Annals Vol 23 (2016)

ANNALS Volume 23 March 2016



ANNALS OF THE ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS Proceedings of the Twenty-Third Convocation of the Royal Australasian College of Dental Surgeons Wednesday 30 March to Saturday 02 April 2016 Published by THE ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS Incorporated Level 13/37 York Street, Sydney, New South Wales 2000 Australia All rights reserved

CONTENTS Royal Australasian College of Dental Surgeons Council 2014-2016 4 Founders & Honorary Fellows of the College 5 Elected Members of Council 5 Office Bearers 6 Convocation Committee 6 Convocations of the College 7 Editorial 8 A/Prof Menaka Abuzar TWENTY-THIRD CONVOCATION, ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS HOBART AUSTRALIA – OPENING CEREMONY 30 MARCH 2016 Presidential Address 9 Dr David Sykes Opening Address 12 Govenor of Tasmania, Prof Kate Warner AM New Fellows and Members 14 HONOURS BESTOWED Admission as an Honorary Fellow Prof Martin Tyas AM 15 A/Prof Werner Bischof 16 Dr Francis Chau 17 Fellow by election without examination Dr John Lockwood AM 18 Prof Michael Morgan 18 Prof Laurence Walsh 19 Dr James Worthington 19 Meritorious Service Award A/Prof Andrew Heggie 20 Young Lecturer Award 21 Seventeenth Robert Harris Oration 22 Vice Chancellor of the University of Tasmania, Prof Peter Rathjen SCIENTIFIC PROGRAM – PAPERS AND ABSTRACTS Oral Biofilms in Health and Disease 26 Dr Svante Twetman Can We Practice Evidence Based Orthodontics? 31 Prof Kevin O’Brien Dementia: Issues in Contemporary Research and Management 32 Prof Andrew Robinson Autumn Leaves: A Journey With Dementia 34 Dr Graeme Ting Preventing Early Childhood Caries: Motivating Families 40 Dr Svante Twetman

Managing the Root Canal Biofilm: 43 Strategy and Possibility Prof Gary Cheung Healthy Tooth, Healthy Mouth, Healthy Body: 49 Endodontics in the Systemic Universe Dr Luke Moloney, Dr Artika Soma Oral and General Health Interface 53 Prof Paul Brunton Diagnosis and “Non Dental” Treatments of 54 Sleep Related Breathing Disorders Prof Matthew Naughton Restorations Under Stress - Can They Survive? 57 Dr Simon Wylie Brushing Up On Antarctic Dentistry 59 Dr Roland Watzl Oral Biofilms: Implications in the Medically Compromised 60 Dr Melinda Newnham Management of Biofilm Disease Around Implants: 63 A Contrast to Disease Management Around Teeth Dr Luan Ngo Living and Dying With Dignity – Pallative Care in 2016 67 Dr Philip Lee Cancer and Pallative Care: Oral and Dental Manifestations, 70 Considerations and Complications A/Prof Mark Schifter Contemporary Surgical Management of Oral Cancer 74 Dr Timothy Wong Why Do Some People Feel Bad About Their Appearance? 75 Understanding Risk and Protective Factors For Poor Body Image Prof Susan Paxton Pyscho-Social Effects of Malocclusion: 78 Do We Measure It and Are We Interested? Prof Kevin O’Brien The Relationship Between Facial Convexity in 80 Young Children and Perceived Intelligence Dr Sivabalan Vasudavan, Dr Andrew Sonis Paradigm Shifts in Orthodontics and Orthognathic Surgery 85 Dr Sivabalan Vasudavan In the Land of No Evidence is The Salesman King? 94 Prof Kevin O’Brien Managing Caries Risk: The Role of Probiotic 96 Bacteria in Oral and General Health Dr Svante Twetman YOUNG LECTURER AWARD PAPERS Caries Experience in Victorian Children with Orofacial Clefts 100 Dr Jyotsna Raj In vivo Confocal Microscopy for the Oral Mucosa 101 Dr Nigel Maher, A/ Prof Pascale Guitera Dental and Crevical Vertebrae Maturation of Isolated 102 Unilateral Clift Lip and Palate in Australian Children: A Controlled, Longitudinal Study Sarah Ting, Wendy Nicholls, John Winters, Kim Seow CONTRIBUTOR’S INDEX & SPONSORS 104

COUNCIL 2014-2016 Back Row: Dr Chris Callahan, Dr Hugh Trengrove, A/Prof Nicky Kilpatrick, Dr Albert Lee, Dr Francis Chau (Immediate Past President), Clin A/Prof Richard Widmer Front Row: Dr Peter Gregory (Executive Officer), A/Prof Paul Sambrook (Honorary Treasurer), Dr David Sykes (President), Dr Patrick Russo (President-Elect), Dr Warren Shnider (Censor-in-Chief) Not Present: Dr John Fricker, A/Prof Peter Duckmanton President COUNCIL APPOINTMENTS Dr David Sykes, BDS(Lond), MDS(Syd), LDSRCS(Eng), MRACDS(Pros), FRACDS Registrar, General Dental Practice Prof Liz Martin, BDS(Hons), MDS, PhD, FRACDS, FPFA, FADI, FICD President–Elect Dr Patrick Russo, BDSc, FRACDS, FPFA Registrar, Specialist Dental Practice Adj A/Prof Neil Peppitt, BDS, MDSc, Executive Officer MRACDS(Pros),FRACDS Dr Peter Gregory, BDSc, MDSc, , MRACDS(Paed), FRACDS Registrar, Oral Maxillofacial Surgery Dr Julia Dando, BDS (Wales), MMedSci, MRACDS(Ortho), Honorary Treasurer Dr Paul Sambrook, MBBS, MDS, FRACDS(OMS) OrthRCS (Eng), FDSRCS (Ed) Assistant Registrar, General Dental Practice Censor- in- Chief Dr Catherine Prineas, BDS(Hons), FRACDS, Dr Warren Shnider, BDSc, FRACDS(SND), FICD GradDipClinDent(Sedation and Pain Control) Immediate Past-President Assistant Registrar, Specialist Dental Practice Dr Francis So Wah Chau, MDS, MRACDS(Pros), FRACDS, MRD A/Prof Werner Bischof, BDSc, MDSc, FRACDS, RCS(Ed), LLB, MBA MRACDS(Perio), FICD, FPFA Councillors Honorary Editor, Annals Dr Chris Callahan, BA, BDSc, FRACDS, FADI, FICD A/Prof Menaka Arundathi Abuzar PhD, A/Prof Peter Duckmanton, BDS, MDSc, FRACDS, FICD, FPFA MDSc(prosthodontics), MRACDS, A/Prof Nicky Kilpatrick, BDS, PhD, FDS, RCPS, FRACDS(Paed) Dr Albert Lee, BDS(Adel), MSc(Lond), FRACDS, FCDSHK(Paed Honorary Editor, College News Dent), FHKAM(Dental Surgery), FICD A/Prof Susan Buchanan, BDSc, MDS, FRACDS, MBA Dr Hugh Trengrove, BDS, MDS, FRACDS Chief Executive Officer Mr Stephen Robbins 4 RACDS ANNALS 2016

FOUNDERS OF THE COLLEGE Committee appointed by the Australian Dental Association to investigate ways and means of establishing an Australian College of Dental Surgeons Alfred Gordon Rowell, Chairman William Alan Grainger Kenneth Thomas Adamson Robert Harris Alwyn James Arnott William Keith Ross Mackenzie H Roy Cash K Robertson 1. Subscribers to the Initial Constitution 2. Interim Council, elected 14 March, 1965 3. First Council, elected 5 November, 1966 Kenneth Thomas Adamson President A G Rowell President A G Rowell Alwyn James Arnott Vice-President K T Adamson Vice-President K T Adamson William Alan Grainger Censor-in-Chief W A Grainger Censor-in-Chief W A Grainger Robert Harris Honorary Secretary R Harris Honorary Secretary R Harris William Keith Ross Mackenzie Honorary Treasurer W K R Mackenzie Honorary Treasurer J S Lyell Alfred Gordon Rowell Councillors: H R Cash* Councillors: G Christensen J F Lavis J F Lavis R L Taylor *Did not serve. HONORARY FELLOWS 1965 Arthur Amies* 1977 George Neville Davies 19 93 Diana, Princess of Wales* 1965 John Hall Best* 1978 Ivor Robert Horton Kramer 19 9 5 Reginald William Hession 1966 Alwyn James Arnott* 1979 Robert Harris* 1998 John Kenneth Harcourt 1966 T Draper Campbell* 1979 John Frederic Lavis* 1998 George Henry Hewitt 1966 Sidney Firth Lumb* 1979 Alfred Gordon Rowell* 2000 Sydney Charles Warneke 1966 John Walsh* 1982 Paul Anthony Bramley 2001 John Hugh Sinclair* 1968 Robert Bradlaw* 1983 Kenneth Joseph George Sutherland 2003 Kenneth Howard Wendon 1968 Terence Ward* 1985 Henry Gordon Lamplough* 2005 Ross Jan Bastiaan 1968 Frank Clare Wilkinson* 1985 Warwick Olver Read* 2007 David Henry Thomson 1970 Gerald Leatherman* 1987 Earle Harold Bastian* 2009 Neil John Joseph Peppitt 1 97 1 Neil William George Macintosh* 1987 Stanley George Kings* 2010 Eric Charles Reynolds 1973 Alan Docking* 1987 John Alfred Sagar* 201 1 Bernadette Kathleen Drummond 1974 William Alan Grainger* 1989 Richard Manning King* 2014 Werner Hans Bischof 1976 Kenneth Adamson* 1989 Robert York Norton* 2015 Braham Anthony Pearlman* 1976 Kenneth Wollaston Cleland* 1991 George Wing 2015 Francis So Wah Chau 1977 Percy Raymond Begg* 1993 John Henry Muller 2015 Martin John Tyas *Deceased. ELECTED MEMBERS OF COUNCIL 1966 – 1969 F G Christensen* 1982 – 1994 R W Hession 2002 – 2006 B M Woodhouse 1966 – 1971 R L Taylor 1982 – 1996 P W McKerracher 2004 – 2010 D D Bambery † 1966 – 1973 W A Grainger* 1986 – 1996 G H Hewitt 2004 – 2012 W H Bischof 1966 – 1975 J S Lyell* 1986 – 1999 S C Warneke 2004 – 2014 F S W Chau ‡ 1966 – 1976 K T Adamson* 1988 – 2000 J H Sinclair 2006 – 2012 J.P. Fricker 1966 – 1978 R Harris* 1988 – 1996 B Feiglin 2010 – 2014 R A Whyman † 1966 – 1978 J F Lavis * 1990 – 2002 K H Wendon 2012 – 2014 R Nair 1966 – 1978 A G Rowell * 1990 – 2004 R J Bastiaan 2008 – 2012 B. Pearlman* 1969 – 1973 G B Ferguson* 1990 – 2004 J P H Rogers 2006 – 2016 D.G. Sykes 1970 – 1982 T B Lindsay 1990 – 2002 G A Thomas 2008 – 2016 P Russo 1971 – 1982 H G Lamplough * 1992 – 2006 D H Thomson 2010 – 2016 W H Shnider 1971 – 1982 W O Read* 1994 – 2004 A N Goss 2010 – 2016 P J Gregory 1974 – 1986 S G Kings * 1996 – 2005 R G Cook 2010 – 2016 A M P Lee ‡ 1974 – 1986 J A Sagar* 1996 – 2008 S C Daymond 2012 – 2016 P Duckmanton 1975 – 1988 R Y Norton* 1996 – 2002 E D Kingsford-Smith 2012 – 2016 P Sambrook 1976 – 1988 R M King 1996 – 2008 N J J Peppitt 2013 – 2016 N Kilpatrick 1978 – 1989 P Hastie 2000 – 2010 B K Drummond 2014 – 2016 C M Callahan 1978 – 1990 G Wing 2000 – 2002 M D Suthers 2014 – 2016 J P Fricker 1978 – 1979 D E Poswillo 2000 – 2012 M J Tyas 2014 – 2016 H G Trengrove † 1979 – 1992 J H Muller 2002 – 2012 S M Hanlin 2014 – 2016 R P Widmer 1982 – 1996 J K Harcourt 2002 – 2010 R D Story *Deceased †Representing the New Zealand Region ‡Representing the Asian Region RACDS ANNALS 2016 5

OFFICE BEARERS President Vice-President Honorary Treasurer 1966 – 1968 A G Rowell 1966 – 1968 K T Adamson 1966 – 1968 J S Lyell 1968 – 1970 K T Adamson 1970 – 1972 W A Grainger 1968 – 1970 J F Lavis 1968 – 1970 W A Grainger 1970 – 1972 J F Lavis 1970 – 1971 R L Taylor 1972 – 1974 J F Lavis 1972 – 1974 J S Lyell 1971 – 1974 H G Lamplough 1974 – 1976 J F Lavis 1974 – 1976 J A Sagar 1974 – 1976 W O Read 1976 – 1978 J A Sagar 1976 – 1978 W O Read 1976 – 1980 R Y Norton 1978 – 1980 W O Read 1978 – 1980 H G Lamplough 1980 – 1982 S G Kings 1980 – 1982 H G Lamplough 1980 – 1982 R Y Norton 1982 – 1988 J H Muller 1982 – 1984 R Y Norton 1982 – 1984 S G Kings 1988 – 1994 S C Warneke 1984 – 1986 S G Kings 1984 – 1986 R M King 1994 – 1996 J H Sinclair 1986 – 1988 R M King 1986 – 1988 G Wing 1996 – 1998 R J Bastiaan 1988 – 1990 G Wing 1988 – 1990 J H Muller 1998 – 2002 J P H Rogers 1990 – 1992 J H Muller 1990 – 1992 R W Hession 2002 – 2004 N J Peppitt 1992 – 1994 R W Hession 1992 – 1994 J K Harcourt 2004 – 2012 S McE Hanlin 1994 – 1996 J K Harcourt 1994 – 1996 S C Warneke 2012 – 2014 R Whyman 1996 – 1998 S C Warneke 1996 – 1998 J H Sinclair 2014 – 2016 P Sambrook 1998 – 2000 J H Sinclair 1998 – 2000 K H Wendon Registrar (General Stream) General 2000 – 2002 K H Wendon 2000 – 2002 R J Bastiaan Dental Practice 2002 – 2004 R J Bastiaan 2002 – 2004 D H Thomson 1996 – 2000 E D Kingsford Smith 2004 – 2006 D H Thomson President-Elect 2000 – 2008 B A Pearlman 2006 – 2008 N J Peppitt 2004 – 2006 N J Peppitt 2008 – 2012 E Martin 2008 – 2010 B K Drummond 2006 – 2008 B K Drummond 2012 – 2016 E Martin 2010 – 2012 W H Bischof 2008 – 2010 W H Bischof 2012 B A Pearlman 2010 – 2012 B A Pearlman RFD Registrar (Special Field Stream) 2012 – 2014 F S W Chau 2010 – 2014 D G Sykes (Specialist Dental Practice) 2014 – 2016 D G Sykes 1996 – 2004 C G Daly 2014 – 2016 P J Russo 2004 – 2013 A C Cameron Censor-in-Chief Honorary Secretary 2014 – 2016 N J Peppitt 1966 – 1968 W A Grainger 1966 – 1978 R Harris Assistant Registrar (General Dental 1968 – 1972 J S Lyell 1978 – 1984 G Wing Practice) 1972 – 1974 W O Read 1984 – 1990 R W Hession 1998 – 2002 A C Cameron 1974 – 1978 H G Lamplough 1990 – 1998 K H Wendon 2002 – 2004 H M Cameron 1978 – 1980 S G Kings 1998 – 2006 S C Daymond 2008 – 2016 C Prineas 1980 – 1984 R M King 2006 – 2008 W H Bischof 1984 – 1986 G Wing 2008 – 2012 F S W Chau Assistant Registrar (Special Field Stream) 1986 – 1992 J K Harcourt Executive Officer Specialist Dental Practice 1992 – 1996 P W McKerracher 2012 – 2014 Patrick Russo 2002 – 2004 A C Cameron 1996 – 2002 D H Thomson 2014 – 2016 P Gregory 2004 – 2013 A F Georgiou 2002 – 2004 A N Goss 2014 – 2016 W H Bischof 2004 – 2006 B K Drummond Registrar Assistant Registrar (Oral Maxillofacial 2006 – 2008 R D Story 1966 – 1980 R Harris Surgery) 2008 – 2012 M J Tyas 1980 – 1988 G Wing 2009 – 2016 J Dando 2012 – 2016 W Shnider 1988 – 1996 G H Hewitt 1997 – 2006 S C Daymond Scientific Arrangements Committee Convocation Arrangements Committee Chair Chair A/Prof Nicky Kilpatrick Dr Patrick Russo Members Members Dr David Sykes, President Dr David Sykes, President Dr Peter Gregory A/Prof Werner Bischof Dr Mathew Lim A/Prof Peter Duckmanton Mr Stephen Robbins, RACDS Dr Aditi Bhide Dr Patrick Oxbrough Mrs Emma Slattery, RACDS Mr Stephen Robbins, RACDS Young Lecturer Award Coordinator Mrs Emma Slattery, RACDS Clin A/Prof Richard Widmer 6 RACDS ANNALS 2016

TWENTY THIRD CONVOCATION ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS HOBART, AUSTRALIA, MARCH 2016 CONVOCATIONS Date Venue Annals 31 August – 1 September 1967 Canberra, Australia Vol. 1 13 – 16 August 1969 Sydney, Australia Vol. 2 11 – 13 August 1971 Sydney, Australia Vol. 3 3 – 6 March 1974 Adelaide, Australia Vol. 4 20 – 23 February 1977 Melbourne, Australia Vol. 5 13 – 16 May 1979 Christchurch, New Zealand Vol. 6 9 – 12 November 1981 Sydney, Australia Vol. 7 2 – 5 April 1984 Brisbane, Australia Vol. 8 30 October – 3 November 1986 Melbourne, Australia Vol. 9 25 February – 2 March 1989 Hong Kong, SAR China Vol. 10 21 – 24 September 1991 Rotorua, New Zealand Vol. 11 16 – 19 April 1994 Canberra, Australia Vol. 12 26 – 30 April 1996 Sydney, Australia Vol. 13 23 – 27 October 1998 Adelaide, Australia Vol. 14 20 – 24 October 2000 Auckland, New Zealand Vol. 15 17 – 20 October 2002 Melbourne, Australia Vol. 16 14 – 17 October 2004 Darwin, Australia Vol. 17 31 August – 3 September 2006 Sydney, Australia Vol. 18 30 May – 2 June 2008 Hong Kong, SAR China Vol. 19 11 – 14 March 2010 Perth, Australia Vol. 20 31 March – 4 April 2012 Queenstown, New Zealand Vol. 21 10 – 13 April 2014 Surfers Paradise, Australia Vol. 22 30 March – 2 April 2016 Hobart, Australia Vol. 23 RACDS ANNALS 2016 7

TWENTY THIRD CONVOCATION ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS HOBART, AUSTRALIA, MARCH 2016 EDITORIAL ‘NO MOUTH IS AN ISLAND – ORAL HEALTH IN THE SYSTEMIC UNIVERSE’ The 23rd convocation took place in the beautiful city of Hobart, Tasmania. The Hotel Grand Chancellor was an excellent venue to share knowledge and celebrate the achievements of Fellows and Members of the College. Dr David Sykes welcomed the guests at the opening ceremony and invited the Governor of Tasmania Her Excellency Professor the Honourable Kate Warner to open the convocation. The families of new Members and Fellows watched proudly as they were admitted to the College in General Dental Practice and Specialist Dental Practice disciplines. The Robert Harris orator Professor Peter Rathjen, Vice Chancellor of Tasmania, captivated the audience with a glimpse of what could be possible with stem cell research in the future. The scientific sessions which followed were well received by participants and to this effect I would like to acknowledge the hard work of the Scientific Arrangements Committee. The keynote speakers Professor Swante Twetman (Denmark) and Kevin O’Brien (England) were both outstanding and enagaing as they discussed curent evidence in the management of caries and malocclusion. There were concurrent sessions in a range of topics presented by Australasion speakers. Several mastercalsses were also conducted in various topics ranging from oral medicine, orthodontics and restorative dentistry. My thanks to the staff at the College office in Sydney for their assistance with the final formatting of the Annals. I would like to extend my gratitude to former editors Dr John Harcourt (OAM) and Prof Martin Tyas (AM) for their support during editing of the 2016 Annals. A/Prof Menaka Abuzar, BDS, GCUT, Grad Dip Clin Dent, MDSc (Prosthodontics), PhD, MRACDS Honorary Editor, Annals 8 RACDS ANNALS 2016

TWENTY THIRD CONVOCATION ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS HOBART, AUSTRALIA, MARCH 2016 Address by the President of the Royal Australasian College of Dental Surgeons David Sykes, BDS(Lond), MDS(Syd), LDS, RCS, FRACDS, MRACDS(Pros) at the Opening Ceremony I would like to respectfully acknowledge the traditional and original • Dr John Lockwood AM, – Chair of the Dental Board of Australia owners of this land the muwinina (mou wee nee nar) people, to pay • Associate Professor Jillian Sewell - President of the Australian respect to those that have passed before us and to acknowledge Medical Council today’s Tasmanian Aboriginal community who are the custodians • Professor Michael Morgan – President of the Australian Dental of this land. Council • Dr Rick Olive AM, RFD, President of the Australian Dental Ladies and Gentlemen, please be seated. Association • Dr John Cosson – President of the Australian and New Zealand It is a great privilege to welcome our guest of honour Her Excellency, Association of Oral and Maxillofacial Surgeons. Professor the Honourable Kate Warner, Governor of Tasmania to the 23rd Convocation of the Royal Australasian College of Dental Surgeons in this beautiful city of Hobart. I would especially like to welcome our international speakers: • Professor Kevin O’Brien – Professor of Orthodontics, University Distinguished guests, Fellows and Members of the Royal of Manchester Australasian College of Dental Surgeons, colleagues, dental • Professor Svante Twetman – Professor of Cariology, University healthcare practitioners, accompanying persons and families, of Copenhagen as President, it is also my honour, on behalf of the Council and the Convocation Committee, to welcome you all to this opening • Professor Paul Brunton – Dean, Faculty of Dentistry, University ceremony. of Otago • Professor Gary Cheung, Associate Dean, Faculty of Dentistry, University of Hong Kong In particular, I extend a warm welcome our other important guests: • Professor Thomas Flemmig – Dean of the Faculty of Dentistry, • Professor Peter Rathjen, Vice Chancellor, University of University of Hong Kong. Tasmania • Dr Sai Kwing Chan, President of the College of Dental Surgeons of Hong Kong RACDS ANNALS 2016 9

Indeed I extend a sincere and heartfelt welcome to all our and knowledge throughout our life. The College, on the surface, conference speakers who have devoted time to honour us with is merely a means to measure our educational goals against their presentations over the next few days and to all participants in our peers. But deeper down, it is a community of peers whose this important biennial occasion for our College. encouragement and role models spur all of us on to be the very best we can be. 2015 was a seminal year for the College being the 50th anniversary of its inception. I made mention of our Past Presidents in my The theme of our scientific meeting - the overlap of systemic address at the opening event of the 50th celebrations and the health with dental health – is also a reflection of this ideal and the importance these dedicated Fellows made to the development of welcome we extend to new Fellows and Members tonight is a the College into the international organisation it is today. It is a formal acknowledgement of their commitment to their patients by delight and honour that we have several of them present tonight. way of their increase in skill and knowledge that they will now be able to bring to bear in their daily practice. I also made mention of the significant and quintessential contribution made by so many Fellows and Members over I congratulate you on your achievements and welcome every one those 50 years of our existence – as Registrars, as examiners, as of you to the College. The College community is here to encourage committee members, as Council Members and Officers of the you in all your further career choices that I know will be a credit to College and as participants in the singular aim of the College – to yourselves, your family and your patients. be a respected international leader in the provision of postgraduate dental education and professional development. The College Council has held two strategic planning days since the last Convocation and considered many aspects of the rapidly changing educational environment in which we operate. The underlying principle in this aim is our motto - ‘Vincat Scientia Continuing professional education has changed significantly Morbis’ – Let knowledge conquer disease. It is the acquisition of since the College was formed and the speed of that change has such knowledge that brings us to the College Convocation, every increased dramatically in the last five years. two years, for a scientific meeting that promotes and presents the very latest in scientific learning on many topics concerning The quality of the offerings varies quite widely and the traditional the profession of dentistry but, most importantly, concerning the providers, such as ourselves, the Universities and the Dental health and well-being of our patients as a whole and in whose care Associations, have been striving to identify themselves as different we play but a small part. Although, as dentists, we would argue is and superior. To this end, the College has implemented an online an essential part. learning management system that, although in its early stages, promises to provide support for our candidates and a means for The programme over the next few days has been expertly prepared other practitioners to access the depth of College educational by our Scientific Committee chaired by Associate Professor Nicky recourses. Kilpatrick, and organised by our Convocation Arrangements Committee chaired by Dr Patrick Russo. Our Annals will be edited The Education Centre at our Sydney Office continues to be used by Associate Professor Menaka Abuzar. I would like to thank all extensively. We hold examinations in the facility together with these Fellows and Members for the many months of work that it courses and lectures, both for our own candidates, our Fellows has taken to pull the 23rd Convocation together. It promises to be and Members but also for the profession as a whole. We recently exciting, enjoyable and rewarding and I am certain that you will hosted an examination diet of the Diploma in Implant Dentistry, wish to thank them yourselves at the conclusion of the event. offered by the Royal College of Surgeons of Edinburgh, and will continue this relationship which adds to our established conjoint Convocation, however, is not just a scientific meeting. It also relationship with the Edinburgh College in orthodontics. provides the opportunity to formally admit into the College, new Members and Fellows in both general and specialist dental practice, The interactions our College has with other like institutions who have completed the considerable study and examination continues to be of importance, especially since our presence in requirements the achievement entails. In addition, we are able the Asia Pacific region expands. The College has renewed the to recognise colleagues who have made significant contributions MOU with the Universiti Sains Malaysia and is in the process of to the College or the profession as a whole, and to confer prizes considering the renewal of our MOU with the College of Dental to those candidates who have performed with distinction in our Surgeons of Hong Kong. The latter agreement has been particularly examinations. successful and rewarding and I would like to acknowledge the President of that College, Dr Sai Kwing Chan who has joined us for The ceremony tonight is at least as important a part of the meeting the conference. I have been welcomed most warmly by Dr Chan as the scientific content. and his Council in recent visits to Hong Kong and I am pleased to be able to reciprocate this hospitality. I was listening to a recent radio documentary concerning a specialist in emergency medicine, Dr David Caldicott, from the The College of Dental Surgeons of Hong Kong hosted, in great Calvary Hospital, Canberra. At one point he was asked how he style, the first Joint Collegiate Scientific Meeting which is a very coped with conveying bad news to relatives of patients he had not tangible manifestation of a relationship our past President, Francis managed to save. He said that, to carry out this extremely difficult Chau, initiated with the Colleges in Hong Kong and Singapore. task with the necessary respect, understanding and support, the The second meeting is to be held in July in Singapore and I would ultimate welfare of the patient had to matter to you. If the patient encourage Fellows and Members to attend as the programme did not matter, you would not be able to do your best in both promises to be most stimulating. patient management and aftercare. It was, in his view, extremely important for health workers to contribute to their patients, to Of course, our relationships with the Universities and Dental society and to the history of their profession. Associations in Australia and New Zealand are as equally treasured. We have renewed MOU’s with the Universities of Queensland and These high ideals underpin the ethos of the College. We are a Western Australia and are hoping to develop similar understandings group of likeminded clinicians who undoubtedly care about our with other dental Faculties. We have excellent communication patients and understand that, in order to provide the very best channels with State and Federal Dental Associations in Australia management of their health issues, we need to improve our skills and with the Dental Association in New Zealand. 10 RACDS ANNALS 2016

The College has contact with the Dental Boards in both Australia During my term as President I have had wise counsel and guidance and New Zealand on several levels. Our training programme for from those that have been before me and I acknowledge Dr Oral and Maxillofacial Surgeons is accredited via the Medical and George Wing AM, Associate Professor John Harcourt OAM, Dr Dental Councils from both countries. The process has been very Ross Bastiaan AM, A/Professor Neil Peppitt, A/Professor Werner beneficial and I can say, that although extremely rigorous, it has Bischof and Dr Francis Chau – all past Presidents present tonight, provided insight into best educational and assessment practice. whom I thank for their considerable contribution to the College This knowledge has flowed through to our other examination over the years. I am also extremely fortunate to have a committed programmes. The Board of Studies in Oral and Maxillofacial and dedicated Council and I would like to thank my Councillors for Surgery is to be congratulated for its dedication to excellence in their sage advice and unreserved support over the last year and training for its candidates which is greatly supported by our strong a half. relationship with the Australian and New Zealand Association of Oral and Maxillofacial Surgeons. I am convinced the College has in important role and bright future in the health education arena, both here in Australia and New The College recognises the difficult statutory requirements both Zealand, but throughout Asia. The quality of the new Fellows and Dental Boards have in administering the requirements of their Members we will welcome tonight, is a testimony to this future respective acts and we would like to offer any support within our and I commend them to you all. Please embrace them into the power to assist in this task. community and encourage them to continue in their endeavours to fulfil their professional dreams. Internally, we have weathered some staff changes including the departure of our Director of Education and, more recently, our CEO, It now gives me great pleasure to invite our Guest of Honour, Her Mr Gary Disher. I must sincerely thank Mr Disher for his work at the Excellency, Professor the Honourable Kate Warner, Governor of College. Tasmania to open the Convocation. We have been blessed with the opportunity to engage Mr Stephen Professor Warner has had a long and distinguished career in the Robbins as Acting CEO. Many will remember Mr Robbins from his law including Dean and Head of School at the Faculty of Law at the previous time as CEO and I extend a warm welcome to him. University of Tasmania and Director of the Tasmanian Law Reform Institute. It goes without saying that the College office team, led by our CEO, are an integral part of the College administration and I cannot On 26 January 2014 Her Excellency was awarded an Order of thank them enough for the dedication and enthusiasm they have Australia (AM) for her significant service to the law, particularly in shown over the last two years. The College would simply not exist the areas of law reform and education. were it not for the hard work of these committed individuals. Professor Warner has received a number of other awards and The themes of introspection that need to be considered as the Fellowships, including Foundation Fellow of the Australian College moves forward are possibly not new but are, nonetheless, Academy of Law in 2007; Visiting Fellow All Souls College Oxford essential for College growth. It is pleasing to report that candidate in 2009; the University of Tasmania Distinguished Service Medal in numbers continue to increase but we must look particularly at all 2013; and the Women Lawyers Award for Leadership in 2013. She our examination programmes, at their curricula, their assessment has been nominated as a finalist in the Tasmanian Australian of the processes and at their relative standards. Year Awards for her contributions to the law, law reform and legal education. We have become aware that we need to change our corporate structure in the light of the size and expanse of the organisation Professor Warner has published numerous journal articles, book which then leads to a reflection on our Regional Committees. chapters and law reform reports. They have been a more than essential part of the way the College manages its geographical footprint. However, support for these I understand that Professor Warner is a passionate gardener, dedicated Fellows and Members must be improved and it is an keen bushwalker and occasional cyclist. What better place than important goal Council has identified. Tasmania to enjoy these pastimes. Council has and intends to engage all areas of the College Ladies and Gentlemen, Please welcome to open the 23rd infrastructure in the process of organisation development. From Convocation of the Royal Australasian College of Dental Surgeons, our examiners, to our Boards of Studies; from our Registrars to our Her Excellency, Professor the Honourable Kate Warner, Governor candidates and new Fellows and Members. I would encourage all, of Tasmania. whether new to the College or whether experienced stalwarts, to contribute in any way you feel you are able as it is this community of likeminded individuals that guide the future of the organisation. RACDS ANNALS 2016 11

TWENTY THIRD CONVOCATION ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS HOBART, AUSTRALIA, MARCH 2016 OFFICIAL OPENING REMARKS BY HER EXCELLENCY PROFESSOR THE HONOURABLE KATE WARNER AM, GOVERNOR OF TASMANIA Good evening everyone. Thank you for the invitation to open your opportunity for intervention in the case of a range of underlying conference. health and social problems, from bulimia and eating disorders, to substance abuse and family violence. I have had an interesting time researching possible topics for my speech to you this evening. My first thought was an historical In the case of partner violence, the face is a common target and so approach, but whilst this material was intriguing – the tooth worm patients may present for treatment of chipped, fractured or avulsed theory of decay, the pre-dentist days of extractions provided only (completely displaced from its socket) teeth. Signs of strangulation by surgeons, blacksmiths and enthusiastic amateurs, I thought I may even be apparent. Dental effects of domestic violence may should try for something more relevant and more contemporary. not just involve trauma. Decay, decalcification and damage also result from neglect because of emotional abuse which isolates or As a criminologist I have always had a keen interest in vulnerable denies the victim access to dental health care. Think here about 1 populations including the socio-economic causes of crime and kidnapped and imprisoned Ma’s toothache in Emma Donoghue’s homelessness; Aboriginal disadvantage; family and sexual violence, novel, ‘Room’, although that is of course an extreme example of far its causes and responses to it – these have been a particular focus. more than neglect. This led me to think about dentists as frontline service providers. I am not suggesting that dentists give advice to a patient Family violence is one of the topics I have chosen to focus on in experiencing domestic violence on what direct action they should my term as Governor. I was Director of the Tasmanian Law Reform take, such as leaving the relationship, but rather that they have a Institute for over ten years before my appointment and prior to role to play in identifying domestic violence and providing referral that I had considerable involvement with law reform and law information. An American journal article I have read suggests that reform bodies. As a law reformer, my focus has been on the power the dental team can create a safe and secure place for victims. of the law to bring about change. In sexual assault law reform I Concurrently, dental surgeries can also be equipped to inform advocated change in the way offences are defined, for example, patients about local resources, recommend strategies to promote removing the words which gave a man immunity from prosecution safety, provide supporting messages, and educate patients about for the rape of his wife; changes to the definition of consent and to the overall effects of abuse on health including dental health. meaning of rape; improvements in the way victims are dealt with There is a tool, the AVDR tool (asking, validating, documenting by the legal system in the hope that victims would be more likely and referring) that can guide and assist communication about the to come forward, offenders more likely to be sanctioned and in issue. The dentist asks the patient about the injury or accident, the hope that the incidence of such crimes would decline. In the provides validating messages about the wrongs of domestic case of family and domestic violence, law reformers have long violence, reinforces that the victim is not at fault, documents the campaigned for the recognition of domestic assault as a criminal signs and symptoms as well as anything the patient has said about offence and not just ‘a domestic’ in the expectation that this would the incident, and finally refers the patient to a domestic violence lead to a reduction in domestic violence by it being denounced service provider. And it adds that it is important for the dentist to and punished rather than condoned. remember that it is not their responsibility to solve the problem. 1 Since becoming Governor I have shifted my focus from legal An article in the British Dental Journal provides similar but more change to society’s responsibility to address the root causes of detailed advice to British dentists. For example, in relation to 2 family and sexual violence, causes that lie in the persistence of rigid asking about domestic violence, it suggests that where there are gender roles in our society. signs suggesting domestic violence, the dentist or dental care professional should ask direct and specific questions, noting that This does not mean that improving our response to family violence vague questions are unhelpful. A list of indicators of domestic violence is given such as frequently missed appointments, injuries through better services for victims and perpetrator programmes, inconsistent with the explanation of cause, multiple injuries at for example, is not important. It is, but we need to reach out beyond the police and victim services to improve the response different stages of healing and a partner of the patient attending unnecessarily. The article also raises the issue of whether the 2 to it. Sometimes a patient’s visit to the dentist will provide an enquiry to patients about domestic violence should be routine, 12 RACDS ANNALS 2016

offers suggestions about how to raise the topic and discusses and has been advocated by health experts to increase the cost of training for dentists and dental care professionals in relation to sugar-rich food and drink. They also advocate curtailing the flow of identifying and responding to domestic violence. sugars in the food chain by reducing sugar production drastically and banning it in the EU. They argue if sugar is produced at all it The issue of what dentists can do to help family violence victims should be converted into alcohol, as in Brazil, to be used in fuel for 9 was raised in an interview with a psychiatrist who was involved in vehicles. preparing a submission to Victoria’s Royal Commission on Family Violence, Dr Manjula O’Connor. She explained that she had given Such a tax has recently been announced in the UK, primarily to talks to dentists advising them that when there was a suggestion tackle obesity but it would no doubt have dental health advantages. that a woman has been hit in the face, she be questioned about it More than 60 organisations including the National Heart Forum 3 with empathy and referred to an appropriate service. and the Royal Society for Public Health have supported the tax and called for the money raised from it to be spent on programmes 10 Oral health and disadvantage to improve children’s health and wellbeing. It is likely to lead to I don’t need to tell a group of dentists that poor oral health and dental a reduction in the sales of sugary drinks if the Mexican example decay are the cause of pain, poor nutrition and embarrassment. But is anything to go by. Mexico went from a healthy country to one it is worth pondering the fact that when appearance and speech where 71% of the adult population was overweight or obese and are impaired by dental disease, this may inhibit opportunities for sugary drinks were blamed for transforming the Mexican diet. The 4 education, employment and social interactions. As Lesley Russell, introduction of a tax on sugary drinks in January 2014 has led to 11 an Adjunct Associate Professor of the University of Sydney points decreased sales particularly in poor communities. Clearly, a tax on out, ‘An Aussie smile is an instant indicator of socio-economic sugary drinks is a public health measure that is worth watching. 4 status, employability and self-esteem. A more modest proposal is for mandatory health warning on sweet drinks which includes the risks to dental health. This was It seems that Australia’s dental health has not improved in recent recommended by researchers from the University of Adelaide after years. In fact it seems that the average number of children’s baby a study of 16,800 Australian children they conducted connected teeth affected by decay has risen. Russell reports that around sugary drink consumption and tooth decay. 10 45% of children aged 12 have decay in their adult teeth. This is 4 based on the 2010 Child Dental Health Survey and, according to In conclusion, my message to you this evening is that I believe all of the Australian Institute of Health and Welfare report on oral health us have a duty to do something about family violence to challenge published in January 2016, this is the latest data. This trend of the rigid gender roles that underlie it. But as dentists I also believe 5 deteriorating child dental health started in the mid-1990s after you can be part of the frontline services that improve our response 6 three decades of improvement. Writing in 2014 Russell reported to it. I also think that you have a responsibility to continue to that over one third of adults have untreated decay. And more than advocate for public health measures to improve dental health and 20% of people aged 65 and over have lost all their teeth. However, to advocate for better access to public dental health services for more recent data suggests there has been some improvement children and adults to try and address the problem of the dental with respect to the prevalence of untreated decay and tooth loss ‘have-nots’ in the ‘lucky country’. in adults. However, between 1994 and 2013 there was an increase 5 in the proportion of people who were uncomfortable with their Thank you. dental appearance, from 20% to nearly 27% and more reported toothache in the previous 12 months in 2013 than in 1994. REFERENCES 5 1. DiMatteo AM, Rafferty T. What’s hiding behind that smile? The picture is worse for Indigenous Australians, especially in Inside Dental Assisting 2013;9(1):14-21. remote communities, where sugar-laden processed foods are 2. Coulthard P, Warburton AL. The role of the dental team in now ubiquitous but dental services scarce. The oral health of responding to domestic violence. Brit Dent J 2013;203(11):645- 4 Indigenous Australians was once better than the oral health of 648. non-Indigenous Australians. Tooth decay and periodontal diseases 3. Hall E. Family violence victims need better-coordinated health: were uncommon in rural and remote Indigenous communities psychiatrists. The World Today with Eleanor Hall 2015. www. but all this changed with availability of foods rich in fermentable abc.net.au/worldtoday/content/2015/s4188092.htm [Accessed carbohydrates. Indigenous people lacked the same access to the 23 Mar 2016]. new preventive measures such as fluoridated water and toothpaste, or easy access to dental care so their oral health deteriorated along 4. Russell L. How to fill the gaps in Australia’s dental health system. with their general health and is now a significant problem. 7 The Conversation, 15 Dec 2014. http://theconversation.com/ how-to-fill-the-gaps-in-australias-dental-health-system-35371. There is a socio-economic divide at work here. In Professor John 5. AIHW 2016. Oral Health and Dental Care in Australia: Key Facts Spencer’s words, there is chasm between rich and poor in oral and Figures 2015. Dental statistics and research series. Cat. no. health, and policy has widened the gap between the dental ‘haves’ DEN 229. Canberra: Australian Institute of Health and Welfare. and the ‘have-nots’. Unsurprisingly, Australians who can afford 6. Spencer J. Don’t just grin and bear it: act now to improve 8 regular and routine dental care report low levels of extractions and children’s dental health. The Conversation, 4 Aug 2011. http:// relatively low levels of fillings. But for far too many Australians going theconversation.com/dont-just-grin-and-bear-it-act-now-to- to the dentist is an unaffordable luxury. Many are forced to seek improve-childrens-dental-health-2658 pain relief from general practitioners and emergency departments, 7. Williams S, Jamieson L, MacRae A, Gray C. Review of 4 which adds to the pressure on these services. In 2013-2014 there Indigenous oral health. Australian Indigenous HealthInfoNet, were 63,456 potentially preventable hospital admissions for dental 2011. www.healthinfonet.ecu.edu.au/uploads/docs/oral-health- conditions. 5 pl-review.pdf Improved access to fluoridation, engaging in dental health 8. Spencer J. Narrowing the Inequality Gap in Oral Health and promotion, preventive dental services for children and more Dental Care in Australia. Australian Health Policy Institute, funding for public dental services, and more generally, bridging the University of Sydney, 2004. dental medical divide have been suggested as solutions. 4,8 9. UCL. Dental and nutrition experts call for a radical rethink on free sugar intake. UCL News 16 Sep 2014. www.ucl.ac.uk/news/ Would a tax on sugar or sugar-sweetened drinks be a good idea news-articles/0914/160914-Experts-call-for-radical-rethink-on- from an oral and dental health perspective? free-sugars-intake [Accessed 30 Mar 2016] 10. Palmer C, Morgan M. Study supports calls for soft drink health Tooth decay is the most common non-communicable disease in warning. The Conversation, 30 Jan 2013. http://theconversation. the world. It affects 60-90% of school-age children and the vast com/study-supports-calls-for-soft-drink-health-warning-11878 majority of adults. The treatment of dental diseases cost 5-10% 11. Pineda E. What the world can learn from Mexico’s tax on 9 of total health expenditure in industrialised countries. As sugars are the cause of tooth decay, it seems sensible to do something sugar-sweetened drinks. The Conversation, 22 Mar 2016. http:// about sugar consumption. A tax on sugar is a possible measure theconversation.com/what-the-world-can-learn-from-mexicos- tax-on-sugar-sweetened-drinks-56696 RACDS ANNALS 2016 13

TWENTY THIRD CONVOCATION ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS HOBART, AUSTRALIA, MARCH 2016 NEW FELLOWS AND MEMBERS FELLOWSHIP BY EXAMINATION MEMBERSHIP IN GENERAL DENTAL PRACTICE Yasmina Andreani Asseman Fayaz Wessam Ahmed Fouad Atteya Ruchika Garg David Che-Wei Chang Priya Gopalakrishnan Ashwini Chaphekar Mathew Albert Wei Ting Lim Zoe Commandeur Darren Ma Liem T Dang Ehsan Nabavi Hosam El-Deen A B El-Haddad Michael Toan Lam Nguyen Marina Salah Kamel Matthew Andrew Crawford Peters Achala Khot Amanda H Phoon Nguyen May Lam Sumit Sachdeva Nigel Gordon Maher Niranjan Eliezer Thomas Alan Mann Irene Wei Ling Thong Alvin Ng Alan T Trinh Grant William O’Donnell Ahmed Adam Wahab Heba Skaros Sarah Rachel Yi-Jiin Ting MEMBERSHIP IN A SPECIALIST DENTAL Ahmed Adam Wahab Alex Ruwan Kumar Warnakula PRACTICE DISCIPLINE Yeung Lin Kit Orthodontics James Jihyo Kim 2015 CHRISTENSEN MEMORIAL PRIZE Special Needs Dentistry Dental Public Health: Noora Sulaiman Ebrahim Mohammed Al Michael Skilbeck and Jason Chew blooshi Endodontics: Ennio F Rebellato and Fatima Mohamed Aldhefairi 2015 KENNETH J.G. SUTHERLAND PRIZE Paediatric Dentistry: Giselle D’Mello Periodontics: Mohammed Shorab Mathew Albert Wei Ting Lim and Michael Toan Lam Nguyen Prosthodontics: Catherine Jane Collins Group photo of new Fellows and Members admitted at Convocation 14 RACDS ANNALS 2016

ADMISSION AS AN HONORARY FELLOW Professor Martin Tyas AM Professor Martin Tyas graduated as a Bachelor of Dental Surgery From 1986 – 2013, Professor Tyas was a Consultant in Dental from the University of Birmingham in 1967. In 1994 he gained both Materials to the Australian Defence Force, with the rank of Group a Doctor of Dental Science of the University of Melbourne and Captain in the Royal Australian Air Force Reserves, and was awarded Fellowship of the Royal Australasian College of Dental Surgeons. the Australian Defence Medal. His research in the field of dental Professor Tyas holds a Doctor of Philosophy from the University materials has been a continual focus and resulted in significant of Birmingham and a Graduate Diploma in Health Sciences from international recognition. This extensive work has resulted in the the Western Australia Institute of Technology. He was awarded publication of over 200 papers and several book chapters. Since Member of the Order of Australia (AM) in 2009 and is an Honorary 1986, he has led the Australian delegation to the International Life Member of the Australian Dental Association Inc. He has made Organization for Standardization Technical Committee 106 – extensive contributions to the Royal Australasian College of Dental Dentistry. He was a member and subsequently Chairman of the Surgeons for over 20 years including: Science Committee of the FDI World Dental Federation from 2003- 2009. • Member of the Victorian Regional Committee, 1999 - 2012 Professor Tyas has served on and continues to serve on the • Examiner for the Final Examination for Fellowship Editorial boards of several international Journals including the • Member of Council, 2000 – 2012 Australian Dental Journal, Dental Materials, the Journal of Dentistry, Evidence Based-Dentistry, the Journal of Applied Oral Science and • Chair, Board of Studies AGDP, 2000 – 2003 the Journal of Clinical and Investigative Dentistry. • Continuing Education Committee, 2000 – 2006 Professor Tyas is a Fellow of the Academy of Dental Materials, • Censor in Chief, 2008 – 2012 Fellow of the International College of Dentists and a Fellow of Academy of Dentistry International. • Constitution Working Party, 2006 – 2012 • Education Policy Board, 2008 – 2012 Over the years, Professor Tyas has worked as a private practitioner in the UK, at the University Birmingham, United Kingdom, the • Honorary Editor of the Annals, 2012 – 2015 Northern Territory Health Department, the Australian Dental Standards Laboratory, Perth Dental Hospital and the University of Professor Tyas is a Professorial Fellow at the Melbourne Dental Melbourne. School, University of Melbourne where he has been involved in tertiary education since 1990 and is highly regarded by many Professor Tyas has represented and contributed to the College former undergraduate and graduate students. Professor Tyas has over a long period and in many roles. His work has been influential held several committee and board appointments in the Faculty in the profession both within Australia and internationally by virtue of Medicine, Dentistry and Health Sciences and the Melbourne of his research, his teaching and his wise counsel, which has always Dental School. been performed to the highest possible standard. RACDS ANNALS 2016 15

ADMISSION AS AN HONORARY FELLOW Associate Professor Werner Bischof Associate Professor Werner Hans Bischof graduated as a Bachelor • Academic Lead in Periodontology, Department of Dentistry of Dental Science from the University of Melbourne in 1988. He and Oral Health, La Trobe Rural Health School, La Trobe was awarded Fellowship of the College in 1993, winning the F G University Christensen prize for the highest mark in the Primary Exam in • Member of the Accreditation Committee of the Australian 1991 and gained a Masters in Dental Science (Periodontics) from Melbourne University in 1998. Subsequent to being registered as Dental Council a Specialist Periodontist , he was awarded a Membership of the • Member – Expert Reference Group Specialist - Dental Board College in the Specialist Dental Practice discipline of Periodontology of Australia in 2009. • Member and Chair - Dental Board of Australia - Victorian Associate Professor Werner Bischof has made and continues to Registrations and Notifications Committee make, extensive contributions to the Royal Australasian College • Member of the Reference group for the Voluntary Dental of Dental Surgeons. He is currently Chair of the Board of Studies, Graduate Year Program Fellowship (GDP) and Assistant Registrar of Specialist Dental Practice and has held a number of senior roles with the College • Member of the Dental Practice Board of Victoria including; • Member - Professional Advisory Committee, Dental Health • Member and Chair - Vic & Tas Regional Committee Services Victoria • Member (Fellowship (GDP)) Exams Committee Associate Professor Werner Bischof is a Fellow of the Pierre • Member - Examination Committee for Primary Examination Fauchard Academy and a Fellow of the International College of FRACDS Dentists. • Councillor Associate Professor Bischof ‘s contribution to the College has been • Honorary Secretary long and enduring. His wise counsel and attention to detail has been invaluable. • Chair of Continuing Professional Development Committee, • President Elect During his time as President, the MOU with the College of Dental Surgeons of Hong Kong was signed. Associate Professor • President 2010 – 2012 Bischof helped steer the College towards new initiatives within • Past President the profession and fostered the strong relationships the College enjoys with Universities and other educational institutions. A most • Board of Studies – Periodontology successful Convocation was held in Queenstown, New Zealand • Deputy Chair Education Board during his Presidency. Associate Professor Bischof has been Chair of the Scientific Program As President, on Council and with the Victorian and Tasmanian Committee and Organising Committee across 5 Convocations. Regional Committee Associate Professor Bischof has represented the College and the profession to the highest possible standard. In other areas, Associate Professor Bischof has practiced as a Specialist Periodontist in Geelong for many years and has managed to fit in being; 16 RACDS ANNALS 2016

ADMISSION AS AN HONORARY FELLOW Dr Francis Chau Dr Francis So Wah Chau graduated as a Bachelor of Dental As the first President of the Royal Australasian College of Dental Surgery from the University of Sydney in 1983, then graduated as Surgeons based in Hong Kong, Dr Chau utilized his unique position a Bachelor of Laws with honours from the University of London in to initiate stronger collaborative relationships between the Dental 1991, and subsequently, Master of Business Administration from the Colleges in the Australasian and Asian Regions. He was instrumental University of Hong Kong in 1995. In 1999, he attained Fellowship in establishing conjoint examinations between the College of of the Royal Australasian College of Dental Surgeons and 10 years Dental Surgeons of Hong Kong and RACDS in both general and later, Membership in Prosthodontics. specialist dental practice. Another initiative was the establishment of a forum involving the College of Dental Surgeons Singapore, the Dr Chau has practiced first with Department of Health, Hong Kong College of Dental Surgeons of Hong Kong and RACDS. This group Government and then in private practice in Hong Kong to this day. now holds a biennial Joint Collegiate Scientific meeting, the first of which was held in Hong Kong in 2014. Dr Chau has made extensive contributions to the Royal Australasian College of Dental Surgeons for over 13 years commencing as Dr Chau has also contributed in a significant way to the profession a member of the Asia Regional Committee rising to Honorary in Hong Kong including teaching for many years at the Faculty of Treasurer between 1999 -2003 and then Chair between 2003 and Dental Surgery, University of Hong Kong and as a prominent leader 2007. He was elected to the College Council in 2004 and then of the local profession that led to the forging of a most successful held a number of senior roles within the College including relationship between the College of Dental Surgeons of Hong • Member of the Education Board, Boards of Studies and other Kong and RACDS. Dr Chau was awarded Honorary Fellowship by various Committees that distinguished College in recognition of this work. • Finance and Audit Committee 2004 – Present Dr Francis Chau has represented the College on Council, as • Chair, Organising Committee of 2008, 19th Convocation in President, with the Asia Regional Committee and the profession Hong Kong as a whole to the highest possible standard both in Australia and in Hong Kong. • Executive Officer, Council 2008 – 2012 • President 2012 – 2014 • Past President 2014 – 2016 Dr Chau retired from the College Council in November 2015 RACDS ANNALS 2016 17

ADMISSION AS A FELLOW WITHOUT EXAMINATION Dr John Lockwood AM Dr John Lockwood has been an extremely prominent and influential member of the dental profession for many years and his contribution was recognized with an Australian Honours award of Member of the Order of Australia in the General Division in 2011. He is the inaugural President of the Dental Board of Australia, recently appointed for the third term, having been previously President of the NSW Dental Board and Dental Council. His contribution to the Australian Dental Association is considerable having served on both the Federal and NSW State branches. He was elected for three terms as President of the NSW State ADA branch. Dr Lockwood has been supportive of the College over the years, has a keen interest in continuing professional development, and it is fitting that his contribution to the profession be recognized by the College. ADMISSION AS A FELLOW WITHOUT EXAMINATION Professor Michael Morgan Professor Morgan is Head of the Melbourne Dental School, University of Melbourne, and holds the Chair of Population Oral Health. He has been involved in dental education and research, both in Australia and internationally. His principal teaching and research interest are in population oral health, focusing on oral disease causation in relation to common risk factors and disease prevention at a population level. He has made significant contributions in this area. Professor Morgan is the President of the Australian Dental Council Board and has been actively involved in Australian Dental Association (Victorian Branch) and the Federal ADA. He is also a Board member of Evident and has been appointed to the Board of VicHealth. Professor Morgan Chairs the Health Professions Accreditation Councils’ Forum, representing all entities appointed under the National Registration and Accreditation Scheme to accredit health profession education programs in Australia. 18 RACDS ANNALS 2016

ADMISSION AS A FELLOW WITHOUT EXAMINATION Professor Laurence Walsh Professor Laurence James Walsh is currently director of research at the University of Queensland School of dentistry and he has made significant contributions to the profession as a teacher and in research with interests in cariology, preventive and conservative dentistry, special needs dentistry, oral rehabilitation, micro-biology and infection control. He is chair of the Australia Dental Association Inc. Infection Control Committee, Associate Editor of the journal “Lasers in Medical Science” and coordinator for the national dental laser training program. Professor Walsh has made long and distinguished contributions to the College as Chief Examiner in microbiology for the Primary Fellowship examination and as lecturer and examiner in infection control for the MRACDS examination. ADMISSION AS A FELLOW WITHOUT EXAMINATION Dr James Worthington Dr James Worthington is a specialist Oral & Maxillofacial Surgeon who has recently retired from the Board of Studies in Oral & Maxillofacial Surgery (OMS), in December 2014. Dr Worthington has made an outstanding contribution to the specialty and the OMS Training Program. He has been the Director of Training for the New Zealand Training Centre and has been the Clinical Director of the Oral Health Centre at Christchurch Hospital. He has served on the Board of Studies since 2007 and been a member of the Accreditation Committee since 2004 and a highly respected Chair of the Accreditation Committee from 2008. Dr Worthington has been an examiner for the RACDS for both the Basic Surgical Training Examination and the Surgical Science & Training Examinations. He was instrumental in setting up the RACDS Oral Pathology Course for final year OMS trainees. RACDS ANNALS 2016 19

MERITORIOUS SERVICE AWARD Associate Professor Andrew Heggie Associate Professor Andrew Heggie has a long and distinguished During these periods, he refined and evolved the examination career in the specialist field of Oral & Maxillofacial Surgery both processes which have been externally reviewed by representatives as a clinician and a teacher. He was most recently the Chair of from other Colleges, including the Royal Australasian College the Examinations Committee of the College and was an ex- of Surgeons, the Royal College of Surgeons of England and the officio member of the Board of Studies (OMS) during his term as American Board of OMS. These examinations were found to be of President of the Australian and New Zealand Association of Oral & a comparable high standard. Maxillofacial Surgeons (ANZAOMS). He has also been a long standing member of the Victorian & He has an extensive history of involvement with the College, Tasmanian Regional Surgical Committee and is currently the through various committees and as member of the Division of Head of Unit and Supervisor of Training for the Oral & Maxillofacial OMS and subsequently the Board of Studies - OMS. Surgery Section, The Royal Children’s Hospital of Melbourne. 20 RACDS ANNALS 2016

YOUNG LECTURER AWARD The Young Lecturer Award has established itself as an important part of College Convocation. Once again it was a well received part of the scientific program. The College is grateful to Colgate for their continued support of this award. Gratitude is also extended to our panel of judges, Professor Elizabeth Martin, Professor Paul Brunton and Dr David Sykes This year’s candidates presented on topics from diverse disciplines and provided the judges with the difficult task of deciding a winner. The candidates and the titles of their presentations were: • Dr Raymond Lam: Epidemiology of Traumatic Dental Injuries: A critical discussion • Dr Nigel Maher: In vivo confocal microscopy for the oral mucosa • Dr Jyotsna Raj: Caries experience in Victorian Children with orofacial clefts • Dr Sarah Ting: Dental and Cervical Vertebrae Maturation of Isolated Unilateral Cleft Lip and Palate (UCLP) in Australian Children: Longitudinal Study The winner was Dr Sarah Ting from the University of Otago. She was awarded a certificate and a cheque from Dr Susan Cartwright from Colgate. The other lecturers were awarded a Certificate of Achievement. The judges noted that all presentations, in both content and delivery, were of a high standard. Convocation delegates were left in no doubt as to the value of the Young Lecturer Award in fostering young presenters and their research, which bodes well for the future of our profession. Clin A/Prof Richard Widmer Convener, Young Lecturer Award Young Lectures (from left to right) Dr Raymond Lam, Dr Sarah Ting, Dr Susan Cartwright (Colgate), Dr Jyotsna Raj, Dr Nigel Maher and Dr David Sykes (RACDS President) RACDS ANNALS 2016 21

TWENTY THIRD CONVOCATION ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS HOBART, AUSTRALIA, MARCH 2016 THE SEVENTEENTH ROBERT HARRIS ORATION Address by Prof Peter Rathjen, Vice Chancellor of University of Tasmania Thank you for that warm welcome and can I extend a further case, an understanding that dental practice and dental health have warm welcome to all of you to our beautiful island and thank you much to contribute to human health more broadly. for bringing the beautiful weather with you! It is, of course, always like this in Tasmania but, if you want a quiet word of advice, far be it Now, oddly enough, dentistry is a topic which comes up from time from me to recommend that you take any sessions off during the to time in my life, increasingly at the moment, and there are really conference but if you get the chance, take a little time to go and two reasons for it. One is as an educator. I observe that we don’t have a look at what it is that we have to offer. have a dentistry school down here and we have no way of training dentists. We’re not likely to get a dentistry school. There are about I spent some time wondering why they would ask a stem cell half a million people on this island. But it does interest me that scientist who is not a dentist, who lives in a state that doesn’t even we don’t provide pathways from the University of Tasmania for have a dentistry school, to present the Robert Harris Oration. So those outstanding students who might be interested in dentistry to I thought it might make some sense to go and find out a little bit enable them to then transition to one of the other medical schools about Robert Harris and what it is that he contributed. He seems or dental schools in this country. I fear that some outstanding to have been a very interesting pillar of this community. Austere students are being lost to your profession and to our profession on perhaps, conservative perhaps; a real sense of what was proper. this island by our failure to provide such pathways. There’s a rather nice story that, at a convocation in Canberra at the Australian National University, he was so intent on bowing to the But, as a biochemist, I don’t think I’ve ever been so interested in distinguished guests, which I have to say included the Chancellor dentistry before. There are a number of big changes that have and the Vice-Chancellor of ANU, that he inadvertently backed into occurred through my lifetime as it comes to our understanding the moat which surrounds the Academy of Sciences in Canberra of biological science. One that seems to be on the go at the and had to be rescued. That’s not too bad but remember that here moment is a much better understanding of the awareness of you’re in very close proximity to the Salamanca water front. The dental health on the broader human condition, the understanding water here is rather deeper and I suggest that we pay a little less that dental health is not just about the mouth and the face but it’s respect on today’s occasion! actually about greater human wellbeing. It’s coupled, I think, to a broader understanding of the importance of the microbiome, the His obituary though I think gives a greater clue as to what it was understanding that there are many more bacteria in our bodies that he contributed and I want to read just a couple of sentences than there are human cells, that those bacterial cells appear to be from it. It talks about the major role he played in the development a significant determinant of disease and predisposition of disease of the profession itself. That he had an opportunity to move from and the growing realisation that dental health may in fact influence the methods of treatment of that time where the accent was the microbiome which, in turn, can influence human health deeply. on the repair of dental caries to the recognition of the need for From knowledge springs cure and it’s from this holistic perspective prevention of the onset of dental disease. This was not easy for of human health that I want to summarise some of what we have most to embrace. However, the profession now enjoys its current learned over two-and-a-half decades of working in the field of stem status due to those few who at that time possessed the vision and cells, recognising that it is not yet of direct relevance to the field of intellect to understand the reason for the rampant caries at the dentistry but that indeed it may represent a very large part of your time and who sought to develop measures of control. He was one future. of those persons. My research group was very early into this area. I started work His passing seals a period of tremendous growth in dental on stem cells in 1989 at the University of Oxford. No-one really knowledge in the twentieth century in which he played a significant knew what they were and in fact we weren’t working on them part. He exemplified the spirit evident amongst his peers; steering because they were stem cells. We were working on them because successfully the profession from craft to science. I think it’s captured we were interested in a far more complex problem. We wanted also, embodied in your motto, “Let Knowledge Conquer Disease.” to know where a human being came from. We were interested in As in all great professions, we see a commitment to the betterment human embryology and human gestation. We were interested in of the human condition, transcending contemporary practice, understanding what, the more you understand, looks like a miracle. transcending that which is easy for an eye to the future. In his The fact that we start life as a single cell, a fertilised egg, and we 22 RACDS ANNALS 2016

finish life as this extraordinarily accomplished organism capable of cells. We can turn them into skin cells. We can turn them into heart doing so many wonderful things. The process by which we came muscle cells, which is a lovely thing to show an undergraduate into being is too hard to understand if you simply look down a student because you can show them on day one non-descript microscope and try to describe the embryo itself but it turns out stem cells that look like nothing and you can bring them back a that, if you look at what’s happening to the cells in the body from fortnight later and get them to look under the microscope. They the time of fertilisation, then the whole of how we came into being will see something which, on many occasions I’ve seen make them can be resolved into three relatively simple processes that are scream because, when the heart muscle cells form, they form repeated over and over again and integrated in a quite beautiful in clumps and those clumps beat at about the same rate as the fashion. human heart. At 37 degrees, which we grow them at, they beat quite nicely. If you leave them on the bench, they cool down and The first is simply an increase in the number of cells that are us. We they get sorry for themselves and they stop beating but, if you put started as one and, in our bodies at the moment, there are many them back in the incubator, they will resume their beating. trillions of cells. Always many trillion cells. Not tenfold too many. Not tenfold too few. That process of giving us the right number The cells that we grow in the dish can not only be grown in unlimited of cells, the right number of cell divisions, the right number of cell numbers, they can be turned into any other kind of cell and, when deaths, is very carefully controlled. we turn them into any other kind of cell, we do that in a way that copies what happened to them in the embryo itself. We use the The second key decision that takes effect during embryogenesis same biological factors that those cells saw that would have told during the formation of us is an increase in cellular diversity. We them to become a red cell or told them to become a nerve cell. start life as a single kind of cell yet in our bodies are many hundreds We use them in the laboratory to tell them to take precisely that of different kinds of cells, each exquisitely suited to the purpose that decision. it must achieve. A red blood cell carries oxygen. A nerve cell does not carry oxygen; it carries nervous impulses. A heart cell doesn’t If you go through what I have just talked about; a cell that is do either of those. It contracts so that we can move blood around immortal, a cell that is pluripotent, you realise that a population of the body. embryonic stem cells can equally be considered to be an infinite number of any kind of cell that is or has ever been found in your Those first two processes give us the right number of cells and body. And from that came the basic excitement about why they the right kind of cells to make a human. The third process at work, might be useful in a therapeutic context. Over the last four or five about which we know rather less, is that there must be some kind decades, a great deal of our medical research has uncovered the of organisation cue that takes those cells and tells them how to fact that many of our diseases come from cells that have been lost, assemble into a structure that, for most of us, is more or less human. cells that have been damaged, cells that have, for some reason, That process; increase in cell number, increase in cell complexity become dysfunctional, perhaps because of a genetic mutation but and organisation, applies to the whole body. It also applies to parts never before have we thought that we might be able to intervene of the body. As we look into the formation of each of our organs, rationally to understand which population of cells is not working as we look into the formation of each of the systems, including and to replace that population of cells with a direct substitute that the dental system, we find that the same story is true. Cells taking can restore function. relatively simple decisions in an organised and coordinated manner finishes up with the complexity of our biology. This works. We’ve become very good at curing diseases in rodents. We’ve cured rodents of Parkinson’s Disease. Many people Now, I’ve talked about this as though the starting point is the have cured rodents of Parkinson’s Disease. We’ve cured rodents fertilised egg, and in one sense it is, but actually the starting point of blindness. We’ve been able to treat heart disease in rodents. for where we came from is not the fertilised egg; it’s a small cluster The concept that you take cells from outside the body, turn them of about 20 identical cells that were us about two weeks into into a cell that you want and put them back in works. You can do embryogenesis. Those 20 cells are the same. Any one of those that within the body but, very interestingly, in the last two years 20 cells can divide as many times as you like. Any one of those it’s become apparent that you can equally do a lot of this outside cells can turn into any other kind of cell. Those 20 cells are the the body as well using very clever techniques. People have been true founder cells of the mammal and we call those cells the stem able to start with stem cells and finish up with organised structures. cells. In my lifetime, one of the key advances in this area, for which People have been able to make quite clear regions of the brain that a Nobel Prize was awarded about 10 years ago, was the discovery function as regions of the brain in the petri dish. They’ve been able that we could isolate those stem cells from the embryo, those to make slices of kidney that behave for all the world exactly as a extraordinary powerful stem cells that can give rise to all of us, kidney ought. They’ve been able to make bits of gut behave as the and we can grow them in the laboratory and we can grow them in gut ought to be behave. the laboratory easily and they retain those extraordinary powerful properties of the cells from which they were derived. You deal with complex organs; they are called teeth, and the sorts of systems that you find in the mouth. These organs don’t just look The first thing that we know about the stem cells I work with like organs; they mimic the pathology of those organs and they (embryonic stem cells) is a surprise. It turns out that they are enable us to study disease in those organs. immortal. Apart from cancer cells, they are the only immortal cells that we can grow in the laboratory and it matters. Why does it So we have an infinite population of cells. We can put them back matter? Because it means that, as long as we keep feeding them into the body if we need. We can turn them into complex structures the right nutrients, we can grow as many of these cells as we want. which in turn might be transplanted. But for many years we We can grow millions of them. We can grow billions of them and ignored the really big question, the question of immune rejection. we can grow trillions of them. That matters because, if we wish The fact that it wouldn’t matter much if we had a stem cell that to use them in the clinic, then we must have a large amount of came from me when I was an embryo because, if we transplanted starting material. They are immortal cells. We can get as many of it into you, your body would reject it. There were many ways that them as we want. They also have this amazing property which we people looked at to try and get around this problem and then a call pluripotence. It’s the property that they had when they were very quiet-spoken Japanese scientist announced, oddly enough in in the embryo that says then can turn into anything else. They Australia, in Cairns, that he had not just cracked the problem; he’d can turn into any of the cells that are in your body. They can turn done it by achieving something that we all knew to be impossible. into any of the cells that used to be in your bodies when you were We all knew that you start as a stem cell and you gradually turn younger or when you were an embryo. That is what they do. That into other cells until you reach the destination that you want. We is what they are meant to do and they can still do that when they all knew that was a one-way process, that it couldn’t go in reverse. are grown in the laboratory. Shinya Yamanaka thought otherwise. He thought that there’s no particular reason why you couldn’t take a cell from the body and We are learning and can generally now turn them into nerve cells. turn it backwards into a stem cell. Everyone in the world knew We can turn them into kidney cells. We can turn them into retinal that was stupid. It took him five years to recruit a post-doctorate RACDS ANNALS 2016 23

student that was silly enough to bet their career on trying to do But they have one other property which we don’t talk about either these experiments. But the point, as with so much great science, or don’t talk about enough and that is because the body takes such is that he was right and it worked and for that he was awarded good care of these cells because they are immortal, it turns out that the Nobel Prize two or three years ago. Since Shinya Yamanaka they have more or less perfect copies of our genome sitting within showed us that we could take more or less any cell from the body, them. Most of our cells have got mutated DNA. They are exposed the following regime has been possible. to environmental insult, ultraviolet light and the like, but the stem cells are always protected. They are protected in terms of the way I could present in the clinic with Parkinson’s Disease. To solve it, I they divide. They are protected in terms of their biochemistry and need a special kind of neuron, a dopaminergic neuron, transplanted it means that their descendants are more or less perfect cells of the into my brain. I could present in a doctor’s surgery and I like to kind that might have been found in us somewhere between about think they might take a fat cell biopsy from me. We could solve 35 and 80 years ago. a couple of problems at the same time. They could take the fat cell biopsy and turn those fat cells back into a stem cell, grow as Can the dental cells, can the embryonic stem cells actually be used many of the stem cells as they want and turn them into as many to make dental targets? The answer is yes. People have shown dopaminergic neurons that they want, all matched identically to that they can make teeth from these things. They can make them me and able to be transplanted without rejection. outside the body on scaffolds. They can make them inside the body, at least in rodents, by transplanting the stem cells into the This is a story of what appears to be possible, of what is clearly right locations. It raises the possibility that future cures might not possible in most mammals and what is just starting to be proven be about using foreign materials but about using the patient’s own in human clinical trials because the FDA has just authorised the cells to replace precisely that which has been lost. It’s not just the first stem cell transplants to tackle spinal cord damage, to tackle teeth. It’s the connective tissue that connects those teeth to the macular degeneration, which is the death of retinal cells in your bone properly. It’s been shown quite clearly in animal models that eye; the most common cause of human blindness. And we await that too can be generated because the environment itself gives with great interest to see whether this cell replacement can in fact rise to the cell types and the structures that are required to replace work. that which it is that has been lost. It’s also a set of stories about science which was thought to be All of what I’ve told you tonight, which I’ve had to be a little superficial impossible, right up until the moment at which science showed about, has strong scientific evidence behind it. The details are that in fact it was possible. It is the replacement of diseased cells yet to be filled in. We will find some uses for stem cells soon and with exact self-copies of those cells, autologous transplantations in they are already in the clinic for some diseases. For other uses, it a way that holds the maximum promise. will take us much longer to work out what can be done. There is some imagination needed too. Where might these sorts of cells Now, I’ve been talking about the mother of all stem cells, the stem be useful? In your field, people talk about the restoration of pulp cell from which all of us arose, but, as this field was expanding over tissue. They talk about regeneration of ligament. They talk about about the last 15 years (the really big discovery came in 1998), so the generation of tooth structures or parts of tooth structures. too there were a series of other completely unexpected discoveries starting to emerge because people suddenly started to find other So what can we predict? We can predict first up that the rate kinds of stem cells all over the body; not just in the embryo but of progress will be frustratingly slow. Slower than the scientists in the adult and in the organs that make us up. We’d known for pretend it’s going to be. Slower than the companies promise you decades that there was a blood stem cell that can give rise to all it will be. There is a lot yet that we don’t know. We can guess of the blood cells. We knew that in Australia because we’re very that pretty much everything that looks like it’s a barrier in the end proud of the fact that it was Don Metcalfe in Melbourne that did will be overcome by smart scientists. We knew you couldn’t turn much of the work that taught us that there was a blood stem cell. a cell backwards, but in fact you could. We knew there were no But then people started to report stem cells in places that we stem cells in the brain. Most of the textbooks will still tell you that, knew they didn’t exist. Again, an Australian group from Melbourne but in fact that was wrong too. Smart people tackling important reported that there were stem cells in the brain. We all knew that problems will find solutions. had to be wrong because the brain doesn’t replace itself. Except that’s wrong. The brain replaces itself very actively and it replaces We do know, though, that there are stem cells with the right itself very actively because of the stem cells that are located within properties for dental repair. They are immortal, so you can get the brain. And that story has continued. I was very suspicious lots of them, and they can turn into the cell types that you would of some of the stories I heard that there was such a thing as a find interesting. We know that there is more than one kind of stem kidney stem cell until another Australian group reported in Nature cell that might be useful in this context. We know that the stem that indeed there was a kidney stem cell and it can be used to cells that exist can be coaxed into the kind of cells that you might replace kidneys. There are people out there who swear that there want. That can be done outside the body using biological signals. is a lung stem cell and their data looks pretty good. And all I can That can be done inside the body by transplanting the cells. We say is, every time you hear these sorts of stories and you think know that those cells can form functional structures; teeth, bond, they sound fanciful, it somehow seems to be the case that rigorous connective tissue, in response to normal signals and we know that scientific investigation shores them up. those cells can be derived in a number of ways from autologous sources. That that then heralds the possibility of replacing defects Now, you’re not interested in those organs but you probably do using the patient’s own cells to produce solutions that look no know that there’s pretty good evidence for dental pulp stem cells. different from the starting point. Stem cells that sit within the dental system that are quite capable of giving rise to the cell types that make up teeth, that make up some The rate of progress, should it occur, will be determined by the of the bone, that make up the connective tissue that organises things that normally control research; the level of investment, the the entire system. You might know that scientists in Australia, legislative permissiveness, which is a big deal in stem cell biology, particularly Adelaide, are at the forefront of this field. and the dedication of inspired researchers. This may be your future. This may be part of your future. This may not be part These cells that we find in the adult body we don’t call embryonic of your future. Research will tell. But Robert Harris would have stem cells. We call them somatic stem cells or adult stem cells. We known and would have respected the fact that further attempts to can’t grow them pure in the laboratory like we can with the stem steer from craft to science are always worthy of investment, that cells that I work with but otherwise the basic principles hold firm. it is precisely that endeavour to always do better in the cause of As best we can tell, they are immortal. They can continue to divide. humanity that defines a real profession. They can’t usually give rise to every cell in the body. The ones that are found in the kidney seem to mainly give rise to kidney cells. And on that note I would like to say thank you for letting me share The ones that are found in the brain seem to mainly give rise to with you this evening. brain cells. That kind of makes sense. 24 RACDS ANNALS 2016

ANNALS OF THE ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS SCIENTIFIC PROGRAMME PAPERS AND ABSTRACTS FROM THE TWENTY-THIRD CONVOCATION OF THE ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS HOBART, TASMANIA, AUSTRALIA, 31 MARCH – 2 APRIL 2016 Readers are advised that since the Annals reports the Proceedings of Convocation, none of the scientific papers has been peer reviewed.

ORAL BIOFILMS IN HEALTH AND DISEASE Dr Svante Twetman, DDS, PhD, Odont. Dr., Spec. Paediatr. Dent Dr Twetman is a specialised paediatric dentist and professor of cariology at the Faculty of Health and Medical Sciences, University of Copenhagen, Denmark. ABSTRACT Analytical epidemiology can be a powerful tool to determine risk factors for diseases, and potentially uncover causality of chronic diseases. However, it is governed by strict research methodology to ensure rigour of the results of studies. In the attempts to identify and quantify risk factors for periodontitis, many of the studies fall short of the scientific rigour, particularly with regard to the measurement and classification of individuals with and without disease, or progression of periodontal disease. The lack of consensus over how to measure and classify periodontitis cases has led to reporting of a plethora of “significant” associations, either identifying periodontitis as a risk factor for systemic diseases, or in identifying risk factors for the development of periodontitis. Many of these results are later not validated by replicate studies, or by studies using a different method of classifying a person with periodontitis. This paper looks as some of these methodological issues and the influence of classification on analytical epidemiological results. INTRODUCTION polymeric substance. Biofilms are present over the entire body and are formed in a dynamic equilibrium with the environment. An interesting detail for dentists is that the dental plaque is one of Dental caries is the most prevalent chronic condition worldwide, the easiest accessible biofilms in the body and thereby increasingly affecting 2.4 billion people. In addition, around 621 million children attractive for interdisciplinary researchers. 1 have untreated caries in their deciduous teeth (10th-most prevalent The properties of biofilm communities are more than the sum condition) making up a caries burden in 45% of the global the component microorganisms. For example, a biofilm can be 4 population. The disease is still the major cause of tooth loss and more than 100 times more resistant to antibacterial agents than the severe forms are associated with pain and feeding problems as planktonic cells. In general, biofilms that are diverse and stable are well as impaired wellbeing and quality of life. Interestingly, there is associated with health (homeostasis) while destabilized biofilms 2 evidence to suggest that the disease shifted from children to adults with a reduced diversity (dysbiosis) are associated with disease. 1 with three peaks at ages 6, 25, and 70 years. Therefore, caries is The resident oral microbiota is normally diverse and beneficial to a concern throughout the entire life course and prevention and the host but the stability can be disrupted by stress. With respect oral health promotion is needed for all age groups. Often described to caries, the repeated exposure to dietary sugars, and hence as multifactorial, caries is a biofilm-mediated disease resulting subsequent to low pH, favors the growth and metabolism of acid- from a complex interaction between the commensal microbiota, producing and acid-tolerating bacteria (i.e. mutans streptococci, 3 host susceptibility and environmental factors such as diet. The lactobacilli, bifidobacteria, scardovia), causing dysbiosis. As this 5 purpose of this paper is to discuss the role of the oral biofilm in shift of the commensal microbiota is driven by ecology, caries is relation to caries and maintenance of oral health. A special focus is not a classical infection but should be regarded and handled as a the establishment of the early biofilm in infant and toddlers and its non-communicable disease. It is however important to know that impact on future caries activity. a stress-derived dysbiosis is reversible; when appropriate actions are taken to counteract the environmental challenge, biofilm may return to stability through a “colonization memory”. From a pure WHAT IS A BIOFILM? chemical point of view, caries is an imbalance between mineral loss and mineral gain. When more minerals are lost over time, a caries lesion eventually becomes visible. In a simplified way, It is nowadays well established and generally recognized that demineralisation occurs at low pH conditions in the oral biofilm bacteria play an important role in health and wellbeing. Many and remineralisation at pH levels around neutral and above. If left terms have been used to describe the accumulation of debris in untreated, the initial lesion will progress in stages and progress to the oral cavity. For many years, it was named materia alba (“the moderate and advanced lesions. The progression rate is generally white materia”) although it was known to consist of accumulated faster in the primary dentition as compared with permanent teeth. microorganisms, desquamated epithelial cells, blood cells, and Severe early childhood caries displays the most rapid and rampant food debris. This term was later replaced by the expression dental progression of the caries disease with advanced cavities before the plaque being a dense, non-mineralized, highly organized biofilm age of 3 years. of microbes, organic and inorganic material derived from the saliva, gingival crevicular fluid, and bacterial byproducts. Plaque is probably still the most commonly used expression among COMPOSITION OF THE ORAL BIOFILM dental professionals and their patients. It is also well established in the context of the non-specific and specific plaque hypothesis that earlier were used to explain the pathogenesis of dental caries. The oral cavity contains hundreds of bacterial species that together Since dental plaque is one of the human biofilms, this term is with fungal and viral inhabitants form highly complex communities now more commonly applied among researchers based on the where they interact with each other and with the host. One ml of increasing understanding of its complex properties. A biofilm is saliva contains around 108 colony forming units (cfu) of bacteria any aggregate of microorganisms in which cells adhere to each and there are more bacteria in one mg plaque (1012 cfu) than people other on a surface that is protected. These adherent cells are on earth! This equalizes the amount in human guts intestines albeit frequently embedded within a self-produced matrix of extracellular the proportion of the taxa Firmicutes is higher in the oral cavity. The 26 RACDS ANNALS 2016

Human Oral Microbiome Database contains over 600 taxa and 13 and decrease the biofilm acid production. A second benefit for phyla. A “healthy” core oral microbiome consisting of 12 genera polyols incorporated in chewing gums is the stimulated saliva 6 that is shared by most humans has been proposed by Zaura and secretion that will be further discussed below. 7 co-workers; Streptococcus, Veillonella, Granulicatella, Neisseria, Haemophilus, Corynebacterium, Rothia, Actinomyces, Prevotella, ii) Regular mechanical removal of biofilm through tooth brushing, Capnocythophaga, Porphyromonas, and Fusobacterium. The flossing and professional tooth cleaning is commonly advocated as the key for dental health. This is without doubt supra-gingival biofilm is dominated by Gram positive species while Gram negative strains are more prevalent in sub-gingival biofilms. a sound habit but the evidence of efficacy in terms of caries 18 It is however important to understand that the architecture and prevention and control is unfortunately unclear. Again, composition of the oral biofilm is individual and unique for each each biofilm is unique and a thin healthy biofilm is protective 8 person (Figure 1) and the composition is depending on a number against erosion. On the other hand, very thick and destabilized biofilms must be disrupted so they can be affected by of factors as listed in Table 1. In this context, the first years of life seem to be of special interest as the fetal tolerance toward the preventive and therapeutic agents. Consequently, a good but mother’s microbiota during pregnancy is a major factor selecting not meticulous oral hygiene seems to mediate and maintain for the acquisition of the oral microbiome. oral health. Oral care products may contain broad-spectrum antimicrobial agents (chlorhexidine, triclosan) to augment mechanical plaque control. Such agents may however drive ORAL BIOFILMS IN EARLY AGE dysbiosis, particularly when used over extended time periods. Thus, according to the ecological approach, antibacterial The oral cavity is colonized by bacteria immediately upon birth. agents should be recommended for short-term use only and However, the sequence and timing of microbes dictate the in sublethal concentrations in order to control the biofilm composition of the oral biofilm on a “first come, first served” basis. without killing. 4 For example, children born through vaginal delivery have more beneficial bacteria and a greater diversity in their oral biofilms iii) Sugar is fueling the biofilm stress and sugar restriction is the than children delivered with caesarian section. The richness of only true causal and upstream mode to combat the acid 9-11 species and taxa diversity increases with age but differences due stress. WHO released updated guidelines in 2015 and issued 12 to the mode of delivery may persist up to at least one year of age. a strong recommendation that the intake of free sugar Consequently, it has been reported that children born via caesarian should not exceed 10% of the total daily energy intake but 19 section display more caries at the age of three years than vaginally suggested a further reduction to below 5% of total energy. delivered children. Interestingly, there is a general link between Free sugars include monosaccharides and disaccharides 13 the mothers and their infants at 6 month of age concerning the added to foods and beverages by the manufacturer, cook biofilm composition but the similarities seem to be greater among or consumer, and sugars naturally present in honey, syrups, vaginally delivered children. Another example is that breast-fed fruit juices and fruit juice concentrates. 5% corresponds to not 11 infants are reported to have a higher diversity than formula-fed more than two tablespoon per day and this is exceeded in at three months of age and this is likely explained by the high most populations and age groups. Thus, dental professionals 14 content of oligosaccharides that act as prebiotics by promoting the must therefore address both the amount of sugar and the growth of beneficial bacteria. As a consequence, breast-fed children frequency of sugar intake in their motivational interviews. 15 have less caries than formula-fed peers. According to the hygiene According to the common risk factor approach, the sugar hypothesis, there is a danger of an over-clean environment; children recommendations are not only focused on caries and oral should be exposed to as many beneficial bacteria as possible early biofilms but also to overweight, diabetes and cardiovascular in life in order to stimulate the development of the immune system diseases. Unfortunately, the evidence of efficacy for dietary and prevent chronic conditions such as allergies and asthma. An modifications is very low. In fact, they are slightly higher for interesting observation concerning the use of pacifiers has been changes in fruit/vegetable and alcohol consumption than for reported by Hesselmar et al. Children whose parents “cleaned” changed dietary sugar consumption. 20 16 their children’s pacifiers by sucking had a greater microbial diversity iv) Saliva contains plays an important role in biofilm control in their saliva than children whose parents did not. Moreover, this through buffering, mechanical cleansing and its content parental sucking resulted in a significantly reduced risk for allergy of mucins, glycoproteins, enzymes, electrolytes and and eczema. A vision is that transfer of oral microbes from parent immunoglobulins. Ageing, radio- and chemotherapy and to infant via the pacifier can be used in primary prevention of polypharmacy constitute significant burdens in many patients general and dental diseases in the future. and these conditions are strongly linked to biofilm stress. 21 Thus, saliva stimulation, or use of salivary substitutes are HOW CAN THE BIOFILM STRESS BE CONTROLLED? helpful in maintaining biofilm homeostasis in frail elderly. As mentioned earlier, the key for maintaining dental health is v) Recent clinical studies and systematic reviews have shown not to eliminate the biofilm but to control and support microbial that fissure sealants and resin infiltrations of occlusal micro- homeostasis through ecological approaches. The main avenues cavities and proximal surfaces are effective in arresting 22,23 are: i) use of metabolic inhibitors, ii) mechanical disruption, iii) enamel and initial dentinal lesions. The minimally invasive sugar restriction, iv) saliva stimulation, v) micro-invasive sealants/ and micro-invasive alternatives are simply locking out the infiltration, and, vi) novel strategies, such as probiotics and alkali substrate to the remaining biofilm within the lesions and the supplements. bacteria are kept dormant and inactive. Such treatments must i) It is well known that fluorides in low to moderate concentrations however always be checked and maintained in order to avoid failures due to leakage. can affect the balance between re- and demineralization through local interactions in the biofilm. Fluoride can also vi) Among the emerging strategies for biofilm control, probiotic hamper the metabolic activity of selected bacteria by blocking supplements and alkali-generating technologies are clinically the enzyme enolase which is catalyzing a crucial step in the in use. The concept of beneficial bacteria is covered in a glycolysis Thus, regular exposure to high fluoride products separate paper. Arginine is a non-essential amino acid that .17 such as varnish, gel and toothpaste can reduce the lactic acid is produced in the body and normally found in saliva but stress in the biofilm and lower the “critical pH”. Similarly, xylitol in very low concentrations. Selected bacteria in the biofilm exposure exerts antibacterial effects. The polyol is transformed are arginolytic and can produce alkali metabolites, such as to xylitol-5-phosphate within the bacterial cells which is toxic ammonia, and raise pH or neutralize the acid formed within the biofilm. The anti-caries effect of adding arginine to RACDS ANNALS 2016 27

toothpaste has been shown in several clinical trials conducted is no preventive approach that fits all and no method that works in both adults and children. 24 without compliance. The current metagenomics sequencing can be used to create a gene catalogue of the oral microbiota and CONCLUDING REMARKS allow functional analyses of the microbial community in health and disease. Eventually, this will be helpful in elucidating the microbial Cariology has moved from “extension for prevention” to pathogenesis of dental caries and open up a novel landscape for “prevention of extension” in the context of halting the disease preventive and therapeutic approaches for the management of and preserving as much natural tooth structure as possible. 25 biofilm stress. In the meantime, maintaining a stable community of The ecological approach to biofilm control is offering a “colorful” commensal and beneficial bacteria in the oral cavity is a sustainable palette of measures that may be used in clinical practice (Figure way to achieve better dental health. 2). The quality of evidence is however contrasting from strong for fluoride to very low for flossing and diet control. It is important to keep in mind that evidence-based practice and clinical decision making is a triad requiring the judicious integration of clinically relevant scientific evidence with the dentist’s clinical expertise and the patient’s treatment needs and preferences. Thus, there REFERENCES and meta-analysis. PLoS One 2015;10(11):e142922. 1. Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray CJ, 16. Hesselmar B, Sjöberg F, Saalman R, Aberg N, Adlerberth I, Wold Marcenes W. Global burden of untreated caries: a systematic AE. 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Oral microbial profile System (ICCMS™) An example of a caries management discriminates breast-fed from formula-fed infants. J Pediatr pathway. BMC Oral Health 2015;15 Suppl 1:S9. Gastroenterol Nutr 2013;56:127-36. 15. Avila WM, Pordeus IA, Paiv SM, Martins CC. Breast and bottle feeding as risk factors for dental caries: A systematic review 28 RACDS ANNALS 2016

Table 1. Factors that may affect the composition of the oral biofilm _____________________________________________________________________ Variable Examples _____________________________________________________________________ Genetics bacterial exchange of genetic material through plasmids Location, oral cavity mucosa, tongue, sub-gingival pocket, access to saliva Location, teeth occlusal fissure, interdental area, smooth surface Age biofilms alter with age, degeneration of glands Diet sugar rich diet vs. beans, fruit and vegetables Smoking non-smokers vs. smokers Alcohol excessive intake may affect composition Medication xerogenic drugs, drug abuse Sexual behavior kisses, and more _____________________________________________________________________ Email address for correspondence: [email protected] Figure 1. Architecture of oral biofilms formed on enamel discs in situ in three subjects during 7 days. The biofilm from subject 1 had a compact structure with mainly spherical cells and low levels of extracellular space. In contrast, biofilms from subjects 2 and 3 were thicker but with the same levels of bacterial biomass as subject 1, consistent with a more open architecture containing sparsely distributed spherical cells and/or filamentous rods. Notably, subject 2 had a lower overall vitality (71%) compared with subject 1 (95%) and subject 3 (98%). Pictures from Rabe and co-workers. 8 RACDS ANNALS 2016 29

Figure 2. A preventive palette showing examples of technologies that are available for the dental practitioner to maintain oral biofilm diversity and stability 30 RACDS ANNALS 2016

CAN WE PRACTICE EVIDENCE BASED ORTHODONTICS? Prof Kevin O’Brien, BDS, FDSRCP, FDSRCS, MSc, D.Orth, PhD Prof Kevin O’Brien is a Professor in the Department of Orthodontics School of Dentistry, University of Manchester, UK. ABSTRACT All aspects of our lives are influenced by uncertainty and this is particularly true for the clinical decisions that we take. It is clear that there is no such thing as 100% uncertainty and the aim of scientific investigation is to try to reduce this uncertainty as much as possible. Conversely, clinical uncertainty is increased by claims for treatments that are not based upon research evidence. We would all like to practice evidence-based dentistry and orthodontics. As a result, reducing uncertainty is integral to this aim. When we consider the nature of evidence that should reduce uncertainty a good place to start is the well-established pyramid of clinical evidence. This ranks the type of research study design in terms of the strength of the evidence that it provides. While this emphasis is commendable, we should not forget that the optimum practice of evidence-based care is not solely influenced by research. For example, Sackett pointed out that we should consider that there are three components that contribute to evidence based care, these are: clinical research, clinical experience, and patient opinion. The proportion of each component that influences a final clinical decision is influenced 1 by their relative strengths. Importantly, all evidence that is based on clinical experience and research should be fully explained to our patients in order that they can make the choice on their treatment. Paradoxically, there is also a resistance to accepting the results of clinical research I have been challenged in discussions on the interpretation of my research and I have put these arguments together as a “pyramid of denial”. How can we practically provide information to our patients when we are uncertain? I would like to illustrate this with information that can be identified from two Cochrane systematic reviews. This first is our recently completed systematic review into orthodontic treatment for prominent teeth. In this review we aimed to assess the effect of early orthodontic treatment for class II malocclusion. This is a treatment 2 that has been provided in two phases. The first being a course of early treatment when the young person is approximately 8 years old. This is then followed by a second phase when they are in early adolescence. We identified three large randomised trials, which are well known in orthodontic research. For most of the orthodontic effects of treatment there was no advantage of treating children early. Nevertheless there was some evidence that this resulted in a 9% reduction in the incidence of trauma. While this finding may be clinically important there was a moderate degree of uncertainty in these findings. A similar Cochrane review in paediatric dentistry looked at the Hall technique of placing preformed metal crowns on carious primary teeth. This was evaluated in five randomised trials and the authors concluded that the crowns placed with the Hall technique are likely to 3 reduce the chance of major failure of the restoration when compared to fillings. There was also less discomfort with the Hall technique. However, the quality of evidence was low and there was a high level of uncertainty. As a result, we can conclude that when we discuss treatment with our patients we can be moderately certain on our recommendations on early orthodontic treatment but less certain on the Hall technique. The provision of evidence-based care clearly has an important role in providing information to operations as part of informed consent. In the United Kingdom this is clearly set out by the professional regulator, the General Dental Council. The issue of consent in the UK has recently changed following a recent court ruling. It is now necessary for healthcare professionals 4 to make sure that they seek fully informed consent from patients. The judgment is rather complicated but may be summarised by considering that the main points are that the relationship between the doctor/dentist be a partnership based on trust and openness. Importantly our patient should be well-informed about significant risks and reasonable alternative treatments. We, therefore, need to be able to provide more information to our patients about our care. When I consider orthodontics, information needs to be provided on the benefits of treatment and the probabilities of risks. This leads us to the difficult question “is some evidence good enough”? Perhaps this will prompt us to carry out more meaningful research in dentistry and orthodontics. REFERENCES 1. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-72. 2. Thiruvenkatachari B, Harrison JE, Worthington HV, O’Brien KD. Orthodontic treatment for prominent upper front teeth (Class II malocclusion) in children. The Cochrane database of systematic reviews 2013;11:CD003452. 3. Innes NP, Ricketts D, Chong LY, Keightley AJ, Lamont T, Santamaria RM. Preformed crowns for decayed primary molar teeth. Cochrane Database Syst Rev 2015;12:Cd005512. 4. D’Cruz L, Kaney H. Consent - a new era begins. Br Dent J 2015;219:57-59. Email address for correspondence: [email protected] RACDS ANNALS 2016 31

DEMENTIA: ISSUES IN CONTEMPORARY RESEARCH AND MANAGEMENT Prof Andrew Robinson, PhD Prof Andrew Robinson is affiliated with the Wicking Dementia Research and Education Centre & School of Health Sciences, University of Tasmania, Hobart, Australia ABSTRACT The primarily age-related condition of dementia is fast becoming a global public health challenge. It is estimated that there are 44.4 million 1 people with dementia worldwide in 2013 and that this will increase to 135.5 million by 2050. Currently, dementia is the second leading cause of death in Australia and there are more than 332,000 Australians living with this condition. 2-4 Dementia is a progressive degenerative condition and is associated with significant morbidity and mortality. The characteristics of dementia include cognitive problems, behavioural responses, functional deficits, movement problems, and psychiatric conditions. The cognitive decline and behavioural difficulties that characterise dementia undermine the ability of these adults to take care of their own health, including maintaining their oral health. Difficulties relating to prognostication, illness trajectory & identification of proximal cause of death mean that many people with dementia often experience inadequate pain and symptom management, invasive and futile diagnostic tests & inappropriate hospitalisations. Mitchell et al. report that despite being a life-limiting condition, 40 per cent of people with advanced dementia who live in nursing homes are likely to 5 be subject to ‘burdensome and inappropriate interventions’. Yet as a terminal condition, dementia is best managed by instituting a palliative approach to care. With respect to the provision of oral care for people with dementia living in nursing homes, the literature indicates that this is fragmented and not delivered consistently. Further, the Better Oral Health in Residential Care report notes that barriers to the provision of effective oral care 6 centre on nursing home residents’ poor health, difficult behaviour, and fear of pain, while also identifying that a lack of staff support, including inadequate staff education and allocated time for care, as compounding these issues. A good knowledge of dementia, including its progression and management, among health care professionals/workers and families is essential for clear decision-making and the provision of appropriate care. However, our research has highlighted significant problems with dementia knowledge among family members of people with dementia and nurses and care workers employed in residential aged care facilities. This is problematic because a good working knowledge of dementia is imperative to provide evidence based, person centred care, 7 not least to the more than 50 per cent of residents in Australian nursing homes who have dementia. 7 Our research highlights the impact of poor educational preparation. It demonstrates that around 50 per cent of aged care staff and 60 per cent of family carers lacked an understanding that dementia is a terminal condition, which we argue may account for Mitchel’s findings, cited 5 above. Further our research identified poor knowledge related to a range of factors encountered in advanced dementia, including delirium, dysphagia, immobility, and pain. Worryingly, our research also identified that family members can have a better knowledge of dementia than the clinical lead registered nurses, which we argued might “contribute to tensions arising when staff and family come together in decision 7 making with possibly divergent understandings”. It was this situation that prompted the Wicking Dementia Research and Education Centre to develop an online education programs that would make high quality dementia education readily available. Our intent was to address the knowledge gap that compromised efforts to provide evidence based care to people with dementia. Consequently, in 2012 the Wicking Centre established a range of online education programs designed to build capacity for dementia care. These include the world first Understanding Dementia (UD) massive open online course (MOOC) and innovative undergraduate degree specifically focussed on dementia, the Bachelor of Dementia Care (BDemCare). Since 2012 the BDemCare has become the third largest course at the University of Tasmania, and now provides a streamlined articulation pathway from the UD MOOC. Currently, around 60% of BDemCare students have completed the UD MOOC. Now fully online, the degree program has undergone significant growth since its inception and currently has 1,256 students enrolled (Sem 1, 2016) nationally. It has a predominantly non-traditional student cohort comprising a mature aged, female cohort that is often the first in their family to attend University, who can access nested completion points at the Diploma and Associate Degree level. The UD MOOC has reached 70,604 participants in 147 different countries since 2013, with record breaking completion rates of 38%. Further, while participants’ level of education ranged from postgraduate study to a primary (elementary) school education, those without a university education (vocational certificate and below) were as likely as those with a university education to complete the course. The UD MOOC 8 involves a 9-week program comprising three modules, the Brain, the Diseases and the Person. It progresses from introducing the nervous system, working through how dementing illnesses specifically affect the brain, to how understanding this disease process and trajectory of progressive dysfunction should inform care. Our commentary in Nature celebrates our tailored approach of the UD MOOC in reaching and engaging non-traditional and disadvantaged learners. 9 In conclusion, the Wicking Centre now offers high quality low cost courses that can address the significant deficiencies in dementia knowledge that in turn frustrate efforts to provide high quality dementia care. 32 RACDS ANNALS 2016

REFERENCES 1. Alzheimer’s Disease International (ADI). World Alzheimer Report. London: ADI; 2015. https://www.alz.co.uk/research/ WorldAlzheimerReport2015.pdf 2. Department of Health and Ageing (Australia). Guidelines for a palliative approach to residential aged care — enhanced version. Canberra: Department of Health and Ageing; 2006. 3. Department of Health and Ageing (Australia). Guidelines for a palliative approach for aged care in the community setting: best practice guidelines for the Australian context. Canberra: Department of Health and Ageing; 2011. 4. Australian Institute of Health and Welfare (AIHW). Dementia in Australia. Canberra: AIHW; 2012. 5. Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med 2009;361(16):1529-1538. 6. Fricker, A, Lewis, A. Better oral health in residential care: Final report. Australian Government Department of Health and Ageing; 2009. 7. Robinson A, Eccleston C, Annear M, Andrews S, Ashby M, Donohue C, Banks S, Toye C & McInerney F. Who knows, who cares: Nurses, care workers and family members’ knowledge of dementia. Journal of Palliative Care 2014;30/3:158-165. 8. Goldberg L, Bell E, King C, O’Mara C, McInerney F, Robinson A, Vickers J. Relationship between participants’ level of education and engagement in their completion of the Understanding Dementia Massive Open Online Course. BMC Med Educ 2015;15:60; doi:10.1186/s12909-015-0344-z. 9. King C, Robinson A, Vickers J. Online education: Targeted MOOC captivates students. Nature 2014;505:26; doi:10.1038/505026a. Email address for correspondence: [email protected] RACDS ANNALS 2016 33

AUTUMN LEAVES: A JOURNEY WITH DEMENTIA Dr Graeme Ting, MSc, MDS, FRACDS (SND), DABSCD, FICD Dr Graeme Ting is a Consultant in Special Care Dentistry at King’s College Hospital NHS Foundation Trust, London, United Kingdom. ABSTRACT This paper presents the current trends in population demographics for older people and how these impact on oral health care provision. In particular it focuses on the relationship between ageing, medical problems in the older population and their potential impact on oral health and oral health care. The main item discussed is dementia and its impact on oral health from the patient, caregiver (including oral health professional care provider) perspective. INTRODUCTION asked to determine what care is in the best interests of someone In developed countries, census figures have shown an increase in who may not be able to advocate for themselves. the proportion of older people in the population. This improved longevity has in general, been brought about by good living Older people with medical problems and disabilities including 1 conditions and advances in medical care. There has been a dementia, often have oral and dental problems with high treatment corresponding increase in the proportion of older people with needs. These people frequently have the poorest access to dementia within this older population. 2 services so are likely to miss out on treatment. They will often present for care late with more severe problems and may present with behavioural challenges if they have dementia. Prevalence of dementia with age Age (years) Prelevence Dementia 40-64 1 : 1000 People with dementia have impaired cognitive function that in 65 - 69 1 : 50 some way impacts on normal living and personal relationships. 7 70 - 79 1 : 20 Dementia is a diagnosis invoked after the effects of a number of disorders affecting the brain become apparent. A diagnosis 80 + 1 : 5 of dementia is made if more than two intellectual functions (e.g. cognitive skills – analysis, reasoning and judgment; language skills – As a consequence of the changing proportions of age groups in speech and comprehension; or memory) are significantly impaired. the population, dental practitioners are being asked to care for Memory loss is a common symptom of dementia, but memory more and older people. These older people are more likely than loss per se does not indicate dementia. Dementia is a term that not, to have several medical problems; a proportion of them will describes a set of symptoms brought about when the brain is have dementia among their medical co-morbidities. 3 affected by a disease or several disease processes. Alzheimer’s disease, cerebrovascular disease, degenerative brain disease are When we consider the dental status of the older population, many three examples of processes that may lead to dementia. The set of these older people are dentate compared to a similar aged of symptoms may include: cognitive and language difficulties and 8 4 cohort from the past. There has been a shift from loss of teeth problems with memory loss alone or in combination. to retention of teeth as dental science, treatment rationales and 9 technology have changed, progressed and improved. Dementia can be classified as either ‘reversible or ‘irreversible’. Reversible dementias may arise from: drugs or alcohol; emotional The most long-lived in society tend to come from higher disturbances; metabolic causes; endocrine dysfunction; nutritional socioeconomic backgrounds. Census figures show an increase in deficiencies; brain tumours or trauma; infections; and cerebral 2 9 the proportion of relatively well-off older people in the community arteriosclerosis. Medical treatments alleviate the dementia-like with dementia. Prior to their diagnosis with dementia, these people symptoms brought on by these precipitating factors and thus the will have come from relatively financially secure backgrounds and dementia associated with them is said to be ‘reversible’. have had high dental treatment expectations and may have had complex dental treatment. Irreversible dementias may be related to: Alzheimer’s disease; multi-infarct dementia; Lewy body disease; dementia pugilistica; As people get older, their contact with medical services increases Creutzfeld-Jackob disease; Pick’s disease; Parkinson’s disease; and their contact with dental services decreases. This means Huntington’s disease and brain tumours. These precipitating 5,6 then when they attend the dentist, any dental disease experienced factors often lead to irreversible changes in brain structure and by that older person, is more likely to be advanced compared to if function and are thus said to cause irreversible dementia. 9 they attended more regularly and the dental problems intercepted earlier. It is not out of the question to expect that dentists will be Drugs for management of dementia asked to see a proportion of dementia sufferers who are likely to At present there are no drugs treatments that can cure dementia have much more complex dental work to maintain and will be and drug management is aimed at temporary management 34 RACDS ANNALS 2016

of symptoms or slowing the progression of the disease. Non- such as placing toothpaste on a toothbrush and brushing teeth, pharmacological care (for example: occupational therapy, cooking, operating appliances, direction finding, and processing music therapy, social activities and outings etc.) that improves words in the correct sequence for speech and comprehension. the quality of life of a person with dementia, is just as important 10 as any pharmacological adjunct. Two broad categories of The frontal lobes are involved with initiation of motor function, medication are used to treat Alzheimer’s disease: these are the speech, planning actions as well as social judgment. Damage to the acetylcholinesterase inhibitors and N-methyl-D-aspartate (NMDA) frontal lobes may result in changes such as the person becoming receptor antagonists. Although the acetylcholinesterase inhibitors uncoordinated with speech and movement, being disinterested or are mainly for the treatment of Alzheimer’s disease, they have also having a flat affect toward other people or activities and displaying be used for people with dementia with Lewy bodies and dementia disinhibited behaviour. related to Parkinson’s disease. The acetylcholinesterase inhibitors lead to an increase in the level of acetylcholine in the brain and The temporal and occipital lobes and the outer cortex of the brain thus may temporarily stabilise the symptoms of Alzheimer’s give a person the ability to interpret somatic sensation, process disease. Some people with Alzheimer’s disease produce excess visual and auditory information, as well as think and reason. A of the neurotransmitter glutamate. NMDA receptor antagonists process of dementia damaging these regions of the brain will alter offer neuroprotective properties by blocking the effects of excess these faculties in the affected person. glutamate on brain function. 10 Memory loss from the parts of brain under control of the Lateralisation of the brain hippocampus tends to be retrograde with information being lost The work of French physician Pierre Paul Broca, in 1861, gave some on a “last-on; first off” basis according to strength of association. of the first evidence that brain function could be specialised and This means that strong familiar memories created early in life tend some cognitive functions are dominated by their location on one to be retained longer than information that is newly acquired or side of the brain or the other. Broca determined that the left frontal accessed less frequently. A dentist can use this to an advantage lobe of the brain was important in speech. German physician Karl by relating to the patient the familiar scenario of a dental checkup; 11 Wernicke found that not every expressive aphasia was the result particularly if the patient has a history of regular dental care. of a speech production deficit. Some expressive aphasias were the result of damage to the left posterior, superior temporal gyrus Activity focused assistive strategies that result in language comprehension deficits. The right side of Assistance with activities such as toothbrushing is frequently 11 the brain has functions that include: recognising faces; expressing required for people with dementia. It is possible to provide emotions; music, reading emotions, recognising and processing assistance by using a combination of helping strategies: colour and images, and using intuition and invoking creativity. The left-side of the brain has functions that involve logic, language • Bridging involves using the person’s senses to engage their and analytical thinking, reasoning, interpreting and manipulating attention to help them focus on and perform a task. For numbers. example placing a toothbrush in their hand may invoke memories that allow them to brush their teeth or realise their Lateralisation of the brain is significant because a neurodegenerative teeth are being brushed. process affecting particular areas of the brain will result in • Distraction involves placing a familiar item such as a towel, soft functional deficits related to the area affected. For example, fronto- toy, or perhaps playing familiar music’s to distract them and temporal lobe involvement produces dementia with disinhibition allow an activity, for example toothbrushing, to be carried out. and sometimes aggressive behaviour. 12 • Chaining means that the caregiver begins the oral hygiene Dementia-related brain damage task and the person then helps to finish it. A consequence of Alzheimer’s Disease is damage in the form • Hand-over-hand is a technique that can help to improve of altered structure and loss of neuronal tissue in the brain. This sensory awareness of a task. For example a caregiver places neurodegeneration is caused by a build-up of amyloid plaques his or her hand over the person’s and then starts to brush and neurofibrillary tangles which causes loss of brain function and their teeth or remove or replace their denture brain volume. Matrix metalloproteinases, enzymes responsible for normal neurological development; are postulated to play an • Rescuing is often used to help with completing tasks for important role in neurodegeneration. people with dementia. For example a person may initiate tooth brushing but a caregiver may be required to complete the task. The symptoms brought about by neurodegeneration depend on which parts of the brain are damaged. In Alzheimer’s disease, this Preventive dental care usually begins in the limbic system and symptoms manifest as Preventive dental care and the role of caregivers or family members cholinergic neurones are destroyed. The limbic system modulates in helping a person with dementia to maintain their oral hygiene is memory, behaviour and emotions; so symptoms can include an important part of providing a stable routine and home-based emotional lability, misplacing or losing items, irritability, depression dental initiatives such as the oral health tool kit: “Healthy Mouth, and anxiety. Healthy Ageing: Oral Health Guide for Caregivers of Older People, developed by the New Zealand Dental Association in conjunction Other important brain structures affected by Alzheimer’s disease with the New Zealand Ministry of Health provides guidance for are the hippocampus, the amygdala, the parietal and the frontal caregivers to assist older people, including those with dementia, in lobes. The hippocampus is involved with the processing of basic oral hygiene. 14 visual and verbal memory while the amygdala is responsible for processing experience and the control of expression of emotions. Dementia and dental care Damage to these parts of the brain explains why memory loss and People in the early stages of dementia may require no special emotional changes are some of the earlier signs of Alzheimer’s considerations related to dental care. They may be able to disease. understand, agree to, and cope with any proposed dental procedure that is indicated to maintain their oral health. They may The parietal lobes process events that rely on sequential memory be able to adequately perform the required level of oral hygiene to and allow a person to have spatial awareness. Parietal lobe damage ensure the success of the dental care that is provided. may lead to a person being unable to do sequence-based tasks RACDS ANNALS 2016 35

Communication strategies for people with dementia Chalmers in 2000, analysed the literature and defined core categories that could be used to communicate with cognitively impaired 13 adults. These are presented in the table below: Communication strategies for use with cognitively impaired adults (adapted from Chalmers, 2000) Verbal Speech Construction Short words; simple sentences; nouns not pronouns; avoid questions if possible; identify yourself and use the person’s name Speech Style speak slowly and clearly in a normal tone of voice; wait for responses; repeat questions or instructions if required; eliminate complex choices; never talk as if the person isn’t there and always assume the person can understand more than they show; Non Verbal stand in front of the person and use eye contact; move slowly and calmly; gentle touch; smile; safe, quiet, non-stimulating environment; allow the person to rest and provide caring cues; visual picture cues may be helpful Other a familiar person is useful; simple tasks broken down into easy steps; praise and reassurance; distraction may assist providing personal care; develop rapport and explain procedures; enlist participation; decrease number of people in room and avoid sensory overload It is when the person’s dementia interferes with their ability to cope surface loss due to attrition, abrasion or erosion or developmental with having a procedure done; or they lack capacity to decide what defects such as enamel hypoplasia; in patients with high caries is in their own best interests; and they cannot adequately maintain susceptibility. In patients where routine oral hygiene measures are their own oral hygiene, that treatment planning and care delivery impaired e.g. patients with special needs and breakdown of intra- modifications may need to be considered. coronal restorations is likely. In patients undergoing restorative care under general anaesthesia if two or more surfaces are involved. 18 Minimally invasive dentistry is well established as a way of treating Perhaps similar criteria may be considered in the care of people dental caries. It combines preventive regimens with restorative with dementia. techniques based on science showing that it is not always necessary to remove large quantities of tooth tissue in order to Some people with dementia have a short attention spanned arrest decay and provide sound and long lasting restorative results. and limited cooperation that can place constraints on the type of restorative dentistry provided. Dental amalgam is durable and Chemo-mechanical treatment of carious lesions has advantages tolerant to a range of placement conditions. However, it is not for children and uncooperative patients because it comfortable suitable in the aesthetic zone and requires mechanical retention and involves only selective removal of carious dentine. It does not that may weaken tooth structure or simply not be able to be placed require the removal of sound dentine which can sometimes be due to a lack of tooth structure to retain the restoration. painful. Chemo-mechanical treatment of tooth decay may also be carried out without the use of dental drills so the vibrations, noise Glass ionomer cements are useful as restorative and preventive 19 and fear generated by this traditional method of treating tooth materials. They are adhesive and can take up and release fluoride decay, are avoided. to assist remineralisation of carious dentine. Glass ionomers are relatively straight-forward to place and are tooth coloured so have Adhesive dental technology and glass ionomer cements have a better appearance than amalgam. They need protection from been shown to be equally effective in minimally invasive treatment moisture for several hours after placement but may be used in of occlusal fissures and glass ionomer cements placed using an conjunction with both amalgam and composite resin. atraumatic restorative technique, have been shown to be as effective as restorations placed using more destructive restorative Chemo-mechanical removal of dental caries and the use of methods. minimally invasive techniques are comfortable (but sometimes slower) ways of treating tooth decay in anxious patients and those The shortened dental arch concept investigated by Kayser in 1981, patients who may have limited cooperation. 20 is a useful and successful treatment planning concept to evoke for older people who may present with a heavily broken down Glass ionomers may also be used as a therapeutic coating. They 15 and unrestorable posterior dentition. It may also be a preferred can be “painted” onto susceptible tooth surfaces. The aim of this treatment planning strategy for people with dementia. The removal is to create a coating that provides some physical and chemical of decayed retained posterior tooth roots or teeth affected by protection against caries. 21 untreatable periodontal disease; but with emphasis on preserving the best possible combination of anterior teeth has been shown to Sometimes people with dementia present with problems with provide good function, aesthetics and quality of life. 16 removable dentures. They may be refusing to wear their dentures or they may have inadvertently “lost” them through misadventure The use of stainless steel crowns to provide some longevity to or forgetfulness. A proportion of patients may tolerate the molar teeth, may also be a restorative options for people with construction of and wear their dentures. However, others may dementia. Placing preformed stainless steel crowns has been tolerate denture construction but not wear the completed shown to be beneficial in paediatric patients whose oral hygiene dentures; while another proportion of dementia sufferers will not is less than optimal and where cooperation for oral care may be tolerate the construction process at all. Dentists may be asked to 17 reduced. Reviews of the indication for stainless steel crowns for review a person’s dentures to eliminate them as a cause of pain paediatric patients include: Restoration of fractured primary molars; or non-eating and weight loss. A full oral examination should be Restoration and protection of teeth exhibiting extensive tooth carried out to eliminate the presence of soft tissue pathology such 36 RACDS ANNALS 2016

as candidal infection or ulcers; or if the patient is partly dentate: body with an arm which permits the individual to move but the dental caries or hard tissue pathology that could be causing pain. person’s arcing arm prevents excessive movement. Alternatively, The cleanliness, fit, border extension, hard and soft tissue support gentle holding of the moving part of the patient’s body; for example and occlusion of the dentures should be reviewed to eliminate an arm, with restraint only being applied in response to excessive potential sources of discomfort. movement. The patient is not held immobile but when they try to move, their movement is obtained to a safe level. Using a blanket Some consideration should be given to copy dentures, modifying to wrap the patient is controversial. In some settings it is only existing dentures, or transitional relines as these may be easier for considered acceptable for urgent treatment. This technique is used the patient to adapt to rather than having new prostheses made. for safety reasons where a patient may be extremely aggressive Denture labelling should also be part of the routine of denture and a danger to themselves or staff. 24 construction for these patients and perhaps residents of nursing homes in general. Some patients may have challenging or uncooperative behaviour that is cyclic. They may be able to be treated with local anaesthetic, The dentist may be required to lead an oral health team to with or without low level clinical holding to ensure their safety, educate caregivers and family members about denture and oral during a period of time when their behaviour is not disruptive and hygiene. Dentists are sometimes placed in a difficult position of they are relatively calm. providing rationale to family members or caregivers as to why is not appropriate to construct dentures for a person with dementia For other patients with more severe dementia, the dental and setting boundaries for realistic expectations for denture practitioner may be asked to weigh up the risks and benefits of construction and use. This can sometimes be a difficult discussion; using sedation or general anaesthesia, for treatment provision. particularly when close family members have a strong desire to see their loved family member’s mouth restored with a denture. The Royal College of Anaesthetists list the following as possible Factors such as behaviour and cooperation, the patient being able very common (1:10) or common (1:100) risks of general anaesthesia: to understand and consent to the procedure, their frailty and ability feeling sick and vomiting; sore throat; dizziness and feeling faint; to cope with impression taking, understanding of instructions to shivering; headache and chest infection; itch, aches and pains; pain comply with finding a centric relationship for the denture occlusion at the site of injection; bruising and soreness; and bladder problems. and having the dexterity and ability to place and remove dentures It is also very common or common for there to be confusion and must all be considered alongside the patient’s ability to actually memory loss, particularly in older people. wear, speak and function with the denture or dentures in situ. Uncommon (1:1000) risks include: breathing difficulty; damage Care philosophy: Clinical holding, local anaesthesia to teeth, lips and tongue; awareness; damage to eyes and nerve damage; and existing medical conditions getting worse. intravenous sedation and general anaesthesia Rare (1:10,000) or very rare (1:100,000) complications include: A proportion of people with dementia have challenging behaviour serious allergy to drugs; equipment failure and death. 25 and may not easily be able to receive care in a traditional dental practice. This means that the oral health team must consider Becoming confused is a common risk associated with a general what is in the person’s best interests in order to provide good anaesthetic, particularly in older people. Post-operative delirium quality oral care. Such best interest considerations will take into and post-operative cognitive dysfunction are the two types of account, alongside the person’s ability to cooperate, their ability confusion that can occur after a general anaesthetic. Post-operative to communicate and provide informed consent; their medical delirium is an early onset event and treatable, in contrast to post- comorbidities; their ability to provide their own oral hygiene care; operative cognitive dysfunction that has no well understood cause. their social, family and financial circumstances; if they are in pain People over the age of 60 and people with dementia are more or have problems eating or their oral health is impacting on their at risk of post-operative delirium and post-operative cognitive quality of life. These considerations must intersect with the length dysfunction than others. 26 and nature of any proposed dental procedure to arrive at an appropriate care path in the best interests of the patient. 22 Disorientation and confusion may be exacerbated after a general anaesthetic in people with dementia after admission to In some circumstances, clinical holding may be required to stop a a strange hospital ward. If a general anaesthetic is indicated then patient injuring themselves and to ensure the safety of staff. The consideration should be given to use of day surgery facilities benefits of the proposed treatment must be balanced against the where, after the patient has recovered post-operatively, the patient need for clinical holding and the risks posed by the technique used. is transferred back to familiar surroundings to minimise confusion. All staff must have had appropriate training and the techniques Intravenous conscious sedation may be a care modality of choice must be reasonable and in proportion to the nature of the care to facilitate dental care for people with dementia. It has advantages required. The person should have been assessed to ensure they for short procedures commonly carried out in the dental setting have no medical (eg cardiovascular), physical (subluxation of joints but may result in degrees of disorientation and delirium when or neck injuries), that could be exacerbated or lead to permanent used in people with dementia. While not an anticholinergic drug, disability should clinical holding be employed. benzodiazepines have been recorded as producing anticholinergic 23 side effects, similar to for example sedating antihistamines, Physical intervention may be: direct physical contact between a and associated with acute cognitive impairment in people with member of staff and a patient. For example, holding a person’s arm dementia. These anticholinergic-like effects may also include dry to stop them hitting someone. Another intervention could be using mouth and urinary retention. adjuncts to modulate movement, for example, using a splint on a person’s leg to prevent injury from inadvertent kicking movements. Propofol sedation offers faster recovery and is less likely to produce Finally, barriers, such as locked doors, limit freedom of movement post-operative cognitive dysfunction or delirium. However, 27 and ensure safety. propofol conscious sedation is an advanced technique and there is no reversal agent for propofol. The British Society of Disability and Oral Health list three different clinical holding techniques that can be used in the event that physical intervention is required: Forming an ‘arc’ over the patient’s RACDS ANNALS 2016 37

Determining pain and discomfort in persons with decision; one that goes against what a clinician thinks is in the best dementia interests of the person concerned. Dentists are frequently asked to determine if a person with dementia has pain arising from their mouth or teeth that could The informed consent process provides the patient with account for a change in behaviour, sleep patterns or eating information about the nature and purpose, the risks, benefits and pattern. Pain can be difficult to assess for any individual but in alternatives of a particular treatment. The process also should cognitively impaired people it can be especially difficult diagnostic ensure that the patient understands the information given to them challenge. 28,29 Communication difficulties may mean that a person and provide them the opportunity to ask questions and access does not accurately report pain or the pain history may be difficult or be provided with additional sources of information. Where or impossible to obtain. practical, the consent process should also give them reasonable time to analyse the information to come to a voluntary decision. The Rotterdam Elderly Pain Observation Scale (REPOS scale) has been developed as a reliable way for caregivers to identify and Where patients are not competent to agree, for example if they 30 quantify a person with cognitive impairment has pain. While there have dementia and impaired cognitive function, or if they are are a number of observational scales that attempt to measure pain recognised as minors through mechanisms of law; a parent, legal in older people with cognitive impairment, none of these scales guardian or legally recognised advocate is usually asked to make a include data from non-verbal people, such as those with dementia. decision in the best interests of the person. The authors of the REPOS scale asset that it appears to be promising In the United Kingdom, the Mental Capacity Act 2005 provides the for identifying pain in residents of various cognitive levels. In order overarching legislation related to the best interests and safeguarding to improve pain management, the researchers developed a cut-off of individuals, including those with cognitive impairment, in the 32 score for pain so that people that were identified above the score informed consent process. The legislation provides a safety received appropriate treatment to eliminate their pain. 30 net of process for people who do not have capacity to make a decision. These people cannot understand information relevant to Lobezzo and others have been developing observation–based the decision to be made. They cannot retain that information in assessment to determine if a person with dementia has pain. their mind, use or analyse that information, or communicate their 28 Below is a table that lists possible indicators and corresponding decision related to information they have been given. changes that may indicate someone with cognitive impairment is in pain. In determining capacity, the clinician needs to consider if the person has all the relevant information they need to make a These pain assessment indicators are not specific for orofacial decision. If a choice is available they also need to be provided pain but in people with cognitive impairment, may represent some with information on the alternatives and this may also include the sort of unmet need. For example, the person may be trying to option of no treatment. The communication methods need to be convey they are cold, hungry, thirsty, anxious, or irritated by their considered: using simple language or visual aids, sign language, surroundings. The care team must try to determine this, or if they Makaton style communication icons, electronic media, interpreters, have a more specific physical pain problem such as toothache. family members etc. There may be particular times of day that are more conducive to better understanding and communications Informed consent and best interest decisions and also the location of the discussion may play a role in facilitating Informed consent for dental treatment is a process of a choice. Finally, consideration should be given as to if the decision communication that acknowledges a person’s free will, and can be deferred to a time when circumstances are favourable for their capacity to make a decision based on knowledge and the individual. 31 understanding of a procedure. They are able to weigh the risks and benefits of a treatment to decide for themselves what is in their Clinicians are responsible for ensuring they comply with capacity best interests. The process of informed consent also acknowledges and consent legislation in their country or region of practice so that 1 that a competent person is entitled to make a potentially unwise they safeguard their patients and act in their best interests. Communication strategies for use with cognitively impaired adults (adapted from Chalmers, 2000) Possible indicator of pain: Observed changes: Changed facial expressions: Frowning, grimacing, distorted expression, rapid blinking Changes in verbalisation or vocalisation: Sighing, moaning, calling out, asking for help, verbal abuse Changes in activity pattern or body movement: Appetite change, sleep change, sudden cessation of common routines; Rigid, tense, guarding, fidgeting, increased pacing/ rocking, mobility changes such as inactivity or motor restlessness Mental status change or changes in interpersonal interaction: Crying, increased confusion, irritability, distress; Aggressive, resisting care, disruptive, withdrawn Changes in physiology: Increased heart rate, increased blood pressure, increased respiration rate, diaphoresis, pupil dilatation 38 RACDS ANNALS 2016

REFERENCES Materials. Dental Clinics. 2010;54(3):551-563. 1. Lichtenberg FR. The Quality of Medical Care, Behavioural Risk 20. Kathuria V, Ankola AV, Herbal M, Mocherla M. Carisolv- An factors and Longevity Growth. National Bureau of Economic Innovative Method of Caries Removal. J Clin Diag Res 2013; Research Working paper No. 15068. June 2009. www.nber. 7(12): 3111-3115. org/papers/w15068 (Accessed Jan 2016) 21. Ngo H, Opsahl-Vital S. Minimal intervention dentistry II: part 2. Alzheimer’s Association. 2015 Alzheimer’s disease facts and 7. Minimal intervention in cariology: the role of glass-ionomer figures. Alzheimer’s & Dementia 2015;11(3): 332-384. www.alz. cements in the preservation of tooth structures against caries. org/facts/downloads/facts_figures_2015.pdf (Accessed Jan Br Dent J 2014; 216:561 - 565. 2016) 22. Holm-Pedersen P, Walls AWG, Ship JA. Dental treatment 3. Chalmers JM, Hodge C, Fuss JM, Spencer AJ and Carter KD. planning guidelines for general anaesthesia. 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Dental Care Utilization Continues to 2009. http://www.requireddentalsystems.com/ (Accessed Jan Decline among Working-Age Adults, Increases among 2016) the Elderly, Stable among Children. Health Policy Institute Research Brief. American Dental Association 2013. www.ada. 25. Royal College of Anaesthetists. Anaesthesia explained. org/sections/professionalResources/pdfs/HPRCBrief_1013_2. Information for patients, relatives and friends. 2015. http:// pdf www.rcoa.ac.uk/system/files/PI-AE-2015.pdf (Accessed Jan 2016) 7. Hoe J, Hancock G, Livingston G, Orwell M. Quality of life of people with dementia in residential care homes. Brit J Psych 26. Royal College of Anaesthetists. Risks associated with 2006;188(5):460-464. your anaesthetic. Section 7: Becoming confused after an operation. 2013. www.rcoa.ac.uk/system/files/PI-RISK07- 8. Alzheimer’s Society. Leading the fight against dementia: Types CONFUSION-2013.pdf (Accessed Jan 2016) of dementia. www.alzheimers.org.uk/site/scripts/documents. php?categoryID=200362 (Accessed Jan 2016) 27. Rundschauen I. Postoperative Cognitive Dysfunction. Dtsch Arztebl Int 2014;111(8):119–125. (Article in English) 9. Ettinger RL. Dental management of patients with Alzheimer’s Disease and other dementias. Gerodontology 2000;17:8-16. 28. Lobbezoo F, Weijenberg RAF. Topical review: orofacial pain in dementia patients. A diagnostic challenge. J Orofac Pain. 2011; 10. Alzheimer’s Society. Leading the fight against dementia: Drug 25:6-14. treatments for Alzheimer’s disease. www.alzheimers.org.uk/ site/scripts/documents.php?categoryID=200348 (Accessed 29. Venable EF, Cruz-Oliver DM. Pain Assessment in Persons With Jan 2016) Cognitive Impairment. April 2015 http://emedicine.medscape. com/article/2113960-overview (Accessed Jan 2016) 11. Wikipedia. Broca’s area. www.en.wikipedia.org/wiki/ Broca%27s_area (Accessed Jan 2016) 30. Van Herk R, Van Dijk M, Tibboel D, Baar FPM, De Wit R, Duivenvoorden HJ. The Rotterdam Elderly Pain Observation 12. Ferry, B. (Ed). The Amygdala - A Discrete Multitasking Manager, Scale (REPOS): A new behavioral pain scale for non- 2012. www.intechopen.com/books/the-amygdala-a-discrete- communicative adults and cognitively impaired elderly multitasking-manager (Accessed Jan 2016) persons. J Pain Management. 2009;1(4):367-378. 13. Chalmers JM. Behaviour management and communication 31. Dougall A, Fiske J. Access to special care dentistry, part 3. strategies for dental professionals when caring for patients Consent and capacity. Br Dent J 2008;205:71-81 with dementia. Spec Care Dent 2000;20(4):147-154. 32. Government of the United Kingdom. Mental Capacity Act 14. New Zealand Dental Association. Healthy Mouth, Healthy 2005, Chapter 9. www.legislation.gov.uk/ukpga/2005/9/pdfs/ Ageing: Oral Health Guide for Caregivers of Older ukpga_20050009_en.pdf (Accessed Jan 2016) People. 2010. www.healthysmiles.org.nz/assets/pdf/ HealthyMouth,HealthyAgeing.pdf (Accessed Jan 2016) Email address for correspondence: 15. Kayser AF. Shortened dental arches and oral function. J Oral Rehabil 1981;8:457-462. [email protected] 16. British Dental Association Evidence Summary. Shortened dental arch therapy in old age. 2013. www.bda.org/dentists/ education/ (Accessed Jan 2016) 17. Randall RC. Preformed metal crowns for primary and permanent molar teeth: review of the literature. Pediatr Dent 2002;24:489-500 18. Kindelan SA, Day P, Nichol R, Willmott N. Clinical Guideline in Paediatric Dentistry Stainless Steel Preformed Crowns for Primary Molars. Guidelines of the Royal College of Surgeons. 2007. www.rcseng.ac.uk (Accessed Jan 2016) 19. Ngo H. Glass-Ionomer Cements as Restorative and Preventive RACDS ANNALS 2016 39

PREVENTING EARLY CHILDHOOD CARIES: MOTIVATING FAMILIES Dr Svante Twetman, DDS, PhD, Odont. Dr., Spec. Paediatr. Dent Dr Twetman is a specialised paediatric dentist and professor of cariology at the Faculty of Health and Medical Sciences, University of Copenhagen, Denmark. ABSTRACT In spite of intensive research, early childhood caries (ECC) remains a public health problem. Unfortunately, recent systematic reviews have failed to establish evidence for the best way to prevent and manage the disease. Apart from the biological risk factors, behavioral and family factors, socio-economy and oral health literacy are significant determinants of ECC. Several attempts to bridge the caries inequalities have been implemented for vulnerable risk groups and ethnic minorities. Although there is no “one-size-fits-all”, the chronic disease management concept, focusing on self-care through identifying facilitators and barriers for a healthy behavior, is most promising. Another key factor is to integrate oral health into the overall health care through establishing a professional skill-mix around the child. Motivational interviewing is associated with significant improvements in tooth brushing, diet and physical activity but the effects on ECC are yet inconclusive. Video games and digital platforms may be used to enhance compliance. INTRODUCTION embrace and communicate the recent WHO guidelines for sugar intake and make them understandable to parents of Early childhood caries (ECC) is a global health problem associated all educational levels. WHO strongly recommends a reduced with impaired quality of life for the individual and high costs for intake of free sugars throughout the life-course and this families and the society in general. ECC is a very complex disease is based on both dental caries, children’s overweight and 1 with numerous biological, medical, behavioral, psychological, future risk of diabetes and cardiovascular diseases according 9 cultural, and life-style determinants. The socioeconomic gradient is to the common risk factor approach. In both adults and very strong and oral health literacy is common among vulnerable children, WHO recommends that the intake of free sugars groups such as poor families, indigenous populations, ethnic should not exceed 10% of the total energy and that a further minorities as well as refugees and migrants. It is commonly reduction to below 5% would be desirable. Free sugars 2 postulated that ECC is a preventable disease but systematic include monosaccharides and disaccharides added to foods reviews have shown that preventive measures are only partly and beverages by the manufacturer, cook or consumer, and successful. Fluoridated toothpaste and fluoride varnish together sugars naturally present in honey, syrups, fruit juices and fruit 3,4 with motivational interviewing are currently the most utilized juice concentrates. Children in Europe are currently getting strategies to prevent ECC while the treatment relies on sealants, 14% (approximately 65 gram per day) of their total energy from 10 temporary restorations, and traditional restorative care. A serious added sugar so there is an obvious room for improvement. 4 concern however is that also the traditional care relies on evidence For example, parents should be informed not to serve any of low quality and the relapse rate in terms of recurrent caries after free sugar before the age of two years and thereafter limit 5,6 restorative treatment is reported to be around 40% within a year. the intake to a maximum of 3-4 table spoons per day. The Consequently, there is a need to rethink and apply novel strategies WHO guidelines focus on sugar amount rather than sugar to combat the development of caries in very young children. frequency, but a high frequency is often the same as a high The aim of the present paper is to address some key factors for amount. Some practical advices to reduce sugar intake in coaching and increasing family motivation in order to achieve childhood are shown in Table 1. better oral health. The focus is on everyday practice and upstream ii) Improper oral hygiene - It is a common wisdom that teeth preventive measures provided by society, such as sugar taxes, are should be brushed at least twice daily. The importance not further discussed. of “meticulous” cleaning removal for caries prevention is however somewhat overrated. Today, the focus of brushing EARLY CHILDHOOD CARIES has shifted to a “gentle” biofilm disruption and plaque removal. In fact, the tooth brush may simply be regarded as 10,11 Early child hood caries (ECC) is commonly defined as any stage the most convenient tool and generally accepted way to bring of caries lesions appearing before the age of 36 months. ECC is in fluoride to the biofilm. Nevertheless, the tooth brushing a biofilm-mediated disease resulting from a complex interaction routine should start with the eruption of the first tooth and between the commensal microbiota, host susceptibility and with a specially designed baby brush. Needless to say, the diet. The disease is certainly multi-factorial and a systematic has brushing should be carried out by the parents or custodians. displayed over 100 different risk factors significantly related to 7 the prevalence or incidence of caries in young children. For the iii) Sub-optimal fluoride exposure – Fluoride acts locally in the average family, this is far too complex and the etiology must be oral biofilm, primarily by affecting the balance between de- explained in three “simple” steps: ECC is driven by i) an increased, or and remineralisation, and should preferably be available 24/7. high, sugar intake, ii) combined with an improper oral hygiene, and For self-care, systematic reviews have shown that fluoridated iii) a sub-optimal topical fluoride exposure. To each of these steps, toothpaste in the rage of 1000-1450 ppm is effective 12,13 a counseling package of advice should be linked as outlined below. in preventing and reducing caries in young children. Toothpaste formulas specially designed for children often contain suboptimal fluoride levels and are less effective. The i) Increased sugar intake - The pivoting role of sugar in fueling amount of fluoride that is swallowed must be controlled by the caries process is undisputable. Dental professionals must limiting the amount of toothpaste on the toothbrush to a 8 40 RACDS ANNALS 2016

smear layer up to two years and a small fingernail up to 5-6 which patients/parents are supported to adopt a self-management years. In order to enhance fluoride retention in the biofilm, the scheme. For ECC, CDM is addressing the underlying disease child should just spit out but not rinse with water afterwards. processes that result in cavities by focusing on self-management For professional use, there is consistent evidence of moderate with evidence-based protocols in order to arrest the course of quality to support the use of fluoride varnish (commonly the disease. Families should simply be aware and activated in 22,600 ppm) 2-4 times per year for primary and secondary order increase their compliance with clinical recommendations. prevention of ECC. Yet, dental professional must be informed This can be accomplished through mother-coaching at well- 14 and prepared to handle the anti-fluoride arguments and baby evaluations, through home visits and regular telephone activities that are common among young parents of today. contacts by culturally and linguistically appropriate professionals or laypersons. The most important factor is that the coaching HOW CAN FAMILY MOTIVATION BE ACHIEVED? activities are frequent (every 14th day) and consistent over the first six months after onset. A dental home should be established at 12 months of age and oral examinations and caries risk assessments Although the healthy message concerning ECC prevention is clear and simple, several dentists feel frustration in their efforts to should be conducted periodically and timed to the eruption of 22 promote oral health, especially in high risk children and low-income new teeth and other life events. The frequency of return visits families; poor cooperation, poor attitudes, social inequality, cultural is based on the estimated caries risk category and the parents’ need of support and adherence to the preventive guidelines. As barriers and practice remuneration are common obstacles It is soon as any sign of ECC is detected, parents should be offered a .15 therefore important to stress that there is no “quick-fix” and no “one-size-fits-all”. An intervention or strategy that works in one separate “awareness-appointment” focusing on caries as a chronic family may not work in another. There is however some key issues disease and, if ignored or neglected, its common short- and long- that may be helpful in addressing the ECC problem as elaborated term consequences. Apart from health and quality of life issues, time consumption, costs and financial aspects may be included in below. the discussions. Motivational interviewing (MI) Integration of oral health into the overall health care Oral health should not be separated from overall health. Based Motivational interviewing is a person-centered approach focusing on skill-mix and inter-professional learning, ECC can successfully on building intrinsic motivation for change and subsequent be integrated and incorporated into primary care settings. As 23 enhancement of self-efficacy. MI differs radically from the mentioned earlier, caries, sugar and childhood obesity are strongly traditional “top-down” health education approach based on the associated according to the common risk factor approach and thinking that new knowledge automatically generates a behavior share the need of chronic disease management. Thus, a reduced change. In MI, the parents are the “experts” to interpret and sugar intake is a shared interest in terms of overall and oral health. integrate the given information in the context of their own lives The primary care medical providers have often frequent contacts and social circumstances. The use of the MI technique requires with target families and the non-dental setting may offer a less proper education and practical training before implementation fearful environment to tackle oral health issues; it is not uncommon and a sufficient time with the parents, including follow-ups, must that parents to children with ECC have dental phobia. A primary be allowed. Examples of open questions related to ECC are listed task for the medical staff is to “lift-the-lip” in order to identify children in Table 2. A recent systematic review and meta-analysis have at risk and refer them to pediatric dentists that are comfortable to 16 shown that MI is associated with significant improvements in oral see young children. The medical professionals are sometimes also health behavior, frequency of tooth brushing, diet and caries, as better trained in motivational interviewing and could integrate well as in parent’s behavior affecting their children such as smoking the teeth in overall health behavior. In some countries, fluoride 17 cessation and house holding. The authors concluded that the MI varnish applications by non-dental health professionals are widely strategy “outperformed” the comparisons groups but the statement implemented. Such programs have been proven successful over was based on a limited number of studies. Nevertheless, the MI time, especially in ethnic minorities and rural populations where concept must be regarded as promising for ECC management. access to dental professionals is limited. From questionnaires, 24 A serious concern is that the sugar consumption seems very parents report that they are satisfied with oral health care provided difficult to influence; a Cochrane-report found evidence that one- by non-dental professionals which is encouraging for the trans- to-one dietary intervention in the dental setting indeed could professional strategies. change behavior, but there was better evidence for change in fruit/vegetable and alcohol consumption than for changed dietary CONCLUSIONS sugar consumption. 18 Although there are considerable knowledge gaps in pediatric Electronic media dentistry, the dental practitioner have effective tools with good 25 With the evolution of “serious games” (games for other purposes evidence to prevent and manage early childhood caries. These than pure entertainment), the interest and opportunity for designing are caries risk assessment, brushing with fluoride toothpaste, and using videogames to positively influence health is emerging. fluoride varnish applications and certain behavioral interventions A systematic review has shown that significant improvements in that affect self-care practices. Nevertheless, ECC is still a public .19 safety or health behavior were obtained in 17 out of 19 studies health problem. The use of clinical guidelines and comprehensive As 97% of the young generation play computer, internet, mobile, strategies (e.g. motivational interviewing and chronic disease or console games, and 50% report a daily habit, there is a great management) in order to enhance motivation may result in better potential in this type of electronic interventions for altering health care at lower costs. behavior among young parents and their children. ACKNOWLEDGEMENT Chronic disease management ECC should be regarded as a chronic disease since an early The author is co-chairing the Pan-European Chapter of the Alliance onset of caries predicts more caries later in life. Chronic disease for a Cavity-Free Future (ACFF), a charity organization with the 20 management (CDM) is a distinct category of intervention located overarching goal that “every child born 2026 and thereafter 21 midway between prevention and acute care. The main goal of should remain cavity-free throughout their lifetime” (www. CDM is to improve the quality of care at lower cost. Childhood allianceforacavityfreefuture.or). asthma and diabetes are successful examples of the holistic CDM in RACDS ANNALS 2016 41

REFERENCES in youth: a systematic review. JAMA Pediatr 2013;167:574-80. 1. Garcia R, Borrelli B, Dhar V, Douglass J, Gomez FR, Hieftje K, 20. Mejàre I, Axelsson S, Dahlén G, Espelid I, Norlund A, Tranæus S, Horowitz A, Li Y, Ng MW, Twetman S, Tinanoff N. Progress in Twetman S. Caries risk assessment. A systematic review. Acta early childhood caries and opportunities in research, policy, Odontol Scand 2014;72:81-91. and clinical management. Pediatr Dent 2015;37:294-99. 21. Edelstein BL, Ng MW. Chronic disease management strategies 2. Arora A, Schwarz E, Blinkhorn AS. Risk factors for early of early childhood caries: support from the medical and dental childhood caries in disadvantaged populations. J Investig Clin literature. Pediatr Dent 2015;37:281-7. Dent 2011;2:223-8. 22. Twetman S. Caries risk assessment in children: how accurate 3. Tinanoff N, Reisine S. Update on early childhood caries since are we? Eur Arch Paediatr Dent 2016;17:27-32. the Surgeon General’s Report. 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Global sugar guidelines: an opportunity their calories from starchy foods, fibers, fruits and vegetables to strengthen nutrition policy. Public Health Nutr 2014;17:2151-5. • Never add sugar to milk, baby formulas, porridge or breakfast cereals. Avoid those covered with honey sugar or chocolate. 11. Marsh PD, Head DA, Devine DA. Ecological approaches to oral biofilms: control without killing. Caries Res 2015;49 Suppl 1:46- • Nighttime baby bottles containing sugars of any kind should 54 be banned 12. dos Santos AP, Nadanovsky P, de Oliveira BH. A systematic • If you are adding sugar when cooking, decrease gradually. Try review and meta-analysis of the effects of fluoride toothpastes halving the sugar amount in your recipes on the prevention of dental caries in the primary dentition of • Choose fresh fruit rather than fruit juices. Dried fruits can part preschool children. Community Dent Oral Epidemiol 2013;41:1- of a meal but not a between-meal snack 12. • Limit intake of all kinds of store-bought smoothies, energy/ 13. Twetman S. Prevention of early childhood caries (ECC)--review soft-drinks and juices and keep them strictly to mealtimes of literature published 1998-2007. Eur Arch Paediatr Dent • Read food labels carefully – even “healthy” alternatives may 2008;9:12-8. contain excessive sugar 14. Chou R, Cantor A, Zakher B, Mitchell JP, Pappas M. Prevention • Select one day of the week to be a family “candy day” in which of dental caries in children younger than 5 years old: a predetermined and controlled amount of sweets are allowed Systematic review to update the U.S. Preventive Services Task Force Recommendation [Internet]. Rockville (MD): Agency for Table 2. Examples of open-ended questions in motivational Healthcare Research and Quality (US); 2014 May. Report No.: interviewing themed around oral health. Modified from Naidu and 12-05170-EF-1. co-workers. 15. Aljafari AK, Gallagher JE, Hosey MT. Failure on all fronts: Start-up talk general dental practitioners’ views on promoting oral health in high caries risk children--a qualitative study. BMC Oral Health. • Tell me about your child? 2015 Apr 9;15:45. • What do you want for your child’s oral health? 16. Naidu R, Nunn J, Irwin JD. The effect of motivational • What are your worst fears about your child’s teeth? interviewing on oral healthcare knowledge, attitudes and • How would you like things to turn out? behaviour of parents and caregivers of preschool children: an • How could it be better? exploratory cluster randomised controlled study. BMC Oral • What are the dental care challenges? Health 2015 Sep 2;15:101. 17. Borrelli B, Tooley EM, Scott-Sheldon LA. 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MANAGING THE ROOT CANAL BIOFILM: STRATEGY AND POSSIBILITY Prof Gary Cheung, BDS, MDS, MSc, PhD, FRACDS, FCDSHK, FAMS, FICD, MRACDS (Endo), FDSRCSEd Prof Cheung is a Clin Prof and Postgraduate Programme Director in Endodontics at the Faculty of Dentistry at the University of Hong Kong. He is currently an Associate Dean at HKU and maintains an intra-mural private practice on a referral basis. ABSTRACT The infected canal is the root cause of apical periodontitis. Bacteria that colonize the root canal system are not free floating, but exist as a biofilm attaching on the canal wall. Management of the infected root canal has customarily been achieved via chemomechanical preparation, with numerous studies in the 21st century focusing on mechanical debridement or instrumentation techniques. In the new millennium, there is a shift in research emphasis to removal of the endodontic biofilm by various physical and chemical means. This presentation examines various clinical strategies, and explores newer and potentially more effective approach to combat the root canal biofilm. INTRODUCTION cleaning the root canal space. The classic series of microbiological 18 evaluation of root canals sampled clinically before and after It has long been established that presence of bacteria in the instrumentation, with or without disinfectant agent as the irrigant, root canal is the root cause of apical periodontitis. After gaining have led to the conclusion that manual instrumentation and access into the root canal, the microbial flora gradually change mechanical flushing using a bland solution would remove 90% in its composition with time and becomes predominantly strictly or more of cultivable bacteria; the extent of bacterial removal is anaerobic in established primary infection. Bacteria there tend significantly enhanced when a disinfecting irrigating solution 1-2 to organize in a plaque-like architecture. Bacteria may also was used. 19,20 As bacteria are attaching to the root canal wall and 3-4 5-7 enter into the dentinal tubules to varying extent. In particular, some penetrating into dentinal tubules for an unknown distance, due to the affinity of streptococci and enterococci to Type I continual enlargement of the root canal (i.e. removal of dentine collagen, these coccal cells have been found extending to a from the canal wall) seems able to reduce the bacterial count greater distance than, and facilitate penetration, of other species further. 21,22 into dentine. Although a clear causal relationship between those 8 specific species residing in dentinal tubules and post-treatment In addition to mechanical scraping of the canal wall by root disease has not been scientifically proven, reactivation of residual canal instruments, an irrigant is typically used during root canal bacteria within the canal was believed to be an important reason preparation. The mechanical flushing action of irrigant solution for post-treatment disease. It is noteworthy that streptococci helps to remove nonadherent debris and those loosely attached 9 and enterococci are regarded as two common species of early bacteria from the root canal. The flushing action would be colonizers involved in the development of the endodontic biofilm. counteracted by the EPS matrix of a biofilm, although one strategy 10 When bacteria are present in the form of a biofilm, they are more was to increase the velocity of the irrigant solution to detach it. 23,24 resistant to antimicrobial agents than their planktonic counterpart As complete eradication of the infected root canal is virtually through various mechanisms, including the barrier effect of the impossible with the use of a bland solution, especially when an extracellular polymeric substances (EPS), quorum sensing and infected root canal system is being treated, the need for a chemical 11 stress response. The EPS matrix not only buffers any antimicrobial disinfecting agent to complement the mechanical action cannot agents and prevents from getting to the bacterial cells situated be overemphasized. 18-21 within, but also provides a niche for the cells to survive. Selective 12 expression of resistance phenotype, especially of the persister cells CHEMICAL CLEANING within the biofilm, would also contribute to cases that are refractory to treatment. 13,14 It is now accepted that apical periodontitis is a Various chemical agents have been advocated and all were 15 biofilm mediated disease, with the microorganisms residing within proposed either for an ability to dissolve soft tissue remnants, for a matrix of extracellular polymeric substances and attached to the their antimicrobial action, for being able to remove (or dissolve) the root canal wall. 3,4 smear layer, or a combination of these. 25 Absence of cultivable bacteria in the root canal before obturation Throughout the years, sodium hypochlorite has evolved as the has been shown to raise the success rate of non-surgical most widely advocated irrigating agent. Household bleach, which endodontic treatment significantly .16,17 On the other hand, the is typically 5.25–6% sodium hypochlorite in an alkaline solution, irregular and complex anatomy of the root canal system has helped is the most common formulation used. Generally, the higher the to provide shelter to those microorganisms present there. Given hypochlorite concentration the greater the efficacy in dissolving 9,12 the vast amount of evidence indicating the association between organic tissues and killing bacteria within the canal. Indeed, using 26 presence of bacteria in the root canal system and development of 3% hypochlorite to rinse the canal is able to kill bacteria residing apical periodontitis, an effective strategy to manage the root canal up to 3 mm in the dentinal tubules. There is some debate as 27 biofilm and to control any residual microflora with the root canal to the best concentration of hypochlorite for use as root canal is necessary. A brief overview of various methods is given below. irrigant, and the optimal concentration seems to be a compromise 25 between efficacy and safety/cytotoxicity. Despite the close-to- MECHANICAL CLEANING ideal properties of sodium hypochlorite, the solution has to be delivered in a suitable manner to ensure the most optimal result in In the past millennium, there had been tremendous amount of removing the biofilm from the root canal system. Many methods interest and investigations into the efficacy of instrumentation for of potentiating its action have been proposed, which include the followings. RACDS ANNALS 2016 43

(i) Temperature (iv) Laser assisted irrigation Warming up the hypochlorite solution has been advocated The action of lasers on the dental tissues and/or biofilm is for speeding up the dissolution of organic debris and it may governed by the absorption characteristics of that particular 26 compensate for a less concentrated solution. On the other hand, wavelength (as laser is monochromatic) by the tissues and/or it has been shown that agitation and efficient circulation of solution surrounding medium. Depending on the various parameters within the root canal system may have a greater impact on the of laser and the physical properties of the irradiated tissue, the tissue dissolution power for hypochlorite. Thus, it is important laser tissue interaction may proceed with one or a combination 28 to ensure good circulation of solution into and out of the canal. of mechanisms: photochemical interaction (example of its Heating up the solution seems to be optional. application being laser-induced biostimulation), thermal effect (at immediate vicinity of the laser tip), photoablation, plasma-induced (ii) Irrigant agitation ablation and photodisruption (generation of cavitation and shock 37 Manual agitation of the irrigant solution within the root canal has waves). Indirect interaction may be achieved via an additional been advocated for a long time, as the “irrigate recapitulate and molecule, the photosensitizer, in a process commonly known as irrigant” regime might be dated back to the manual step-back photodynamic therapy (PDT) that, in fact, is a form of photochemical 37 preparation. More recently, the use of a tapered gutta-percha point interaction. In PDT, a drug containing the photosensitizing agent to agitate the solution in situ has been proposed, in the so-called is administered; the photosensitizer is retained by the target cells. “manual dynamic agitation” technique. This technique produces Upon irradiation by the appropriate wavelength, the photosensitizer 23 cleaner canal walls 29,30 but seems to be associated with a greater is excited into a reactive state, leading to the formation of singlet 38,39 risk of irrigant extrusion than sonic or ultrasonic irrigation. oxygen that is responsible for the bactericidal action. The 24 main disadvantage of antimicrobial PDT is the accessibility of the target microorganisms both to the drug (photosensitizer) and to Some manufacturers introduced a form of plastic root canal brush, illumination. In endodontic treatment, the laser light typically is 39 which employs the principle of mechanically scrubbing the canal carried into the root canal via, and exits through the end of, an wall to clean it. However, the miniaturized brush might not extend optical fibre. There is a paucity of information of its effectiveness to the whole length of the canal and could carry the risk of packing to reach the isthmus areas that is on the side, rather than near the debris into the apical region of the canal after its use. Various end of the optical fibre. Most studies of the efficacy of PDT had 31 40 other devices have been advocated to induce turbulence flow, been performed by sampling the root canal content with paper to encourage the irrigant to reach all areas within the root canal points, which method carries the inherent risk of failing to capture 41 system. Sonic and ultrasonic, as well as some vibration devices those bacteria within a biofilm or inside the dentinal tubules. There 31 fall into this category. has been a quest for “side firing” optical fibre to direct the laser towards the canal wall after insertion into the root canal. 40,42 More The use of an ultrasonically activated endodontic file to deliver studies are required to evaluate such method that improves the and agitate the irrigant within the root canal is commonly called accessibility of the canal wall and isthmus areas to laser irradiation. ultrasonic irrigation. When an ultrasonic file is loose (i.e. with a diameter smaller than the canal lumen) and is held stationary in Another mode of laser-assisted irrigation is through the generation the canal while being activated, the technique is called “passive of cavitation and shock waves by the photodisruption process. A ultrasonic irrigation”. Other devices, which agitate the irrigant near-infrared wavelength that excites water molecules would be 32 at a lower frequency, in the audible range, is referred to as sonic most suitable for this. Water would be immediately vaporized irrigation; examples are Vibringe (Cavex, Haarlem, Netherlands) upon irradiation, creating cavitation bubbles. Implosion of these and EndoActivator (Dentsply Tulsa, Tulsa, OK). While both sonic bubbles leads to vigorous and turbulent flow of the fluid within the and ultrasonic methods are significantly better than unassisted canal, thus enhancing the action of the hypochlorite solution. With 43 needle-and-syringe irrigation for removing bacteria, debris or this method, the direction of incident laser beam is not important, smear layer, there are still limitations in their ability to eradicate the as the effect is medicated through a different mechanism. This biofilm and tissue remnants at isthmus, fins and cul-de-sacs of the approach has been called “photon-induced photoacoustic complex root canal systems. 23,29-32 streaming” by a manufacturer and some authors. 44 Very recently, a “multisonic ultracleaning” device (GentleWave CANAL MEDICATION System; Sonendo, Laguna Hills, CA) was introduced, which apparently is based on inducing vibrations in the fluid medium In primary endodontic infections, there seems to be little evidence to using sound waves of multiple and broad range of frequencies. support an absolute necessity for root canal medication, compared 45 Initial report has suggested highly effective cleaning of the isthmus to retreatment cases. That implies that maximal biofilm reduction 33 areas when hypochlorite solution is agitated by this equipment. can be achieved by the instrumentation and irrigation regime Further studies will be required for confirmation. carried out in a modern practice. If the endodontic treatment needs to extend into another visit, a root canal medicament should (iii) Reversing the flow be placed. A thin slurry of calcium hydroxide has been and still Conventional approach of irrigation is by injecting the solution into is the preferred choice for that purpose. 45,46 Other agents that the root canal lumen, with the cleaning effectiveness dependent on are also frequently used as root canal medicament include 2% the ability of the irrigant to wet the canal wall. The deleterious effect chlorhexidine gel, iodine compounds, and mixture of antibiotics 47 of air entrapment near the root apex (the root canal being a closed- (with and without corticosteroid). Antibiotic combinations applied end channel) has been recognized. 23,31 The use of an aspiration locally to “fill” the root canal as an inter-appointment medication 48 needle inside the canal with the irrigant solution delivered to the have had a long history. Recently, there is some interest for the 34 pulp chamber was proposed and reported in 2006. This principle use of antibiotics in the pulp revascularization procedure, where a of creating a negative pressure at the apical region of the canal has mixture of metronidazole, ciprofloxacin and minocycline is used to disinfect the canal for one week. Clinical success of managing 49 been adopted and later marketed as the EndoVac system (Discus refractory cases with intracanal antibiotic medication is available Dental, Culver City, CA) and the iNP needle (Mikuni Kogyo Inc, (Fig. 1). However, in view of the concern for sensitization and allergic 35 Nagano, Japan). This negative-pressure irrigation seems able to reaction, widespread use seems not being advocated as a routine. produce cleaner canals near the apex and at isthmus areas. This 36 hopefully would translate into an increased chance of treatment In today’s age of nanotechnology, various nanoparticles have been success, although such evidence is yet to become available. explored for their ability to disinfect the root canal, either as an 31 44 RACDS ANNALS 2016

irrigant or medicament. Examples include nano-silver, zinc and 4. Ricucci D, Siqueira JF. Biofilms and apical periodontitis: Study chitosan particles. All of them show antibacterial action. Various of prevalence and association with clinical and histopathologic 50 mechanisms have been proposed for the antimicrobial action by findings. J Endod 2010;36:1277-1288. nanoparticles, which include direct action on the bacterial cell wall 5. Haapasalo M, Orstavik D. In vitro infection and disinfection of and/or membrane, damage to the bacterial DNA, production of dentinal tubules. J Dent Res 1987;66:1375-1379. reactive oxygen species, and interfering with bacterial attachment 6. Siqueira JF Jr., De Uzeda M, Fonseca MEF. A scanning electron and biofilm formation. 51,52 As there are multiple sites of action of many nonopeuticals on the bacterial cells, it is unlikely that microscopic evaluation of in vitro dentinal tubules penetration 52 resistant strain would develop by single-gene mutation. Hence, by selected anaerobic bacteria. J Endod 1996;22:308-310. nanoparticles would be a viable option to combat resistant strains 7. Peters LB, Wesselink PR, Buijs JF, van Winkelhoff AJ. Viable and refractory infections. bacteria in root dentinal tubules of teeth with apical periodontitis original research article. J Endod 2001;27:76-81. CONTAINING THE RESIDUAL BACTERIA 8. Love RM, McMillan MD, Park Y, Jenkinson HF. Coinvasion of dentinal tubules by Prophyromonas gingivalis and Given that bacteria may either escape or survive the instrumentation streptococcus gordonii depends upon binding specificity and irrigation process, strategy should be in place to alleviate the of streptococcal antigen I/II adhesion. Infect Immunity effect of any residual bacteria present within the root canal system 2000;68:1359-1365. after treatment. Possibilities are: (i) sealing the bacteria within the 9. Vieira AR, Siqueira JF Jr, Ricucci D, Lopes WS. Dentinal tubules dentinal tubules, and (ii) preventing bacterial leakage along the root infection as a cause of recurrent disease and late endodontic filling material. treatment failure: a case report. J Endod 2012;38:250-254. 10. Love RM. Biofilm-substrate interaction: from initial adhesion Sealing of dentinal tubules may be achieved by the root canal sealer, to complex interactions and biofilm maturity. Endod Topics bonding resin, and deposition of minerals at the tubular openings. 2012;22:50-57. The first two methods have been practiced or advocated for some time, albeit with some limitation for both, and they will not be 11. Stewart PS, Costerton JW. Antibiotic resistance of bacteria in discussed here. The use of bioactive glass to achieve closure of biofilms. Lancet 2001;358:135-138. dentinal tubules has enjoyed some success as a treatment method 12. 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Figure 1 A 51-year old woman with a chronic suppurative apical periodontitis affecting tooth 16 that showed periapical radiolucency associated with all root apices (A). The tooth was endodontically treated and was dressed on 3 occasions, over 2 months, with calcium hydroxide or iodoform paste (B). The canals remained “wet” with clear exudate at the fourth visit, for which a tri-antibiotic mix was used as intra-canal medicament; the canal could not be dried prior to medication. In the fifth visit, the sinus tract was closed and canals without any discharge, with periapical radiograph showing a reduction in size of the rarefaction (C). All canals were finally obturated with warm vertical compaction technique and a layer of glass ionomer placed as the orifice seal (D). (Courtesy of Dr Shirley Lai, private endodontist, Hong Kong) Figure 2 Scanning electron micrograph of: (A) Geoko skin showing the nano-spikes on its surface and the interaction with (in fact, piercing throough the cell mebrane of) a Streptococcus mutans cell; and (B) a resin replica of Geoko skin and its interaction with the same bacterial strain. (Li and Cheung, unpublished data) RACDS ANNALS 2016 47

Figure 3 Nano-scale features engineered on the surface of polymethymethacrylate material (right hand column), compared to same material with smooth surface. All of them have been immersed in bacterial cultured for 3 days: (top four) scanning electron micrographs [*Note: the figure with asterisk is at a higher magnification to demonstrate the nanopyramid structure]; (bottom four) confocal laser scanning micrographs after Live/Dead BacLight staining. (Li and Cheung, unpublished data) Smooth PMMA surface PMMA surface with nano-pyramids S. mutans E. Coli S. mutans E. Coli 48 RACDS ANNALS 2016