Annals Vol 23 (2016)

HEALTHY TOOTH, HEALTHY MOUTH, HEALTHY BODY: ENDODONTICS IN THE SYSTEMIC UNIVERSE Dr Luke G Moloney, MDSc (Melb), FRACDS, FICD, FPFA Dr Artika Soma, BDS (Otago), DClinDent (Endo) (Otago) Dr Moloney is in private specialist practice as an Endodontist in Camberwell and Brighton, Victoria. Dr Soma is practicing as an Endodontist and teaches at La Trobe University, Bendigo. ABSTRACT For the most of the last century ‘dead’ teeth were considered by many to be potential sources of infection that could contribute to or cause disease elsewhere in the body. Even healthy endodontically treated teeth were considered by many doctors and dentists to harbour bacteria that could leach toxins into the surrounding tissues or again cause disease in other organs. Many believed that extraction was the only option for non-vital teeth. Despite the great volume of research that has shown no association between non-vital teeth and systemic disease, many health practitioners still advocate removal of teeth to remedy any number of non-dental ailments. This presentation revisits the focal infection theory and asks the question ‘Are your root filled teeth causing you harm?’ Focal infection relates to a theory proposed by Dr E Rosenow in and simple impression techniques and casting equipment allowed 1909 as a localised or generalized infection caused by bacteria “Dentists” to restore missing teeth and tooth structure ravaged by travelling through the bloodstream from a distant focus of infection. caries. 1 A focus of infection is a localized area of infection. Most likely the first mention of focal infection could be attributed to Hippocrates Hunter states “No-one has probably had more reason than I have 4 who described a patient with rheumatism whose arthritis was had to admire the sheer ingenuity and mechanical skill constantly cured by the removal of an infected tooth. Rush in 1818 reported displayed by the dental surgeon. And no-one has had more cure of general diseases flowing the extraction of decayed and reason to appreciate the ghastly tragedies of oral sepsis which his 2 diseased teeth. The invention of the microscope allowed clinicians misplaced ingenuity so often carries in its train” to actually see micro-organisms and many claimed to have isolated bacteria from synovial fluid in joints. These bacteria were thought “Gold fillings, gold caps, gold bridges gold crowns fixed dentures to have travelled to the joints from distant sites or foci of infection. built in on and around diseased teeth” thunders Hunter to his 4 The most common foci implicated in metastatic infections were audience “form a veritable mausoleum of gold over a mass of the teeth and tonsils. 3 sepsis”. This infection, trapped under these false teeth led to Americans In 1910 a British Physician presented a lecture to the Medical Faculty “dirty gray sallow pale wax-like complexions and consequently a at McGill University in Montreal. What we know of Dr William Hunter number of maladies such as chronic dyspepsias, anaemias and M.D. Edin. FRCP London is that he was a Physician and Lecturer on nervous complaints.” Technically he was describing periodontally Pathology to the Charing Cross Hospital, London and Physician to compromised teeth and not endodontically involved teeth. the London Fever Hospital. He delivered an address to the new students at the opening of the session of the Faculty of Medicine of To use a bad pun, Hunter’s words hit a nerve. Suddenly doctors McGill University Montreal on October 3rd 1910. Not much detail is and patients believed that the removal of a diseased tooth may 4 available about the life, and demeanour of Dr Hunter. However, his well resolve any number of systemic illnesses. Dentists too were lecture has become a pivotal moment in dentistry and medicine convinced. Earlier work by Dr Willoughby D Miller (1853-1907) a with repercussions still being felt over 100 years later. If I can be brilliant dental researcher had shown the link between infected given some licence to add to the “Hunter story” I would suggest dental pulps and alveolar abscesses. In 1904 Dr Frank Billings called he may have been a dedicated Doctor who strived to offer his these circumscribed areas of tissue infected with micro-organisms patients the best possible care. However 100 years ago medicine “foci of infection”. Billings was a President of the American Medical was a challenging field. Hunter would have had a busy practice Association and was the chief researcher at Rush Medical College, with perhaps 100s of patients, many afflicted with chronic diseases one of the few centres actively involved in research into focal which at the time were incurable and often fatal. With no antibiotics, infection. A student of Billings Dr EC Rosenow reported in 1909 histo-pathology, blood tests and only very early radiography any that streptococci present in diseased organs could travel via the dedicated physician would be frustrated by an inability to provide bloodstream to a distant organ and cause infection. The theory relief for many patients. I imagine him looking into the mouth of of Focal Infection and the association with teeth rapidly gained another sick patient, tongue depressor in hand examining tonsils, credibility. In 1915 Rosenow left Rush and Billings for the Mayo Clinic pharynx, searching for clues to provide an explanation for another at the invitation of Charles Mayo. The new clinic in Experimental illness. He often notices the foul odour emanating from the mouths Bacteriology was mainly involved in research into focal infection of many of his patients. He starts to delve further and notices the and Rosenow produced over 200 papers. Central to his work 3 calcific deposits around the necks of the teeth, yellow, brown and was the experiment that showed when streptococci were isolated green. He sees pus seeping up around the gums of these teeth from arthritic patients with sites of focal infection and injected which are also loose. He has seen some teeth so loose they fall out into healthy animals, these animals went on to develop joint and the same appalling odour emanates from these teeth. He has inflammation. However, Rosenow also showed similar transfer of read of the work by Pasteur and others and feels sure these teeth diseases such as gastric ulcers into previously healthy animals from are associated with a bacterial infection. To his concern he also infected patients. Also Rosenow described the symptomless foci observes many of his patients have had gold dental work done. that could be present in the teeth, tonsils prostate, cervix and nasal Dentistry at the time was more of a trade than a medical speciality sinuses. Rosenow concluded that “The prevention of oral sepsis RACDS ANNALS 2016 49

in the future, with a view to lessening the incidence of systemic with the University of Melbourne as a medical training centre and diseases, should henceforth take precedence in dental practice renamed Prince Henry’s Hospital. 8 over the preservation of the teeth almost wholly for mechanical or cosmetic purposes, as has largely been the case in the past”. In the late 1950s a young Melbourne Dental Graduate returned to private practice in Melbourne after 5 years abroad furthering Another brilliant dental thinker at the time was Dr Weston Price. his knowledge in the United Kingdom and Canada. He also took Price has long been (unfairly in my opinion) pilloried as one of up a position as a part time visiting dental consultant at Prince the proponents of the focal infection theory based on some Henry’s Hospital where he stayed until the hospital closed in 9 extensive but quite flawed research. However his work on the 1969. After becoming frustrated with the outdated attitude of a role of sugar in dental caries and his research into nutrition was senior urologist at the Hospital who repeatedly asked the dental ground-breaking and deserves recognition. Price’s main body of department to extract teeth from his patients to improve their work revolved around the implantation of diseased human teeth kidney function the young dentist penned a referral to the head into the subcutaneous tissues of rabbits. He observed the resultant of the Urology Unit “Regarding Pt Mr X. Please remove left kidney, infections but then also theorised that he could induce the same the Patient has toothache and I believe the left kidney is causing arthritic joints in rabbits as had been present in the original owner of the pain” The requests from the urologist stopped. For those of the diseased tooth. As a result of this and other work and theories you who have not yet worked it out the young dentist was Dr many dentists and physicians recommended the extraction Ernst “Effy” Ehrmann who is widely regarded as the Grandfather of of all non-vital and endodontically treated teeth, with or without Endodontics in Australia. He was an inaugural Fellow of the College symptoms or signs of infection. More than simple extraction was and went on to an outstanding career as a teacher, researcher and advocated however. The protocol at the time was to aggressively clinician sadly passing away in 2011. scrape or remove with a bur the bone lining the socket to remove any “infected bone” adjacent to the diseased tooth. Anecdotal In response to a letter in the Medical Journal of Australia “Are evidence and case reports describing miraculous cures of all sorts Dead Teeth a Health Hazard?” by Webster in 1971, Effy wrote a 11 10 of maladies abounded and provided sufficient evidence for the reply under the same heading “Are Dead Teeth a Health Hazard?” extraction of thousands of teeth and the mutilation of dentitions all published in the Medical Journal of Australia in 1972. over the world. In addition, tonsils were removed, colons irrigated and a vast array of gastric and genito-urinary surgical procedures Webster, an Adelaide Physician had written of the perils to health performed. that dead teeth imposed. He described having dead teeth in the mouth as akin to “Keeping Grandma’s corpse in the bedroom just In 1930 an editorial in Dental Cosmos challenged the logic because she was a fine old lady”. To quote further from Webster’s behind the focal infection theory and recommended a return letter, “Case 3 – A young man aged 25 years approached me in 10 to constructive dentistry rather that destructive dentistry. It the last resort as a friend. He was contemplating matrimony and was argued that it was more beneficial to patients to “make the had submitted himself to a complete physical examination as a masticatory apparatus a useful organ rather than a crippled and preliminary. His blood pressure was 100/60 mmHg, and he became constant menace to the patient”. 5-6 distressed when submitted to the usual exercise tolerance tests, with marked tachycardia. He had been referred to a cardiologist Three unanswered questions regarding focal infection led to its who regarded his condition as sufficiently serious to warrant demise. advising him against marriage. I had a complete radiological dental survey carried out, which revealed nothing except a root 1. The benefits of removal of infected foci were never proven in filled upper central incisor. The root filling had been done very suitable studies. Most of the evidence was anecdotal. competently, and the alveolar bone showed no evidence whatever 2. The incidence of infected foci in arthritic patients was never of infection. I referred the patient to the dentist who had carried compared to a normal population. When it finally was the number out the root filling, with a request that the tooth be extracted. This of “infected foci” was similar in both groups drew forth an indignant response from the dentist and a point blank refusal to remove the tooth. I told the dentist who was a 3. Attempts to reproduce Rosenow’s work failed to confirm his highly skilled and respected member of the profession that I would conclusions. Arthritic change in experimental animals was thought have the tooth removed elsewhere if he did not agree to it. Some to be the result of the cell wall components as the same effects weeks afterwards I received a letter from the dentist who stated could be achieved by injecting denatured and dead bacteria. that he had removed the tooth “aseptically” and had personally supervised the breaking open of the tooth and obtaining a culture An article in the Annals of Internal Medicine in 1938 by Physicians from the root canal. This culture had grown an extremely virulent R.L. Cecil and D.M. Angevine reported following up 156 rheumatoid streptococcus and both dentist and the bacteriologist whom he arthritis patients who had foci of infection such as teeth or tonsils had consulted were impressed by this. Without my knowledge a removed. Of 52 patients who had teeth extracted 47 did not vaccine was prepared. This was later forwarded to me, and I gave 7 get better and 3 became more ill. Finally, as antibiotics became the patient a course of injections. Whether the vaccine had any available the treatment of infections also changed. The seeds of bearing on the ultimate result I do not know but within months change had been sown but change is often not rapid and many the patient’s cardiac condition was normal, his blood pressure had dentists in Australia during the 1940s and 1950s and up to the risen to a normal level and the cardiologist passed him as 100% fit 1970s still faced challenges from the medical profession regarding for wedded life.” the management of chronically ill patients. Effy’s response to this letter was swift, comprehensive and extensively Prince Henry’s Hospital in St Kilda Road in Melbourne started out referenced. “I cannot accept his analogy between non-vital teeth as the Melbourne Homeopathic Hospital in Collins Street in 1869. and Grandma’s corpse in the bedroom”. He stated and added It was founded by a group of doctors who favoured homeopathy “Grandma’s corpse fulfils no useful purpose, but many thousands of as a treatment regime. This involved treating patients with minute properly treated non-vital teeth continue to function in the mouths amounts of drugs to replicate the symptoms of the disease under of their owners without doing any harm.” With the aid of a number treatment. Needless to say the Melbourne Homeopathic Hospital of his own cases Effy showed the bone regeneration that typically was blacklisted by the British Medical Association (BMA) for many occurs after infected abscessed teeth are properly endodontically years. By the 1920s the practice of homeopathy was fading and treated. He pointed out that the focal infection theory had fallen into in 1924 the BMA ban was lifted. By 1934 the hospital was affiliated disfavour because of the following observations: 50 RACDS ANNALS 2016

1. Many patients with diseases presumably caused by foci of REFERENCES infection have not been relieved of their symptoms by removal of the foci. 1. American Association of Endodontists. Oral disease and systemic heath: What is the connection? Endodontics 2 Many patients with these same systemic diseases have no Colleagues for Excellence, Newsletter Spring/Summer 2000. evident focus of infection. 2. Duke WW. Oral Sepsis in its relationship to systemic disease. 3. Foci of infection are, according to some statistical studies, as St Louis: Mosby 1918. Reviewed in California State Journal of common in apparently healthy persons as in those with disease. Medicine 1918;16(12): 530-531. 3. Hughes R A, Focal Infection Revisited. Brit J of Rheumatol Effy’s article had a significant effect and a number of articles in 1994;33:370-377. support were subsequently published by the Journal. 4. Hunter W. An address on the role of sepsis and antisepsis in So why 50 years later, does ‘focal infection’ still resonate with some medicine. Lancet 1911;1:79-86. members of the medical and dental professions and patients? 5. American Association of Endodontists. Endodontics Well, obviously all of the work done a hundred years ago is readily Colleagues for Excellence, Newsletter Fall/Winter 1994. available to anyone with a computer. However, the quality of the ‘research’ can be seen on some dental practice websites who 6. Kirk EC, Anthony LP. Why not save the pulpless tooth? advertise homeopathic dentistry including photos of ‘William (Editorial) Dental Cosmos 1930;72(4):408-410. Hunter’ unfortunately the wrong William Hunter – the ‘other’ one 7. Cecil RL, Angevine DM. Clinical and experimental observations being a Scottish anatomist born in 1718 – around 150 years before on focal infection, with an analysis of 200 cases of rheumatoid the William Hunter of McGill University Fame! arthritis. Annals of Internal Medicine 1938; 12(5):577-584. However, things are rarely black and white. For example, sub- 8. Templeton J. Prince Henry’s: the evolution of a Melbourne acute bacterial endocarditis fits the definition of a ‘focal infection’ hospital, 1869-1969. Melbourne: Robertson & Mullens, 1969. quite well and an unexplained prosthetic joint infection with an 9. Feiglin B. Tribute to Dr E Ehrmann. Australian Endodontic oral bacterium, following dental treatment, may raise questions. Newsletter 1994; 20. Because the pulp and the periodontium are so intricately connected to the circulatory system, bacteraemia following dental 10. Webster V. Are Dead Teeth a Health Hazard? Med J Aust 1971 treatment is almost inevitable. The severity of the bacteraemia is 2(7):378-9. dependent on the amount and complexity of the plaque and the 12 degree of gingival inflammation present. However, this does not 11. Ehrmann EH. Are Dead Teeth a Health Hazard? Med J of Aust cause a catastrophic issue in majority of the individuals undergoing 1972; 1(18):931-935. invasive dental procedures because their immune system is able to 12. Debilian GJ, Olsen I, Tronstad L. Systemic diseases caused by manage it successfully. However, individuals who are systemically oral microorganisms. Endod Dent Traumatol 1994;10:57-65. vulnerable (e.g. diabetes, long term steroid therapy, congenital heart disease, artificial heart values or/and artificial joints) are more 13. Thornhill MH, Dayer MJ, Forde JM, Corey GR, Hock G, Chu likely to suffer morbidity as a result of bacteraemia. Some of the VH, Couper DJ, Lockhart BP. Impact of the NICE guideline systemic conditions reported on are shown in Figure 1. recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: before and after study. Infective endocarditis is one of the more serious outcomes of Brit Med J 2011; 342:1-7. invasive dental treatment. It has been suggested that prophylactic antibiotics be given to susceptible individuals to reduce the number of viable micro-organisms subsequently present in the circulatory system. However, the notion of antibiotic prophylaxis has received a lot of attention in recent years as more sensitisation to antibiotics and adverse drug reactions are reported. The National Institute for Health and Care Excellence (NICE) in UK carried out extensive research and concluded that no antibiotic prophylaxis is required for any medical conditions. In Australia antibiotic prophylaxis 13 is still required for both; prevention of infective endocarditis and in certain prosthetic implant cases as assessed by the operating surgeon. Future investigations and clear guidelines are required (Table 1). RACDS ANNALS 2016 51

Table 1. Pre-existing medical conditions requiring antibiotic prophylaxis Figure 1. Possible systemic problems resulting from bacteraemia Email address for correspondence: [email protected] [email protected] 52 RACDS ANNALS 2016

ORAL AND GENERAL HEALTH INTERFACE Prof Paul Brunton, BChD, MSc, PhD, FDSRCS (Edin), FDSRCS (Rest Dent) (Edin), FDSRCS (Eng), FFGDP (UK), FADM Prof Paul Brunton has over 20 years experience in academic dentistry in the UK and more recently in New Zealand where he is Dean of the Faculty of Dentistry at the University of Otago. INTRODUCTION SUMMARY Over recent years dental education has made a paradigm shift • Increased understanding of the oral and general health from training “tooth fixers” to educating oral physicians who can interface can only improve treatment outcomes for patients also fix teeth as and when required. Consequently, the importance • Oral health professionals have a role in the early indentification of oral health to general health and vice versa has gained increasing and referral of individuals with gastrooesophageal disease importance and is now more than ever relevant to how we both effectively and safely manage our patients. The management of • Treatments for non-carious tooth surface loss are becoming simpler and less interventive with an increasing focus on non-carious tooth tissue loss specifically intrinsic dental erosion, prevention sleep bruxism and myalgia make excellent examples of how an increased understanding of the impact of general health on oral • Recognition and diagnosis of patients with sleep bruxism and health and vice versa can only serve to improve patient outcomes. myalgia needs to improve and the complications of these conditions need to be clearly understood. • A muliti-professional approach is beneficial to patients in NON-CARIOUS TOOTH TISSUE LOSS managing conditions such as intrinisc dental erosion and sleep bruxism The association between gastroesophageal reflux disease (GORD), bulimia, anorexia nervosa and intrinsic dental erosion has long REFERENCES 1-5 been established in the literature. Management options for the dental consequences of this disease have simplified over recent 1. Nunn JH. Prevention of dental erosion and the implications for years with minimally interventive treatments largely based around oral health. Eur J Oral Sci1996;104:156-161. the direct placement of resin composites becoming the norm. The 2. Filipi K, Halackova Z and Filipi V. Oral health status, salivary use of canine risers in combination with direct placement of resin factors and microbial analysis in patients with active gastro- 6 composite can be particularly effective. oesophgeal reflux disease. Int Dent J 2011;61:231-237. 3. Holbrook WP, Furuholm J, Gudmundsson K, Theodórs A and But what of prevention and early identification? Specifically the Muerman JH. Gastric reflux is a significant factor of tooth oral signs prompting rapid medical referral for further investigation erosion. J Dent Res 2009;88:422-426. where appropriate, it is suggested, is an area where clinical practice 4. Tantbirojn D, Pintado MR, Versluis A, Dunn C and Delong could be improved. R. Quantitaive analysis of tooth surface loss associated with gastroesophageal reflux disease. J Am Dent Assoc 2012;143:278-285. SLEEP BRUXISM AND MYALGIA 5. Wang GR, Zhang H, Wang ZG, Jiang GS and Guo GH. Relationship between dental erosion and respiratory Our understanding of these conditions is increasing and they symptoms in patients with gastro-oesophageal reflux disease. are relatively common conditions. Sleep bruxism is defined as J Dent 2010;38:892-898. an oral movement disorder involving clenching or grinding of 6. Murray MC, Brunton PA, Osborne-Smith K and Wilson NHF. the teeth whilst asleep. The prevalence of sleep bruxism in the Canine risers: Indications and techniques for their use. Eur J general population is reported to be around 8-13%. Sleep bruxism Prosthodont Restor Dent 2001;9:137-140. 7 may lead to tooth surface loss, fracture of restorations or teeth, 7. Manfredini D, Winocur E, Guarda-Nardini L, Paesani D and 8-9 hypersensitive or painful teeth and muscle hypertrophy. Myalgia, Lobbezoo F. Epidemiology of bruxism in adults: a systematic which might be acute or chronic is a term used to describe the review of the literature. J Orofac Pain 2013;27:99-110. 10 condition previously termed myofacial pain. Chronic myalgia may result in both disability and is a risk factor for insomnia and 8. Fernandes G, Franco AL, Goncalves DA, Speciali JG, Bigal ME, poor sleep quality. Practitioners are somewhat confused about Camparis CM. Temporomandibular disorders, sleep bruxism, the diagnosis and the significance of these conditions. These and primary headaches are mutually associated. J Orofac Pain conditions can be associated with sleep apnoea, for example, with 2013;27: 14-20. up to 15% of patients with sleep buxism at high risk of obstructive 9. Lobbezoo F, Ahlberg J, Manfredini D, Winocur E. Are bruxism sleep apnoea. Practitioners need to be aware of this association and the bite causally related? J Oral Rehabil 2012;39:489-501. and how to identify patients at risk. The clinical management of 10. Dworkin SF, LeResche L. Research diagnostic criteria for sleep bruxism and myalgia share some parallels with that of non- temporomandibular disorders: review, criteria, examinations carious tooth surface loss and again a multi-professional approach and specifications, critique. J Craniomandib Disord 1992;6:301- is required. 355. Email address for correspondance: [email protected] RACDS ANNALS 2016 53

DIAGNOSIS AND “NON DENTAL” TREATMENTS OF SLEEP RELATED BREATHING DISORDERS Prof Matthew T. Naughton, MBBS MD FRACP Mathew Naughton is the head of general respiratory and sleep medicine at the Alfred Hospital and Adj Prof of Medicine at Monash University. ABSTRACT The diagnosis and management of sleep related breathing disorders requires an understanding of basic upper airway anatomy and sleep physiology. Snoring and obstructive sleep apnoea are the commonest SRBD in adults, estimated to occur in up to 25% of women and 50% of men. They are associated with a doubling of the risk of developing cardiovascular disease and post-operative complications. A detailed history and examination should be undertaken prior to management decisions which include conservative, dental, surgical and positive airway pressure devices. Identification and management of SRBD can be both professionally rewarding and challenging. Outcomes of treatment vary depending upon patient selection, severity of disease and the underlying lifestyle choices and associated medical disorders. A multidisciplinary team approach, involving dental, surgical and medical colleagues is the norm rather than the exception, and accordingly should be discussed with all patients seeking an opinion for underlying SRBD. INTRODUCTION oxygen storage facilities in our bodies (the lungs), oxygen levels rarely drop during sleep. Carbon dioxide levels rise 1-2 mmHg in healthy normal subjects’ sleep. Whilst all dentists and anaesthetists are trained to assess the upper airway in detail, a minority of medical practitioners have also learnt this skill. Of this subset of medical practitioners, ear nose and The third fundamental is that of sleep and the factors that change throat surgeons and some respiratory physicians with an interest sleep due to arousals. Sleep is thought to be important for healthy in sleep related breathing disorders (SRBD) have a strong interest functioning of immune system, protein synthesis, neuro- endocrine 2 in the upper airway anatomy and physiology. Accordingly, many function and clearance of cerebral toxins via glymphatic activation. patients with snoring and obstructive sleep apnoea (OSA) who are Sleep has three stages (non REM stages 1 and 2; slow wave sleep; missed by their primary care and specialist medical practitioners REM [rapid eye movement]. Across a single night, a healthy person are identified by their dentist. will have 4-5 cycles, each cycle containing all three stages of sleep. Arousability is defined as a level of stimulus which increases the level of alertness (eg from slow wave sleep [aka deep sleep] to PHYSIOLOGICAL CONTROL OF VENTILATION light non REM sleep [aka stages 1 or 2], or from REM to stages 1 or 2 sleep. More subtle examples of arousability can be seen in the This review takes a respiratory physician’s approach to common change in heart rate or blood pressure, where they are defined as SRBD in adults. Three basic fundamentals underpin the autonomic arousals. The degree of arousability (as measured by 1 understanding of SRBD. First is the control of ventilation during sound) varies between stages. The least arousability state is slow wakefulness which has three inputs: (a) a chemical control wave sleep, and is often referred to as deep sleep. For this reason, [mainly PaCO2, but also influenced by pH and PaO2] at the snoring is usually loudest and continuous during slow wave sleep. chemoreceptors situated at the carotid body and brain stem; (b) the waking neural control (or respiratory pacemaker) situated SLEEP RELATED BREATHING DISORDERS – SUBTYPES within the brain stem medulla [which allows ventilation to be timed with other non-volitional functions such as swallowing], and (c) the cerebral cortex [which allows ventilation to be timed with acts of Awareness of the above three fundamentals, can assist in volition such as speech]. During nonREM sleep, ventilation is under understanding the pattern of SRBD. Sleep related breathing chemical control. During REM sleep, ventilation is under chemical disorders can be subdivided into those related to dysfunction of and brainstem control. upper airway (snoring and obstructive sleep apnoea), respiratory pump muscles (eg hypoventilation disorders) and respiratory control (Cheyne Stokes Respiration). 3 The second fundamental, is the respiratory pump musculature. Three muscle groups are responsible for ventilation. The main group are the left and right diaphragms, stimulated by the phrenic Upper airway disorders result in snoring and obstructive sleep nerve which travels from the cervical spinal cord on either side of apnoea. The bony space through which patients breathe may be the mediastinum (and accordingly can be damaged by mediastinal compromised (eg nasal obstruction, enlarged tonsils, mandibular surgery, trauma or malignancies). The diaphragm activity during or maxillary insufficiency), or the UA motor activity compromised wakefulness is 100% for comparative purposes, and drops to by an increased load (obesity) or the motor activity is impaired ~ 80% during nonREM sleep and ~70% during REM sleep. The (alcohol and other drugs). Some racial groups (eg Asians) have a intercostal muscle group are ~ 80% active during nonREM sleep smaller airway for a given height and weight. With sleep onset, there and switch off during REM sleep. The upper airway muscle group is a loss of UAW motor activity, leading to an increase in inspiratory (and it is estimated there are 13 pairs of such muscles from the tip resistance, leading to an increase in diaphragm and intercostal of the nose to the larynx) are 80% active during non REM sleep activity (ie intrathoracic pressures become excessively negative and minimally active during REM sleep. Thus in normal subjects, and work of breathing increases). With further UAW narrowing ventilation drops from 100% during wakefulness , to about 80% and apnoea development, oxygen inflow and carbon dioxide during nonREM sleep and 70% during REM sleep. Because of large outflow both decrease, leading to hypoxemia and hypercapnia, 54 RACDS ANNALS 2016

with increasing negative intra-thoracic pressures. The apnoea is (ODI). The AHI, RDI and ODI are sometimes used interchangeably terminated by the brainstemis recognition of hypercapnia and an by sleep clinicians and confuse non sleep clinicians. Accordingly it arousal occurs, restoring strength to the upper airway muscles and is important to understand the test type before placing importance thereby ventilation and subsequent restoration of normal oxygen on a numeric value. and CO2 levels. This cyclic pattern of apnoea-arousal-apnoea occurs in stage 1 + 2 nonREM sleep. Non-cyclic apnoea-arousal- Additional markers of severity include a level of hypoxia (often apnoea with significant hypoventilation (severe hypoxemia) occurs during REM sleep. Loud continuous snoring without apnoea and the minimum SpO2) and a marker of sleepiness (the Epworth arousals is seen in slow wave sleep. Thus, the type of apnoea Sleepiness Scale [ESS)). Minimum SpO2 levels indicative of mild, changes with differing stages of sleep. moderate and severe levels are 88-92%, 80-88% and 50-80% respectively. The ESS ranges from 0 to 24, with values above 10 generally being regarded as indicating pathological sleepiness. Our Hypoventilation disorders occur due to either central (brain, spinal group has found the ESS also to correlate closely with depression. 7 cord, nerve pathology) or peripheral (chest wall [eg kyphoscoliosis] or muscle [eg muscular dystrophy]) pathology. Patients with advanced lung disease (eg chronic obstructive lung disease ASSESSMENT OF THE SNORING PATIENT related to smoking) can also hypoventilate. Such patients may have hypoventilation continuously (and need 24 hour invasive ventilatory Assessment of the snoring patient should incorporate a thorough support via a tracheostomy) or hypoventilation confined to sleep history, an examination, an objective measurement of ventilation (and need overnight non-invasive ventilation support via a mask). and (sometimes) a trial of treatment. The features in the history of Such patients usually have profound REM related hypoventilation. snoring which should alert the dentist that intervention is required include: when snoring occurs > 3 nights per week, in all body Respiratory control disorders are characterised by a cyclic positions and independent of alcohol, is associated with witnessed hyperventilation following by hypoventilation (aka periodic apnoeas and is of sufficient noise severity to disturb the sleep of breathing). The “hyper-hypoventilation cycle length” can guide the others. In addition, snoring should be investigated if associated 5 clinician to the cause. If the cycle length is short (eg 20-45 sec) with medical conditions (hypertension, heart disease, stroke) or 8 then narcotic induced SRBD should be suspected; if long (45-75 anaesthetic complications (difficult intubation , difficult weaning sec) then heart failure with Cheyne-Stokes respiration should from ventilation and other post-operative complications 9-10 ). A be suspected. A short cycle length is also seen in ~ 1% of adults history of medications, medical illnesses and symptoms of OSA initiating CPAP, in all adults at high altitude (high altitude periodic (sleepiness) in addition to safety to drive are imperative. breathing) and many premature infants. Examination should include basic parameters (height, weight, SNORING AND OBSTRUCTIVE SLEEP APNOEA- neck circumference), craniofacial appearance, nasal patency, CLINICAL INFORMATION oropharyngeal patency (Mallampati, tonsils, width of pharynx, distance posterior to soft palate), dentition, mandibular to hyoid distance, inaddition to a thorough cardiopulmonary, endocrine For the remainder of this review, the focus will be upon snoring and neurological examination. Due attention to mood disturbance and obstructive sleep apnoea. Both conditions overlap. They is also important. are common, estimated to occur in ~ 25% of women and 50% 4 of men aged 40-85year olds in Europe. Greater concern has An objective measurement of snoring is undertaken by a variety been the observation that OSA appears to double the relative of overnight tests, from portable and simple to laboratory risk for developing cardiovascular disease and post-operative based polysomnography. Portable and simple incudes sound complications. 5 continuous high fidelity oximetry with heart rate with sound and body position: this can be done at home, repeated many times The metric of snoring is sound, which is not easy to measure for and inexpensively. This is ideal for high probability “OSA” patients. several reasons. Sound dissipates exponentially with distance (ie More complex laboratory based polysomnography in which sleep the sound measured at 0.5 meters will vary considerably with that (EEG, EMG, EOG), heart (ECG and blood pressure) and ventilation measured at 1 meter), will vary depending upon the stage of sleep (sound, oxygen, carbon dioxide, tidal volume, arterial blood gas) (greatest in slow wave sleep, less in REM sleep) is measured with a are measured under supervision (ie control of medical and social logarithmic scale. Moreover one inspiratory snore will consist of a drugs) with accurate body position (rotational and head elevation) series of sub-snores as the soft palate swings back and forth. Most, is undertaken. This testing is ideal for symptomatic but low but not all, snoring is inspiratory. Finally snoring intensity, however probability OSA and other SRBD (due to hypoventilation and/or measured, does not equate with the apnoea hypopnoea index control of ventilation). (AHI). 6 MANAGEMENT OF SNORING AND OBSTRUCTIVE The apnoea hypopnoea index (AHI) is the commonly used metric SLEEP APNOEA which classifies patients into mild (5-15) moderate (15-30) and severe (>30 events [apnoeas and hypopnoeas] per hour) OSA(3). An apnoea is defined by a > 10 sec pause to ventilation, whereas The management of snoring and OSA can be broadly considered a hypopnoea is a > 10 sec reduction in ventilation sufficient to in 5 domains: (a) conservative, (b) dental, (c) surgical, (d) positive cause a fall in oxygen or an arousal. The combined number of airway device and (e) other. The decision to choose from the above apnoeas and hypopnoeas divided by the hours of sleep, provides is dependent upon (a) age and duration of the snoring or OSA, (b) the AHI. When cardiopulmonary monitoring is used (ie sleep is the severity of the snoring and OSA and (c) the associated medical, not quantified) the denominator used is the total recording time dental and anaesthetic history. and the metric is referred to as the Respiratory Disturbance Index (RDI). When finger pulse oximetry alone is used, with no measure Conservative management includes reversing contributing factors of sleep or respiratory effort, the total number of dips on oxygen such as reducing nasal resistance (avoid nasal irritants [allergens, level are divided by recording time to provide an oxygen dip index cigarette smoke]), manage allergic rhinitis [antihistamines, nasal RACDS ANNALS 2016 55

steroids], weight loss, minimizing alcohol consumption, review of Developing a trust and bond between clinician and patient will drug treatments (steroids, sedatives, antiepileptics, antidepressants, assist in managing the 4th dimension. analgesics), sleeping in lateral position with raised head of bed. Ensure other medical problems are optimally managed (endocrine, REFERENCES haematological, renal, cardiac, neurological, respiratory or mental health disease). Encourage a healthy sleep pattern (cautious 1. Dempsey JA, Veasey SC, Morgan BJ, O’Donnell CP. caffeine, daily exercise with bright light and a cool, dark and quiet Pathophysiology of sleep apnea. Physiological reviews. sleep environment with minimal shift work). 2010;90:47-112. 2. Xie L, Kang H, Xu Q, Chen MJ, Liao Y, Thiyagarajan M, et al. Dental management can be via mandibular advancement and Sleep drives metabolite clearance from the adult brain. maxillary widening devices. Good dental hygiene with patent Science (New York, NY. Oct 18;342(6156):373-7. 11-12 nasal flow and a positional nature to the snoring predict success. 3. Kee K, Naughton MT. Investigation of the snoring patient. Newer devices have built in sensors that detect usage that allows Medicine Today 2014; 15(2): 42-47. accurate adherence to treatment. 4. Heinzer R, Vat S, Marques-Vidal P, Marti-Soler H, Andries D, Tobback N, Mooser V, Preisig M, Malhotra A, Waeber Surgical management can be directed towards bariatric or upper G, Vollenweider P, Tafti M, Haba-Rubio J. Prevalence of airway. Bariatric surgery should be considered if the body mass sleep-disordered breathing in the general population: the index (BMI) is >40 kg/m2 or > 35kg/m2 with medical complications HypnoLaus study. Lancet Respir Med. 2015;3(4):310-8. of obesity. Upper airway surgery can be considered to be “soft 5. Hamilton GS Naughton MT. Impact of obstructive sleep 13 tissue” surgery (tonsils, adenoids, nasal septum, sinus, soft palate) apnoea on diabetes and cardiovascular disease. Med J Aust or bony surgery (mandibular or maxillary). 2013;199(8):S27-S30. Treatment with a positive airway device (continuous positive 6. Marshall, NS, Wong KKH, Cullen SRJ Knuiman MW, Grunstein, airway pressure [CPAP] via a soft silicon nasal, or oro-nasal, mask RRG. Sleep Apnea and 20-Year Follow-Up for All-Cause is worn during sleep. The devices are extraordinarily quite (less Mortality, Stroke, and Cancer Incidence and Mortality in the than back ground noise ie < 28dB) and can have inbuilt humidifiers, Busselton Health Study Cohort. J Clin Sleep Med. 2014 Apr pressure ramps and other pressure varying computers which may 15;10(4):355–362. improve compliance. As with dental devices, modern CPAP devices 7. Douglas N, Young A, Roebuck T, Ho S, Miller BR, Kee K, have built in computers that record usage, residual apnoea and Dabscheck EJ, Naughton MT. Prevalence of depression in hypopnoeas and quality of mask fit. patients referred with snoring and Obstructive Sleep Apnoea. Int Med J 2013;43:630-634. Other devices which remain to find their place in the treatment 8. Hiremath AS, Hillman DR, James AL, et al. Relationship of snoring and OSA are upper airway pacemakers, nasal valves, between difficult tracheal intubation and obstructive sleep medications and sublingual puffers. apnoea. Br J Anaesth 1998;80:606-611. 86. 9. Memtsoudis S, Liu SS, Ma Y, Chiu YL, Walz JM, Gaber-Baylis LK, The decision to choose one therapy above another is dependent upon the patient’s age, age of snoring onset and associated medical, Mazumdar M: Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery. Anesth Analg dental and anaesthetic history. In general however, in young 2011;112: 113-21. patients a surgical or dental approach is often chosen. In a young patient with huge tonsils and adenoids or severe retrognathia, a 10. Practice guidelines for the perioperative management of surgical approach should be considered. If a young patient has a patients with obstructive sleep apnea: an updated report narrow maxilla, a maxillary expansion device should be considered. by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep In middle aged patients who began snoring after adolescence apnea. Anesthesiology 2014;120(2):268-86. associated with the excesses of the fruits of life (food and alcohol) 11. American Academy of dental Sleep Medicine. Practice should be advised to modify their lifestyle. Manage the rhinitis if Guidelines for Dental Sleep Medicine. www.aadsm.org/ present. Consider a mandibular advancement splint if snoring, statementsguidelines.aspx mild OSA (AHI 5-15) or moderate OSA (AHI 15-30) associated with 12. Gotsopoulos H, Kelly JJ, Cistulli PA. Oral appliance therapy failed CPAP. For patients with moderate (AHI15-30) to severe OSA reduces blood pressure in obstructive sleep apnea: a (AHI>30), especially those with co-existent medical or anaesthetic randomized, controlled trial. Sleep 2004;27(5):934-41. complications 9-10 , CPAP should be considered. 13. Dixon JB, Schachter LM, O’Brien PE, Jones K, Grima M, Lambert G, Brown W, Bailey M, Naughton MT. Surgical In the elderly patients, it is imperative to manage the underlying or associated medical problems (eg heart failure). Usually such versus conventional therapy for weight loss treatment of patients do not have good dental hygiene. Alterations in lifestyle obstructive sleep apnea: a randomized controlled trial. JAMA 2012;308(11):1142-1149. can be difficult. As such CPAP therapy is often considered. In those frail or confused patients, CPAP may be reserved for use when “decompensated” requiring hospitalization. Email address for correspondence: SUMMARY [email protected] A “4th dimension to treatment of snoring and OSA is required, and that is time! As with the initiation of any treatment, follow-up of patients with snoring and OSA is crucial to confirm adherence and abolition of the initial signs and symptoms. Many patients are reluctant to begin, or undergo, treatment. In others, treatment has been less than satisfactory. Ongoing surveillance should be offered to these patients. Quite often changes in OSA severity occur with time, and treatments are developed de novo and old ones refined. 56 RACDS ANNALS 2016

RESTORATIONS UNDER STRESS - CAN THEY SURVIVE? Dr Simon Wylie, MDSc (Pros), FRACDS Dr Simon Wiley is a specialist prosthodontist in a private practice in Geelong/Melbourne. He is a part time instructor for the postgraduate prosthodontic program at the University of Melbourne and contributes to the Charles Sturt University Diploma in Implant Dentistry. ABSTRACT Restoration of teeth is undergoing a revolution in preparation concepts, materials, and production. CAD technologies are opening opportunities for indirect restorations that were the domain of large direct amalgams or composite resins. But are we meeting the specifications required for long term results? Are the lesson learned in the previous decades in the area of ‘resistance and retention form’ relevant to the adhesive age? This paper aims to review he specifications required to successfully restore the posterior tooth and to evaluate our progress with the advancement of novel ceramic options. The restoration of the tooth aims to restore the biomechanics and Although occlusal loading is nominally compressive, some tensile integrity of the tooth. The indirect restoration has experienced an forces are inevitable in function. We tend to see cracks that will evolution with the traditional alloy used in partial and full veneer follow the paths where these tensile stresses are greatest. While restorations, followed by the popularity of the porcelain fused to there may be one catastrophic ceramic restoration fracture, it is gold crown, and more recently the all ceramic restoration. The more likely that failure will occur cumulatively after an extended purpose of this paper is to evaluate the progress of the ceramic period of seemingly innocuous but lower level biting events. restoration. We also have an issue that the ceramics with the most desirable The impact of endodontic and restorative procedures on tooth of aesthetics, notably the porcelains, tend to have the lowest stiffness was evaluated and compared using extracted maxillary resistance to crack propagation or fracture toughness and the 1 second premolars. A strain gauge was used as a measurement lowest flexural strength. At the other end of the scale we have the of tooth stiffness following various endodontic and restorative toughest ceramics such as the alumina and zirconias, but in this procedures. The restorative procedures involved standardised category we tend to lose the translucent nature of porcelain and occlusal restorations that extended into major developmental the etchability for intimate bonding. In the middle ground we have grooves. The experiment revealed only a 5% decrease in relative the glass ceramics. tooth stiffness following endodontic access preparation compared to 20% decrease after an occlusal preparation, 46% reduction So what have we done in the past to maximise the benefit of after a two-surface restoration and 63% reduction after MOD ceramics. Ceramic material does not like to be bent and if we preparation. Endodontic access preparation had minimal impact strain the ceramic approximately 1% a catastrophic fracture will on the reduction of tooth rigidity, when compared to larger cavity occur. However if we back the same beam of ceramic with a metal preparation. alloy as we have done traditionally with the porcelain fused to metal crown, and if this ceramic is intimately adhered to that alloy Using direct current differential transformers (DCDTs), the previous through oxide layers then we can apply that same force to this results were confirmed, showing increasing cuspal deflection with ceramic with the alloy below the ceramic and its high modulus of increasing cavity size. The deflection was the greatest following elasticity preventing that 1% distortion of the ceramic and therefore 2 endodontic access and MOD cavity preparation with cusp isolation. preventing catastrophic failure. The reduction in cuspal stiffness was mainly due to the increasing loss of tooth structure during restorative procedures. Therefore, In the all ceramic restoration there is a need to substitute the 1-4 extensively broken-down teeth appear to exhibit lower tooth role played by the metal alloy. We look to the ceramic itself and strength and stiffness, and thus are more susceptible to fractures. introduce a crystal structure that will resist crack propagation and we’ve been through the evolution of leucite reinforced ceramic and So what is the effect of restorations on the pattern of cuspal lithium disilicate ceramic in the past 15 years. As a result there is an deflection? This is described by the extension of the study by increase in the flexural strength and fracture toughness of the glass 1 Reeh et al (1989) . Restoring a class one restoration or endodontic ceramics. access with amalgam has little effect on cuspal deflection. With composite resin there is some improvement in the relative stiffness The ceramic needs to have an intimate relationship with the of the tooth with the integrity of the adhesion to the enamel there is cement and the tooth below through adhesion. In one instance we an inner binding effect. Some argue that the actual reinforcement could replace the metal for enamel and the intimate bonding can of the tooth is likely to reduce over time. The dramatic difference come from adhesion through resin cements, ceramic primers, and occurs when the restoration not only restores the defect but in etched surfaces at both the tooth end and the ceramic end. addition to this it provides cuspal overlay protection. It is illustrated in this study it is possible with the use of an alloy to provide cuspal More often than not in the posterior dentition we have a cusp protection which changes the overall stiffness of the restored fracture with a residual direct restoration defect and after elimination tooth complex to a level above that of the control, the unaltered, of any active disease we are facing a different restorative challenge. unprepared or unrestored tooth. Unlike enamel which provided a high modulus elasticity foundation for our ceramic, dentine has a low modulus, more organic, less There has been a general shift towards ceramic restorations for mineralised foundation. No longer do we have the foundation that partial veneer crowns, full crowns and even fixed bridges. However will help resist that ceramic strain and hence there is a need to ceramic restorations are brittle and susceptible to fatigue fracture increase the resistance in the ceramic with an increase in thickness. in repetitive function. 5 We now need the ceramic itself to resist these forces rather thanks rely on the high modulus foundation. RACDS ANNALS 2016 57

Researchers evaluated the influence of ceramic thickness and the REFERENCES type of dental bonding surface on the fracture resistance of non- 1. Reeh E, Messer H, Douglas WH. Reduction in tooth stiffness as retentive full coverage adhesively retained occlusal veneers made a result of endodontic and restorative procedures. J Endodont 6 from lithium disilicate material (IPS emax cad). The study verified 1989;15(11): 512-516. the need to maintain adequate thickness and that ceramic bulk may be preferable to an enamel subsurface in some situations. 2. Panitvisai P, Messer H. Cuspal deflection in molars in relation to endodontic and restorative procedures. J Endodont Another study looked at the effect of porcelain and enamel 1995;21(2):57-61. 7 thickness on porcelain veneer failure loads in vitro. They found that 3. Linn J, Messer H. Effect of restorative procedures on the the increased enamel thickness and increased porcelain thickness strength of endodontically treated molars. J Endodont and the increased combined enamel on porcelain thickness all 1994;20(10):479-485. profoundly raised the failure loads necessary to cause catastrophic 4. Taha NA, Palamara JEA, Messer H. Fracture strength and failure. fracture patterns of root filled teeth restored with direct resin restorations. J Dent 2011;39(8):527-535. So in summary then we are seeking the functional benefits that we 5. Zhang Y, Sailer I, Lawn BR. Fatigue of dental ceramics. J Dent achieved through an alloy restoration with a ceramic restoration 2013;41(12):1135-47. and we attempting to do this via: 1. selecting a ceramic with improved physical properties from 6. Sasse M, Krummel A, Klosa K, Kern M. Influence of restoration our traditional porcelains thickness and dental bonding surface on the fracture 2. backing the ceramic with a high modulus material like enamel resistance of full-coverage occlusal veneers made from when possible lithium disilicate ceramic. Dent Mater 2015;31(8):907-15. 3. etching the ceramic and the subsurface to allow for an intimate 7. Ge C, Green CC, Sederstrom D, McLaren EA, White SN. Effect adhesion between the materials odf porcelain and enamel thickness on porcelain veneer 4. when dealing with a lower modulus dentine subsurface failure loads in vitro. J Prosthet Dent 2014;111(5):380-387. following all the above principles however thickening the 8. Collares K, Correa MB, Laske M, Kramer E, Reiss B, Moraes ceramic in order to decrease the likelihood of the material RR, Huysmans MD, Opdam NJ. A practice-based research straining network on the survival of ceramic inlay/onlay restorations. Dent Mater 2016 ( in publication) The literature assessing the survival of these restorations in the 9. Fabbri G, Zarone F, Dellificorelli G, Cannistraro G, De Lorenzi M, posterior regions of the mouth has all the deficiencies that we Mosca A, Sorrentino R. Clinical evaluation of 860 anterior and are familiar of with long-term survival studies- lack of prospective posterior lithium disilicate restorations: retrospective study studies- multiple variables that can’t always be controlled- different with a mean follow-up of 3 years and a maximum observational bonding agents, different operators and various ceramics. period of 6 years. Int J Periodont Rest 2014;34(2):165-177. A practice based study recently focussed on the ceramic inlay/ 10. Beier US, Kapferer I, Burtscher D, Giesinger JM, Dumfahrt H. onlay restoration8. The objective was to look at the longevity of Clinical perforamance of all-ceramic inlay and onlay restorations the ceramic inlay and onlay restorations and they did so on 5791 in posterior teeth. Int J Prosthodont 2012;25(4):395-402. restorations in 5523 patients by 167 dentists between 1994 and 11. Ferderlin M, Hiller KA, Schmalz G. Effect of selective enamel 2014. For the restorations some of the variables in materials and etching on clinical performance of CAD/CAM partial ceramic cements were recorded and the annual failure rates (AFRs) were crowns luted with self-adhesive resin cement. Clin Oral Invest calculated. 2014, 18(8):1975-1984. Despite the period of the study the mean survival time was only Email address for correspondence: three years and the maximum 15 years- so weighted towards young restorations as many studies are. The annual failure rate [email protected] when you passed through the three-year period is about 1% per year however this progresses to 1.6% per year for the 10 year restorations. Some other interesting trends from the study were that restorations with a cervical outline in dentine had a 78% higher risk of failure compared to restorations with margins in enamel.The presence of a liner or a base of glass ionomer cement resulted in a risk of failure twice as large as that of restorations without a liner or base material. Restorations with a two-step adhesive approach presented a risk of failure 142% higher than restorations performed with a three step etch prime and bond. The most predominant reason for failure was fracture of the restoration or the tooth and this occurred in just under half of all failures. Other studies can collectively support the success and survival 9-11 of ceramic onlays. The evolution of the partial ceramic veneer restoration in the posterior mouth indicates that it is a restoration that highlights the value of an understanding of material science, the importance in preserving the biology of the tooth and the significance of strict laboratory protocols. The use of the ceramic in this region requires great sensitivity with case selection, strict protocols of adhesion, moisture control, and correct occlusal adjustments. With all this taken into account and with the scientific justification for restoring these posterior teeth and returning bio- mechanical integrity to these teeth, it is a valid restorative option. 58 RACDS ANNALS 2016

BRUSHING UP ON ANTARCTIC DENTISTRY Dr Roland Watzl, MBBS (Syd) FACRRM Dr Roland Watzl is a General Practitioner, and the Deputy Chief Medical Officer of the Australian Antarctic Division. His special area of expertise is the provision of medical services in the extremely remote expedition setting. ABSTRACT There are few places as remote as Antarctica. Australia has stewardship of 42% of the continent under the Antarctic Treaty system and maintains three permanent research stations there as well as a Sub-Antarctic station at Macquarie Island. These stations are staffed year- round. For some fifty years the Australian Antarctic Division (AAD) has had its own in-house medical support, the Polar Medicine Unit (PMU), which provides holistic medical support to Australia’s endeavours in Antarctica and the Southern Ocean. This includes training and 24/7 support of Antarctic Medical Practitioners who become the de facto dentist while on expedition. Expedition doctors are usually generalist practitioners rather than specialists and all receive critical upskilling prior to deployment. All are trained and supported to be able to deal with any medical eventuality that might occur. Once deployed they work in a single doctor model without the on-site support of other trained medical or paramedical staff, within a medical paradigm where medical evacuation is never first line management. The medical support provided by the PMU is robust, efficient and effective. It is the sum of sixty years of continuous medical support provision in the most extreme environment on Earth. It is arguably the benchmark against which other support models can be measured, especially at a time when many other Antarctic programs are curtailing their medical capabilities. There are many past accounts of dental problems encountered in Antarctica. Often mentioned phenomena that capture the imagination 1-6 have been the shattering of teeth and the falling out of fillings due to seemingly extreme low environmental temperatures. Many of these have since been debunked and attributed to poor dental hygiene and caries rather than extreme temperatures. However there does appear to be an increased incidence of caries among Antarctic expeditioners. Many accounts detail the challenges posed by dental problems 7 that require treatment by medical doctors with limited dental training and limited practical dental experience. An account of Sir Douglas Mawson’s Australasian Antarctic Expedition (1911-14) is instructive and details the problems faced by one of its three expedition doctors when confronted with a painful tooth. Consequently the wrong tooth was removed (misdiagnosis), was broken in the process (iatrogenic injury), necessitating extraction of another (correct) tooth and broken remnant roots under general anaesthesia. The patient in this instance being one of the other expedition doctors, Dr Archibald McLean. 8,9 The current PMU dental support model addresses past challenges and aims at providing the best of dental care that is realistically achievable in an extreme and remote environment devoid of specialist dentists, knowing that each station group in Antarctica has to be fully self- sufficient for eight months of winter isolation each year and that dental problems constitute 9.4% of the clinical workload. This support model consists a standardized dental inventory, standardized dental training and standardized specialist dental telemedicine advice, the three components being in perfect tune. Dental training for AAD doctors is delivered each year by the Royal Dental Hospital of Melbourne. This training is now in its sixth decade and has evolved into a structured nine day course which trains doctors to effectively diagnose common dental conditions and emergencies and then also to deal with them, including the application of temporary fillings (45% of all dental procedures over the last 12 years), doing the first stages of root canal therapy, and repairing broken dentures. The extraction of teeth is also a taught but not used commonly in Antarctic clinical practice. Of a total of 553 dental procedures performed over the last 12 years, only three were extractions. All of the medical support systems provided by the Polar Medicine Unit are under constant review and the aim is always to provide best safe clinical practice. Most recent projects have provided a full electronic medical record system and a fully digital x-ray system both of which have vastly improved tele-medicine capabilities. A current review of our dental support model is also under way, aimed at simplifying dental materiel and training provided to our de facto dentists in Antarctica. ACKNOWLEDGEMENTS The assistance of Prof Des Lugg with providing some historic background and context is gratefully acknowledged. I am also grateful to Dr Jeff Ayton and Dr Clive Strauss for their assistance and input. REFERENCES 7. Beynon AD, Effects of an Antarctic environment on dental 1. Knoedler D, Stanmeyer W. Dental Observations Made While structures and health. In: Polar Human Biology – The Wintering in Antarctica, 1956-1957. J Dent Res 1958;37:614. Proceedings of the SCAR/IUPS/IUBS Symposium on Human 2. Koss RJ, NMRL Report No. 415 - Report of Dental Officer for Biology and Medicine in the Antarctic. William Heinemann Antarctic Support Activities for Operation Deep Freeze. 1963: Medical Books Ltd, 1973. MR005.12-5220-2.12. 8. Madigan CT, Madigan’s account: the Mawson Expedition: the 3. Lisney SJ. Dental Problems in Antarctica. Br Dent J 1976;141:91- Antarctic diaries of C.T. Madigan, 1911-1914 /transcribed by J.W. 92. Madigan. p 221, Wellington Bridge Press 2012 4. Fletcher LD. Dental observations at Australian Antarctic Stations. 9. Hunter JG, Rise and Shine: Diary of John George Hunter Aust Dent J 1983; 281-285. Australasian Antarctic Expedition 1911-1913. P 122, Hunter House 5. Bowden T. The Silence Calling: Australians in Antarctica 1947-97. Publications, 2011. Allen & Unwin, Sydney, 1997. 6. Guly HR, Dental Problems During the Heroic Age of Antarctic Email address for correspondence: Exploration. Dental History Magazine 2011; 5:8-13. [email protected] RACDS ANNALS 2016 59

ORAL BIOFILMS: IMPLICATIONS IN THE MEDICALLY COMPROMISED Dr Melinda Newnham, BDSc (W.A.), FRACDS DCD (Perio), FRACDS (Perio) Dr Newnham is the consultant periodontist at the Alfred Hospital in Melbourne and is in private practice in Moonee Ponds (Victoria). She has teaching positions at the University of Melbourne and La Trobe University, Bendigo and is currently the president of the Australian Society of Periodontology Victorian branch. ABSTRACT Medically compromised patients in Australia are generally affected by chronic disease. Chronic disease accounts for the majority of hospitalisations in Australia and results in a heavy burden of debilitation, disability and mortality. Chronic disease is currently Australia’s biggest health challenge. The dental management of oral biofilm-related disease in medically compromised patients is often complex, requiring consultation with the patient’s physician. Eliminating dental foci of infection is of vital importance to prevent infective sequelae during invasive medical treatment. The objective of this paper is to review the health status of Australians, specifically those who are hospitalized and to consider the significance of oral biofilm-related disease within this susceptible population. INTRODUCTION of inflammation within a periodontal pocket. The bacterium upregulates the expression of gingipains on its cell surface, thereby Australians are living longer, largely due to improved health care. increasing its proteolytic activity in the presence of the tissue Babies born in 2013 are predicted to live to 80 years of age for boys breakdown product haemin. 9 and 84 for girls. Currently 15% of the population is aged 65 years or over, a figure that has tripled within the past 50 years. It is estimated The pathogenesis of periodontal disease is based upon an that by 2054, 8.4 million Australians will be over 65, corresponding imbalance between the pathogenicity of the plaque biofilm and to 21% of the population. 1 the susceptibility of the host. A “hyper responsive” reaction of the host to the microbial challenge triggers an immuno-inflammatory Longer lifespans result in an increased burden of disease. Forty process resulting in loss of attachment and ultimately, loss of percent of hospital admissions in 2013-2014 were for Australians the tooth. The susceptibility of the host to the effects of plaque aged 65 and over, with many affected by more than one condition. 2 is modulated by genetic, acquired and environmental conditions According to the Australian Institute of Health and Welfare, such as such as smoking and diabetes. 10 cardiovascular disease (CVD), neoplasms, chronic obstructive pulmonary disease (COPD), diabetes mellitus and dementia An interesting feature of immunosuppressed patients is that they accounted for the majority of hospitalisations in 2013-20142. frequently do not present with obvious signs of infection due to 11 Chronic disease is currently Australia’s greatest health challenge their immunocompromised state. For example, in 2012, a 19 year and was responsible for 90% of all deaths in 2011. 2,3 old female who received an allogenic renal transplant in 2004 was seen in dental unit at the Alfred Hospital. She had developed The centralizing of populations, cheaper food sources and rising necrotising ulcerative gingivitis, 24 hours after a routine scale disposable incomes promotes chronic disease through increasingly and clean at her dentist’s office. She presented to the dental unit sedentary lifestyles, resulting in significant numbers of overweight with pain, a bad taste and small, bleeding ulcers between 11 and 4 and obese Australians. In 2014-2015, 63.4% of Australian adults 12, 31 and 32, 43 and 44. The interproximal papillae were flattened, (18 years of age and over) were overweight or obese, equating to mildly inflamed with heavy plaque deposits present. Periapical 5 11.2 million people. Therefore, it is not surprising to discover the films revealed moderate crestal bone loss associated with small common risk factors for CVD, COPD, cancer and diabetes include subgingival calculus deposits. Subsequent investigations by tobacco use, poor nutrition, physical inactivity and the misuse of the renal, infectious diseases and dental units revealed that she alcohol. Furthermore, these risk factors are preventable. Chronic was mildly over-immunosuppressed and treatment included a diseases are frequently the cause of long lasting debilitation and change in immunosuppressant [from rapamycin (Sirolimus) to many patients are affected by more than one form of chronic mycophenolate mofetil (Cell Cept)], intravenous antimicrobial disease. 4 agents (ceftazidime, fluconazole, metronidazole and ciprofloxacin) and periodontal treatment utilizing chlorhexidine rinses and ORAL BIOFILMS nystatin drops. The lesions resolved six days after periodontal treatment. The patient had been placed into a long-term periodontal maintenance program and has been asymptomatic to date. The oral microbiome is one of the most dynamic and diverse in the human body. Distinctive biofilms colonise specific mucosal and tooth surfaces, each unique to its environment. It contains IMPLICATIONS OF ORAL BIOFILMS IN MEDICALLY 6 approximately 700 species of microflora including viruses, COMPROMISED PATIENTS mycoplasma, bacteria, archaea, fungi and protozoa, of which bacteria are the most common. Each oral biofilm is capable of Medically compromised patients hospitalised for management 6,7 maintaining health or promoting disease. Changes in the host of chronic disease are frequently older, hypertensive, diabetic, 4 environment frequently induce shifts in the microbial ecology, overweight and are smokers. Polypharmacy and poor glucose potentially allowing pathogens to flourish and instigate disease. control often leaves them with hyposalivation. Others will also be 8 For example, the destructive activity of the putative periodontal immunosuppressed due to organic disease or through therapeutic pathogen Porphyromonas gingivalis increases in the presence interventions. 60 RACDS ANNALS 2016

These patients often have poor self-care, or rely upon carers to IE is a relatively uncommon condition, but can be difficult to detect, support them during hospitalisation and/ or at home, including causing significant morbidity and mortality. provision of oral and denture hygiene. Therefore, plaque control is often poor, the incidence of caries and periodontal disease Therapeutic strategies aimed at reducing the risk of bacteraemia becomes high and the frequency of dental treatment is low. include improved periodontal treatment, managing mucositis These patients are frequently at an economic disadvantage as in addition to preventing the establishment of the bacteraemia their disability does not allow them to work or they work part- through the use of prophylactic antibiotics for invasive dental time. In addition, they often suffer from stress and can be anxious procedures. However, for hospitalized patients, the need for 4 4 and depressed, further suppressing self-care and promoting oral prophylactic antibiotics needs to be assessed on a case by case biofilm-related disease. basis, based on risk of infective endocarditis, potential infection of transplant grafts, the risk of systemic infection and the current OROMAXILLOFACIAL INFECTIONS immune status of the patient. 11, 12, 14, 15 Infections of the oral cavity commonly include periodontitis, caries, NOSOCOMIAL INFECTIONS endodontic infections, musculoskeletal infections, necrotising fasciitis and osteomyelitis. In addition, oral microbes from intraoral It has been estimated that 6% of hospitalised patients in Australia infections have the potential to spread along fascial planes or acquire nosocomial (hospital-acquired) infections. Most of penetrate into adjacent tissue spaces such as the cavernous sinus, these infections occur in surgical wounds, are associated with mediastinum, the sinuses and the floor of the mouth. The resulting intravascular cannulas, or are respiratory and urinary tract infections. infections (cavernous sinus thrombosis, mediastinitis, sinusitis and Nosocomial infections are commonly caused by methicillin- Ludwig’s angina) can have serious consequences for all patients, resistant Staphylococcus aureus (MRSA), antibiotic-resistant gram- particularly for those who are medically compromised. 12 negative bacilli and vancomycin-resistant enterococci (VRE). 22 BACTERAEMIA In 2015, the Australian federal government departments of Health and Agriculture launched a national directive to investigate and 12 13 Oral microbes have been found within atheromas, heart valves, address antibiotic-resistance. The program includes a formal organ grafts and in the lungs of COPD patients. 12,16 In the case of framework to assess current strategies and to implement 15 COPD, bacteria are thought to translocate from oral biofilms to antimicrobial stewardship and surveillance programs within the lungs. This process is thought to occur through aspiration of Australian hospitals. Antimicrobial stewardship aims to promote 23 dental plaque or via the transfer of plaque microbes to the lungs the optimal use of antimicrobials, to result in improved patient during intubation or through mechanical ventilators. Case control outcomes, minimization of bacterial resistance and restriction of 12 studies have associated periodontal disease, poor oral hygiene and the spread of nosocomial infections caused by multidrug-resistant raised IgG titres against P. gingivalis with more frequent episodes organisms. 22,23 These policies are supported by surveillance of obstructive lung disease and acute bacterial exacerbations programs which verify the efficacy of selected antimicrobials (pneumonia). 16,17 Interventions such as improved plaque control, against target pathogens, minimizing the risk and restricting periodontal treatment and simple swabbing of the mouth the spread of nosocomial infections. Surveillance programs 17 with chlorhexidine four times daily has been demonstrated to also promote infection control interventions such as timely significantly reduce the incidence of acute infective incidents handwashing using suitable antiseptics, aseptic techniques, short including ventilator-assisted pneumonia in COPD patients. 18 hospital stays, minimal and early removal of invasive devices to prevent transmission of skin bacteria such as Staphylococcus Portals of bacterial entry from the mouth into the systemic aureus into wounds, percutaneous endoscopic gastrostomy tubes circulation are typically gained through breaches in epithelial (abdominal feeding and medication tubes) and intravascular barriers. Typically, this occurs through mucosal ulceration and catheters. 22,23 ulcerated periodontal pocket epithelium. Haematogenous spread of oral microbes results in bacteraemia and dissemination into Medically compromised patients are frequently hospitalised for distant systemic sites. Organ transplants and prosthetic heart short stays or reviewed in outpatient clinics, repeatedly exposed valves are particularly vulnerable to infection originating from to the risk of nosocomial infections at varying levels of immunity. 22 dental foci. 11,12,15 These same patients can present to our practices for treatment. Therefore, dental clinicians also have a responsibility to control Poor oral hygiene produces heavy plaque biofilms and antibiotic resistance whilst aiming for optimal patient outcomes inflammation of the periodontal tissues. In such an ecological utilizing the strategies of antimicrobial stewardship and microbial niche, a viable bacteraemia can be generated due to routine, daily surveillance. activities such as chewing, tooth brushing and flossing. A recent 20 cross sectional study revealed no significant difference in the DENTAL MANAGEMENT OF MEDICALLY magnitude of bacteraemia produced from flossing or periodontal COMPROMISED PATIENTS debridement, however the bacteraemia post debridement had 21 the potential to be of a longer duration. Healthy patients have Invasive medical treatment such as heart valve replacement, sufficient immunity to address transient bacteraemia. However organ or stem cell transplantation, chemotherapy, radiotherapy bacteraemia in immunosuppressed patients can result in systemic and intravenous bisphosphonate therapy can be required for the infection. 12 management of severe chronic disease. A patient may therefore be referred for dental treatment prior to the intervention, during INFECTIVE ENDOCARDITIS the acute phase of the intervention or after treatment is complete and an adequate healing time has elapsed (during the rehabilitation An infrequent but potentially life-threatening consequence of phase). Consultation with the patient’s physician is often necessary bacteraemia is infective endocarditis (IE). IE is caused by microbial to determine the optimal timing of dental treatment and the need damage to the endothelial lining of native or prosthetic heart for prophylactic antibiotics, management of bleeding and steroid valves commonly due to viridans streptococci bacteraemia. The cover. 11,12,14,15 incidence of infective endocarditis in Australia is low, however is associated with an in-hospital mortality rate of 15-20%. Therefore 13 RACDS ANNALS 2016 61

Many major hospitals have a dental unit and therefore patients CDA8 52 A 3 49B 4CEE6CA 2 57F 150 0 0 9FC 53/$File/ are more frequently referred within the preoperative phase. This national%20health%20survey%20first%20results,%202014- provides a valuable opportunity for oral infections such as apical 15.pdf periodontitis, pericoronitis, periodontal disease, cysts, unrestorable 6. Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE. Defining teeth, or abscesses to be eliminated prior to further invasive the normal bacterial flora of the oral cavity. J Clin Microbiol 12 medical interventions. Preoperative dental management also 2005;43:5721-5732. minimizes the ongoing risk of bacteraemia through resolution of 7. Dewhirst FE, Chen T, Izard J, Paster BJ, Tanner ACR, Yu WH, periodontal inflammation. Lakshmanan A, Wade WG. The Human Oral Microbiome, J 20 Bacteriol. 2010 Oct;192(19):5002–5017. During the acute phase of invasive medical interventions, dental 8. Duran-Pinedo AE1, Frias-Lopez J2. Beyond microbial treatment is not advisable unless it is on an emergency basis community composition: functional activities of the oral or for the palliation of side effects (for example treatment of microbiome in health and disease. Microbes Infect. 2015 mucositis and xerostomia). Organ transplantation patients are Jul;17(7):505-16. particularly susceptible to infection from the time of surgery 9. Marsh PD, McDermid AS, McKee AS, Baskerville A. The effect and postoperatively for six months. It is during this early healing of growth rate and haemin on the virulence and proteolytic stage that acute rejection and potential infection of the graft is a activity of Porphyromonas gingivalis W50. Microbiology significant risk. Transplant patients are encouraged to continue 1994;140:861-865. 11-13 with plaque control routines, supplementing mechanical cleaning 10. Page RC and Kornman KS. The pathogenesis of human with chlorhexidine rinses as required as this minimizes the risk of periodontitis: an introduction. Periodontol 2000. 1997:14:9-11. bacteraemia. 12 11. Sulemanjee NZ, Merla R, Lick SD, Aunon SM, Taylor M, Manson M, Czer LS, Schwarz ER. The first year post-heart During the rehabilitation and maintenance phase of systemic transplantation: use of immunosuppressive drugs and early treatment, that is, once the patient is stable and a sufficient complications. J Cardiovasc Pharmacol Ther. 2008 Mar;13(1):13- healing time has elapsed, the objective of dental treatment is the 31. maintenance of oral health. Organ transplant patients are subject 12. Maddi A, Scannapieco FA. Oral biofilms, oral and periodontal to long-term immunosuppression whereas prosthetic heart valve infections, and systemic disease. Am J Dent 2013:26:249-254. patients are at increased risk of bacterial endocarditis and the 13. Therapeutic Guidelines eTG Complete. Prevention of concomitant bleeding risks with anticoagulant therapy. Achieving endocarditis: general considerations. 2015. [Accessed 2016 14 a state of oral health preoperatively simplifies maintenance of Feb 27]. https://www.tg.org.au/etg_demo/desktop/tgc/ dental health over the long term. 12,14 abg/16628.htm 14. Rustemeyer J1, Bremerich A. Necessity of surgical dental FINAL COMMENTS foci treatment prior to organ transplantation and heart valve replacement. Clin Oral Investig. 2007 Jun;11(2):171-4. The medical management of chronic disease has improved 15. Velich N, Remport A, Szabo G. Dental screening of patients significantly, allowing affected Australians to live a longer life. Dental after organ transplantation. Orv Hetil 2002;10:505–508. clinicians are seeing more medically compromised patients in 16. Takahashi T1, Muro S, Tanabe N, Terada K, Kiyokawa H, Sato S, practice, with increasing dental treatment needs. These patients Hoshino Y, Ogawa E, Uno K, Naruishi K, Takashiba S, Mishima require careful management as their systemic condition can M. Relationship between periodontitis-related antibody and predispose them to biofilm-associated diseases, particularly within frequent exacerbations in chronic obstructive pulmonary the oral cavity. It is often necessary to consult with the patient’s disease. PLoS One 2012;7(7):e40570. physician to determine the optimal timing of dental treatment, 17. Chung JH, Hwang HJ, Kim SH, Kim TH. Associations Between to determine healing times after extractions and surgery and to Periodontitis and Chronic Obstructive Pulmonary Disease; the consider the need for adjunctive cover. Achieving a state of oral 2010-2012 Korean National Health and Nutrition Examination health prior to the onset of systemic treatment and subsequently Survey (KNHANES). J Periodontol 2016 Feb 25:1-11. enrolling patients into a maintenance program greatly simplifies 18. Kucukcoskun M1, Baser U, Oztekin G, Kiyan E, Yalcin F. Initial dental management for medically compromised patients in the periodontal treatment for prevention of chronic obstructive long term. pulmonary disease exacerbations. J Periodontol. 2013 Jul;84(7):863-70. 19. Özçaka Ö1, Başoğlu OK, Buduneli N, Taşbakan MS, Bacakoğlu REFERENCES F, Kinane DF. Chlorhexidine decreases the risk of ventilator- 1. Australian Institute of Health and Welfare (AIHW). Australia’s associated pneumonia in intensive care unit patients: a welfare 2015. Australia’s welfare series no. 12. [Internet]. randomized clinical trial. J Periodontal Res 2012 Oct;47(5):584- 2105; AIHW Cat. no. AUS 189. www.aihw.gov.au/WorkArea/ 92. DownloadAsset.aspx?id=60129552019 [Accessed 2016 Feb 20. Tomas I, Diz P, Tobias A, Scully C, Donos N. Periodontal health 27] status and bacteraemia from daily oral activities: systematic 2. AIHW. Australia’s hospitals 2013–14 at a glance [Internet]. review/meta-analysis. J Clin Periodontol 2012;39:213–228. 2105. www.aihw.gov.au/WorkArea/DownloadAsset. 21. Zhang W, Daly CG, Mitchell D, Curtis B. Incidence and aspx?id=60129551482 [Accessed 2016 Feb 27] magnitude of bacteraemia caused by flossing and by scaling 3. AIHW. Australia‘s hospitals 2009–10: at a glance. Health and root planing. J Clin Periodontol 2013;40:41–52. services series no. 39. [Internet]. 2011b [Accessed 2016 Feb 22. Spelman D. MJA practice essentials. Infectious diseases 2: 27]; AIHW Cat. no. HSE 106. www.aihw.gov.au/WorkArea/ Hospital-acquired infections. MJA 2002;176:286–291. DownloadAsset.aspx?id=10737418861 23. Australian Government Department of Health and Department 4. AIHW. Australia’s health 2014. Australia’s health series no. of Agriculture. Australia’s first national antimicrobial resistance 14.[Internet]. 2014 [Accessed 2016 Feb 27] AIHW Cat. no. strategy 2015-2019. Commonwealth of Australia 2015. AUS 178. www.aihw.gov.au/WorkArea/DownloadAsset. http://www.health.gov.au/internet/main/publishing.nsf/ aspx?id=60129547726 content/1803C433C71415CACA257C8400121B1F/$File/amr- 5. Australian Bureau of Statistics. National Health Survey strategy-2015-2019.pdf [Accessed 2016 Feb 27]. First Results Australia 2014-15. Commonwealth of Australia [Internet]. 2015 [Accessed 2016 Feb 27] Email address for correspondence: www.ausstats.abs.gov.au/Ausstats/subscriber.nsf/0/ [email protected] 62 RACDS ANNALS 2016

MANAGEMENT OF BIOFILM DISEASE AROUND IMPLANTS: A CONTRAST TO DISEASE MANAGEMENT AROUND TEETH Dr Luan Ngo, BDSc (Hons), PhD, DCD, FRACDS (Perio) Dr Luan Ngo is an Honorary Fellow of the Melbourne Dental School and has been involved in teaching the undergraduate students for over a decade at the University of Melbourne. ABSTRACT Dental implants are becoming an increasingly common part of dental treatment offered to our patients for the replacement of teeth in partial and fully edentulous situations. In many cases, dental implant retained single crowns, bridges or dentures are the gold standard for tooth replacement. Infections can occur around implants as they do around teeth. The different physical characteristics of implants, as well as the differing peri-implant tissues, create a challenge to the practitioner for effective management. INTRODUCTION Periodontal disease is a bacterial mediated infection of the supporting structures of the teeth, resulting in inflammation of the periodontium and eventual bone loss around teeth. The bone loss which occurs as a result of periodontal disease is generally irreversible in nature, and so the prevalence of periodontal disease increases with age. Periodontal disease is common, with around half of the adult population affected by periodontitis. 1 Since the introduction of the titanium solid screw implant, pioneered by PI Brånemark in 1965, the use of dental implants has become a predictable method to help replace missing teeth. The original Brånemark fixture had a machined polished surface and an external-hex type connection to the abutment. An evolution in the design of implants has seen the development of modern dental implants with roughened surfaces and more secure abutment connections (mostly incorporating a morse taper). These changes to dental implants increase bone-to-implant contact and have improved the success and survival rates of implants in sites of bone poor bone quality and in smokers. 2,3 The peri-implant tissues are similar to periodontal tissues in many aspects. A fundamental difference however is the lack a proper connective tissue attachment in the supracrestal area. Teeth have collagen fibres inserting directly into cementum and oriented perpendicular to the tooth, providing a complete barrier for the crestal bone to the oral environment. In contrast, collagen fibres are unable to insert into the implant, and run parallel with the implant surface , providing what can be regarded as a seal (rather 4 than a barrier) for the crestal bone. Peri-implant mucositis related to inflammation of the peri-implant tissues with no loss of bone. Peri-implant mucositis is clinically BIOFILM MEDIATED PERI-IMPLANT INFECTIONS diagnosed by bleeding on probing in conjunction with inflamed peri-implant tissues. Peri-implantitis is a bacterial mediated Over half a century ago, Löe et al. demonstrated the role of 5 inflammatory disease affecting the peri-implant tissues resulting in plaque biofilm in initiating gingival inflammation around teeth. The loss of supporting bone. It is diagnosed by increases in probing potential role of specific subgingival bacteria (putative periodontal depth (Figure 1) and radiographic bone loss (Figure 2) over baseline pathogens) in the initiation and progression of bone loss due to levels. The different surface characteristics of dental implants and periodontal disease was highlighted by Socransky et al. 6 the peri-implant tissues provide unique challenges to clinicians in managing peri-implant infections. RACDS ANNALS 2016 63

Evidence which supports a bacterial cause for peri-implant diseases The following methods have been described for the surface include: 7 decontamination of implant surfaces in the treatment of peri- 1. Experimentally induced peri-implant mucositis: plaque implant mucositis and peri-implantitis: accumulation on implants leads to peri-implant mucositis 2. Demonstration of distinct quantitative and qualitative • Mechanical means (plastic, carbon fiber or titanium coated differences in the microflora associated with successful and scalers, ultrasonic devices) failing implants • Chemical means (topical antimicrobials, local delivery 3. Peri-implant microflora is established shortly after implant antibiotics, systemic antibiotics) placement. Successful implants experience no shifts in • Other (photodynamic therapy, lasers, air abrasive methods) microbial composition over time • A combination of the above 4. Periodontal pathogens may be transmitted from residual teeth to implants 5. Induction of peri-implantitis by placement of plaque retentive Non-surgical management of peri-implant mucositis is able to ligatures in animals improve clinical parameters (such as bleeding on probing and gingival inflammation). In a systematic review and meta-analysis 6. Therapy aimed at a reduction of the peri-implant microflora of non-surgical therapy to manage peri-implant mucositis (with improves clinical conditions or without adjunctive therapy) it was found that while clinically 7. Edentulous patients with poor oral hygiene have more bone significant improvements in pocket depth, bleeding and gingival resorption around fixtures than do subjects with good hygiene index were achieved, complete resolution of the infection was not 18 Peri-implant mucositis and peri-implantitis are common, however achieved. Adjunctive therapy did not improve the efficacy of non- differences in case definitions have made exact estimates difficult. surgical treatment. The prevalence of peri-implant mucositis and peri-implantitis has 8 been reported to range from 19-65% and from 1-47% respectively. For the non-surgical management of peri-implantitis, Karring et al. 19 used carbon fibre curette and the Vector system (ultrasonic device THE IMPLANT SURFACE with a carbon fibre tip combined with hydroxyapaptite aerosol spray) to manage peri-implantitis around 22 implants (Brånemark, ITI, Astra). Implants were instrumented for 2-3 minutes without Salivary proteins adsorb onto implant surfaces in the oral local anaesthetic at baseline and 3 months. After six months, environment, allowing for the attachment of bacteria and the only minor changes in bleeding on probing (BOP) and probing formation of plaque biofilm. The surface free energy and surface depths (PD) were noted (despite improvements in oral hygiene). roughness influence the formation of biofilm. It makes sense No improvements in PD values or radiographic bone levels were that a rough implant surface will harbour more plaque than a noted. Mechanical therapy alone was found to be insufficient to polished one. In a 3 month study in vivo study of biofilm formation treat peri-implantitis. on standard and roughened abutments (Ra of 0.3 and 0.8 mm, respectively) Quirynen et al. found that supragingivally rough In a similar study, Renvert et al. examined the use of either 9 20 abutments harboured significantly fewer cocci (64% vs. 81%). Quirynen stated that this was indicative of a more mature plaque. titanium curettes or the Vector system in the treatment of peri- 9 Subgingivally, rough surfaces harboured 25 times more bacteria, implantitis. In this prospective randomized study (37 subjects with with a slightly lower density of cocci. 6 dropouts - 5 smokers - 24 Nobel Biocare, 6 Astra, 1 unknown implants), subjects received treatment and individual oral hygiene instructions (OHI), and were followed for 6 months after treatment. Modern implant surfaces generally fall in the micro-rough range Neither treatment significantly reduced bacterial loads after 30 (Ra ~0.2-0.3 µm), thus their surface roughness may facilitate more min, 1 week, 1,3, or 6 months. Despite the OHI given to patients at plaque formation over a machined surface. These roughened each recall, it was reported that oral hygiene and bleeding scores surfaces (and surface modifications) are important in the improved but remained poor. The study found no difference in osseoinductive, osteoconductive and osteogenic properties treatment outcomes between the two treatment methods, with of these implants. Damage or modifications to these surfaces both treatments unable to reduce pocket depths around implants. during instrumentation may affect the surface properties and thus reintegration processes. TiUnite, which is a porous additive surface, Thus, in contrast to the management of periodontitis around teeth, may harbor more plaque than the other commercially available the management of peri-implantitis with non-surgical means is very surfaces. limited in its effectiveness. Where bacteria have contaminated the implant surface, open debridement and polishing of the implant Roughened implant surfaces may favour re-osseointegration surface may be required to remove the biofilm. On extracted teeth, compared with smooth implant surfaces. Persson et al. reported Waerhaug demonstrated that the subgingival plaque front never 21 10 significantly more re-osseointegration following treatment of came closer than 0.2 mm from the base of the pocket. With peri- ligature induced peri-implantitis at implants with a sand-blasted implant tissues, the situation may be different as no connective (large grit) and acid-etched (SLA) surface compared with those tissue fibres directly attach onto the implant surface, but instead run 4 with a turned surface. Following biopsy, 21-22% re-osseointegration parallel to it. Periodontal probing in inflamed peri-implant tissues was found with turned implants, while 82-84% re-osseointegration results in the probe tip approaching the crestal bone, while in 22 was found with implants with an SLA surface. periodontal tissues there is always connective tissue intervening. 23 When this is combined with an implant surface which is micro- roughened (and potentially retains and harbors plaque), we may NON-SURGICAL MANAGEMENT have a situation where the plaque front can come into closer proximity with supporting bone. This situation may compromise In the management of periodontal disease, non-surgical treatment the non-surgical debridement of implant surfaces in the treatment (in conjunction with adequate maintenance care) has been shown of peri-implantitis. to be highly effective in arresting the progression of disease and preventing future attachment loss. 11-17 64 RACDS ANNALS 2016

fresh osteotomy sites. 27-28 This may suggest that factors other than surface decontamination of implants limit the regeneration potential in the treatment of peri-implantitis. Surgical therapy with bone regeneration techniques have generally demonstrated greater improvements in PD reductions and bone fill when compared with surgery alone. Aghazadeh et al. in a 12 29 month study compared respective surgery with an autogenous bone graft and respective surgery with a xenograft. A collagen membrane and systemic antibiotics were used in both groups. Results demonstrated improvements in both groups, with greater radiographic bone fill when a xenograft was used. A recent systematic review and meta-analysis on the surgical management of peri-implantitis has demonstrated the superiority of grafting procedures over surgery alone. It must be pointed out that due to the lack of high-quality comparative studies on this topic, over half of the studies included in this paper were case series SURGICAL MANAGEMENT studies. Treatment modalities compared included: Access flap and debridement; surgical resection; application of bone grafting The benefit of surgical management of peri-implantitis lesions materials; and guided bone regeneration. All treatments were compared with non-surgical treatment can be seen in split mouth able to PD and BOP. The use of graft materials and guided bone studies which have utilized both treatment modalities. In a dog regeneration techniques resulted in the greatest PD reductions as 30 model with ligature induced peri-implantitis, Schwarz et al. showed well as radiographic defect fill. 24 that after 3 months of healing, although both surgical and non- surgical methods showed statistically significant improvements in We are limited by the short nature of many of these studies. The the clinical parameters of plaque index (PI), PD, BOP and clinical longest reported study duration of 5 years does demonstrate attachment level (CAL), only the surgically treated implants showed favourable long-term outcomes following surgical therapy of peri- significant radiographic improvements and re-osseointegration (1- implantitis. 31 1.2% versus up to 44%). In contrast to teeth, dental implants can be removed and replaced In a case series, Leonhardt et al. reported on the treatment (following the appropriate grafting procedures if required). The fate 25 outcomes of access surgery in 9 patients with 26 implants after of implants placed within grafted sites is similar to those placed 5 years. Treatment of the Brånemark implants involved access in native bone. Thus while the management of peri-implantitis 32 surgery with decontamination of the implant surface using H2O2 may be both difficult and unpredictable, there may be the option and adjunctive systemic antibiotics. Healing was obtained in 58% of replacing the implant in a like-for-like manner which cannot be of implants, with 7 implants lost and 4 of the remaining implants said for teeth. suffering from progressive bone loss in spite of the treatment. CONCLUSIONS The surface modification of rough implant surfaces contaminated with biofilm to reduce the roughness and provide for a more cleansable surface has been studied (Figure 3). Romeo et al. The use of dental implants to assist in the replacement of missing 26 in a comparative study looked at apically repositioned flaps in teeth has become a common part of modern dentistry. Just the treatment of ITI TPS implants with or without adjunctive as periodontal disease affects a large proportion of the adult implantoplasty (modification of the implant surface topography). community, peri-implantitis will become an important issue for Systemic antibiotics and full mouth disinfection were also done dental practitioners to manage. The differences between the with surgery. Radiographic evaluation after 3 years showed a supporting structures around teeth versus dental implants make more favourable result for the implants which had received the management of peri-implantitis more challenging and less implantoplasty, and the authors suggested that this treatment predictable. should be considered as an adjunct to respective therapy in the treatment of peri-implantitis. Non-surgical management of peri-implant mucositis may be effective in improving clinical parameters, however is less effective Open debridement with surface decontamination for the treatment where bone loss has occurred with peri-implantitis. Even with peri- of peri-implantitis may be effective in resolving inflammation, but implant mucositis, the literature shows that non-surgical therapy as the previous studies have demonstrated, complete resolution cannot completely treat this condition is all situations, a stark of the peri-implant defects and reosseointegration does not occur. contrast to the ease with which gingivitis can be treated. This may be due to either issues with the implant surface (failure to decontaminate or altered surface characteristics), or an inadequate Peri-implantitis may be managed surgically in a manner similar to tissue healing process (e.g. instability of the blood clot, failure of the blood clot to adhere to the implant surface, rapid proliferation of teeth. Improvements in clinical parameters as well as radiographic epithelial cells). bone fill can be obtained (particularly with grafting procedures). Whilst surgical treatment may be effective in improving clinical parameters, outcomes are not predictable. There is however as In regards to surface decontamination, it has been demonstrated yet no consensus on the most effective treatment modalities and in animal studies that implant surfaces exposed to oral biofilm and more research is required in this area to guide clinical practice. decontaminated with either citric acid, saline or hydrogen peroxide, can successfully osseointegrate after they were implanted into RACDS ANNALS 2016 65

REFERENCES 19. Karring ES, Stavropoulos A, Ellegaard B, Karring T. Treatment 1. Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ. of periimplantitis by the Vectors system. A pilot study. Clinical Prevalence of periodontitis in adults in the United States: 2009 Oral Implants Research 2005; 16, 288–293. and 2010. J Dent Res 2012;91(10):914-20. 20. Renvert S, Samuelsson E, Lindahl C, Persson GR. Mechanical 2. Balshe AA, Eckert SE, Koka S, Assad DA, Weaver AL. The effects non-surgical treatment of peri-implantitis: a double-blind of smoking on the survival of smooth- and rough-surface randomized longitudinal clinical study. I: clinical results. J Clin dental implants. Int J Oral Maxillofac Implants 2008;23(6):1117- Periodontol 2009; 36(7): 604-9. 22. 21. Waerhaug, J. Healing of the dento-epithelial junction following 3. Balshe AA, Assad DA, Eckert SE, Koka S, Weaver AL. A subgingival plaque control. II: As observed on extracted teeth. retrospective study of the survival of smooth- and rough- J Periodontol 1978; 49(3): 119-34. surface dental implants. Int J Oral Maxillofac Implants 22. Lang NP, Wetzel AC, Stich H, Caffesse RG. Histologic probe 2009;24(6):1113-8. penetration in healthy and inflamed peri-implant tissues. Clin 4. Berglundh T, et al. The soft tissue barrier at implants and teeth. Oral Impl Res 1994; 5: 191-201. Clin Oral Impl Res 1991;2:81-90. 23. Robinson and Vitek. The relationship between gingival 5. Löe H, Theilade E, Jensen SB. Experimental gingivitis in man. J inflammation and resistance to probe penetration. J Periodontol. 1965 May-Jun;36:177-87. Periodontol Res. 1979; 14: 239-243. 6. Socransky SS, Haffajee AD, Cugini MA, Smith C, Kent RL Jr. 24. Schwarz F, Jepsen S, Herten M, Sager M, Rothamel D, Becker Microbial complexes in subgingival plaque. J Clin Periodontol J. Influence of different treatment approaches on non- 1998; 25(2):134-44 submerged and submerged healing of ligature induced 7. Mombelli A, Lang NP. The diagnosis and treatment of peri- peri-implantitis lesions: an experimental study in dogs. J Clin Periodontol 2006; 33: 54-595. implantitis. Periodontology 2000 1998; 17, 63-76. 25. Leonhardt A, Dahlén G, Renvert S. Five- year clinical, 8. Derks J, Tomasi C. Peri-implant health and disease. A microbiological, and radiological outcome following treatment systematic review of current epidemiology. J Clin Periodontol. of peri-implantitis in man. J Periodontol 2003; 74:1415-1422. 2015 Apr; 42 Suppl 16. 9. Quirynen, M., H. C. van der Mei, et al. An in vivo study of 26. Romeo E, Lops D, Chiapasco M, Ghisolfi M, Vogel G. Therapy of periimplantitis with resective surgery. A 3-year clinical trial the influence of the surface roughness of implants on the on rough screw-shaped oral implants. Part II: radiographic microbiology of supra- and subgingival plaque. J Dent Res outcome. Clinical Oral Implants Research 2007; 18, 179–187. 1993; 72(9): 1304-9. 10. Persson LG, Mouhyi J, Berglundh T, Sennerby L, Lindhe J. 27. Kolonidis S, Renvert S, Hämmerle CHF, Lang NP, Harris D, Claffey N. Osseointegration on implant surfaces previously Carbon dioxide laser and hydrogen peroxide conditioning in contaminated with plaque. An experimental study in the dog. the treatment of peri-implantitis: an experimental study in the Clinical Oral Implant Research 2003; 14, 373–380. dog. Clinical Implant Dentistry and Related Research 2004; 6, 230–238. 28. Alhag M, Renvert S, Polyzois I, Claffey N. Re-osseointegration on rough implant surfaces previously coated with bacterial 11. Hill RW, Ramfjord SP, Morrison EC, Appleberry EA, Caffesse RG, biofilm: an experimental study in the dog. Clinical Oral Implant Kerry GJ et al. Four types of periodontal treatment compared Research. 2007; 26, 182–187. over two years. Journal of Periodontology 1981; 52(11):655-662. 12. Pihlstrom BL, McHugh RB, Oliphant TH, Ortiz-Campos 29. Aghazadeh A, Rutger Persson G, Renvert S. A single-centre randomized controlled clinical trial on the adjunct treatment C. Comparison of surgical and nonsurgical treatment of of intra-bony defects with autogenous bone or a xenograft: periodontal disease. A review of current studies and additional results after 12 months. J Clin Periodontol. 2012 Jul; 39(7):666- results after 61/2 years. Journal of clinical Periodontology 1983; 73. 10(5):524-541. 13. Pihlstrom BL, Oliphant TH, McHugh RB. Molar and nonmolar 30. Chan HL, Lin GH, Suarez F, MacEachern M, Wang HL. Sugical Management of Peri-Implantitis: A Systematic Review and teeth compared over 6 1/2 years following two methods Meta-Analysis of Treatment Outcomes. J Periodontol 2014; 85: of periodontal therapy. Journal of Periodontology 1984; 1027-1041 55(9):499-504. 14. Lindhe J, Nyman S. Long-term maintenance of patients 31. Deppe H, Horch HH, Neff A. Conventional versus CO2 laser-assisted treatment of peri-implant defects with the treated for advanced periodontal disease. Journal of clinical concomitant use of pure-phase beta-tricalcium phosphate: A periodontology 1984; 11(8):504-514. 5-year clinical report. Int J Oral Maxillofac Implants 2007; 22: 15. Lindhe J, Westfelt E, Nyman S, Socransky SS, Haffajee AD. 79-86 Long-term effect of surgical/non-surgical treatment of 32. Tran DT, Gay IC, Diaz-Rodriguez J, Parthasarathy K, Weltman periodontal disease. Journal of clinical periodontology 1984; R, Friedman L. Survival of Dental Implants Placed in Grafted 11(7):448-458. and Nongrafted Bone: A Retrospective Study in a University 16. Ramfjord SP, Caffesse RG, Morrison EC, Hill RW, Kerry GJ, Setting. Int J Oral Maxillofac Implants. 2016 Mar-Apr;31(2):310-7. Appleberry EA et al. 4 modalities of periodontal treatment compared over 5 years. Journal of clinical periodontology 1987; 14(8):445-452. Email address for correspondence: 17. Kaldahl WB, Kalkwarf KL, Patil KD, Molvar MP, Dyer JK. [email protected] Long-term evaluation of periodontal therapy: I. Response to 4 therapeutic modalities. Journal of Periodontology 1996; 67(2):93-102. 18. Schwarz F, Becker K, Sager M. Efficacy of professionally administered plaque removal with or without adjunctive measures for the treatment of peri-implant mucositis. A systematic review and meta-analysis. J Clin Periodontol; 2015; 42 (Suppl. 16): S202–S213 66 RACDS ANNALS 2016

LIVING AND DYING WITH DIGNITY – PALLIATIVE CARE IN 2016 Dr Philip G Lee MBBS, Post Grad Diploma Palliative Medicine, FAChPM Dr Philip Lee is Senior Staff Specialist Supportive & Palliative Medicine, Crown Princes Mary Cancer Centre, Westmead Hospital and Director of Supportive & Palliative Medicine Department, Western Sydney Local Health District. ABSTRACT Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification, assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care is not just about end of life care. What it does is provide relief of these symptoms while a patient continues to receive disease-controlling treatment. In this sense palliative care is about living better with life limiting illnesses, not just focussing on the terminal phase. There are problems with how Australians are dying, but access to good-quality palliative care can change that. As a society we need to invest more in giving people more time to live as well as they can for as long as they can. However we all require honesty in communication to have sufficient time to prepare for death. “I am prepared for the worst, but hope for the best.” (Benjamin Disraeli, British Prime Minister) INTRODUCTION • Uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated; Patients, families, carers, the general population and even medical • Will enhance quality of life, and may also positively influence staff often poorly understand the meaning of palliative care. It is the course of illness; frequently thought to only involve end of life care, the start of the • Is applicable early in the course of illness, in conjunction big slippery slide towards death. With this misconception, it is not with other therapies that are intended to prolong life, such surprising that many patients and their families are very confronted as chemotherapy or radiation therapy, and includes those when initially referred to palliative care services. investigations needed to better understand and manage distressing clinical complications. However palliative care may be just as important early in the course of an incurable illness, to improve the quality of life, control One of the challenges facing modern medicine is the assumption symptoms and improve patient’s performance to enable them by many that everything is curable. There appears at times to be a to have ongoing disease modifying therapies. Most importantly lack of acceptance when a condition is considered to be incurable, palliative care may enable patients to continue living as well as that the patient is in fact dying. possible, for as long as possible. The British Medical Journal publishes a regular spotlight series and in September 2010 published a series titled “Palliative care beyond cancer”. Within that article were several pieces by different authors 2 WORLD HEALTH ORGANISATION PALLIATIVE CARE titled DEFINITION 1 • We’re all going to die. Deal with it Palliative care is an approach that improves the quality of life of • Dying matters: let’s talk about it patients and their families facing the problem associated with life- threatening illness, through the prevention and relief of suffering • Recognising and managing key transitions in end of life care by means of early identification and impeccable assessment and • Having the difficult conversations about the end of life treatment of pain and other problems, physical, psychosocial and • Achieving a good death for all spiritual. Palliative care: • Spiritual dimensions of dying in pluralist societies • Provides relief from pain and other distressing symptoms; A common theme throughout the articles was encouraging • Affirms life and regards dying as a normal process; clinicians to ask a simple question, would I be surprised if this • Intends neither to hasten or postpone death; patient died within the next year? By thinking about this simple • Integrates the psychological and spiritual aspects of patient question, medical teams may start conversations around end of care; life care and decision making much earlier. • Offers a support system to help patients live as actively as possible until death; • Offers a support system to help the family cope during the patients illness and in their own bereavement; RACDS ANNALS 2016 67

• Increase the likelihood of the patient being cared for at his/her place of choice Dr Jennifer S Temmel and her research group in Thoracic Oncology, Massachusetts General Hospital, Boston published a landmark paper in the New England Journal of Medicine in August 2010 of 4 outcomes from a study of patients with newly diagnosed metastatic non-small-cell lung cancer who were randomly assigned to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone. The conclusion was that among patients with metastatic non-small-cell lung cancer, early palliative care not unsurprisingly led to significant improvements in both quality of life and mood. An unexpected outcome was, compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life and also longer survival. A subsequent paper by Greer et al published from the same study 5 found that the overall number of chemotherapy regimens did not vary between the two groups. The palliative care group had half the odds of receiving chemotherapy within 60 days of death and there was a longer interval between receiving intravenous chemotherapy and dying. SUPPORTIVE CARE A third paper from the study by Yoong et al. found that palliative 6 care doctors focused on establishing relationships with patients Internationally, some palliative care services have attempted and families and also on determining their individual needs and to address the misconceptions surrounding palliative care by preferences for information early in the illness. This compared changing the name of their service. In Western Sydney we to oncologist’s discussions regarding end of life care planning changed our department name in 2014 to the Supportive and occurred which later, often when patient’s disease progressed. This Palliative Medicine Department. Interestingly this resulted, in a very led to the conclusion that continuity of care and greater familiarity short period, to a significant increase in requests for consultations with the patient and family may facilitate smoother transition at for supportive care, something that was already being provided later stages when challenging discussions regarding progression, within palliative care. cancer treatment and end of life care are necessary. Supportive care is classified as care that aims to optimise the PALLIATIVE CARE CONSULTATIONS comfort, function and social support of the patients and their family at all stages of a life limiting illness. End of life care is defined as palliative care when death is imminent. Supportive and palliative When a palliative care consultant first meets a referred patient care should be initiated early during the active treatment phase and their family, there are several questions that will facilitate the of patients with a life limiting illness and all clinicians treating conversation. patients with a life limiting illness should provide supportive care. • What do the patient and family understand about palliative Increasingly, supportive and palliative care services are helping care? to manage patients with non-malignant diagnoses. Currently at Westmead Hospital, 30% of consultations are for this group of • What do they understand about their illness and the current situation? patients with diagnoses including heart failure, end stage kidney failure, respiratory failure, dementia and neurodegenerative • What do they understand are the goals of treatment? conditions. • What is important to them? • What do we need to know about them to care for them as PALLIATIVE APPROACH best we can? A palliative approach should be used for any medical condition that is considered incurable and used by all clinicians involved. It is not unusual for patients to be unsure about their current During this phase of an illness, active treatment for the disease condition or goals of treatment. Often during the interaction may still be very important and provided concurrently with the with treating teams, no one has actually asked the patient what palliative approach. There should be a focus on not only controlling is important to them, what are their goals. For many it will be the disease process, but also managing symptoms, improving the to pursue whatever treatments are on offer, to prolong their level of comfort and function. There should also be a process to survival. For others it will be all about quality of life, living with their prepare for the eventual deterioration and decreasing response to families and achieving those “bucket list” goals, trips and holidays, treatment. “Hoping for the best, preparing for the worst” (Benjamin important events in life rather than spending all their remaining Disraeli). days attending clinics and hospitals having treatment. Specialist Palliative Care Services On occasions there is conflict between a patient’s own goals, their A systematic literature review focusing on palliative care services family’s goals and the treating clinicians goals. As well as focusing by Hearn and Higginson found that these services: on optimising quality of life, palliative care teams aim to maintain 3 • Improve patient and family satisfaction patient dignity, assist the patient to maintain control and assist • Reduce family anxiety them to focus on their priorities. • Provide better pain control and symptom management 68 RACDS ANNALS 2016

DIGNITY CONSERVING CARE Chochinov’s dignity approach reflects the manner in which I am sure most of us would like to be respected and treated. The oft repeated quote of Dr Frances Peabody, ‘‘The secret of the care Harvey Max Chochinov, a professor of psychiatry at the University of the patient is in caring for the patient.’’ sums up the need for 8 of Manitoba, Canada has developed a programme focussing on physicians to really care for our patients. Dr Diane Meier also nicely patient dignity. His paper ‘Dignity and the essence of medicine: the described, “The only way to know what is best for patients is to 7 A, B, C, and D of dignity conserving care’, contributes greatly to listen to them, to know them, and to begin to understand what communication with palliative care patients at this most vulnerable matters most to them” (D Meier – personal communication with time. Harvey Chochinov, August 1st, 2013). So often doctors appear to be A = Attitudes focussing on the next treatment option, new drug, new trial without • How would I be feeling in this patient’s situation? pausing and asking what is it that really matters to the patient. What • What is leading me to draw those conclusions? are their remaining goals in life? • Have I checked whether my assumptions are accurate? To sum up, I will quote some well known clinicians and authors: • Am I aware how my attitude towards the patient may be affecting him or her? Sir William Osler – “The good physician treats the disease. The great • Could my attitude towards the patient be based on something physician treats the patient who has the disease.” to do with my own experiences, anxieties, or fears? Philippe Ariés – “Death should simply become a discreet but dignified exit of a peaceful person from a helpful society … without • Does my attitude towards being a healthcare provider enable pain or suffering and ultimately without fear.” 9 or disenable me to establish open and empathic professional relationships with my patients? Dame Cicely Saunders - “How people die remains in the memory of those who live on.” 10 B = Behaviours • Act in a manner that shows the patient that he or she has your Atul Gawande - “I learned about a lot of things in medical school, 11 full and complete attention but mortality wasn’t one of them.” • Always invite the patient to have someone from his or her support network present, particularly when you plan to REFERENCES discuss or disclose complex or “difficult” information 1. World Health Organisation “WHO Definition of Palliative Care” • Personal issues should be raised in a setting that attempts to (www.who.int/cancer/palliative/definition/en) respect the patient’s need for privacy 2. BMJ Spotlight Series: Palliative Care Beyond Cancer BMJ 25 • When speaking with the patient, try to be seated at a September 2010 Volume 341 comfortable distance for conversation, at the patient’s eye 3. Hearn J, Higginson IJ Do specialist palliative care teams level when possible improve outcomes for cancer patients? A systematic literature • Given that illness and changing health status can be review. Palliative Med 1998;12(5):317-32 overwhelming, offer patients and families repeated 4. Temmel JS et al. Early palliative care for patients with metastatic explanations as requested non-small-cell lung cancer. New Engl J Med 2010;363(8):733- • Present information to the patient using language that he or 742. she will understand; never speak about the patient’s condition 5. Greer et al. Effect of early palliative care on chemotherapy use within their hearing distance in terms that they will not be able and end-of-life care in patients with metastatic non-small-cell to understand lung cancer. J Clin Onc 2012; 30(4):394-400. • Always ask if the patient has any further questions and assure 6. Yoong et al. Early Palliative Care in Advanced Lung Cancer. them that there will be other opportunities to pose questions JAMA Int Med 2013;173(4):283-90. as they arise 7. Chochinov HM. Dignity and the essence of medicine: the A, B, C =Compassion C and D of dignity conserving care. Brit Med J 2007:334:184- • An understanding look 187. • A gentle touch on the shoulder, arm, or hand 8. Francis W. Peabody to Harvard students on October 21, 1925, • Some form of communication, spoken or unspoken, that and the words have lasted well. The lecture, entitled “The Care acknowledges the person beyond their illness. of the Patient”. D = Dialogue 9. Ariés P. The Hour of our death. Oxford University Press, 1977. • This must be frightening for you. 10. Saunders C. Pain and impending death. In: Wall PD, Melzak R, eds. Textbook of pain. 2nd ed. Churchill Livingstone, 1989: • I can’t imagine what you must be going through. 624-31. • It’s natural to feel pretty overwhelmed at times like these. 11. Gawande A. Being mortal. Medicine and what matters in the • What should I know about you as a person to help me take the end. Metropolitan Books 2014. best care of you that I can? • What are the things at this time in your life that are most Email address for correspondence: important to you or that concern you most? [email protected] • Who else (or what else) will be affected by what’s happening with your health? RACDS ANNALS 2016 69

CANCER AND PALLIATIVE CARE: ORAL AND DENTAL MANIFESTATIONS, CONSIDERATIONS AND COMPLICATIONS A/Prof Mark Schifter, BDS, MDSc (Oral Med), M RCSEd (SND), M RCSEd (Oral Med), FFD RCSI (Oral Med), FRACDS (Oral Med) A/Prof Mark Schifter is Staff Specialist in Oral Medicine and Head, Department of Oral Medicine, Oral Pathology & Special Care Dentistry, Westmead Centre for Oral Health, Westmead Hospital and the Faculty of Dentistry, University of Sydney ABSTRACT Cancer and its treatment has been revolutionised by our improved understanding of genetics and is now increasingly managed as a chronic disease. When cure is not possible, durable remission is achievable. Notwithstanding, many cancers are, or become, incurable and their treatments are still acutely and chronically painful, distressing and unpleasant. A management approach that emphases comfort, relief of pain and suffering, as well as symptom control, is the remit of palliative care. The oral and dental manifestations and complications seen in patients receiving palliative care has to date, been under-recognised, is poorly researched and so the care provided often fails to address or improve such patients comfort and/or quality of life. This paper (presented at the 23rd Convocation of the RACDS) aims to provide a classification of the oral and dental problems seen in patients receiving palliative care, provide a practical treatment approach and give examples of the management of such problems. INTRODUCTION: THE EXTENT OF THE PROBLEM an unprecedented decline in edentulism; therefore, an increasing number of Australians are now living longer, with severe, complex Imagine if you had been told you had “two weeks to live”. Now and chronic medical and medication-related co-morbidities (for consider what you, or someone you loved or cared for, would example MRONJ) and also retaining their teeth. want to do with the limited time available. For many the answer would be to make the most of their time with the people they love, STOMATOGNATHIC PROBLEMS IN PATIENTS taking, communicating, sharing their thoughts and aspirations REQUIRING PALLIATIVE CARE for their family and friends, enjoying the best cuisine and wine and even intimacy, a kiss and an embrace, holding of hands. In Specific Issues summary, enjoying all the things which make us human, socialising HYPOSALIVATION/XEROSTOMIA and communicating to the fullest, requiring the full use of the As stated, one of the most frequent and severe causes of oral stomatognathic system, to chew, taste, swallow, breathe and talk. morbidity for terminally ill cancer patients is hyposalivation Accepting this, it may be reasonable to suggest that the mouth (salivary hypofunction) that is objective evidence with clinical signs would be the “centre of one’s universe” for this brief period of time. of diminished or inadequate saliva, as opposed to xerostomia, that Yet, the fact is for many patients dying from cancer, their mouth is the subjective complaint of a feeling of a dry mouth (a symptom). is sore, dry and painful, their oral-related pain poorly understood, Assessment and distinguishing between hyposalivation and under-estimated and so frequently undertreated. Despite the xerostomia, relies on a comprehensive evaluation starting with the dearth of any substantial research addressing the frequency, patients’ relevant past and current medical history, with a particular severity and management of the stomatognathic manifestations emphasis on direct contributors to hyposalivation and if these are and complications seen in patients receiving palliative care for their modifiable as opposed to those which may only be able to be terminal cancer, two papers highlight the extent of the problem. mitigated. (Table 2). Clinical assessment can be reliably undertaken Firstly, a 2012 Norwegian paper, based on cohort of 99 hospital in- by means of simple clinical examination with a good fixed light 1 patients from two palliative care units, with terminal malignancies, source (such as head light) and use of dental mirrors. 3 not of the head and neck region, with an estimated life expectancy less than three months. Of these, 78% had a severely dry mouth Simple interventions can be undertaken for all patients to address that was rated as one of the patients’ worse symptoms, 34% their hyposalivation and resultant discomfort. Even in those and clinically overt candidiasis, but 86% were found to have oral patients who have a restricted fluid intake lubricating and hydrating candidiasis following taking of swabs for culture, with mouth pain the mouth can be undertaken, using extra-large cotton-tipped affecting 67% and affecting the oral intake of 56%. The mean sticks and/or atomisers to regularly spray a small volume of water. number of teeth with visible dental decay was 1.9 (per patient) Use of saline humidifiers attached to ventilators and with the use of and one patient had medication-related osteonecrosis of the jaws oxygen masks is simple yet proven and effective measure. Review 4 (MRONJ) related to bisphosphonate use. A smaller 2010 study of and rationalisation of the patients’ medications can mitigate drug- 14 terminally ill patients identified severe debilitating mouth related related hyposalivation, as can the use of non-narcotic analgesics, pain, discomfort from salivary hypofunction, citing “a lack of oral for example ketamine. Replacements in the form of water 5 assessment and virtually no input from dental experts to assist with are usually not effective, but despite the paucity or research 2 palliating oral problems”. regarding appropriate concentrations and its effectiveness, bicarbonate mouthwashes (baking soda) are widely used and The Australian population is undergoing dramatic demographic empirically appear to be of some benefit. Artificial replacements changes, it is older, increasingly medicated and is seeing significant based on proprietary carboxymethyl cellulose of mucin-based improvements in cancer survivorship, with many and differing preparations are worth trialling, but their expense and their limited types of cancers being treated as a chronic disease, for which there benefit tends to inhibit patient use. Salivary stimulation generally is no cure, but an ongoing requirement for treatment that can defer provides a greater benefit and greater comfort to patients, but death, but with associated morbidity. Accompanying this has been relies on the presence of functioning salivary gland tissue. Simple 70 RACDS ANNALS 2016

gustatory stimulants, such as chewing gum, lollies even vitamin treatment with anti-herpes viral agents, given their safety and C tablets, have demonstrated some benefit. There are limited efficacy, until swabs can be taken to confirm or exclude if active pharmacological stimulants, of which the most readily available herpetic infection is present. Topical agents are to be avoided in and best researched is pilocarpine, a muscarinic (cholinergic) this setting, particularly so in immune-suppressed patients as this agonist. This can be simply administered by using the topical agent can lead to extensive and painful infections form inoculation of the used for glaucoma, available as 4% isopto carpine and using up to 8 patient’s finger used to apply the topical agent, and in turn infecting drops in a quarter-cup of water and swallowed up four times/daily. the sites touched by the same finger (see Figure 3). The usual contraindications to this agent are not such a concern in the setting of palliative care, namely asthma, bradycardia and ODONTOGENIC INFECTIONS narrow-angle glaucoma, but it is patient tolerance of the adverse side effects, that is the “cold” sweats, increased urinary frequency Dental diseases (caries and periodontitis) and bowel movements, which will limit patients acceptance. The consequences of dental caries and periodontitis with regards to pulpitis, irreversible pulpitis, and acute and chronic periapical CANDIDIASIS periodontitis are not treated any differently in the palliative care Angular Cheilitis (“perleche”) setting than in normal clinical practice, but the emphasis is on Easily recognizable by the presence, often bilaterally, of excoriation control of pain and discomfort. Conservative measures so as to of the angles of the mouth, with small seemingly “fissure” of the avoid extraction of teeth are favoured, that is root canal dressing skin, running vertically, that appears to be erythematous, moist and scaling and cleaning, supplemented with antibiotics, again and causes discomfort, particularly when the patient opens their using the usual empiric choices of a penicillin, supplemented by mouth wide. The pathobiology is that the skin on being constantly metronidazole, or clindamycin or later generation macrolide in case wetted, by the saliva escaping from the commissure (angle of of penicillin allergy. Control of pain by means of local anaesthetics, the mouth) irritates the skin, which becomes inflamed, allowing especially long-acting agents, is often underappreciated as means candida present in the saliva from the mouth as well as bacterial of providing immediate pain control until appropriate levels of commensals of the skin, such as staphylococcal species, to analgesics are given and exert their effect. If invasive or surgical penetrate and infect the irritated and inflamed skin. Management procures are indicated, consideration need to be given to relative entails recognition, exclusion if required of herpes labialis (angular contraindications to dental extractions, that being local factors cheilitis tends to be uncomfortable but not distinctly painful as with such as more than 50 Gy of radiotherapy of the supporting bone herpes labialis, but if uncertain a swab for herpes viral PCR can or protracted or high dose anti-resorptive therapies for control of be undertaken) with treatment directed against the inflammatory metastases of the bones, with bisphosphonate agents. Systemic component and the consequent infection(s). Hydrozole contains factors that are a contraindication to dental extractions include 1% hydrocortisone, a mild topical corticosteroid to address the profound neutropenia, with a neutrophil count less than 0.5 x 109 inflammatory component and an azole, clotrimazole that is active cells/mL, thrombocytopenia, with a platelet count of less than 50 against candida and has degree of antibacterial activity as well. As x 109 cells/mL. A prothrombotic state is a frequent complication of important, is to address the intra-oral candidial source, by use of late stage cancer, often requiring anti-coagulation therapy, but as 7 topical or if appropriate systemic antifungal agents. with normal clinical practice, these usually do not require cessation prior to the undertaking of dental extractions. Oral/Oro-Pharyngeal Candidiasis Acute pseudomembranous candidiasis is a frequent consequence TRIGEMINAL NEUROPATHIES of marked hyposalivation, or systemic immunosuppression either Peripheral neuropathies affecting the mental branch of the secondary to immunosuppressive agents, for example high- mandibular division of the trigeminal nerve are an infrequent but dose corticosteroids, or leukopenia. Often not painful, diagnosis well documented complication of leukaemias and lymphomas. is readily made by examination and the finding of white milk-like Differentiation from central neuropathies due to meningeal curds that can be removed by wiping with gauze resulting in involvement is vital to ensure the correct treatment, especially with mucosal excoriation and superficial bleeding. In the palliative care regards to painful neuropathies and an important role for dental setting, systemic antifungals, namely one of the azole agents, such clinicians attending to such patients. as fluconazole and as little as 50 mg/daily will clear the infection. Caution is needed with regards to the use of azole agents in Burning mouth syndrome (“neuropathic-related oro-facial patients who are concurrently taking warfarin, as this may lead to dysaesthesia’) is seen with greater frequency in high anxious or a significant increase in the degree of anticoagulation and serious stressed individuals. Its recognition and ensuring there is no 8 consequences such as intracranial bleeding. contributory oral or dental pathology is again an important role for dental clinicians can undertake. Management with low dose HERPETIC INFECTIONS: HERPES LABIALIS/STOMATITIS tricyclics agents (such as amitriptyline 10-20 mg/nightly) or anti- AND TRIGEMINAL ZOSTER neuropathic pain agents such as pregabalin can be effective. Reactivation of the latent herpetic infections, herpes simplex 1 and NON-CURATIVE ORAL/HEAD AND NECK CANCERS 2 (HSV-1/2) and varicella zoster virus (VZV) is a frequent issue in the The specifics of palliative care for the patient with terminal oral 6 palliative care setting resulting in very painful eruptions of the skin, cancer are beyond the remit of this paper. However, dental lips and in the mouth, given these viruses erupt from the peripheral clinicians can have a useful role in the care of such patients. Such branches of the trigeminal nerve into the overlying tissues, directly oral cancers that are likely to prove difficult or unlikely to be cured, damage the nerves in doing so causing neuropathic pain. Under- included those seen in patients with syndromes of either telomere 9 recognised and so underdiagnosed, such virally-mediated eruptions shortening, for example, Dyskeratosis Congenita, or defects or 10 cause considerable distress and are preventable. Diagnosis can deficiency of DNA-repair mechanisms, such as Fanconi anaemia. be confirmed, on observing the typical, crusted, localised lesions One condition which dental clinicians may be seeing with of the skin, lips or in the mouth that are exceptionally painful, greater frequency and require active clinical monitoring for the particularly on light touch, by taking a viral swab for undertaking development of oral cancers are syndromes of “condemned oral of PCR confirmation for the presence of HSV-1, HSV-2 or VZV. mucosa” and include conditions such as proliferative verrucous Treatment entails the use of the highly effective and very safe leukoplakia. anti-viral agents; either by oral or intravenous administration (see Table 4). However, a history of intense pain with ulceration of the orofacial and or nasal or pharyngeal tissues should prompt empiric RACDS ANNALS 2016 71

CONCLUSIONS REFERENCES Within medicine, there has been a growing recognition that rational 1. Oral health is an important issue in end-of-life cancer care. decisions regarding the management of end-of life care for patients Wilberg P, Hjermstad MJ, Ottesen S, Herlofson BB. Support with cancer need to be made to end unnecessary pain, suffering Care Cancer. 2012; 20:3115-3122. and needless treatment with subsequent further complications 2. Rohr Y. Adams J. Young L. Oral discomfort in palliative care: and distress and give care, that is palliative care, that provides results of an exploratory study of the experiences of terminally relief from pain and distress, emphasises quality of life and dignity. ill patients. Int J Palliative Nurs 2010;16:439-444. Palliative care is increasingly not only undertaken or based in the 3. Osailan SM, Pramanik R, Shirlaw P, Proctor GB, Challacombe in-patient that is hospital setting, but supports patients based and SJ. Clinical assessment of oral dryness: development of a living in the community. Care of the oral cavity is best undertaken scoring system related to salivary flow and mucosal wetness. by and the responsibility of the dental profession. Therefore, clearly Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 114: 597–603. the dental profession needs to be better educated and informed 4. Oto J, Imanaka H, Nishimura M. Clinical factors affecting regarding the goals and principles of palliative care and find ways inspired gas humidification and oral dryness during to better contribute to the care of such patients who are reaching noninvasive ventilation. J Crit Care. 2011;26:535.e9-535.e15. the terminal phase of their disease. 5. Glare P, Walsh D, Sheehan D. The adverse effects of morphine: a prospective survey of common symptoms during repeated dosing for chronic cancer pain. Am J Hosp Palliative Med Table 1. Overview of Stomatognathic Problems in patients 2006; 23:229-35. requiring Palliative Care 6. Sweeney MP, Bagg J, Baxter WP, Aitchison TC. Oral disease in terminally ill cancer patients with xerostomia. Oral Oncol 1998;34:123-126. 7. McLean S, Ryan K, O’Donnell JS. Primary thromboprophylaxis in the palliative care setting: a qualitative systematic review. Palliative Med 2010;24: 386-395. 8. Zakrzewska JM, Forssell H, Glenny AM. Interventions for the treatment of burning mouth syndrome. Cochrane DB Syst Rev 2005; Issue 1, CD002779. 9. Alter BP, Giri N, Savage SA, Rosenberg PS. Cancer in dyskeratosis congenita. Blood 2009; 113: 6549-6557. 10. van Monsjou HS, Wreesmann VB, van den Brekel MW, Balm AJ. Head and neck squamous cell carcinoma in young patients. Oral Oncol 2013;49:1097-1102. Email address for correspondence: [email protected] Table 2. Hyposalivation: aspects of the past and current medical history that may be relevant and/or contributory Table 3. Risk Factors for Oral/Oro-pharyngeal Candidiasis 72 RACDS ANNALS 2016

Table 4. Anti-Viral Treatment for Herpes labialis/stomatitis & Trigeminal Zoster Figure 1. Herpes stomatitis of the right and left palate Figure 2. Trigeminal zoster involving the right ophthalmic and maxillary divisions Figure 3. Consequences of the application of topical acyclovir in a severely immunosuppressed patient RACDS ANNALS 2016 73

CONTEMPORARY SURGICAL MANAGEMENT OF ORAL CANCER Dr Timothy Wong, MBBS (Hons), BDSc (Hons), FRACDS (OMS) Timothy Wong is an Oral & Maxillofacial Surgeon at the Royal Melbourne Hospital, Victorian Comprehensive Cancer Centre, Melbourne, Australia. INTRODUCTION Every patient with oral cancer presents the Oral & Maxillofacial The goals of reconstructive surgery are the restoration of both surgeon with a unique set of challenging, complex and facial aesthetics and oral function (mastication, speech, swallow, multidisciplinary clinical problems, the solutions to which impact occlusion and temporomandibular joint mobility). In the majority both their quantity and quality of life. In the vast majority of cases, of these cases, due to the size or nature of the defect, microvascular surgery remains the mainstay of their overall treatment. Dental free flap reconstruction is employed, where tissue, along with its professionals play a critical role in the early detection of oral blood supply is detached from the donor site, transferred to the cancers. A majority of referrals for new and recurrent oral cancers oral cavity and the blood supply re-established by microvascular are from dental professionals. anasmatoses. There are many soft tissue, hard tissue and composite microvascular free flaps that have been described and utilised to reconstruct the complex head and neck surgical CURRENT CONCEPTS IN THE MANAGEMENT OF defect. Although these flaps have revolutionised head and neck ORAL CANCER reconstruction, there are still inherent limitations due to differences in tissue volume and characteristics of the donor site compared with the oral cavity, in addition to the morbidity associated with the Every patient with the diagnosis of oral cancer should be managed donor site. in a Multidisciplinary Head and Neck Oncology Unit with access to a full range of support services and specialists with expertise in the management of head and neck oncology. This includes, The primary reason for bony reconstruction of the mandible or but not limited to, the specialist of head and neck, ablative and maxilla is to allow for the possibility of dental implant rehabilitation. reconstructive surgeons, radiation and medical oncologists, Dental and craniofacial implant rehabilitation has certainly led radiologists, anatomical pathologists, dental specialists including to improvements in patient quality of life. However, there are oral medicine and prosthodontists, speech and language therapists, significant anatomical and physiologic challenges to overcome in dieticians, physiotherapists, head and neck nurses, social workers, order to achieve successful results when compared with implant psychologists and facial prosthetists. rehabilitation in a non-cancer patient. Following the establishment of a tissue diagnosis of oral cancer, Future reconstructive techniques will likely involve tissue staging of the tumour (assessment of the extent of the primary engineering and regenerative medicine (the regeneration of tumour, cervical nodes and distant metastases) consists of tissues using biologic mediators and matrices) which will allow computed tomography of the neck and chest, magnetic resonance reconstruction of the surgical defect without the requirement of imaging of the neck, ultrasound +/- fine needle aspirate of the a donor site. cervical nodes and intraoral ultrasound for accessible tongue and floor of mouth tumours, with PET MR/CT usually reserved for advanced stage (III, IV) cancers or salvage / recurrent cancers. The REFERENCES TNM (tumour, node, metastases) classification is used for staging. 1. Batsakis JG. Surgical excision margins: a pathologist’s perspective. Adv Anat Pathol 1999;6:140-148. The goal of ablative surgery remains the complete excision of the 2. Sutton DN, Brown JS, Rogers SN, Vaughan ED, Woolgar JA. The tumour along with a margin of normal tissue in all dimensions prognostic implications of the surgical margin in oral squamous (5mm microscopic margin) often accompanied by removal of cell carcinoma. Int J Oral Maxillofac Surg 2003; 32:30-34 1 the draining cervical nodes (T1 > 3mm depth and all T2/T3/T4 tumours). The pre-operative imaging along with intraoperative clinical assessment guides the ablative surgeon in achieving a Email address for correspondence: clear surgical margin. Clear surgical margins lead to a significantly [email protected] reduced local recurrence rate and increased disease specific survival in oral cancer. To achieve clear margins, the ablative 2 surgeon often uses a macroscopic measurement of 10-15mm around the tumour. 74 RACDS ANNALS 2016

WHY DO SOME PEOPLE FEEL BAD ABOUT THEIR APPEARANCE? UNDERSTANDING RISK AND PROTECTIVE FACTORS FOR POOR BODY IMAGE Prof Susan J Paxton, BA (Hons), MPsych, PhD Susan Paxton is Professor of Clinical Psychology in the School of Psychology and Public Health at La Trobe University ABSTRACT Body dissatisfaction and appearance concerns predict the development of serious psychological problems including depressive symptoms, health risk behaviours such as smoking and clinical eating disorders. In addition to cosmetic dental procedures, body dissatisfaction is of particular relevance to dental care as a predictor of disordered eating behaviours which frequently have a negative impact on dental health. This paper reviews the negative impact of body dissatisfaction and risk and protective factors for body image problems. Research into biological, psychological and social risk factors will be discussed including the recent findings of a relationship between social media use and body image concerns. Our understanding of risk factors for body dissatisfaction has guided the development of prevention and therapy interventions. As dentists may observe the dental results of an eating disorder, their role in secondary prevention is discussed. BODY IMAGE AND BODY DISSATISFACTION RISK AND PROTECTIVE FACTORS Body dissatisfaction is frequently occurring, but at the same “Body image” describes an individual’s thoughts, feelings, time does not affect everyone equally. Further, although more perceptions and behaviours in relation to his or her body This vulnerable, not all those who noticeably depart from societal .1 concept incorporates thoughts and feelings related to a wide range beauty ideals, such as those who have a higher body weight or of body experiences, including those related to physical well-being a visual difference such as birthmarks or cleft palate, experience and sexuality, but research into body image has tended to focus on high levels of body dissatisfaction. So why is it that some people 10 thoughts and feelings that relate to appearance, especially weight move up the continuum from body satisfaction to extreme body and shape concerns in females and leanness and muscularity in dissatisfaction: that is, what are risk and protective factors for males. These reactions lie on a continuum from positive feelings body dissatisfaction? This is a crucial question because early to extreme dissatisfaction. Positive attitudes towards one’s body modification of these factors may prevent the development of later include acceptance of and comfort in one’s body independent body dissatisfaction and its negative consequences. of whether it fits social stereotypes of appearance ideals. On the other hand, although “body dissatisfaction” is the widely used term To understand risk and protective factors for body dissatisfaction, for negative feelings about one’s appearance and may sound recent authors have drawn on sociocultural and biopsychosocial 11 innocuous, this term incorporates the most extreme rejection of models summarised in Figure 1. It is appreciated that genetic 12 one’s body, hatred, disgust and loathing. factors are likely to play a part in the development of body dissatisfaction, but at present little is understood about their mode Although often thought of as a young female problem, a substantial of action, so this knowledge cannot direct prevention or therapy. number of males also experience body dissatisfaction. In a recent survey of over 15,000 Australian adolescents, 43% of girls and 19% Psychological factors also increase risk of body dissatisfaction. of boys described themselves as extremely or very concerned In particular, low self-esteem in girls and depressive symptoms about body image. However, the nature of body image concerns in boys increase risk. It is likely that if a person feels negative 2 13 varies between girls and boys, with girls being most concerned about themselves in general, they will also evaluate their body about weight, shape, and facial appearance, and boys being negatively. These findings have been used to guide therapy concerned about leanness, muscularity and athleticism. Once interventions which assist clients to challenge negative thinking established, body dissatisfaction frequently continues unabated about themselves. 14 through adult years to midlife and beyond. Sociocultural pressures to conform to appearance ideals have Body dissatisfaction has been demonstrated to have negative received particular research attention as these factors are potentially consequences. In addition to causing immediate pain, body modifiable in prevention interventions. These pressures include dissatisfaction is a prospective risk factor for low self-esteem parent, media and peer pressures to conform to appearance ideals. and depression smoking onset, unhealthy dieting or muscle It has been proposed that these pressures have their influence on 4 3 building behaviours and overweight and obesity. Importantly, body dissatisfaction by contributing to an individual coming to value 5,6 7 body dissatisfaction is the strongest risk factor for clinical eating themselves on the basis of their attainment of this ideal (described 8 disorders, notably bulimic disorders. It is this latter relationship as internalisation of the appearance ideal) and this leads to greater which is crucial for dentists as a number of aspects of eating comparisons between the self and the appearance of others disorders have direct repercussions for dental health. In particular, (described as appearance comparison). As appearance ideals are self-induced vomiting and malnutrition may result in particular generally impossible to attain, and appearance comparisons tend patterns of tooth erosion and dental caries requiring treatment. 9 to be made with people who have more of a desired quality than the individual, body dissatisfaction follows. 15 RACDS ANNALS 2016 75

Parents usually provide the first appearance related environment HOW CAN A DENTIST HELP? for their children and our research has demonstrated that weight bias (attributing positive characteristics to thinner figures and negative characteristics to fatter figures) is typically present in Dentists may play a critical role in treatments of craniofacial 4-year-old children, and these attitudes are strongest in boys conditions, thereby alleviating much anxiety and boosting body when their fathers endorse particularly negative attitudes towards satisfaction. In addition, dentists assist many people to meet obese people, and in girls when their mothers diet, supporting our society’s beauty ideal of straight, white teeth. However, they 16 a gendered transmission of body image attitudes in early years. also play a vital role in assisting individuals with eating disorders In adolescent years, research suggests that parents may influence improve their dental health. In particular, specific patterns of dental the development of body dissatisfaction in their children in part erosion and caries may alert the dentist to the likelihood of self- 9 by modelling behaviours consistent with particular body image induced vomiting and eating disorder symptoms. The dentist attitudes (e.g., dieting as a result of body dissatisfaction), but, more may then wonder what can be done to assist. In fact, the dentist importantly, by encouragement to lose weight or build muscle. 17 may be the first person to become aware of the possibility of an eating disorder as patients may not have disclosed this information to others previously as a result of the stigma surrounding mental The influence of media on the development of body dissatisfaction health conditions in general and eating disorders in particular. over the long term has been hard to tie down in research. However, Consequently, the dentist’s non-judgemental and kind reaction research demonstrates that exposure to idealised figures increases is particularly important in encouraging future help seeking. In body dissatisfaction in the short-term when an exposed individual addition, as the first concern for the dentist is optimal dental care 18 already has poor body image and places a high value on thinness. for their patient, ensuring the patient feels relaxed and safe is On the other hand, having a positive body image is protective essential to encourage return visits. against these environmental pressures. In our research with 19 young children, we were particularly interested to find that 34% of girls reported engaging in dieting behaviours to avoid getting fat, As patients often do not raise the issue of an eating disorder, the and this was not predicted by parents’ attitudes or behaviours but dentist may need to open this conversation. However, this is not rather by level of media exposure (screen time) and appearance typically easy. The dentist may wish to suggest that sometimes based conversations with friends (i.e. about hair or clothes). patterns of dental problems such as the ones they are observing 20 These findings suggest an early influence of media exposure. can be caused by eating disorder symptoms but may also be due to other aspects of diet or medical conditions, creating an The peer environment may also influence body dissatisfaction. For opportunity for patients to disclose their eating problems. This example, frequent appearance conversations with peers, such as may open an avenue for referral to an eating disorder professional, about weight and shape, dieting, fashion and clothes, have been but importantly, the patient may not be ready for this step. shown to increase body dissatisfaction, most likely by establishing Whether disclosure occurs or not, there is excellent advice that can norms about the importance of appearance within the peer be provided to reduce dental problems to mitigate the effects of group. Appearance related behaviours such as friends’ dieting eating disorder symptoms including about appropriate brushing 21 25 has also been shown to predict an increase in body dissatisfaction. 21 and approaches to harden enamel. Thus, the dentist can play a crucial secondary prevention and referral role. Social media is a new influence on body dissatisfaction which brings together media and peer pressures. In Australia, 97% of REFERENCES adolescents are Internet users, and of these, 90% use the Internet 1. Wertheim EH, Paxton SJ, Blaney S. Body image in girls. In for social networking. One Australian study found that 75% of 13- Smolak L, Thompson JK, eds. Body image, eating disorders 22 15 year-old girls had a Facebook page and girls spent an average of and obesity in youth (2nd edition). Washington, DC: American 23 1.5 hours there daily. Social media is not only interactive, it is highly Psychological Association, 2009:47-76. visual with self-photos often being a central focus. However, recent research shows that greater social media use is associated with 2. Mission Australia. Youth Survey. Mission Australia, 2012. greater body dissatisfaction. Further, manipulating images for 3. Goldschmidt AB, Wall M, Choo TJ, Becker C, Neumark-Sztainer 23 social media is related to body dissatisfaction in adolescent girls. D. Shared risk factors for mood-, eating-, and weight-related 24 However, neither the causal direction of these relationships nor the health outcomes. Health Psychol 2016;35:245-252. mechanisms of action are yet known. 4. Kaufman AR, Augustson EM. Predictors of regular cigarette smoking among adolescent females: Does body image matter? Nicotine Tob Res 2008;10:1301-1309. INTERVENTIONS FOR BODY DISSATISFACTION 5. Neumark-Sztainer D, Paxton SJ, Hannan PJ, Haines J, Story M. Does body satisfaction matter? Five-year longitudinal A range of prevention, early interventions and therapies designed associations between body satisfaction and health behaviors to reduce body dissatisfaction and related disordered eating in adolescent females and males. J Adolesc Health symptoms have been developed that specifically aim to assist 2006;39;244-251. individuals to cope with or challenge environmental pressures and to change attitudes which increase vulnerability to body 6. Pope HG, Kanayama G, Hudson JI. Risk factors for illicit dissatisfaction. For example, school-based prevention interventions anabolic-androgenic steroid use in male weightlifters: A cross- have addressed roles of media and peers and how these pressures sectional cohort study. Biol Psychiatry 2012;71:254-261. can be minimised. Therapy programs assist clients in examining 7. Loth KA, Watts AW, van den Berg P, Neumark-Sztainer D. their own values and considering ways other than appearance to Does body satisfaction help or harm overweight teens? ascertain their own self-worth. They may also increase awareness A 10-Year longitudinal study of the relationship between of appearance comparisons and teach ways to reduce these. 14 body satisfaction and body mass index. J Adolesc Health 2015;57(5):559-561. Different needs have been identified for people with visible 8. Stice E, Marti CN, Durant S. Risk factors for onset of eating differences where negative self-perceptions and fear of negative disorders: Evidence of multiple risk pathways from an 8-year evaluation by peers and strangers can result in social withdrawal. prospective study. Behav Res Ther 2011;49:622-627. In this situation, building social and communication skills has been 9. Frydrych AM, Davies GR, McDermott BM. Eating disorders and shown to be valuable. 10 oral health: a review of the literature. Aust Dental J 2005;50:6-15. 76 RACDS ANNALS 2016

10. Jenkinson E, Williamson H, Byron-Daniel J, Moss TP. Systematic satisfaction: Does body appreciation protect women from review: Psychosocial interventions for children and young negative effects? Body Image 2013;10:509–514. people with visible differences resulting from appearance 20. Damiano SR, Paxton SJ, Wertheim EH, McLean SA, Gregg altering conditions, injury or treatment effects. J Pediatr KJ. Dietary restraint of 5-year old girls: Associations with Psychol 2015;40:1017-1033. internalization of the thin ideal, maternal, media and peer 11. Thompson JK, Heinberg LJ, Altabe M, Tantleff-Dunn S. influences. Int J Eat Disord 2015;8:1166–1169. Exacting beauty: Theory, assessment, and treatment of body 21. Paxton SJ, McLean SA. Peer interactions and relationships - image disturbance. Washington, DC: American Psychological risk factors for eating disorders. In Wade TD, ed. Encyclopedia Association. 1999. of Feeding and Eating Disorders, Springer. 2015. 12. Rodgers RF, Paxton SJ, McLean SA. A biopsychosocial model 22. ABS. Household Use of Information Technology, Australia of body image concerns and disordered eating in early 2012-2013. 2013 adolescent girls. J Youth Adolesc, 2014;43:814-823. 23. Tiggemann M, Slate A. NetGirls: The Internet, Facebook, and 13. Paxton SJ, Eisenberg ME, Neumark-Sztainer D. Prospective body image concern in adolescent girls. Int J Eat Disord predictors of body dissatisfaction in adolescent girls and boys: 2013;46:630-633. A five-year longitudinal study. Dev Psychol 2006;42:888-899. 24. McLean SA, Paxton SJ, Wertheim EH, Masters J. Photoshopping 14. Paxton SJ, McLean SA, Gollings EK, Faulkner C, Wertheim the selfie: Self photo editing and photo investment are EH. Comparison of face-to-face and internet interventions for associated with body dissatisfaction in adolescent girls. Int J body image and eating problems in adult women: an RCT. Int Eat Disord, 2015;48:1132-1140. J Eat Disord 2007;40:692-704. 25. Burkhart N, Roberts M, Alexander M, Dodds A. Communicating 15. Jones DC. Body image among adolescent girls and boys: A effectively with patients suspected of having bulimia nervosa. longitudinal study. Dev Psychol, 2004;40:823-835. J Am Dent Assoc 2005;136:1130-1137. 16. Damiano SR, Paxton SJ, Gregg K, Spiel EC, McLean SA, Wertheim EH. Relationships between body size attitudes and body image of 4-year-old boys and girls, and attitudes of their Email address for correspondence: fathers and mothers. J Eat Disord 2015;3:16 [email protected] 17. Rodgers RF, Chabrol H: Parental attitudes, body image disturbance and disordered eating amongst adolescents and young adults: A review. Eur Eat Disord Rev 2009, 17:137–151. 18. Durkin SJ, Paxton SJ. Predictors of vulnerability to reduced body image satisfaction and psychological wellbeing in response to exposure to idealized female media images in adolescent girls. J Psychosom Res 2002;53:995-1005. 19. Halliwell E. The impact of thin idealized media images on body Figure 1. Biopsychosocial risk factors for the development of body dissatisfaction RACDS ANNALS 2016 77

PSYCHO-SOCIAL EFFECTS OF MALOCCLUSION: DO WE MEASURE IT AND ARE WE INTERESTED? Prof Kevin O’Brien, BDS, FDSRCP, FDSRCS, MSc, D.Orth, PhD Kevin O’Brien is a Professor in the Department of Orthodontics School of Dentistry, University of Manchester, UK. ABSTRACT One of the most common reasons for a person to have orthodontic treatment is to improve their appearance and perhaps increase the way that they feel about themselves. As a result, if we are to study the effects of orthodontic treatment it could be suggested that we should measure the effect of the change of dental appearance. However, when we evaluate the orthodontic research literature, it has been suggested that reported outcomes may be mostly relevant to clinicians and not patients. 1 ORTHODONTIC OUTCOMES measuring these means they are often omitted in studies. However, recent advances in the development and validation of scales and questionnaires to measure patient reported outcomes should In order to evaluate this problem we carried out a systematic review encourage the use of such outcome measures. Indeed, a few such 3 to evaluate the outcomes that were used in orthodontic trials and tools have already been reported in the literature and have been to consider if they were relevant to our patients. We searched the shown to be valid and effective for use in orthodontic patients. 4-6 2 literature from January 2008 until December 2012 and identified A recent systematic review, however, by Liu and colleagues, which all the orthodontic trials. We then extracted all the outcomes that evaluated evidence from studies on malocclusion and quality were used. We then classified the outcomes into several main of life, identified only twenty three studies that employed such domains. These were: disease activity (the morphological features/ measures, out of one hundred and forty three eligible articles. This 7 changes of malocclusion), physical consequence of malocclusion, figure is slightly higher but comparable to our findings of 12 studies functional status, social outcomes and quality of life (QoL), health employing QoL measures. Nevertheless, this trend seems to be service resource utilization (HRU), adverse effects of treatment. gradually increasing in orthodontic research. We found that there was a wide range of outcomes. Importantly, the ORTHODONTIC STUDIES most common domain was disease activity. This included mostly outcomes that measured morphological differences from an ideal, for example, occlusal index and cephalometric measurement. When we look at the type of studies that have been used to Understandably, this is both necessary and important when measure socio-psychological status in orthodontics, it is clear that assessing effectiveness of care, as clinicians need to know whether most of them have been cross-sectional or prospective cohorts. an intervention has worked or not. Unfortunately, other outcomes This means that the effect of time and childhood development of comparable value, such as cost-benefit analysis, adverse effects cannot be taken into account. There has only been one randomised of treatment, patient perceptions, impact of and compliance with trial which evaluated the effects of providing early treatment for treatment, were largely unexplored. These outcomes are relevant prominent front teeth to a sample of 8 year old children. This study to patients, and provide essential information when operators and showed that there was a short term gain in self esteem but any patients make shared decisions on care. This is particularly relevant difference had disappeared when the children completed all their when we consider outcomes that measure the way that people orthodontic treatment when they were in adolescence. 8, 9 perceive their teeth and any effects on socio-psychological status. Arguably, it is often difficult to ascertain whether changes in such psychosocial measures occurs as a result of treatment or due to WHAT IS THE BEST WAY FORWARDS? developmental changes, and perhaps the difficulty in accurately measuring these means they are often omitted in studies. However, It is difficult to suggest an easy way forwards. When we consider recent advances in the development and validation of scales and study design there are many difficulties with carrying out a questionnaires to measure patient reported outcomes should randomised controlled trial. For example, it is not possible to encourage the use of such outcome measures. Indeed, a few such allocate participants to receive orthodontic treatment or to an 3 tools have already been reported in the literature and have been untreated control. The next level of study could be a prospective shown to be valid and effective for use in orthodontic patients. 4-6 cohort or cross sectional study. However, this study design will not A recent systematic review, however, by Liu and colleagues, which take into account the effects of time and age of patient at a time of evaluated evidence from studies on malocclusion and quality great developmental change. of life, identified only twenty three studies that employed such 7 measures, out of one hundred and forty three eligible articles. This figure is slightly higher but comparable to our findings of 12 studies It could also be possible that this could be one of the great employing QoL measures. Nevertheless, this trend seems to be unanswered questions in orthodontic treatment. Or is the answer gradually increasing in orthodontic research. so obvious that there is no need for further research? Arguably, it is often difficult to determine whether changes in such psychosocial measures occurs as a result of treatment or due to developmental changes, and perhaps the difficulty in accurately 78 RACDS ANNALS 2016

REFERENCES 1. O’Brien K. Northcroft Memorial Lecture 2004. Consumer 7. Liu Z, McGrath C, Hagg U. The impact of malocclusion/ centred research...what do they think? J Orthod 2005;32:187- orthodontic treatment need on the quality of life. A systematic 190. review. Angle Orthod 2009;79:585-591. 2. Tsichlaki A, O’Brien K. Do orthodontic research outcomes 8. O’Brien K, Wright J, Conboy F, et al. Effectiveness of early reflect patient values? A systematic review of randomized orthodontic treatment with the Twin-block appliance: a controlled trials involving children. American Journal of multicenter, randomized, controlled trial. Part 2: Psychosocial Orthodontics and Dentofacial Orthopedics 2014;146:279-285. effects. Am J Orthod Dentofacial Orthop 2003;124:488-494; discussion 494-485. 3. Vig KW, Weyant R, O’Brien K, Bennett E. Developing outcome measures in orthodontics that reflect patient and provider 9. O’Brien K, Wright J, Conboy F, et al. Early treatment for Class II values. Seminars in orthodontics 1999;5:85-95. Division 1 malocclusion with the Twin-block appliance: a multi- center, randomized, controlled trial. Am J Orthod Dentofacial 4. Bennett ME, Michaels C, O’Brien K, Weyant R, Phillips C, Orthop 2009;135:573-579. Dryland K. Measuring beliefs about orthodontic treatment: a questionnaire approach. J Public Health Dent 1997;57:215-223. 5. Mandall NA, Vine S, Hulland R, Worthington HV. The impact Email address for correspondence: of fixed orthodontic appliances on daily life. Community Dent [email protected] Health 2006;23:69-74. 6. O’Brien K, Wright JL, Conboy F, Macfarlane T, Mandall N. The child perception questionnaire is valid for malocclusions in the United Kingdom. Am J Orthod Dentofacial Orthop 2006;129:536-540. RACDS ANNALS 2016 79

THE RELATIONSHIP BETWEEN FACIAL CONVEXITY IN YOUNG CHILDREN AND PERCEIVED INTELLIGENCE Dr Sivabalan Vasudavan, BDSc, MDSc, MPH, MOrth, RCS, MRACDS (Ortho), FDSRCS Andrew L. Sonis, DMD Dr Sivabalan Vasudavan is a Specialist Orthodontist in Claremont, Western Australia; Senior Research Fellow, Faculty of Science, University of Western Australia; and Visiting Lecturer at Boston Children's Hospital, and the Developmental Biology, Harvard School of Dental Medicine, Boston, Massachusetts, USA Dr Andrew L. Sonis is a Senior Associate and Specialist in Orthodontics, Paediatric Dentistry, and Oral Medicine, Boston Children's Hospital, and Clinical Professor of Developmental Biology, Harvard School of Dental Medicine, Boston, Massachusetts, USA ABSTRACT Objective: The principle objective of this study was to investigate the relationship between a pre-adolescent child’s perceived intelligence and their sagittal facial relationship as determined by second and third grade elementary school educators. Materials and Methods: A digitized lateral cephalogram and photograph of an eight-year old child with Class I occlusion and normal overbite and overjet were entered into the Dolphin software program. The lateral cephalogram and photograph were linked to allow computerized manipulation to generate five profiles with a Steiner ANB value ranging from two to ten degrees by retruding the mandible in four profiles at two degree intervals and one profile by proclining the maxillary incisors to create an overjet relationship of 10 mm. Each profile simulation was then converted to a simple silhouette and printed out to create a series of “flashcards”. Results: Fifty Elementary School teachers force ranked the profile silhouette flashcards for perceived intelligence. Profile images corresponding to Steiner ANB angles of two and four degrees consistently filled the position of highest in intelligence perception. Conversely, the position of lowest intelligence was exclusively filled by profile images with ANB angles of eight and ten degrees. Images with ANB angles equal to two and four degrees had a 48% and 52% chance respectively to be ranked as having the highest intelligence, while figures with ANB angles of eight and ten degrees had 16% and 84% chance respectively to be ranked as having the lowest intelligence. Conclusion: According to our data, elementary school teachers almost uniformly associate a retrognathic profile of a pre-adolescent child with decreased intelligence. The findings of our study re-affirm the need for considering psychological indications for initiating interceptive orthodontics treatment in class II child patients. INTRODUCTION Early interceptive orthodontics has been studied in order to The psychosocial effects of facial appearance are well documented determine its true benefits. Early treatment is intended to augment in the literature. The benefit of early interceptive orthodontics for skeletal and dental maturity, prior to the eruption of the permanent Class II malocclusions is a source of conjecture amongst clinicians. dentition. Phase 1 therapy is said to intercept malocclusions in a The answer is further complicated by psychosocial considerations manner that will produce a superior, more stable result than that and the very multifactorial presentation of molar class II would have been achieved if treatment commencement was relationship, which has been reported by many investigators. 1-3 deferred to the permanent dentition. Proponents of early treatment While it is understood that class II malocclusion can result from firmly believe that any subsequent full-fixed orthodontic appliance a combination of dental and skeletal components, the study of therapy would be reduced in duration and complexity. In 1992, McNamara (1981) suggests that mandibular skeletal retrusion is the one-third of children in the USA undergoing orthodontic treatment most common characteristic contributing to this diagnosis. were treated in two phases. 4 Clinically, these characteristics produce a facial profile view that in What are the benefits of treating patients with a two-phase therapy social settings is subject to judgment by others. As such, a profile as opposed to a single phase? What are the benefits of early with a five-degree increase in Subspinale-Nasion- Supramentale treatment to the orthodontist? Is early treatment more efficient (SNB) angle is rated significantly as more attractive than a profile than a later, singular phase of orthodontic treatment? Do the 5 with a five-degree decrease in SNB angle. Furthermore, it has benefits of early treatment justify the added expenditure, timing been shown that both orthodontist and lay people are relatively and effort involved? Is the quality of treatment better, same, or sensitive to small horizontal changes, 3 mm or more, in the worse in cases treated early? mandible’s position. 6 Joondeph (1993) stated that, “the objective of early orthodontic Comparison and judgment of peers is common amongst children, treatment is to create a more favourable environment for future and increased overjet is a significant predictor of teasing amongst dentofacial development. Interceptive treatment can reduce 7 children and parents seeking treatment. It has also been reported the amount of dental compensations to skeletal discrepancy that both parents and children expect improvements in social that is often associated with a more severe malocclusion in late interaction in addition to improvements in appearance and oral adolescence”. 9 function from orthodontic treatment. Thus, it is critical for a 8 clinician to be informed about psychosocial factors affected by Justus (2008) tabled the proceedings of the workshop discussion 10 malocclusion in a child’s life in order to both educate the child/ on early treatment. One hundred and fifty nine Diplomats of the parent and address the concerns and expectations of a child/ American Board of Orthodontics were surveyed on their perceived parent regarding orthodontic treatment. benefits of early treatment and these included: 80 RACDS ANNALS 2016

• A better and more stable result. temporarily), and helping with a patient’s self-image are thought • A greater ability to modify skeletal growth. to motivate orthodontists to initiate interceptive treatment. The 22 • Improved patient self-esteem and parental satisfaction. rational for such motivations is explained at least by one study • Less extensive therapy is required later. which positively correlates physical attractiveness with happiness • Reduced potential for iatrogenic tooth damage such as for both men and women, and self-esteem for women. 23 trauma, root resorption and decalcification. Since children with normal dental appearance are judged to be Furthermore, King and associates (1999) published their findings better looking, more desirable as friends and more intelligent, 22 from a survey of orthodontists, who believed that their patients early interceptive orthodontics gains more importance. The who had received phase 1 orthodontic treatment, had seemingly importance of attractiveness has been shown in several studies. less complex malocclusions as compared to untreated patients Human beings judge one another based on physical appearance, requiring full-fixed appliance therapy. Other perceived benefits despite the old maxims of “beauty is only skin deep” or “never judge 11,12 to the orthodontists include a greater ability to modify growth, a a book by its cover”. It has been demonstrated that in general, subsequent back-up or second attempt that is available to solve human beings designate positive attributes to more attractive the malocclusion, reduction in complexity of mechanics in full fixed individuals and negative attributes to less attractive individuals. 23 appliance therapy and subsequently reduced chair time. This judgment of character based on appearance has also raised questions regarding social and psychosocial costs of obesity. As The goals of early treatment may include the following : such, it has been reported that there exists anti-fat bias amongst 13 1. To prevent progressive, irreversible soft-tissue or bony the general population and to a lesser degree amongst health care changes. professionals. 24 2. To improve skeletal discrepancies and provide a more favourable environment for normal growth. In several meta-analyses, researchers have found that, while there 3. To improve occlusal function. is agreement within and across cultures on who is attractive, 4. To enhance and possibly shorten phase II comprehensive attribution of positive characteristics to attractive individuals are treatment. followed by more positive treatment and behavior towards those 5. To provide more pleasing facial aesthetics, thus improving the individuals relative to less attractive individuals. One can imagine 25 psychological development of the child. the influence of this discriminatory behavior, which is often unconscious, on development of a child. Indeed it has also been The indications for the commencement of orthodontic treatment shown that attractive children and adults exhibit more positive in the mixed dentition include: characteristics. The mechanism of the phenomenon perhaps • Posterior and anterior crossbites. can be explained by the “self-fulfilling prophecy”, a term coined by • Functional improvement. sociologist Robert K. Merton. Through the positive feedback that • Improved esthetics that occurs with the anterior crossbite more attractive individuals receive from others, the false premise correction. of more attractive individuals actually having more positive • Ankylosed teeth. characteristics becomes a true premise. Thus, contrary to beliefs • Excessive protrusions and diastemas. that beauty is not determinant of character and behavior, beauty • Severe anterior and lateral open bites. plays an important role in social interaction and development. • Ectopic molars are best treated when discovered. • Severe arch length discrepancies are found in the mixed As for a child spending ample time in school, interactions with dentition, and it is clear that bicuspid extractions are needed teachers become subject of scrutiny when evaluating social for resolution. and academic development. Teacher’s perception regarding a • Patients with cleft palates. child’s characteristics has been shown to influence the teacher’s • Pseudo Class III patients. expectation of performance in a child. There are several variants that influence a teacher’s expectancy; ethnicity, attractiveness or The above indicators pertain to scenarios of a specific nature, even an older sibling’s prior academic performance have been where early or interceptive care is necessitous. However, an shown to be powerful factors in forming a teacher’s perception. assessment of philosophy of early treatment should focus on the Specifically, previous studies seem to predict a positive relationship routine treatment of malocclusions. between a child’s attractiveness and the teacher’s expectation. 26 Teacher expectancy has been shown to account for year-end However, results of several prospective randomized clinical trials all ethnicity achievement gap. Furthermore, in a double blind study, 27 demonstrated no statistically significant improvement in treatment it was shown that teachers rated attractive children higher and outcomes with the initiation of an early phase I treatment. 14-16 More held lower expectations regarding future social and academic specifically, a completed 2-phase treatment produces comparable performance for less attractive children. Even an older sibling’s 28 skeletal changes to that of a 1-phase treatment by the end of academic performance has been shown to influence the teacher’s treatment course; thus early phase I interceptive orthodontics only expectancy and child’s performance. 29 17 temporarily causes skeletal changes. It has also been shown that by the end of treatment, both 1 and 2-phase orthodontics produce The significance of these findings is evident in the link between similar arch dimensions and have similar incisor injury incidence. teachers’ expectation and a child’s achievement. Hence, teacher’s 19 18 One can also point to the overall longer course of treatment in expectation of a child has been shown to influence child’s 30 combined phase I and II treatment relative to phase II only and the achievements. Thus, factors that influence the perception and 20 need for follow up in permanent dentition after phase I interceptive judgment of teachers are a matter of concern. As such, ethnicity, orthodontics as a disadvantage. However, none of these studies race and attractiveness have been studied in relation to teacher 21 consider any psychosocial variables in their analyses. bias; yet, no study has explored the teacher’s perceived intelligence judgment that may stem from a profile view of a child, mainly a It is worth noting that, though it doesn’t produce finished quality class II appearance. treatment without the second phase, interceptive orthodontics is effective in reducing malocclusion. As such it has been shown that it When deciding whether to start interceptive orthodontics for improves esthetics, crowding, crossbite and overbite as compared a child patient, a clinician may consider possible psychosocial 21 to no intervention. Nevertheless, benefits such as eliminating benefits in addition to parent and child’s expectation of treatment destructive habits, improving certain growth patterns (though and the stage of growth and development of a child. In this regard, RACDS ANNALS 2016 81

for a patient with class II malocclusion, it would be beneficial for orthodontics affects general health or oral health related quality 30 a clinician to consider the perceived intelligence of the child, of life minimally in adolescents. Furthermore, lack of orthodontic specifically by teachers. The purpose of the present study was to treatment does now seem to lead to adverse psychological 31 investigate the effect of a child’s profile on perceived intelligence as problems. More specifically, one of the topics under study judged by second and third grade elementary school educators. has been early interceptive orthodontics. This study aimed to examine the psychological benefit of early interception in class II MATERIALS AND METHOD malocclusion from the angle of teacher-student relationship. Hypothesis: The hypothesis of this study is that a child’s profile According to our data, teachers almost uniformly associate a class impacts a teacher’s perception of intellectual ability. Specifically, II profile of a child with less intelligence. In this study, teachers were the severity of a child’s class II malocclusion is inversely related to given one minute to deduce a judgment after looking at all the perceived intelligence by elementary school educators. profile photos. A limited time was allowed for ranking of the profile photos to illicit the first impression that comes to mind. The rational Subjects: Following approval by the IRB, letters were sent out to the for this technique is that only a fraction of a second of exposure principles and headmasters of 30 public and private elementary to a facial profile is sufficient for people to make an inference on schools to recruit 50 subjects for the study. A convenience sample character or trait. Increased time only allows for more confidence was obtained by enrolling the first fifty “Second” or “Third” grade in judgment and a more differentiated character designation. 32 teachers to volunteer for the study. The mean age of subjects was 33.8 years with a range of 22-58 years. The gender distribution In this study, the ethnicity of teachers were not recorded, thus was 10 males, 40 females with 24 located in private schools and ethnicity of teachers as a variable could not be controlled. Another 26 in public schools. All participants were from the greater Boston, limitation of this study was the sampling method of the study. A Massachusetts area. convenience sample allows for introducing selection bias. Although more women chose to participate in the study than men, for the Profile Silhouettes: An eight year old Caucasian male with a Class I purpose of this study, the population of teachers was presumed molar and canine relationship, normal overbite and overjet of 2mm homogeneous. and normal cephalometric values of SNA: 82˚, SNB: 80˚ and ANB: 2˚ was used as the template. A digital lateral cephalogram and When thinking of examples of a severe class II profile, one may profile photograph were obtained with the patient in natural head recall images of Bart Simpson or Disney’s Goofy. Both characters position. The photograph and cephalogram were linked using represent a silly or dumb character. In the same manner our Dolphin software version 9 and altered to create 4 additional modern media sets standard for what is a fit or thin body and what images. The four digitally altered images were created by moving is an attractive face, in more subtle ways it can lead us to form the mandible posteriorly at 2˚ intervals. Thus, images were created impressions or stereotypes of what intelligent or dumb people look with a SNA of 82˚ and SNB ranging from 78˚ to 72˚, and ANB like. Hence, a class II facial appearance in a child may be a tool ranging from 4˚ to 10˚. Silhouetted facial profiles were then created for teasing by others, a cause for a teacher’s bias, and a cause of on the original and four altered images by reducing the gamma- concern for parents. The findings of our study re-affirm the need scale to produce a two-tone black and white image (Figure 1). The for considering psychological indications for initiating interceptive resulting five images, including the original image, were printed on orthodontics treatment in class II child patients. Future studies on 3” by 5” photographic grade copy papers to produce “profile flash impression forming and behaviors towards children with class II cards”. Letters a, b, c, d and e were assigned to each profile flash malocclusion could shed more light on possible benefits of early card randomly and in no particular order. interceptive orthodontics. Intelligence Ranking: The “profile flash cards” were manually shuffled and laid out on a flat surface in front of a seated individual Rank 1 Rank 2 Rank 3 Rank 4 Rank 5 subject in a well-lit isolated room. The subject was then asked to arrange the “profile flash cards” in order of perceived intelligence ANB=2˚ 24 25 1 0 0 from low to high. The subjects were given 60 seconds to complete this task. The time constraint placed on the subjects was enforced ANB=4˚ 26 24 0 0 0 to invoke their first impression. The order of the profiles was then recorded on a data collection sheet which also included the ANB=6˚ 0 1 39 10 0 subject’s age, gender, and employment sector (private vs. public). ANB=8˚ 0 0 10 32 8 RESULTS ANB=10˚ 0 0 0 8 42 Fifty teachers ranked five images in order of decreasing intelligence. Profile images corresponding to ANB angles of 2˚ and Table 1. Distribution of ranks 4˚ consistently filled the position of first in intelligence perception. Conversely, position of lowest intelligence was exclusively filled by Rank 1 Rank 2 Rank 3 Rank 4 Rank 5 profile images with ANB angles of 8˚ and 10˚ (Table I). Images with ANB angles equal to 2˚ and 4˚ had a 48 and 52 percent chance respectively to be ranked as having the highest intelligence, while ANB=2˚ 0.48 0.5 0.02 0 0 figures with ANB angles of 8˚ and 10˚ had 16 and 84 percent chance respectively to be ranked as having the lowest intelligence ANB=4˚ 0.52 0.48 0 0 0 (Table II). Figures 3 show the distribution of rank orders. ANB=6˚ 0 0.02 0.78 0.2 0 DISCUSSION ANB=8˚ 0 0 0.2 0.64 0.16 Modern dentistry emphasizes evidence based clinical practice. The impact and influence of orthodontic treatment has been ANB=10˚ 0 0 0 0.16 0.84 studied in various arena so that its’ public health and psychosocial benefits are better measured. As such, various studies suggest that Table 2. Chance of intelligence rank for each silhouette 82 RACDS ANNALS 2016

REFERENCES 1. Sassouni V. The Class II syndrome: differential diagnosis and 18. Wortham JR, Dolce C, McGorray SP, Le H, King GJ, Wheeler TT. treatment. Angle Orthod 1970;40:334-341. Comparison of arch dimension changes in 1-phase vs 2-phase treatment of Class II malocclusion. Am J Orthod Dentofacial 2. Sassouni V. A classification of skeletal facial types. Am J Orthod 1969;55:109-123. Orthop 2009;136:65-74. 19. Koroluk LD, Tulloch JF, Phillips C. Incisor trauma and early 3. Moyers RE, Riolo ML, Guire KE, Wainright RL, Bookstein FL. Differential diagnosis of class II malocclusions. Part 1. Facial treatment for Class II Division 1 malocclusion. Am J Orthod types associated with class II malocclusions. Am J Orthod Dentofacial Orthop 2003;123:117-125; discussion 125-116. 1980;78:477-494. 20. Tulloch JF, Phillips C, Proffit WR. Benefit of early Class II treatment: progress report of a two-phase randomized clinical 4. McNamara JA, Jr. Components of class II malocclusion in children 8-10 years of age. Angle Orthod 1981;51:177-202. trial. Am J Orthod Dentofacial Orthop 1998;113:62-72, quiz 73- 64. 5. Johnston C, Hunt O, Burden D, Stevenson M, Hepper P. The influence of mandibular prominence on facial attractiveness. 21. King GJ, Brudvik P. Effectiveness of interceptive orthodontic Eur J Orthod 2005;27:129-133. treatment in reducing malocclusions. Am J Orthod Dentofacial Orthop 2010;137:18-25. 6. Romani KL, Agahi F, Nanda R, Zernik JH. Evaluation of horizontal 22. Shaw WC. The influence of children's dentofacial appearance and vertical differences in facial profiles by orthodontists and lay people. Angle Orthod 1993;63:175-182. on their social attractiveness as judged by peers and lay adults. Am J Orthod 1981;79:399-415. 7. Kilpelainen PV, Phillips C, Tulloch JF. Anterior tooth position and 23. Dion K, Berscheid E, Walster E. What is beautiful is good. J Pers motivation for early treatment. Angle Orthod 1993;63:171-174. Soc Psychol 1972;24:285-290. 8. Kiyak HA. Patients' and parents' expectations from early 24. Teachman BA, Brownell KD. Implicit anti-fat bias among health treatment. Am J Orthod Dentofacial Orthop 2006;129:S50-54. professionals: is anyone immune? Int J Obes Relat Metab 9. Joondeph DR. Early orthodontic treatment. Am J Orthod Disord 2001;25:1525-1531. Dentofacial Orthop 1993;104:199-200. 25. Langlois JH, Kalakanis L, Rubenstein AJ, Larson A, Hallam M, 10. Justus R. Are there any advantages of early Class II treatment? Smoot M. Maxims or myths of beauty? A meta-analytic and Am J Orthod Dentofacial Orthop 2008;134:717-718. theoretical review. Psychol Bull 2000;126:390-423. 11. King GJ, Wheeler TT, McGorray SP, Aiosa LS, Bloom RM, 26. Shaw WC, Humphreys S. Influence of children's dentofacial Taylor MG. Orthodontists' perceptions of the impact of phase appearance on teacher expectations. Community Dent Oral 1 treatment for Class II malocclusion on phase 2 needs. J Dent Epidemiol 1982;10:313-319. Res 1999;78:1745-1753. 27. McKown C, Weinstein RS. Teacher expectations, classroom 12. McGorray SP, Wheeler TT, Keeling SD, Yurkiewicz L, Taylor MG, context, and the achievement gap. J Sch Psychol 2008;46:235- King GJ. Evaluation of orthodontists' perception of treatment 261. need and the peer assessment rating (PAR) index. Angle Orthod 1999;69:325-333. 28. Ross MB, Salvia J. Attractiveness as a biasing factor in teacher judgments. Am J Ment Defic 1975;80:96-98. 13. Ngan PW, Hagg U, Yiu C, Wei SH. Treatment response and long-term dentofacial adaptations to maxillary expansion and 29. Seaver WB. Effects of naturally induced teach expectancies. protraction. Semin Orthod 1997;3:255-264. Journal of Personality and Social Psychology 1973;28:333-342. 30. Crano WD, Mellon, P.M. . Causal influence of teachers' 14. King GJ, McGorray SP, Wheeler TT, Dolce C, Taylor M. Comparison of peer assessment ratings (PAR) from 1-phase epectations on children's academic performance: A cross- and 2-phase treatment protocols for Class II malocclusions. lagged panel analysis. Journal of Educational Psychology Am J Orthod Dentofacial Orthop 2003;123:489-496. 1978;70:39-49. 31. Shaw WC, Richmond S, Kenealy PM, Kingdon A, Worthington 15. Tulloch JF, Phillips C, Koch G, Proffit WR. The effect of early intervention on skeletal pattern in Class II malocclusion: a H. A 20-year cohort study of health gain from orthodontic randomized clinical trial. Am J Orthod Dentofacial Orthop treatment: psychological outcome. Am J Orthod Dentofacial 1997;111:391-400. Orthop 2007;132:146-157. 32. Willis J, Todorov A. First impressions: making up your mind 16. Tulloch JF, Proffit WR, Phillips C. Outcomes in a 2-phase randomized clinical trial of early Class II treatment. Am J after a 100-ms exposure to a face. Psychol Sci 2006;17:592- Orthod Dentofacial Orthop 2004;125:657-667. 598. 17. Dolce C, McGorray SP, Brazeau L, King GJ, Wheeler TT. Timing of Class II treatment: skeletal changes comparing 1-phase Email address for correspondence: and 2-phase treatment. Am J Orthod Dentofacial Orthop [email protected] 2007;132:481-489. RACDS ANNALS 2016 83

Figure 1. From Upper left to lower right: Silhouettes corresponding to ANB of 2˚, 4˚, 6˚, 8˚, 10˚. Figure 2. Distribution ranking orders for all five silhouette profiles 84 RACDS ANNALS 2016

PARADIGM SHIFTS IN ORTHODONTICS AND ORTHOGNATHIC SURGERY Dr Sivabalan Vasudavan, BDSc, MDSc, MPH, MOrth, RCS, MRACDS (Ortho), FDSRCS Dr Sivabalan Vasudavan is a Specialist Orthodontist in Claremont, Western Australia. ABSTRACT The orthodontic specialty has observed a significant paradigm shift in the delivery of orthodontic care, as evolving technological advances have been incorporated into specialist practice. However, particular attention to sound biomechanical design and treatment planning principles continue to underpin the successful resolution of many presenting malocclusions. Practitioners must be able to distinguish between marketing hyperbole and the utility available for their patient. The orthodontic profession is being split between ‘appliance-drive fast-food orthodontics’ where the results to a large extent are dependent on both growth and function and ‘orthodontist-driven slow-food: treatments attempt’ to push the limits of the possible in relation to complicated problems and reversal of degeneration of adult patients. The latter treatment is performed with individualized appliances adapting the specific force system to the patient. Orthodontists work towards establishing a comprehensive diagnosis and synthesis of the pertinent issues for each patient. Individualized treatment objectives are then established which leads to the formulation of a biomechanical plan and ordered treatment sequence. Orthodontic treatment is performed and outcomes can be objectively evaluated at completion. A prioritized problem list establishes an ordinal sequence of the issues that require to be addressed. Specific treatment objectives are established that address facial, skeletal, dental and biological needs. The biomechanical plan can consist of an exclusive orthodontic approach or include adjunctive surgical procedures. Pure orthodontic treatment planning, which does not include orthopaedic and functional aspects, should include the following stages: • Definition of a three-dimensional treatment objective • Definition of the necessary force systems to displace active units • General anchorage evaluation • Subdivision of treatment in stages • Selection and design of the orthodontic appliance for each stage The SureSmile® system (Orametrix, Richardson TX) was developed in the early 2000s and was intended to overcome the potential problems associated with statistically indeterminate mechanics commonly associated with conventional straightwire systems including manual wire bending, bracket placement, variations in surface tooth morphology, and the lack of control when using clear aligners. Utilizing highly accurate robots to custom bend archwires for each patient, the SureSmile® system attempted to circumvent the problems encountered in the past that include the difficulty in achieving accurate finishing bends, and ideal final occlusions. The SureSmile® system now encompasses 1 the facilities for the designation of virtual bracket positioning and tooth movement, and the concomitant rapid prototyping of indirect bonding trays and aligner systems. SureSmile® provides an integrated digital technology platform that enables clinicians to diagnose, plan, and design a customized therapeutic solution in the form of a prescription archwire for the patient. SureSmile®’s 3D-imaging environment allows for improved spatial visualization, 2 localization, and measurement of the dentition in all three planes of space. Bouwens et al. noted a significant difference between root angulation measurements from panoramic and 3D cone beam computed tomography (CBCT) images. SureSmile® provides a robust, interactive decision support system driven by simulations. Through simulations, a clinician can visualize and validate the mental model of a plan with regard to treatment position. Furthermore, the treatment plan can be designed interactively with the patient. Almog et al. demonstrated that computer-imaging simulations provide patients with a better understanding of proposed treatment 3 plans. The SureSmile® decision support system also allows for interprofessional collaboration since clinicians share their treatment plans with and seek clinical advice from one another. Both patient-clinician and interprofessional collaboration may minimize the disconnection in treatment objectives. SureSmile® software has built-in workflow automation and standardized checklists that provide a framework for the sequential management 4 of patient care. Wolff et al. showed that the incorporation of checklists in clinical pathways results in improvements in the quality of patient care and builds reliability. The use of conventional appliances largely requires iterative changes to bracket position coupled with archwire bends, which prolongs care. Studies on the reliability of conventional straight-wire appliances reveal that bracket slots have relatively poor tolerances, which may lead to imprecise tooth movement and add to treatment time. Conversely, a predefined plan drives the design of the SureSmile® customized prescription archwire. The angular and torsional bends of the robotically bent archwire are precise to ± 1 degree and linear bends are precise to ± 0.1mm. The coupling of the clinician’s plan and the prescription archwire overcomes the reactive elements of orthodontic care and enhances the reliability of appliance design. The movement of the dentition is more directed, potentially resulting in a shorter care cycle. SureSmile® technology in itself is not a panacea. It is only an enabling technology. Successful treatment outcomes can only be achieved in a timely manner when care is driven by an expert who has accumulated experience through deliberate practice. Visual light scans resulting in digital dental models of the patient’s dentition after the leveling and aligning procedure allowed the provider to treatment plan each RACDS ANNALS 2016 85

patient digitally. These customized appliance systems combine the precision of the pre-adjusted brackets and computer fabrication with the versatility and customization of manual wire bending, resulting in a treatment system that is individualized to each patient. Without the development of digital models many of the customized orthodontic appliance systems would be impossible. The first of these appliances was the Invisalign® system (Align Technology, San Jose CA), where clear aligners are custom fabricated to move teeth slowly. Invisalign® uses computer modelling to design and manufacture its aligners. The ClinCheck® software was developed by Align Technology to give the practitioner a preview of the prescribed tooth movements so that they can make any changes, as needed, before the aligners are fabricated. CAD-CAM technology was the first technology that allowed the doctor to see the intended finish before starting the treatment. However, it has been shown that the Invisalign® system is not as precise as using traditional orthodontic brackets for correcting large anteroposterior discrepancies and results in less than ideal occlusal contact. Invisalign® is inaccurate in several movements, especially extrusion and the 5 rotation of round teeth. Align Technology has attempted to correct the flaws with the system by developing new attachments that they 6,7 claim are more effective in producing the prescribed movements. In order to address the issues of inaccuracy, Orametrix, Inc. developed the SureSmile® system. The system allows orthodontists to use their choice of bracket, and integrates digital treatment planning with highly accurate, robotically bent custom archwires. Much like the Invisalign® system, a digital diagnostic setup (termed the “plan” by SureSmile®) of the anticipated final occlusion is necessary with the SureSmile® system. In contrast to previous iterations of the Invisalign® Clincheck treatment simulation platform, SureSmile® allows the clinician to modify the predicted tooth positions directly. Once approved by the clinician, a robot bends the wires from the doctor’s .8,9 choice of several materials, including copper-nickel-titanium alloy, beta-titanium alloy, and Elgiloy™ According to SureSmile®, approximately 80-90% of the wires bent are copper-nickel-titanium. SureSmile® claims that because the system is so accurate and round tripping is eliminated, the finished result is superior and completed more quickly than traditional pre-adjusted orthodontic treatment. The SureSmile® system allows compensation for the bracket choice and final 1 wire size, in that each orthodontist has a preference as to the bracket system they use, and many never use a full sized archwire. The ability to place compensatory bends in the arch wire allow precise tooth positions to be attained without having to use heavy, full-sized archwires. Recently, several studies have investigated the SureSmile® system. The first, a study by Saxe and coworkers, indicated that using this system was more efficient than traditional orthodontic appliances. Patients finished, on average, in six fewer months when treated with the 10 SureSmile® system. In addition, those patients treated with SureSmile® had statistically lower CRE scores than those treated with conventional means. There were a limited number of patients from three providers included in the study by Saxe et al. and the demographics of the 10 treatment groups were not disclosed. Furthermore, parametric statistical analyses were incorrectly used. Due to the ordinal nature of the ABO grading system nonparametric statistics are appropriate. Until very recently, no fully independent study had been conducted investigating both the efficiency and quality of treatment rendered using the SureSmile® system. The study published by Alford et al. concluded that patients treated with SureSmile® finished more quickly and had 11 improved alignment and rotations and interproximal contacts when using the CRE criteria, when compared to conventional pre-adjusted orthodontic patients. Interestingly, Alford and co-workers also found that the root alignment in the conventional group to be superior to the 11 SureSmile® group. They hypothesized that the robot-bent .019” x .025” copper-nickel-titanium wire that many SureSmile® providers use to finish their cases is not strong enough to upright the roots effectively. Their data sample did not include any patients who had Cone Beam Computer Tomography (CBCT) scans, which serves to model the initial root morphology more accurately. Additionally, there is availability for practitioners to elect to use different archwire materials including i) Beta Titanum (commercially available as Titanium Molybdenum Alloy (TMA)) which has a modulus of elasticity approximately twice that of Nickel Titanum, ii) and Chrome Cobalt Alloys (commercially available as Elgiloy.) It is difficult to extract meaningful conclusions from the study, as the average DI of the SureSmile® group was statistically lower than that of the conventional group, and the demographics of each group were not disclosed. As new technologies emerge, it is imperative that proper research be conducted to evaluate their efficacy. 9 Sachdeva et al. audited the first 12, 335 completed patient histories from the OraMetrix database, Comparative Effectiveness Research Program (CERP), and attempted to determine the efficiency of SureSmile® vs conventional treatment in terms of treatment time and additional variables that influence treatment time. The following statistically significant (P < 0.001) conclusions were made: • SureSmile® patients experienced a median treatment time of 15 months, which is 8 months less than that of conventional patients (23 months). • SureSmile® patients experienced a median treatment visitation period of 14 visits, which is a period of four fever visits than that of conventional patients (18 visits). • Class I, II, and III SureSmile® patients experienced care cycles 8 to 9 months shorter than those of Class I, II, and III conventional patients. • Class II SureSmile® patients experienced shorter cycles than Class I SureSmile® patients, and Class III SureSmile® patients experienced the longest care cycles in the SureSmile® patient group. • SureSmile® adolescents and adults did not experience statistically significant difference in treatment time. A combined orthodontic and orthognathic approach is routinely used to produce aesthetically and functionally superior treatment results in patients presenting with significant dentofacial deformities. A successful surgical outcome is determined by the correction of skeletal and dental abnormalities leading to an aesthetic improvement and facial soft tissue harmony as judged by both patients and practitioners. Surgical movements of the skeleton can influence the overlying soft tissue dimensions and these factors must be taken into consideration during orthognathic planning. Complex congenital, developmental, and acquired deformities of the facial skeleton are managed by re- establishing the facial symmetry and projection through restoration of the maxillomandibular relationships. Computer planning systems have been developed for use in the craniofacial skeleton and provide individualized, 3-dimensional manipulation of CT Dicom data sets. Numerous CAD/CAM (Computer Aided Design/Computer Aided Manufacturing) programs are commercially available in orthognathic surgery. 86 RACDS ANNALS 2016

13 De Riu et al. conducted a randomized clinical trial with 20 subjects, to determine the accuracy of computer assisted orthognathic surgical planning versus conventional surgical planning in the correction of facial asymmetry. Specifically, the objective of this study was to measure and compare the rates of alignment and reduction of cant of the dental and facial midlines between the two groups. The investigators found differences between the two groups in the alignment of the lower inter-incisal point (p = 0.03), mandibular sagittal plane (p = 0.01), and 13 centering of the dental midlines (p = 0.03) which were significant, with the digital planning group being more accurate. Centenero and Hernandez-Alfaro conducted a cross-over study to assess the superiority of intra-operative accuracy of intermediate surgical 14 splints produced by a CAD/CAM technology over conventionally produced surgical splints across 16 subjects. There was a high degree of correlation in 15 of the 16 cases. Furthermore, there was a high coefficient of correlation in the majority of predictions of results in hard tissue, although less precise results were obtained in measurements in the soft tissue in the labial area. Plooij et al. conducted a systematic review of fifteen articles describing 3D digital image fusion models of two or more different imaging 15 techniques for orthodontics and orthognathic surgery, and concluded that image fusion and especially the 3D virtual head are accurate and realistic tools for documentation, analysis, treatment planning and long-term follow-up. Marchetti et al. conducted an investigation to validate the computer imaging software, SurgiCase-CMF® Materialise, that enables surgeons 16 to perform virtual orthognathic surgical planning using a three dimensional (3D) utility that previews the final shape of hard and soft tissues. A soft tissue simulation module creates images of soft tissue altered through bimaxillary orthognathic surgery to correct facial deformities, using a CT Dicom-based treatment simulation platform. The software rapidly follows clinical options to generate a series of simulations and soft tissue models. Comparing simulation results with postoperative CT data, the reliability of the soft tissue preview was > 91%. Two patients are presented that underwent coordinated surgical-orthodontic care, utilizing a virtual surgical planning approach with SimPlant OMS (Materialise). Physical examination was performed and anthropometric measurements were obtained and analysed. Cone Beam CT scan data was obtained for each patient. Digital clinical photographs, maxillary and mandibular stone casts, clinical anthropometric measurements, and data from natural head position readings and final occlusion registration was electronically remitted to a software engineer for computer rendering (Medical Modelling, Golden, Colarado, USA). Case 1 A fit and healthy 28 year female presented with an Angle Class II Division I malocclusion, increased facial convexity secondary to mandibular retrognathia, an anterior openbite with dual occlusal planes in the maxilla, and an anterior diastema. An increased overjet relationship was noted. A vertical maxillary excess was noted, with a concomitant narrow maxillary arch, and bilateral TMJ clicking. The coordinated surgical plan included a segmental Le Fort I maxillary osteotomy with a maxillary advancement of 2mm, differential impaction with anterior superior repositioning of 1mm and posterior superior repositioning of 2mm, and rotation of the maxillary midline to the left by 0.5 mm. Interdental osteotomies were performed between teeth 13 and 14, and teeth 23 and 24. The maxilla was fixed with mini- plates and mini-screws and bone grafting was performed at the Le Fort I level and an alar base cinch suture was placed to control the nasal tip relationships. Bilateral sagittal split osteotomies (BSSO) of the mandible were performed with advancement of 5.5 mm and rigid fixation with mini-plates and mini-screws. A sliding augmentation genioplasty of 4 mm was performed, with anterior down-grafting of 1 mm, and secured with rigid fixation with mini-screws. Full fixed appliances were removed approximately four months following the bimaxillary orthognathic surgery procedure. Improvements in the patient’s facial aesthetics, symmetry, balance and occlusion were noted (Figures 1- 7). Case 2 A 23 years 10 month old healthy and fit female presented with a chief concern about her facial convexity, excessive gingival display and recessive chin. She reported a previous history of full fixed orthodontic treatment as an adolescent with the adjunctive use of a rapid maxillary expansion appliance. The patient presented with an Angle Class II Division I with vertical maxillary excess, maxillary and mandibular retrognathia, maxillary constriction, anterior openbite, convex facial profile, increased overjet, and increased lower anterior facial height relationships. The patient had a prominent nose with a dorsal hump, an obtuse nasolabial angle, and lip incompetence. An anterior vertical maxillary excess was noted, with increased maxillary gingival display. The coordinated surgical plan included a Le Fort I maxillary osteotomy with a maxillary advancement of 5 mm, differential impaction with anterior superior repositioning of 6 mm and posterior inferior repositioning of 2 mm, and expansion of the maxilla. The maxilla was fixed with mini-plates and mini-screws and bone grafting was performed at the Le Fort I level and an alar base cinch suture was placed to control the nasal tip relationships. Bilateral sagittal split osteotomies (BSSO) of the mandible were performed with advancement of 11.5 mm and rigid fixation with mini-plates and mini-screws. A sliding augmentation genioplasty of 4 mm was performed with a vertical reduction of 2 mm, and secured with rigid fixation with mini-screws. Approximately six weeks following the orthognathic procedure, an intra-oral scan with a TRIOS scanner was obtained. A series of customized SureSmile wires were produced including 17x25 Copper Nickel Titanium, 19x25 Copper Nickel Titanium, and 19x25 Beta Titanium (TMA). The post-surgical orthodontic period was approximately eight months (Figures 8-14). Acknowledgement: The author would like to express sincere gratitude and professional appreciation to Dr. Brent P. Allan, Specialist Oral and Maxillofacial Surgeon, for the provision of the coordinated orthognathic surgical care for the patients presented within this article. RACDS ANNALS 2016 87

REFERENCES 1. Sachdeva RC. SureSmile technology in a patient--centered 9. Sachdeva R. Sure-Smile: technology-driven solution for orthodontic practice. J Clin Orthod 2001;35:245-253. orthodontics. Tex Dent J 2002;119:608-615. 2. Bouwens, Daniel G., et al. \"Comparison of mesiodistal root 10. Saxe AK, Louie LJ, Mah J. Efficiency and effectiveness of angulation with posttreatment panoramic radiographs and suresmile. World J Orthod 2010;11:16-22. cone-beam computed tomography.\" American Journal of Orthodontics and Dentofacial Orthopedics 2011; 139.1:126-132. 11. Alford TJ, Roberts WE, Hartsfield JK, Eckert GJ, Snyder RJ. Clinical outcomes for patients finished with the SureSmile 3. Almog D, MARIN CS, PROSKIN HM, COHEN MJ, KYRKANIDES method compared with conventional fixed orthodontic S, MALMSTROM H. The effect of esthetic consultation therapy. Angle Orthod 2011;81:383-388. methods on acceptance of diastema-closure treatment plan: a pilot study. The Journal of the American Dental Association 12. Sachdeva RCL, Aranha SLT, Egan ME et al. Treatment Time: 2004;135(7):875-81. SureSmile vs Conventional. Orthodontics (Chic) 2012; 13:72-85. 13. De Riu G, Meloni SM, Baj A, Corda A, Soma D, Tullio A. 4. Wolff AM, Taylor SA, McCabe JF. Using checklists and reminders in clinical pathways to improve hospital inpatient Computer assisted orthognathic surgery for correction of care. Medical Journal of Australia 2004;181:428-31. facial asymmetry: results of a randomised controlled clinical trial. Br J Oral Maxillofac Surg 2014;52:251-7. 5. Djeu G, Shelton C, Maganzini A. Outcome assessment of Invisalign and traditional orthodontic treatment compared 14. Aboul-Hosn Centenero S, Hernandez-Alfaro F. 3D planning with the American Board of Orthodontics objective grading in orthognathic surgery: CAD/CAM surgical splints and system. Am J Orthod Dentofacial Orthop 2005;128:292-298; prediction of the soft and hard tissues results—our experience discussion 298. in 16 cases. J Craniomaxillofac Surg 2012;40:162-8. 6. Alcan T, Ceylanoglu C, Baysal B. The relationship between 15. Plooij J.M., Maal T. J.J., Haers P. et al. Digital three-dimensional digital model accuracy and time-dependent deformation of image fusion processes for planning and evaluating alginate impressions. Angle Orthod 2009;79:30-36. orthodontics and orthognathic surgery: A systematic review. Int. J. Oral Maxillofac. Surg. 2011; 40:341-352. 7. Kravitz ND, Kusnoto B, BeGole E, Obrez A, Agran B. How well does Invisalign work? A prospective clinical study evaluating 16. Marchetti C., Bianchi A., Muyldermans L., et al. Validation of the efficacy of tooth movement with Invisalign. Am J Orthod new soft tissue software in orthognathic surgery planning. Int. Dentofacial Orthop 2009;135:27-35. J. Oral Maxillofac. Surg. 2011; 40:26-32. 8. Mah J, Sachdeva R. Computer-assisted orthodontic treatment: the SureSmile process. Am J Orthod Dentofacial Orthop Email address for correspondence: 2001;120:85-87. [email protected] Figure 1 88 RACDS ANNALS 2016

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IN THE LAND OF NO EVIDENCE IS THE SALESMAN KING? Prof Kevin O’Brien, BDS, FDSRCP, FDSRCS, MSc, D.Orth, PhD Kevin O’Brien is a Professor in the Department of Orthodontics School of Dentistry, University of Manchester, UK. ABSTRACT This abstract is closely based on a previous publication that was published in the American Journal of Orthodontics and Dentofacial Orthodontics 2010: 138: 3, and on Kevin O’Brien’s Orthodontic Blog (www.Kevinobrienorthoblog.com). This is reproduced by permission of the editor of the American Journal of Orthodontics THE EFFECT OF ADVERTISING ON ORTHODONTIC that underpinned this change was the marketing literature available PRACTICE both directly from the manufacturing companies and indirectly from orthodontists’ websites. Interestingly, this advertising was directed not only to the profession but also often to our patients When we consider the changes in orthodontic research over and their parents. the past 20 years, 2 notable milestones coincide with an acknowledgment that all was not well. The most well-known quote is that of David Sackett, an American-based medical researcher The advertising material often quoted research that was at a low 1 and a doyen of the ‘‘evidence-based care’’ movement. When scientific level and published in journals that were not refereed; asked to review the quality of orthodontic research at the Moyers some of these were actually produced by the manufacturers. Symposium of 1986, he stated that ‘‘orthodontics is reliant on an Paradoxically, several randomized clinical trials and now systematic evidence base that is on a par with podiatry, chiropractitionary reviews that were published in the refereed literature showed that and aromatherapy.’’ This was soon followed by the conclusions of self-ligating brackets do not have any of the claimed advantages 2 a review into the ‘‘functional’’ appliance literature by Tulloch et al, over conventional brackets with regard to the speed of initial published in 1990. They concluded that ‘‘the literature was so weak, alignment, increased comfort for the patient or total treatment in terms of reliance on poorly controlled, retrospective studies, time. 10-16 poor sample size calculations and inappropriate use of statistical tests, that it was not possible at that time to support or dismiss the It could be assumed that having experienced the situation with self- growth modifying effects of functional appliances.’’ ligating brackets the orthodontic profession would have learnt from this experience. Unfortunately, this is not the case and there is now Since then many important studies have been published about widespread adoption and selling of devices that applies vibration a variety of treatments including early Class II treatment, bracket to the teeth with the aim of decreasing treatment time. The studies types, retainer regimens, management of displaced canines, and that have supported this new technology are characterised by 17 extraoral headgear. These articles should not only have changed small numbers and flawed methodology. Whereas, studies that 3-8 the orthodontic practice of more enlightened clinicians but should are carried out to a higher standard are providing information that 18 change the practice of everyone. suggests that these devices are not effective. While the profession waits for more trials to be published the advertising and the selling of this technology direct to patients continues. Although the advantages of randomized controlled trials are undeniable, the findings of orthodontic trials are not always universally accepted, because they tend to challenge long-held In summary, it is clear that, over the last 20 years, orthodontics beliefs that are often ingrained into our treatment approaches. has begun to develop a strong scientific basis to support some of our treatment modalities. Unfortunately, there is a tendency for This has meant that orthodontics is often unwilling to accept the our specialty to forget its research base when ‘‘new and better results of well-conducted, scientifically valid trials of common treatments’’ are developed. We fear that we are currently ignoring treatment methods but enthusiastically embraces treatment our scientific knowledge with the increasing pressure to provide methods that have not been clinically tested to a level of evidence treatment that is ‘‘faster, better, and more comfortable.’’ that withstands scientific scrutiny but are perhaps beautifully described and illustrated in marketing brochures. If we are to have the respect of our colleagues and our patients, we must very carefully consider the claims of sales representatives and Current examples of this include the promotion and widespread interpret them with due consideration of our scientific knowledge. adoption of noncompliance Class II correctors and new methods If we do not do this every time a new product hits the marketplace, that attempt to increase the speed of tooth movement. we are in serious danger of letting down not only the general public but ultimately the entire profession. However, the best example of this was the wholesale acceptance of self-ligating brackets, often accompanied by a new treatment One other solution to this problem is for those who have carried 9 philosophy. These are orthodontic brackets that close with a out the research and the Orthodontic societies to counteract metal clip instead of an elastic or steel ligature. The theoretical the effect of advertising by publicising the research findings and advantage of this design was that friction was reduced and thus issuing statements that are understandable to the public with the tooth movement was faster. This was also incorporated into a “new aim of educating both the public and the professions. However, philosophy” that promoted treatment without dental extractions with the exception of the American Association of Orthodontists and the stimulation of bone growth. The main source of information the silence is deafening. 94 RACDS ANNALS 2016

REFERENCES 11. Fleming PS, DiBiase AT, Sarri G, Lee RT. Efficiency of 1. SackettD. Nine years later: a commentary on revisiting the mandibular arch alignment with 2 preadjusted edgewise Moyers Symposium. Orthodontic treatment outcome and appliances. American Journal of Orthodontics and Dentofacial effectiveness. Craniofacial Growth Series. Center for Human Orthopedics 2009;135:597-602. Growth and Development; University of Michigan; 1995. 12. Fleming PS, DiBiase AT, Sarri G, Lee RT. Pain experience during 2. Tulloch JF, Medland W, Tuncay OC. Methods used to evaluate initial alignment with a self-ligating and a conventional fixed growth modification in Class II malocclusion. American Journal orthodontic appliance system. A randomized controlled of Orthodontics and Dentofacial Orthopedics 1990;98:340-7. clinical trial. Angle Orthod 2009;79:46-50. 3. Shawesh M, Bhatti B, Usmani T, Mandall N. Hawley retainers 13. Scott P, DiBiase AT, Sherriff M, Cobourne MT. Alignment full- or part-time? A randomized clinical trial. Eur J Orthod efficiency of Damon3 self-ligating and conventional orthodontic 2010;32:165-70. bracket systems: a randomized clinical trial. American Journal of Orthodontics and Dentofacial Orthopedics 2008;134:470- 4. Tulloch JF, Proffit WR, Phillips C. Outcomes in a 2-phase e1-8. randomized clinical trial of early Class II treatment. American Journal of Orthodontics and Dentofacial Orthopedics 14. Pandis N, Polychronopoulou A, Eliades T. Self-ligating vs 2004;125:657-67. conventional brackets in the treatment of mandibular crowding: a prospective clinical trial of treatment duration 5. Dolce C, McGorray SP, Brazeau L, King GJ, Wheeler TT. Timing and dental effects. American Journal of Orthodontics and of Class II treatment: skeletal changes comparing 1-phase and Dentofacial Orthopedics 2007;132:208-15. 2-phase treatment. American Journal of Orthodontics and Dentofacial Orthopedics 2007;132: 481-9. 15. Miles PG. Self-ligating vs conventional twin brackets during en- masse space closure with sliding mechanics. American Journal 6. O’Brien K, Wright J, Conboy F, Appelbe P, Davies L, Connolly I, et of Orthodontics and Dentofacial Orthopedics 2007;132:223-5. al. Early treatment for Class II Division 1 malocclusion with the Twin-block appliance: a multi-center, randomized, controlled 16. Fleming PS, Johal A. Self-ligating brackets in orthodontics. trial. American Journal of Orthodontics and Dentofacial Angle Orthod 2010;80:575-84. Orthopedics 2009;135:573-9. 17. Pavlin D, Anthony R, Raj V, Gakunga PT. Cyclic loading 7. Baccetti T, Mucedero M, Leonardi M, Cozza P. Interceptive (vibration) accelerates tooth movement in orthodontic treatment of palatal impaction of maxillary canines with rapid patients: A double-blind, randomized controlled trial. Seminars maxillary expansion: a randomized clinical trial. American in Orthodontics 2015;21:187-194. Journal of Orthodontics and Dentofacial Orthopedics 18. Woodhouse NR, DiBiase AT, Johnson N, Slipper C, Grant 2009;136:657-61. J, Alsaleh M, Donaldson AN, Cobourne MT. Supplemental 8. Silvola AS, Arvonen P, Julku J, Lahdesmaki R, Kantomaa T, vibrational force during orthodontic alignment: a randomized Pirttiniemi P. Early headgear effects on the eruption pattern of trial. J Dent Res 2015;94(5):682-689. the maxillary canines. Angle Orthod 2009;79:540-5. 19. Marshall SD, Currier GF, Hatch NE, et al. Ask us. Self-ligating 9. Damon DH. The Damon low-friction bracket: a biologically bracket claims. American Journal of Orthodontics and compatible straight-wire system. J Clin Orthod 1998;32:670- Dentofacial Orthopedics 2010;138(2):128-131. 80. 10. Fleming PS, DiBiase AT, Sarri G, Lee RT. Comparison of Email address for correspondence: mandibular arch changes during alignment and leveling with [email protected] 2 preadjusted edgewise appliances. American Journal of Orthodontics and Dentofacial Orthopedics 2009;136:340-7. RACDS ANNALS 2016 95

MANAGING CARIES RISK: THE ROLE OF PROBIOTIC BACTERIA IN ORAL AND GENERAL HEALTH Dr Svante Twetman, DDS, PhD, Odont. Dr., Spec. Paediatr. Dent Svante Twetman is a specialised paediatric dentist and professor of cariology at the Faculty of Health and Medical Sciences, University of Copenhagen, Denmark. ABSTRACT Probiotic bacteria are live microorganisms which when administered in adequate amounts confer a health benefit on the host. The background thinking is that a harmless effector strain is implanted in the host’s microflora to maintain or restore the natural microbiome by interference and/or inhibition of other microorganisms. Typically, probiotic bacteria are natural species belonging to the Lactobacillus or Bifidobacterium genera but host effects are strain specific. In addition to locally-induced oral events, systemic effects through immunomodulation have been demonstrated although a permanent colonization of probiotic bacteria seems unlikely. Recent clinical trials have gathered evidence of probiotic effectiveness in caries prevention, gingival and periodontal health. Studies in early childhood have suggested a metabolic domino effect with long-term improvements of oral and general health according to the common risk factor approach. The use probiotics may be a valuable adjunct to the established methods in preventing and combating caries and other oral diseases. INTRODUCTION the effects of probiotic bacteria are strain specific and findings from 5 one strain cannot directly be applied to other strains. Also, the very same strain may have different effects in different individuals. Replacement therapy describes the event when “a harmless effector strain is implanted in the host’s microflora to maintain or restore a natural microbiome by displacement and/or inhibition PROBIOTICS AND GENERAL HEALTH of other microorganisms”. The first successful attempt with such 1 “bacteriotherapy” was described by the French physician Tissier already in 1908 when he successfully was treating diarrhea with The concept of using harmless bacteria early in life in order to stool transplants containing bifidobacteria. Since then, fecal expose and strengthen the child’s natural immune system has transplantation with bacteria from a healthy donor is a reality a long tradition in pediatric medicine. A gut microbiota with low in the management of diarrhea caused by antibiotic resistant diversity is associated with an increased risk for ectopic eczema strains of Clostridium difficile. In 1907, the Nobel Prize laureate during first year of life. According to the “hygiene hypothesis” Elie Metchnikoff postulated that Bulgarians lived longer because children exposed to a diversity of friendly bacteria has a lower of their consumption of yoghurt containing lactic acid bacteria risk of developing asthma and ectopic eczema which has led promoting good health and wellbeing. Probiotic bacteria, defined to recommendations to use baby drops, baby formulas or gruel as “live microorganisms which when administered in adequate containing probiotic bacteria. In adults, there is good evidence that amounts confer a health benefit on the host”, are probably the probiotic bacteria can prevent and treat several types of diarrhea, 2 most common examples of “harmless effector strains” used for in particular antibiotic-associated diarrhea and tourist diarrhea. replacement therapy. The term probiotic derives from the Greek A meta-analysis of 63 placebo-controlled trials comprising over language meaning “for life” and thereby an antonym to “antibiotics”. 12,000 patients has shown that the risk for diarrhea was reduced Probiotic bacteria are human natural commensal strains but in by 40% when probiotic bacteria were taken in adjunct to antibiotic 6 recent years, genetically modified bacteria have appeared in which treatment. There is also emerging evidence that probiotics may certain properties have been added or deleted. The aim of this alleviate several conditions such as inflammatory bowel disease paper is to provide a brief overview of the mechanisms of action (IBD) and Crohn’s disease. In adults, probiotic bacteria are also and clinical effectiveness of probiotic bacteria in relation to caries suggested to lower serum cholesterol levels and beneficially affect management with special reference to childhood caries prevention. colon cancer progression. In recent literature, the possible benefits on childhood hyperactivity and autism spectrum disorders have been discussed. MECHANISMS OF ACTION PROBIOTICS AND ORAL HEALTH The mechanisms of probiotic action are yet not known in detail but it seems clear that a chain of local and systemic events is occurring. The local events in the oral biofilm include co- Probiotic bacteria have been employed for a number of oral aggregation, competitive exclusion, bacteriocin (hydrogen conditions including caries, gingivitis, periodontal conditions, peroxide) production and competition for nutrients. The ability halitosis and dry mouth (Table 1). As this paper is limited to the 3 to produce of toxins is perhaps the most powerful property and role of probiotics in caries management, more comprehensive 7 probiotic bacteria can thereby modify the composition of the oral overviews are available elsewhere. biofilm and/or its metabolic activity. The systemic effects rely on immunomodulation of the innate and adaptive immune systems Dental caries and significant effects on IgA and cytokine expression in the guts Since the pioneering study by Näse and co-workers in 2001, a 8 and the oral cavity have been displayed. The main probiotic strains large number of clinical trials employing the probiotic concept 4 used for oral replacement therapy belong to the Lactobacillus and with focus on caries have been published. However, the majority Bifidobacterium genera but also some Streptococcus strains (i.e. are limited to intermediate endpoints such as microbial counts or S. salivarius) may express probiotic properties (Figure 1). Generally, plaque index. Two recent systematic reviews have disclosed clear 96 RACDS ANNALS 2016

evidence of a significant decrease in mutans streptococci counts It is however important to stress that a permanent colonization is in plaque and saliva during a regular intake of probiotic bacteria. not a pre-requisite for probiotic action. For example, Toiviainen et 9,10 Interestingly, there were no clear cut differences in the magnitude al. showed that short-term consumption of L. rhamnosus GG and 22 of reported results in relation to neither the species or strains used Bifidobacterium animalis subsp. lactis BB-12 reduced plaque and (lactobacilli vs. bifidobacteria) nor the route of administration. There improved the periodontal status of otherwise healthy volunteers are unfortunately very few prospective studies available on caries without affecting the profile of the oral microbiota. incidence in adolescents and adults, but beneficial effects on root caries arrest and remineralization of early carious lesions have 11 12 been reported following interventions with lactobacilli-derived The common vehicles for administration are dairy products probiotics. (milk, yoghurt, sour cream) or tablets, capsules and lozenges. In some countries, food-items with probiotic additives are marketed; examples are cheese, bread, energy bars and fruit drinks. For Childhood caries infants, probiotic drops are available and for topical applications, Seven clinical trials concerning childhood caries are available up special oils, gels and toothpastes have been developed. In to date and the results are summarized in Table 2. 8,13-18 Probiotics general, probiotic dairy products are less costly than tablets but supplements were better than placebo in preventing or reducing unfortunately, many of them have high sugar content. The common childhood caries in all seven studies although the difference dose recommendations are 1-2 deciliter of yoghurt/milk per day was not statistically significant in three of them. 8,13,14 This clearly with each milliliter containing 1x108-9 live cells or 1-2 tablets per day supports the hypothesis of Devine and Marsh that it is possible (1x108-9). The recommended dose for infants is five drops per day. 19 to modify and/or alter the caries-associated oral microbiota in early The clinical recommendations are derived from gastrointestinal childhood in order to combat caries development in the primary health and although it seems to be a dose–response relationship dentition. Due to the low age of the enrolled children, probiotic milk for oral effects, this area is yet almost unexplored. or placebo milk served in day-care settings was the most common route of administration. The mean caries-preventive fraction was The safety of administration of probiotic bacteria must also be 33% in three milk-studies over 7-21 months. 8,16,18 In addition to the considered. Probiotic supplements are from a regulatory point of improved dental health, children of the probiotic milk groups view classified as food additives and labeled “generally recognized displayed better general health. In one study, the probiotic ingestion as safe” (GRAS). There are no reasons to fear overconsumption or resulted in fewer infections and a reduced need of antibiotics adverse effects but critically ill patients or very fragile elderly should 20 16 and this was later confirmed by Stecksén-Blicks and co-workers be handled with some caution. In spite of the fact that probiotic 23 who reported improved general health, fewer doctor’s visits and lactobacilli are highly aciduric, there are no indications that a significantly less prescription of antibiotics among the test children. regular intake would increase the caries risk. Yet, in the rapidly 24 Collectively, the two studies suggest a metabolic “domino effect”, growing interest in self-controlled health, a wide range of probiotic illustrating that the oral cavity is a significant and integrated part products have been marketed directly to the consumer with none of the gastro-intestinal tract. Milk is however not the only possible or very limited background research. It is the responsibility of the vehicle for preschool children. In a recent study, probiotic chewing clinician to advocate safe products with documented effectiveness tablets were distributed to a group of multi-cultural children living in in clinical trials. a low socioeconomic community in Sweden. The duration of the 17 intervention with three Streptococcus-derived strains was one year and resulted in significantly fewer new caries lesions compared CONCLUDING REMARKS with the placebo group. The caries prevalence was 24% in the test group after the intervention compared with 47% in the placebo group. Notably, the clear-cut results were obtained in spite of the Probiotics in the dental practice is an emerging and promising fact that around 80% of the families reported supervised tooth strategy to combat biofilm-related diseases in the oral cavity. Several brushing twice daily and a far from optimal compliance with the beneficial effects are already well recognized but the influence probiotic lozenges. on oral health still needs to be elucidated by more long-term, randomized clinical trials. Future studies should focus on defining the optimal strains for the various dental diseases. Moreover, more The concept of probiotic intervention during infancy is particularly studies are needed to clarify whether a mix of different strains interesting as long-term effects on dental health have been works better than single strains, determine the optimal daily dosage demonstrated. In one study, newborn children were given 5 and find a vehicle allowing a prolonged retention time in the oral daily drops containing two strains of the probiotic bacterium cavity. Although there is not sufficient evidence to make any 15 Lactobacillus reuteri during their first year of life. The infants in clinical recommendations, probiotic bacteria may be considered the control group were given placebo drops. At the age of 9 years, as an adjunct, not an alternative, to the established evidence-based the children in the probiotic test group displayed a 50% reduction methods and best clinical practice. in deciduous caries experience compared with the control children. 82% of the children in the probiotic group were caries- free compared to 58% in the placebo group. Two other studies CONFLICT OF INTEREST based on a similar concept in which the infants were exposed to the probiotic bacteria via pacifiers or gruel reported consistent The author has supervised two PhD-students funded by Biogaia 14 13 but non-significant caries reductions at the age of 4 and 9 years, AB, Sweden. respectively. REFERENCES ADMINISTRATION, DOSE AND SAFETY 1. Hillman JD, Socransky SS. Replacement therapy of the prevention of dental disease. Adv Dent Res 1987;1:119-25. Live “friendly” bacteria must be taken on a daily basis in order to be 2. Sanders ME. Probiotics: definition, sources, selection, and uses. detectable in plaque, saliva or stools. Therapeutic levels are obtained Clin Infect Dis 2008;46 Suppl 2: S58-61. after approximately 4 days of ingestion but are lost again within a 3. Reid G, Younes JA, Van der Mei HC, Gloor GB, Knight R, week after termination. It has been suggested that the chance of Busscher HJ. Microbiota restoration: natural and supplemented permanent installation increases following exposure early in life. 21 recovery of human microbial communities. Nat Rev Microbiol RACDS ANNALS 2016 97

2011;9:27-38. Birkhed D, Wendt LK. Oral administration of Lactobacillus 4. Wan LY, Chen ZJ, Shah NP, El-Nezami H. Modulation of reuteri during the first year of life reduces caries prevalence in intestinal epithelial defense responses by probiotic bacteria. the primary dentition at 9 years of age. Caries Res 2014;48:111- Crit Rev Food Sci Nutr 2015;Jan 28:0. 17. 5. Koll-Klais P, Mandar R, Leibur E, Marcotte H, Hammarstrom 16. Stecksén-Blicks C, Sjöström I, Twetman S. Effect of long-term L, Mikelsaar M. Oral lactobacilli in chronic periodontitis and consumption of milk supplemented with probiotic lactobacilli periodontal health: species composition and antimicrobial and fluoride on dental caries and general health in preschool activity. Oral Microbiol Immunol 2005;20:354-61. children: a cluster-randomized study. Caries Res 2009;43:374- 81. 6. Hempel S, Newberry SJ, Maher AR, Wang Z, Miles JN, Shanman R, Johnsen B, Shekelle PG. Probiotics for the prevention and 17. Hedayati-Hajikand T, Lundberg U, Eldh C, Twetman S. Effect treatment of antibiotic-associated diarrhea: a systematic of probiotic chewing tablets on early childhood caries – a review and meta-analysis. JAMA 2012;307:1959-69. randomized controlled trial. BMC Oral Health 2015; Sep 24;15:112. 7. Twetman S, Rose Jørgensen M, Keller MK. Pro- and Prebiotics for Oral Health. In: Venema K, do Carmo AP. eds, Probiotics 18. Rodríguez G, Ruiz B, Faleiros S, Vistoso A, Marró ML, Sánchez and Prebiotics. Current research and future trends. Norfolk UK: J, Urzúa I, Cabello R. Probiotic compared with standard milk Caister Academic Press 2015:417-28. for high-caries children: A cluster randomized trial. J Dent Res 2016;95(4):402-7. 8. Näse L, Hatakka K, Savilahti E, Saxelin M, Pönkä A, Poussa T, Korpela R, Meurman JH. Effect of long-term consumption of 19. Devine DA, Marsh PD. Prospects for the development of a probiotic bacterium, Lactobacillus rhamnosus GG, in milk on probiotics and prebiotics for oral applications. J Oral Microbiol dental caries and caries risk in children. Caries Res 2001;35:412- 2009;1:10.3402/jom.v1i0.1949. 20. 20. Hatakka K, Savilahti E, Pönkä A, Meurman JH, Poussa T, Näse 9. Cagetti MG, Mastroberardino S, Milia E, Cocco F, Lingström P, L, Saxelin M, Korpela R. Effect of long term consumption of Campus G. The use of probiotic strains in caries prevention: a probiotic milk on infections in children attending day care systematic review. Nutrients 2013;5:2530-50. centres: double blind, randomised trial. BMJ 2001;322:1327. 10. Laleman I, Detailleur V, Slot DE, Slomka V, Quirynen M, 21. Twetman S, Stecksén-Blicks C. Probiotics and oral health Teughels W. Probiotics reduce mutans streptococci counts effects in children. Int J Paediatr Dent 2008;18:3-10. in humans: a systematic review and meta-analysis. Clin Oral 22. Toiviainen A, Jalasvuori H, Lahti E, Gursoy U, Salminen S, Investig 2014;18:1539-52. Fontana M, Flannagan S, Eckert G, Kokaras A, Paster B, Söderling 11. Petersson LG, Magnusson K, Hakestam U, Baigi A, Twetman S. E. Impact of orally administered lozenges with Lactobacillus Reversal of primary root caries lesions after daily intake of milk rhamnosus GG and Bifidobacterium animalis subsp. lactis BB- supplemented with fluoride an probiotic lactobacilli: a clinical 12 on the number of salivary mutans streptococci, amount and microbiological study on older adults. Acta Odontol of plaque, gingival inflammation and the oral microbiome in Scand 2011;69:321-7. healthy adults. Clin Oral Investig 2015;19:77-83. 12. Keller MK, Nøhr Larsen I, Karlsson I, Twetman S. Effect of 23. Cannon JP, Lee TA, Bolanos JT, Danziger LH. Pathogenic tablets containing probiotic bacteria (Lactobacillus reuteri) relevance of Lactobacillus: a retrospective review of over 200 on early caries lesions in adolescents: a pilot study. Benef cases. Eur J Clin Microbiol Infect Dis 2005;24:31-40. Microbes 2014;5:403-7. 24. Marttinen A1, Haukioja A, Karjalainen S, Nylund L, Satokari 13. Taipale T, Pienihakkinen K, Alanen P, Jokela J, Soderling E. R, Öhman C, Holgerson P, Twetman S, Söderling E. Short- Administration of Bifidobacterium animalis subsp. lactis BB-12 term consumption of probiotic lactobacilli has no effect on in early childhood: a post-trial effect on caries occurrence at acid production of supragingival plaque. Clin Oral Investig four years of age. Caries Res 2013;47:364-72. 2012;16:797-803. 14. Hasslof P, West CE, Videhult FK, Brandelius C, Stecksen-Blicks C. Early intervention with probiotic Lactobacillus paracasei Email address for correspondence: F19 has no long-term effect on caries experience. Caries Res [email protected] 2013;47:559-65. 15. Stensson M, Koch G, Coric S, Abrahamsson TR, Jenmalm MC, Table 1. Examples of probiotic bacteria investigated with respect to oral health 98 RACDS ANNALS 2016