons) in Biomedical Sciences from the University of Southampton and a Postgraduate Diploma in Clinical Education from the University of Plymouth. Working as a hygienist in a mixed orthodontic practice in Halesowen, she has previously delivered presentations for TePe, been a sales representative for GlaxoSmithKline, and a lecturer in Community-Based Dentistry at Peninsula Dental School. An assessor for the National Examining Board for Dental Nurses, Fellow of the Higher Education Academy and past Chair of the South West and South Wales group of the British Society of Dental Hygiene and Therapy, she was an Affiliate Member of FGDP from 2013-21, and the DCP representative on both its West Midlands and national boards. 

    Abhi Pal FCGDent, President of the College, said:

    “On behalf of our members, I congratulate Patricia on her election as Vice President, Tashfeen on her re-election for a second term, and Louise, Bill, John and Sarah on their re-appointment as dental team representatives. I look forward to drawing on their vast and varied experience, knowledge and expertise as the College continues to fulfil its historic mission to build a professional body for all dental professionals.

    “I would also like to thank Roshni for her service as Vice President, and look forward to continuing to work with her as we launch Certified Membership and in her new role overseeing our professional affairs activity.”

    Sign up to our monthly newsletter

    Domestic abuse in dentistry – speak out

    CGDent recorded webinar, Tuesday 1 November 2022

    Safeguarding training is mandatory for all members of the dental team, and this webinar explores how dental professionals play an essential role in the safeguarding of patients and colleagues.

    In this College-hosted webinar, speakers Preetee Hylton, Dr Alison Gregory and Dr Sandi Dheensa examine different types of abuse, explain how to recognise signs that someone is being subjected to abuse and how to act accordingly to preserve your patients’ and colleagues’ safety. The webinar also explores the importance of creating a safe space for employees to ask for help and will introduce the Employer’s Initiative for Domestic Abuse (EIDA), an evolving community working towards supporting domestic abuse victims, and providing access to services to help perpetrators to stop.

    Introduction:

    • Abhi Pal, President of the College of General Dentistry

    Speakers:

    • Preetee Hylton, Restorative Dental Nurse, Safeguarding Lead and survivor of domestic abuse
    • Dr Alison Gregory, Senior Research Fellow, Domestic Violence and Abuse Health Research Group, Bristol Medical School
    • Dr Sandi Dheensa, Research Fellow, Domestic Violence and Abuse Health Research Group, Bristol Medical School

    GDC development outcomes: A, D

    CPD approx 1.5 hours

    This webinar is hosted by the College of General Dentistry and powered by our CPD delivery partner, ProDental CPD – watch the recording below.

    It was free to view live for all dental professionals, and College members also have free access to the recorded webinar and can claim CPD hours for free.  A £20 fee will apply for non-members who wish to claim CPD.

    Membership of the College of General Dentistry is open to all registered dental professionals. Membership for dentists is available from £94, and for other registered dental professionals from £33. The full list of CGDent membership rates is at https://cgdent.uk/membership-fees/

    Sign up to the College’s monthly newsletter

    College endorses menopause policy for dental employers

    The College has endorsed the menopause policy and advice recently published by the British Association of Dental Nurses (BADN).

    In the UK, 99% of dental nurses, 96% of orthodontic therapists, 94% of dental hygienists,  92% of dental therapists, 52% of dentists and 27% of dental technicians are female – 78% of the regulated dental profession as a whole – and the policy outlines the challenges faced by menopausal women in the workplace and suggests ways in which employers can support menopausal employees. 

    The Association is asking dental practices, laboratories and clinics to adopt the policy and implement it in their workplace, and is asking dental organisations to support it by encouraging its widespread adoption.

    The College of General Dentistry, membership of which is open to all dental and oral health professionals, is the first organisation representing dentists to do so. The College is the independent professional body into which the Faculty of General Dental Practice transferred last year, and is the UK’s only medical college run by and for oral health professionals.

    Abhi Pal, President of the College of General Dentistry, said:

    “The BADN’s Menopause Policy is important, practical and succinct advice which helps dental professionals to better understand the menopause, to appreciate relevant employment law, and to implement a menopause policy in their practice.

    Making appropriate adjustments for staff affected by the menopause is both a moral duty enabling committed and experienced colleagues to remain in valuable employment, and a legal duty not to discriminate on the grounds of gender, age or disability. Supportive dental practices and understanding employers will also find they benefit in return from improved staff retention and reduced sickness absence.

    On behalf of the College, I congratulate the BADN on its publication, and am pleased to endorse it.”

    The policy is also supported by the British Society of Hygiene and Therapy (BSDHT), the British Association of Dental Therapists (BADT), the British Dental Industry Association (BDIA), the Dental Laboratories Association (DLA), the Dental Technologists’ Association (DTA), the Orthodontic National Group (ONG), and the British Veterinary Nurses’ Association (BVNA).

    The publication is available on the BADN website here

    Sign up to our monthly newsletter

    Looking after your data

    Recorded webinar, Tuesday 11 October 2022

    This webinar was previously scheduled for 15 September 2022

    In this webinar, we aim to demystify issues around handling patient data: how to store data, how to use it and how to share it within current guidelines and best practice. We provide an overview of Caldicott Principles, information sharing for patient care and GDPR. We also look at the role of digital technology in information sharing, and how to share information safely and securely in your practice.

    Speaker:

    • Pat Langley, CEO Apolline

    GDC learning outcomes: A, D

    CPD approx 1.5 hours

    CGDent members and ProDental subscribers have free access to the recorded webinar and can claim CPD hours for free.  A £20 fee will apply for non-members/non-subscribers who wish to claim CPD.

    This webinar is powered by our CPD delivery partner, ProDental CPD

    Membership of the College of General Dentistry is open to all registered dental professionals. Membership for dentists is available from £94, and for other registered dental professionals from £33. The full list of CGDent membership rates is at https://cgdent.uk/membership-fees/

    Sign up to our monthly newsletter

    Professional Framework for general dental professionals to be launched

    The College has announced that it will be launching its much-anticipated Professional Framework next month.

    Guests celebrating the launch of the College at Barber-Surgeons’ Hall, where the Professional Framework will be launched next month at the Fellows’ Summer Reception

    The Professional Framework will describe the knowledge, skills and other attributes that primary care dentists and other dental professionals may aspire to at different stages of their career, and underpins the College’s Career Pathways programme. An initial framework published last year identifies five domains:

    • Clinical and technical: the capability to diagnose, to advise and to treat
    • Professionalism: the conduct and behaviour to engage patient trust and confidence
    • Reflection: awareness of personal impact, abilities and limitations
    • Development: commitment and capability to improve the service to patients
    • Agency: the ability to resolve solutions independently and through others

    The creation of career pathways for general dental practice was a key founding purpose of the College, which has been developing sets of progressive steps for each dental team role in order to provide purpose and direction for dental careers, to enhance professional standing, and to help retain and nurture a motivated workforce.

    These are being mapped out by four working groups – representing dentists, dental hygienists & therapists, dental nurses & orthodontic therapists, and dental & clinical dental technicians – working together through a programme board chaired by Professor Avijit Banerjee and a reference group chaired by Dr Shamir Mehta.

    The Professional Framework will be launched at the inaugural Fellows’ Summer Reception, which takes place on Wednesday 15 June at Barber-Surgeons’ Hall in London. It will be preceded by the conferral of Fellowships, President’s Commendations and the prestigious College Medal, and will take place in front of around a hundred guests.

    Fellows and Associate Fellows of the College, as well as FGDP Fellows who were unable to enjoy formal conferral of their fellowship during 2020-21 due to coronavirus restrictions, are eligible to attend. Tickets are £20, to include wine and canapés, and a small number of spaces remain.

    The College’s Career Pathways programme is generously supported by Colgate.

    Sign up to our monthly newsletter

    Transforming oral health: A fellow’s journey

    Dental Hygienist, Frances Robinson AssocFCGDent, has recently completed the Clinical Oral Health Transformation Fellowship with HEE. As the first ever dental care professional in any clinical fellowship role, Frances explains what was involved.  

    A fellowship is a position, often combined with clinical work, that focuses on the learning and development of the individual taking part. Fellowship roles in the healthcare profession aim to expand opportunities for aspiring leaders; helping them gain the necessary experience and skills for future system leadership roles. As such, there are a range of opportunities to be involved with projects and programmes and to work in settings outside a clinician’s normal exposure. There can be specific goals of writing, submitting, and publishing papers, attending meetings and conferences, and working on particular projects, as well as networking. The balance of these is dependent on the host organisation.

    I have just completed a one-year position with Health Education England (HEE) as their Clinical Oral Health Transformation Fellow. HEE’s purpose is to support the delivery of excellent healthcare to patients, by ensuring that the workforce has the right numbers, skills, values and behaviours. Thus, the areas I worked on related to the development of the oral health work force.

    I was the first dental care professional (DCP) to be awarded the clinical fellowship, these roles are typically fulfilled by a dentist. I am extremely grateful for this innovative appointment both for my personal development and the development of my career, but also for other DCP colleagues, for now it has opened up new realms of opportunities for us to progress in system roles.

    I applied for the role because of the potential to gain experience working in the public health sector, whilst allowing me to work clinically at the same time. Having completed a Masters in Dental Public Health in 2017 – spurred on by my interests in health inequalities research – I felt this position would be an excellent opportunity for me to develop my career.

    At the CDO stand with Sara Hurley and other fellows at the BDIA showcase

    During a fellowship there is flexibility to align the projects undertaken to individual interests, whilst working for the greater aims of an organisation. This means there is a real opportunity to tailor a role to where there is the most personal or organisational benefit. My aims for the year working with HEE were to work on projects that I’m interested in, for example oral health inequalities, oral health empowerment and promotion, increase my skill mix and exposure to multidisciplinary team working in primary care, as well and develop opportunities for leadership and management for all members of the dental team.

    I am currently writing up multiple papers to be published; one evaluates the success of a pilot that aimed to reduce the number of paediatric patients sent to secondary care for dental extractions under general anaesthetic. A subsequent paper will evaluate the success of the “return to work” therapy scheme, a programme aimed at supporting Dental Therapists who have not been using their full scope of practice, back into therapy work by providing them with training opportunities, supervisor support and a practice placement. I will also be helping to write a concept paper for a Dental Hygiene postgraduate training programme.

    During my time with HEE, I have had the chance to sit on various working groups like a “Managed Clinical Network” and interact with external organisations such as Public Health England, academic institutions, professional societies and local councils.

    A clinical fellow may also have the opportunity to attend courses and gain qualifications that are not linked to their clinical work; I was selected to complete an Institute of Leadership and Management, level 7 qualification through HEE. I received three days of training with UMD Professional and then completed a research element which involved interviewing my colleagues at the HEE dental office.

    Furthermore, I am currently completing a “Becoming an Expert Educator in the Healthcare Professions” course with the University of Nottingham. These additional skills and qualifications are important for demonstrating tangible outcomes from the year.

    It has sometimes been a trying year due to the pandemic – working from home during a fellowship has meant less interaction with colleagues and difficulty integrating into an office very different from a clinical setting. Natural communication with colleagues is often stilted when working virtually. I subsequently created ice breakers for meetings with my peers to stimulate organic conversation!  

    There are other fellows across the country with HEE and in other organisations for example with the Chief Dental Officer, General Dental Council, Care Quality Commission and NHS England and NHS Improvement (NHSE&I). We have a clinical fellow networking group where collaborations across work streams can be facilitated and a journal club takes place. This has given me the chance to network with new professionals across medicine and dentistry which has been really enjoyable! The fellows try to see each other in person despite being spread out across the country– the most recent of which was at the BDIA Dental Showcase at ExCel London.

    As I was the first fellow at Health Education England to be a DCP I was – and still am – in a unique position to be an advocate for DCPs, working hard to make our voices heard across a variety of settings. I was asked to do a presentation at the BDIA conference on workforce and skill mix. I focused on the skill mix in our systems, policy, planning, commissioning, leadership and management. I am passionate about DCP representation in all of these areas as I truly believe that if we are represented throughout the system we will have a more empowered workforce. If you’re interested in taking up a Fellowship position, keep an eye on NHS jobs, HEE jobs, FMLM for dentists and your professional society pages.

    Presenting at the BDIA showcase

    The College of General Dentistry has a unique structure with exciting opportunities to create connections between different dental professionals against an academic backdrop. There are no other organisations in the industry now that represents all dental registrants in this way. The careers pathway programme will be able to support individuals navigating their fields; there will be guidance, support networks and mentors available to enhance learning and progression. I personally am very excited to have a structure in which to work, with industry recognition of the level attained. I know that many DCPs have much to offer the wider industry with postgraduate qualifications and extensive experience in many areas, as well as evidence of enhanced learning. The College will enable these efforts to be verified through a framework where all dental professional are assessed equally. This certainly is an exciting time for us all.

    Frances Robinson chairs the Dental Hygiene & Dental Therapy Group on the College’s Career Pathways programme.

    Sign up to our monthly newsletter

    Developments in minimum intervention dentistry

    In-person expert panel discussion and Q&A, Tuesday 4 October, 6.30pm

    King’s College London, New Hunt’s House, Guy’s Hospital Campus, London

    Professor Avijit Banerjee and an expert panel of guests, explored the renewed emphasis on Minimum Intervention oral healthcare prevention delivery and the College of General Dentistry’s related career pathways for primary care team members.

    Discussion programme

    • Primary care, team-delivered prevention-based MI oral healthcare delivery in the context of impending NHS dental contract reform and post-pandemic primary care service delivery.
    • NHS policy development for prevention-based phased care and its wider implications in society.
    • Structured postgraduate career pathways for all oral healthcare team members, delivered through the College of General Dentistry frameworks, and highlighting the King’s master’s programme in Advanced Minimum Intervention Restorative Dentistry (AMIRD) designed for dentists and dental therapists working in primary care, globally.

    Speakers

    Chair:

    Panel:

    • Dr Abhi Pal, President of the College of General Dentistry
    • Dr Amanda Gallie, past-President of the British Association of Dental Therapists and MSc AMIRD graduate
    • Dr Len D’Cruz, GDP and dento-legal expert, Head of Indemnity at the British Dental Association
    • Dr Sara Hurley, Chief Dental Officer, England

    Sign up to our monthly newsletter

    College of General Dentistry broadens membership eligibility

    The College of General Dentistry has broadened its eligibility criteria for membership, enabling suitably qualified non-registrants to join, and offering practitioners with relevant non-dental qualifications the ability to progress to higher grades of membership.

    Registration with the General Dental Council or an equivalent overseas authority is normally required for entry as an Associate Member. However former registrants, and those who hold a relevant qualification but may not be required to register with the GDC due to their job role – such as dental academics – are now eligible to join.

    Those wishing to join as Full Members (MCGDent), or upgrade to Full Membership, have until now been required, in addition to meeting the requirements for Associate Membership, to hold either the DGDP, MJDF, MFGDP(UK), MFDS or a Postgraduate Certificate level qualification in a ‘relevant dental subject’. However Full Membership is now also open to those whose qualification is in a ‘subject relevant to the enhancement of oral healthcare’.

    Those wishing to join at, or upgrade to, Associate Fellowship (AssocFCGDent), have up to this point needed to hold the MGDS, a Specialty Membership of a UK dental faculty, or a Postgraduate Diploma level or Masters level qualification in a dental subject. However, this recently-instituted membership grade, which offers a stepping stone to Fellowship, is similarly now available to those whose qualification is relevant to oral heath rather than being strictly ‘dental’ in scope.

    Individuals qualifying under these extended criteria would then be eligible to apply for Fellowship (FCGDent) on the same basis as all other members of the College. This is currently open to existing Fellows of a UK Royal College or overseas equivalent, with a Fellowship by Experience route expected to be announced soon.

    The changes are further to earlier departures from the eligibility criteria of the former Faculty of General Dental Practice, from which the College evolved – most notably the ability of Dental Hygienists, Dental Therapists, Dental Nurses, Dental Technicians and Clinical Dental Technicians to apply for membership at all grades, and for Practice Managers and other non-clinical members of the dental team to join as Affiliate Members.

    The College’s updated membership eligibility criteria are available at https://cgdent.uk/membership-eligibility/

    Dr Abhi Pal, President of the College, said:

    “Among the key aims behind the establishment of The College of General Dentistry were the promotion of both dental and oral health, and to create a new type of college, breaking down barriers which are unnecessarily prescriptive and exclusionary, and replacing them with an inclusive approach fit for the 21st century.

    “We are implementing this step by step, and are already a College open to all members of the dental team, formed of practitioners across the UK and beyond, and bridging the NHS/private divide.

    “These latest changes offer recognition to a wide range of individuals and professional roles whose contribution to the advancement of general dental practice and oral healthcare is hugely significant, and we look forward to welcoming them into membership, and to bringing their significant knowledge, expertise and experience to bear in the fulfilment of our mission.”

    Sign up to our monthly newsletter

    Notice of forthcoming College Council elections

    Elections will soon be held for seven seats on the Council of the College of General Dentistry, and eligible members are encouraged to consider standing.

    The Council is elected by College members to provide leadership and support for the dental professions, and to guide the College Trustees in fulfilling the College’s mission.

    It includes representation based both on geographical region and professional role.

    Members of the Council serve three-year terms, and elections will shortly take place for the following seats:

    • Yorkshire and Northern
    • Central London
    • Wessex & Oxford
    • East of Scotland
    • West & North of Scotland
    • Overseas representative
    • National representative

    Those elected would be expected to serve from June 2022 – June 2025, and would then be able to stand for re-election. Further seats will be due for election in 2023 and 2024.

    Council members are expected to attend three face-to-face meetings each year, which normally take place on a Friday morning in June, October and February, as well as regular online meetings outside of business hours. Those elected this year will be formally inducted at the Council meeting on Friday 24 June in Cardiff.

    Members of the Council may serve up to three elected terms (i.e. nine years), and are eligible to stand in the annual election of two Vice Presidents, and the triennial election of a College President.

    All Full Members, Associate Fellows and Fellows of the College, regardless of their dental team role, are eligible to nominate themselves as candidates for election to Council.

    Candidates for regional seats must live or work within that region, and be registered with that region with CGDent.

    Candidates for the National seat must live or work in the UK, and have a registered UK address with CGDent.

    Candidates for the Overseas seat must practice dentistry wholly outside the UK, and have a registered overseas address with CGDent.

    Associate Members wishing to nominate themselves for election will need to have successfully completed an upgrade to Full Membership before submitting an application.

    An online application process, accompanied by a full description of the role, will be published no later than Friday 18 March 2022, and the deadline for submission of applications will be no earlier than Friday 15 April.

    A full election timetable will be published in due course; please return to this page over the coming weeks for updates.

    The CGDent UK regions map (above) can be downloaded here. Prospective candidates unsure of their CGDent region should contact us here.

    Sign up to our monthly newsletter