Annals Vol 21 (2012)

Ann Roy Australas Coll Dent Surg 2012;21:49-50 THE MUTILATED DENTITION – MANAGEMENT OF THE DEBILITATED DENTITION Suzanne M Hanlin, MDS, FRACDS, MRACDS(Pros), FPFA, FADI, FICD* Dr Hanlin is a specialist Prosthodontist in the Department of Oral Rehabilitation at the Faculty of Dentistry, University of Otago, Dunedin, New Zealand. Abstract An interdisciplinary treatment plan is often required to allow restoration of function and aesthetics in the “mutilated dentition”. Loss of teeth is associated with social and psycological impacts for the patient, however most often aesthetic requirements and financial constraints predominate in the treatment decision making. Historically, unfavourable occlusal contacts have been viewed as predisposing factors in the development of temporo-mandibular joint dysfunction (TMD). This linkage has now been refuted by many authors and it is understood that occlusion may be a co-factor only in TMD. In determining the “ideal occlusion” to restore the mutilated dentition consideration must be given to an occlusion that is physiologic for the patient, and the simplest scheme to construct from a clinical and technical view point. In successfully restoring function of the teeth an aesthetic outcome can be achieved. The planning and treatment for three patients is reviewed to highlight interdisciplinary patient care from a prosthodontics perspective. Patients present to the prosthodontist for treatment for a (anterior and premolar) were sufficient to satisfy most of the variety of reasons often some years after teeth are removed criteria for an adequate level of oral function however this and after the first signs of occlusal break down are evident to does not satisfy the aesthetic and functional requirements of the dentist. This may be when the ramifications of occlusal all patients. change start to impact on aesthetics, function or comfort and the treatment options have become so limited, that the The dental profession has historically viewed dentist and the patient seek a re-evaluation of the arch and “malocclusion” as a predisposing factor for Temporo- the options available. mandibular Dysfunction (TMD). Ramfjord in his text “Bruxism, an electromyographic study” helped to stimulate With all the good intentions in the world the general the suggestion that TMD was due to “unfavourable dynamic dentist may have been helping to maintain an ailing and occlusal contacts”.5,6 Interferences were said to lead to failing dentition while attempting to encourage the patient parafunction, muscle pain, joint overload and dysfunction.7 to embrace the broader scenario of rehabilitation. The management of the patient may require an interdisciplinary McNamara, Seligman and Okeson8 however, found approach to allow careful planning of treatment and to only weak support for an occlusal aetiology in TMD as provide a stable and long term outcome. The prosthodontist, did Okeson,9 and Pullinger and Seligman10 suggested that although often acting as treatment co-coordinator, is unable “Occlusal factors may be cofactors… but their role should to progress with definitive occlusal management and tooth not be overstated.” De Boever, Carlsson and Klineberg7 replacement until preparatory stabilization and rehabilitation concluded that, loss of posterior tooth support did not seem is completed by the Orthodontist and Oral and Maxillofacial to be a significant aetiologic factor in TMD and prosthetic surgeon and although there is not the opportunity in this treatment to replace missing teeth is not appropriate for presentation to cover liaison with all potential team members, initial management of TMD patients nor is replacement this discussion does not undervalue the role of endodontists, of lost teeth to prevent TMD advocated. Although the periodontists and paediatric dentists in coordinated care for relationship between TMD and occlusion remains somewhat these patients. contentious there is no-longer support for treatment aimed at reducing muscle hyperactivity by using occlusal adjustment, Buschang1 reviewed studies of masticatory function and irreversible splint therapy, orthodontics or surgery with the commented that in subjects with “mutilated dentitions” and to expectation of TMD “cure”. a slightly lesser degree, with a malocclusion, the masticatory performance and masticatory ability is reduced. Masticatory Hypodontia, trauma, caries and periodontal disease are performance deteriorates with reduction in tooth number and common causes of missing teeth and tooth loss. Unrestored surface area of contact and can be linked to quality of life. tooth loss, loss of inter- and intra-arch contacts between remaining teeth and loss of the anatomical contours of Loss of teeth is associated with social and psychological cusps following placement of large restorations can result impacts. However site of tooth loss is important in determining in tipping, tilting and rotation of teeth, migration and over- treatment undertaken. Aesthetics is a more important factor eruption creating the “mutilated dentition”. These occlusal to patients in this decision than function.2 Teofilo and Leles changes often preclude restoration until ideal space is concluded that the prosthodontic treatment needs are often recreated and arch levelling has been achieved. The request determined by both clinical and financial factors.3 Kayser4 by the patient for a single restoration often highlights skeletal following a review of the literature concluded that 20 teeth problems which have remained unmanaged while the natural dentition remained functional. Unless addressed in planning, * Presented at the Twenty-first Convocation of the Royal Australasian College these factors often prevent further prosthodontic care. of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012

50 THE MUTILATED DENTITION What constitutes an ideal occlusion for Coordinated care involved pre-surgical orthodontics to decompensate the arches in preparation for orthognathic restoration of function and aesthetics? surgery. Restoration was achieved in conjunction with the placement of a distal implant in the right quadrant of the A narrow definition can be limited to describing maxilla to assist in support of a removable cobalt chrome occlusion as the arrangement of maxillary and mandibular partial denture and a removable cobalt chrome base partial teeth, while in a broader context occlusion can embrace the denture was constructed to restore missing teeth in the dynamic and functional relation between all the components mandible. of the masticatory system.11 Most of the controversy that has existed in the philosophies of occlusion over the years has Patient three was a 58 year old male with a heavily revolved around which are the key components of occlusion restored and worn dentition seeking treatment options that should be used in treatment when the dentition is to replace a single missing premolar in the right quadrant severely debilitated and the dentist is unable to conform to of his mandible. He had been a regular and conscientious the patient’s existing occlusal scheme. During this debate, dental attendee for many years. Examination indicated that prosthodontics has come to be recognized as a biologically restoration was not possible without arch alignment and and not solely mechanistically based discipline. There is now recreation of space because of occlusal change over time. acceptance that there are significant psychosocial, functional Patient management involved orthodontic arch alignment and aesthetic implications for each patient in treatment and and recreation of premolar space in the right quadrant of the that an informed patient–centred decision-making process mandible and the surgical placement of two single implants and partnerships in care should be employed. The clinician in the left and right mandibular first premolar sites. An should avoid changing occlusion in healthy functioning opposing molar tooth was crowned to complete this first patients. Key features of a treatment occlusion are: a mutual phase of care. protection occlusion when canine support is present and adequate, an occlusion that is physiologic for the patient, References and the simplest scheme to construct from a clinical and technical view point.8 1. Buschang PH. Masticatory Ability and Performance: The Effects of Mutilated and Maloccluded Dentitions. Semin Orthod, 2006; 12:92-101. The ability to control active disease is a key component 2. Elias A, Sheiham A. The relationship between satisfaction with mouth to the successful outcome of all prosthodontic therapy and number and position of teeth. J Oral Rehabil 1998. 25: p. 649-661. and ongoing liaison with the patient’s general dentist is an 3. Teofilo L, Leles,CR. Patient’s self-perceived impacts and essential part of disease control and maintenance especially prosthodontic needs at the time and after tooth loss. Braz Dent J 2007; 18: through the phases of pre-surgical orthodontics and surgery. 91-96. 4. Kayser, A.F., Clinical aspects of shortened dental arches. Proceedings Case reports of the European Prosthodontic Association, 1979 (3rd Annual Meeting). 5. Luther F. TMD and occlusion part II. Damned if we don’t? To highlight some of the planning considerations Funcitonal occlusal problems: TMD epidemiology in a wider context. required in the management of the “mutilated dentition”, Br Dent J 2007;202:E3; discussion 38-9. Review. Erratum in: Br Dent J three patients are briefly reviewed. 2007;202:474. Br Dent J 2007; DOI:10.1038/BDJ.206.123 Online article number E3. Patient one presented for treatment aged 43 years 6. Luther F. TMD and occlusion part I. Dammed if we do? Occlusion: following many years with unrestored hypodontia. She the interface of dentistry and orthodontics. Br Dent J 2007;202:E2; had raised and educated three children who were settled in discussion 38-9. Review. Erratum in: Br Dent J 2007;202:474. stable employment and she wished to address her significant 7. De Boever J, Carlsson GE, Klinberg IJ. Review in two parts of the concerns about the appearance of “her smile”. Function was role of occlusal therapy and prosthodontic treatment in the management of importance but a secondary concern and she was healthy of temporomandibular disorders. Part II : Tooth loss and Prosthodontic and financially able to progress with treatment. There had treatment. J Oral Rehabil 2000;27:367-79, 647-59. been space loss in the arches and disruption of the occlusal 8. McNamara J, Seligman,DA, Okeson JP. Occlusion, Orthodontic plane. Wear was present on many remaining anterior teeth treatment, and temporomandibular disorders: a review. J Orofac Pain, and tooth morphology varied from normal in response 1995;9:73-90. to genetic variation. Her care was co-ordinated with the 9. Okeson J. ed. Orofacial Pain. Guidelines for Assessment, Diagnosis orthodontist to optimize space distribution, level the arches and Management. 1996, Quintessence, Chicago IL. . and provide reduction in the overbite. Surgical management 10. Pullinger AG, Seligman DA. Quantification and validation of involved placement of implants into selected sites to support predictive values of occlusal variables in temporomandibular disorders crowns and selected sites were restored with conventional using a multifactorial analysis. J Pros Dent 2000;83:66-75. bridges. Treatment progressed over a three year period. 11. Turp JC, Greene CS, Strub JR. Dental occlusion: a critical reflection on past, present and future concepts. J Oral Rehabil 2008;35:446-53. Patient two was a 60 year old male nearing retirement who had a severe Class III skeletal and dental relationship, Address for Correspondence: multiple missing teeth and a heavily restored remaining Department of Oral Rehabilitation dentition. He presented on referral from his dentist of many Faculty of Dentistry years realizing that both the dentist and he had exhausted their PO Box 647, Dunedin 9054 avenues of stabilizing his challenging dentition and seeking New Zealand options to retain his remaining teeth and restore function. [email protected]

Ann Roy Australas Coll Dent Surg 2012;21:51-52 THE MUTILATED DENTITION – ORTHODONTIC CONSIDERATIONS Winifred Harding, BDS, MDS* Dr Harding is in private orthodontic practice in Dunedin and is a part time teacher at the University Otago. She is an examiner in orthodontics and co-supervisor of a number of graduate research projects. She is a Past President of the New Zealand Association of Orthodontists. Introduction tooth movement that can be achieved without surgery. A mutilated dentition is one in which teeth have been General goals of treatment are to provide good extracted, traumatically lost, extensively restored or extensively worn. Patients have become more dentally aware aesthetics, function and stability. over the years and have been led by both television and the Internet to expect instant makeovers and perfect smiles. In Specific orthodontic goals of treatment can include any the USA there was an 800% increase in adults receiving or all of the following: orthodontic treatment between 1970 and 2003.1 Despite this, it still comes as a surprise to many adult patients that braces Root parallelism of abutment teeth, redistribution of are effective and widely used as part of the rehabilitation spaces between teeth, redistribution of occlusal and incisal process. forces, acceptable occlusal plane and the potential for incisal guidance at satisfactory vertical dimension, lip competency Diagnosis and treatment planning in such cases is and support, improved crown/root ratios, improvement of complex and frequently takes longer than the actual mucogingival and osseous defects, aesthetics and function. treatment. In saying that, orthodontic treatment is usually the longest part of any interdisciplinary treatment and Diagnosis requires a very committed patient. When treating a mutilated dentition it is important to recognize current and potential As with any treatment, adequate data must be collected periodontal problems, to diagnose temporomandibular joint and analysed, a problem list and tentative treatment plan(s) dysfunction, to distinguish between orthodontic camouflage formulated, other specialists consulted, the treatment and skeletal management and to work cooperatively with sequence and the final plan(s) decided and patient agreement the Prosthodontist, Periodontist, Oral and Maxillofacial reached. The challenging and difficult cases are those Surgeon, and sometimes a Psychologist. with an underlying skeletal discrepancy. There are many cephalogram analyses available to determine where the exact Goals discrepancies are but “…a descriptive analysis should consist only of those measurements that are needed to illuminate the Determining what the patient perceives as their problem clinically significant idiosyncrasies of the patient at hand.”7 requires careful listening and questioning. There are many Trial set ups and predictive tracings are very helpful both for comprehensive proforma questionnaires available that can planning and for showing the patient. One must be careful be used as a guide.2 After determining what the patient sees with morphed computer images as they can give the patient as their problem, a lot of education may be required to help false hope. them understand the complexity. A patient’s expectations must be clearly established. It is not always possible to meet Orthodontic treatment can readily exacerbate periodontal all expectations, or the treatment needed to achieve these disease. Therefore periodontal awareness by both the expectations may well be beyond their means or exceed treating orthodontist and the patient are vitally important acceptable risks. Any planned compromises need to be well and orthodontic treatment should not be started until the understood. periodontal condition is stable, and the patient is cognisant of his/her status as well as the required periodontal treatment Orthodontists have long been trained to treat to ‘the and maintenance.8 Similarly, TMD must be understood in ideal’ occlusion. Moreover, research now emphasises the light of its prevalence and relationship to the anticipated importance of the entire face. Since 1972, Andrews’ six keys treatment.9 to normal occlusion3 have been the gold standard. ‘Divine proportions’4 have been quantified and the ‘ideal smile’5 has Treatment been defined. However in the cases being discussed in this paper, the pre-existing conditions frequently interfere with It helps to follow a simple order. Active disease achievement of the ideal in any other than patients with class (periodontal disease and decay) must first be arrested and I skeletal relationships, and treatment has to be customized controlled, periodontal defects corrected, relevant structural to the individual patient. Profitt6 has clearly defined the malrelationships should be corrected (orthodontics and envelopes of discrepancy to give guidance as to the extent of orthognathic surgery), restorative and reconstructive dentistry completed and optimal oral health maintained. * Presented at the Twentiy-first Convocation of the Royal Australasian College For the orthodontist, the first decision is whether or not the of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012 skeletal problem requires surgical intervention to create a stable correction. The risks of orthognathic surgery should not be underestimated, but weighed carefully against the benefits.

52 THE MUTILATED DENTITION - ORTHODONTIC CONSIDERATIONS Accurate and predictable tooth positioning in most References adults requires fixed appliances. The mechanotherapy is frequently complex because of reduced anchorage and less 1. Keim RG, Gottlieb EL, Nelson AH, et al. 2003 JCO orthodontic than optimal crown:root ratios.10,11 Temporary anchorage practice study. 1. Trends. J Clin Orthod 2003; 37:545-53. devices have simplified mechanics hugely, but there must 2. Arnett GW, McLaughlin RP. Facial and Dental Planning for be adequate bone before their use. Disarticulation by means Orthodontists and Oral Surgeons. St Louis, 2004, Mosby. of a bite plane is frequently necessary to prevent breakages 3. Andrews LF. The six keys to normal occlusion. Am J Orthod 1972; and facilitate tooth movement. Sectional mechanics are often 63:296. required because of a lack of teeth. Progress records are a 4. Pancherz H, Knapp V, Erbe C, Heiss AM. Divine proportions in useful adjunct during treatment, especially centric relation attractive and nonattractive faces. World J Orthod 2010;11:27-36. study models and a panoramic radiograph. It is essential to 5. Durgekar SG, Nagaraj K, Naik V. The ideal smile and its orthodontic have the other specialists confirm the orthodontic endpoint implications. World J Orthod 2010; 11:211-20 before removal of the fixed appliances. 6. Profitt WR, White RP. Surgical Orthodontic Treatment. St Louis, 1991, Mosby The extent of treatment undertaken will vary hugely 7. Johnson L. Template analysis. J Clin Orthod 1987; 21:585. depending on what the patient wants and can afford. In NZ 8. Mathews DP, Kokich VG. Management treatment for the orthodontic there is virtually no third party financial contribution to dental patient with periodontal problems. Semin Orthod 1997; 3:21. treatment, and certainly none for orthodontic treatment or 9. Okeson JP. Management of temporomandibular disorders and orthognathic surgery. Costs are a major issue for patients and occlusion, 2003, St Louis, Mosby. are frequently a determining factor in the chosen treatment. 10. Kokich VG, Spear FM. Guidelines for managing the orthodontic- restorative patient. Semin Orthod 1997; 3(1):3-20. Retention / Maintenance 11. Melsen B. Adult orthodontics: factors differentiating the selection of biomechanics in growing and adult individuals. Int J Adult Orthodon The retention requirements are often a forgotten part Orthognath Surg 1998; 3:167. of the treatment plan. They are however vitally important, 12. Behrents RG. A treatise on the continuum of growth in the ageing should have been discussed initially and recorded in the plan craniofacial skeleton. 1984, Ann Arbor, WB Saunders. which had been offered for consent. Retention is important 13. Eckberg E, Vallon D, Nilner M. The efficacy of appliance therapy in both to prevent relapse and to minimize normal ageing patients with temporomandibular disorders of mainly myogenic origin: a changes. Many authors have studied continued changes in randomized, controlled, short-term trial. J Orofac Pain 2003;17:13. the teeth, face and skeleton throughout life.12 Address for correspondence: In an ideal occlusion, retention is routine. Without L5 Burns House an ideal occlusion, retention may be more difficult if for 10 George Street example, there is a resultant overjet. It may not be possible Dunedin to provide canine guidance or to stop the lower anterior New Zealand segment from over-erupting without fixed palatal/lingual [email protected] retainers. These however are limited by the availability of enamel and the patient’s ability to keep them clean. Lifelong wear of a removable retainer may be necessary and can often double as a bite plane to eliminate muscle dysfunction.13

Ann Roy Australas Coll Dent Surg 2012;21:53-55 CARIES MANAGEMENT: IS THE “SEAL THE DEAL”? Lyndie A. Foster Page, BSc, BDS, DipClinDent, MComDent, PhD (Otago)* Dr Foster Page is a Senior Lecturer and Head of Discipline of Preventive and Restorative Dentistry in the Department of Oral Rehabilitation, Faculty of Dentistry, University of Otago, New Zealand. Abstract A barrier to providing sealants has been the concern about inadvertently sealing over caries, but today the management of dental caries has evolved from the domain of techniques based on complete removal of carious tissue prior to tooth restoration or sealant, to include a range of techniques where some, or even all caries is sealed in beneath restorations, sealants or infiltrants. There is a significant, and growing, evidence base supporting these techniques as caries management strategies for children and adolescents. These techniques are not new but build on earlier concepts and research. These concepts offer a real way forward and departure from invasive restorative treatments. Some issues, however, are not completely resolved, and future solutions may herald a new era of restorative dentistry, perhaps with the concept of filling with no drilling since the “seal is the deal”. These techniques and issues will be considered in the New Zealand context. Overall, the oral health of New Zealanders has improved dentition prior to the placement of a stainless steel crown.12 considerably over the past 20-30 years. Dental decay The Hall Technique is a method for managing carious remains the most prevalent chronic (irreversible) disease in primary molars with decay sealed under pre-formed metal New Zealand, and there are still inequalities in oral health crowns without any caries removal, tooth preparation or in New Zealand.1 Approximately 50% of New Zealand five- local anaesthesia.13 In New Zealand, there are little data on year-olds have had caries, and substantial differences in outcomes of restorative care in children which is largely caries experience by ethnicity, region and access to water provided in State-funded oral health services. Preformed fluoridation have been observed.2 Free, publicly-funded oral stainless steel crowns (SSCs) have been recommended as the health care is available for all New Zealand children and treatment of choice for primary molar caries involving two adolescents, with the aim of them having equitable access to or more surfaces and have been shown to be more durable oral health care and good oral health status. Even so, the most than all other restorative materials in children.14,15 However, recent national study has revealed inequalities1 while a study they have not been widely used in New Zealand except reporting on adolescents’ changes in caries experience has by specialists in paediatric dentistry. The Hall Technique also shown substantial caries experience occurring between presents a fundamental shift in the New Zealand primary ages 13 and 16 (mean net caries increment dominated by care setting and although shown to be a predictable option pit-and- fissure surfaces).3 This supports findings from in a Scottish study it requires more evidence from different industrialized countries which show the prevalence of populations and settings.12 dental caries having declined,4,5 but that among school-aged children the majority of the dental caries increment has While sealants were introduced in the 1960s to protect been detected on pit and fissure surfaces of first and second pits and fissures on occlusal surfaces it still appears that the permanent molars.6 indication of when to use them varies considerably among dental practitioners, even in paediatric dentistry teaching Many practitioners when managing caries in New departments internationally.16 Sealants have been recognized Zealand children and adolescents are still concerned about as an effective approach to preventing pit and fissure caries inadvertently sealing over caries, whether this is with but many questions still remain.17 From a public health care traditional operative procedures, the placement of fissure perspective there appears to be insufficient information sealants or the sealing of approximal lesions. Randomized on how effective sealants are at different caries levels.18 Clinical Trials (RCT) have given us growing evidence with However, the greatest controversy for many is the concern regard to ‘complete’ versus ‘incomplete’ caries removal.7-10 around the ‘sealing’ of occlusal pits and fissures that exhibit For those of us teaching operative dentistry there is clear carious enamel and dentine. A recent systematic review evidence that it is not deleterious to leave infected dentine supports the findings of sealing carious occlusal pit and fissure and this approach is preferable.11 The challenge lies in how lesions to reduce the probability of lesion progression.19 The ‘clean’ must a cavity be before restoration? The growing evidence for sealing non-cavitated versus cavitated lesions evidence base supports caries management strategies from was found to be stronger, although this may be accounted for the indirect pulp cap through stepwise caries removal and by 90% of the lesions in the review being non-cavitated.19 partial caries removal.11 There is now evidence to support These findings should lessen the reluctance of practitioners techniques involving no caries removal in the primary providing sealants, especially for non-cavitated lesions in the early carious stages but also where caries status is uncertain. * Presented at the Twentiy-first Convocation of the Royal Australasian College Utilizing sealants not only for prevention but also as caries of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012 management tools should be included in teaching curricula.

54 CARIES MANAGEMENT Research is underway with clinical trials in the USA and of time and materials would need to be acceptable since the Europe to investigate sealants for cavitated occlusal surfaces. time involved for the sealant and/or infiltration technique is similar to those for conventional procedures.16 Further As dental caries also affects the smooth surfaces of research is required but interventional studies with caries teeth, data from industrialized countries indicate that the are expensive as a result of the chronicity of the disease prevalence of deciduous smooth-surface caries in children and the time for lesion progression. A more concerted effort is relatively high (for example, 25% and 52% of Danish 7 to clinically evaluate these promising new approaches and 9-year-olds respectively) with similar patterns seen in is needed in populations that are at most risk.40 For New other countries.20-22 Accordingly, operative treatment needs Zealand these studies are required in the community clinics are substantial, and New Zealand is no exception.23,24 where child and adolescent oral health is managed by dental therapists. If successful, these new approaches may Invasive treatment options for proximal caries involve become an effective population health strategy for managing the destruction of considerable amounts of sound tissue in caries and improving oral health outcomes in childhood, order to gain access to the lesions.25 Moreover, restorations adolescence and into adulthood. The future solution may be a have only a limited lifetime and teeth frequently need to be combination of approaches where we see a further shift from restored repeatedly. Thus, the first operative intervention the classic operative approach whereby sealing becomes a should be postponed as long as possible26 and for early routine procedure. This may herald a new era of dentistry, proximal caries, it is often particularly difficult to determine perhaps since the “seal is the deal”. the optimal treatment, with the associated risk of under- or over-treatment.27,28 Although fissure sealing is an effective References method to prevent caries formation and lesion progression in occlusal carious surfaces, it has not been used for smooth- 1. Ministry of Health. Our Oral Health: Key findings of the 2009 New surface lesions with any great success. The sealing of smooth Zealand Oral Health Survey. Wellington: Ministry of Health, 2010. surfaces and use of sealants was described in the 1970s29,30 and was demonstrated in in-vitro artificial lesions31-33 but 2. Ministry of Health. Age 5 and Year 8 oral health data from the School not confirmed for natural lesions.29,34 Clinical studies show Dental Services .http://www.moh.govt.nz/moh.nsf/indexmh/oralhealth- promise, with reduction in lesion progression, however close resources#statistics, 2009. to 50% of the sealed surfaces in the deciduous dentition sealed after 2.5 years showed evidence of progression.35 3. Foster Page LA, Thomson WM. Dental caries in Taranaki adolescents: Approximal sealing with a ‘patch’ takes the sealing concept a cohort study NZ Dent J 2011;107:91-6. but uses a pre-cured adhesive patch for protection of caries lesions. A 2-year study with this showed no clear benefit over 4. Marthaler TM, O’Mullane DM, Vrbic V. The prevalence of dental the non-operative approach of flossing.36 caries in Europe 1990-1995. ORCA Saturday afternoon symposium 1995. Caries Res 1996;30:237-55. An alternative approach for arresting these lesions is caries infiltration. In contrast to conventional sealing, where 5. WHO: Caries for 12-year-olds by country/area. WHO, 2003. http:// a resin coat is applied to the enamel surface, caries infiltration www.whocollab.odont.lu.se/countriesalphab.html. aims to penetrate the porous smooth-surface lesion with resin in order to slow it down or even arrest its progression. The 6. Brown LJ, Selwitz RH. The impact of recent changes in the mechanism of action of resin infiltrates in delaying lesion epidemiology of dental caries on guidelines for the use of dental sealants. J progress is still not fully understood at the ultra-structural Public Health Dent 1995;55:274-91. level, although recent progress in infiltrant development has resulted in a low-viscosity light-cured resin. This has been 7. Magnusson BO, Sundell SO. Stepwise excavation of deep carious shown to be efficacious in preventing further progression lesions in primary molars. J Int Assoc Dent Child 1977;8:36-40. in bovine enamel artificial caries lesions.26 The initial use of phosphoric acid to etch the enamel did not allow resin 8. Leskell E, Riddell K, Cvek M, Mejare I. Pulp exposure after stepwise infiltration because of insufficient erosion of the surface versus direct complete excavation of deep carious lesions in young posterior layer, but recent work using 15% hydrochloric acid on permanent teeth. Endo Dent Traumatol 1996;12:192-6. exfoliated deciduous teeth was successful.37,38 A pilot study in Greenland (a population with high caries experience) 9. Metz-Fairhurst EJ, Curtis JWJr, Ergle JW, Rueggeberg FA, Adair Sm. reported that the clinical and radiographic therapeutic effect Ultraconservative and cariostatic sealed restorations: results at year 10. J in deciduous molars (over fluoride varnish alone) was Am Dent Assoc 1998;129;55-66. significant, with a greater than 35% reduction in the number of lesions progressing.39 This has also been shown in young 10. Ribeiro CC, Baratieri LN, Perdigao J, Baratieri NM, Ritter AV. A German adults where infiltration of early carious approximal clinical, radiographic, and scanning electron microscopic evaluation of lesions was found to be efficacious in reducing lesion adhesive restorations on carious dentin in primary teeth. Quintessence Int progression.36 Further evidence of the safety and efficacy of 1999;30:591-9. infiltration of approximal smooth-surface lesions is required. 11. Kidd EAM. How ‘clean’ must a cavity be before restoration? Caries Res 2004;38:305-13. If these new techniques are shown to be effective in reducing approximal lesion progression certain issues 12. Innes NPT, Evans DJP, Stirrups DR. Sealing caries in primary molars: would have to be overcome. Particularly the cost in terms randomized control trial, 5-year results. J Dent Res 2011;90:1405-10. 13. Innes NPT, Ricketts DNJ, Evans DJP. Preformed metal crowns for decayed primary molar teeth. Cochrane Database Syst Rev 2007(1):CD005512. 14. Attari N, Roberts JF. Restoration of primary teeth with crowns: a systematic review of the literature. Euro Archives of Paed Dent 2006;7:58- 62. 15. Innes NPT, Marshman Z, Vendan RE. A group of general dental practitioners’ views of preformed metal crowns after participation in the Hall technique clinical trial: a mixed-method evaluation. Prim Dent Care 2010;17:33-7. 16. Splieth CH, Eksttrand KR, Alkilzy M, Clarkson J, Meyer-Leukel H, Martignon S, paris S, Pitts NB, Ricketts DN, van Loren C. Caries Res 2010;44:3-13. 17. Beauchamp J, Caufield PW, Crall JJ, Donly K, Feigal R, Gooch B, et al. Evidence-based clinical recommendations for the use of pit-and-fissure sealants: a report of the American Dental Association Council on Scientific

LYNDIE A. FOSTER PAGE 55 Affairs. J Am Dent Assoc 2008;139:257-68. 32. Gray GB, Shellis P. Infiltration of resin into white spot like lesions of enamel: an in vitro study. Eur J Prosthodont Restor Dent 2002;10:27-32. 18. Ahovuo-Saloranta A, Hiiri A, Norblad A, Makala M, Worthington HV: 33. SchmidlinPR, Kluck I, Zimmermann J, roulette JF, Seeman R. Caries- Pit and fissure sealants for preventing dental decay in the permanent teeth of preventive potential of an adhesive patch after thermomechanical loading: a children and adolescents. Cochrane Database Syts Rev 2008;4:CD001830. microbial-based in vitro study. J Adhes Dent 2004;6:111-115. 34. Paris S, Meyer-Lueckel H, Kielbassa AM. Resin infiltration of natural 19. Griffin SO, Oong E, Kohn W, Vidakovic B, Gooch BF, Group caries lesions. J Dent Res 2007;86:662-6. CDCDSSRW, et al. The effectiveness of sealants in managing caries 35. Martignon S, Tellez M, Santamaria RM, Gomez J, Ekstrand KR. lesions. J Dent Res 2008;87:169-74. Sealing distal proximal caries lesions in first primary molars: efficacy after 2.5 years. Caries Res 2010;44:562-70. 20. Ekstrand KR, Martignon S, Ricketts DJN, Qvist V. Detection and 36. Alkilzy M, Berndt C, Meller C, Schidlowski M, Splieth CH. Sealaing activity assessment of primary coronal caries lesions: a methodologic study. of proximal surfaces with polyurethane tape: a two-year clinical and Oper Dent 2007; 32:225-35. radiographic feasibility study. J Adhes Dent 2009;11:91-94. 37. Paris S, Dorfer CE, Meyer-Lueckel H. Surface conditioning of natural 21. Kuzmina IN, Kuzmina E, Ekstrand KR. Dental caries among children enamel caries lesions in deciduous teeth in preparation for resin infiltration. from Solntsevsky – a district in Moscow, 1993. Comm Dent and Oral J of Dent 2010; 38:65-71. Epidemiol 1995; 23:266-70. 38. Meyer-Lueckel H, Paris S. Improved resin infiltration of natural caries lesions. J Dent Res 2008;87:1112-6. 22. Duggal MS. Research summary: carious primary teeth: their fate in 39. Ekstrand KR, Bakhshandeh A, Martignon S. Treatment of proximal your hands. Br Dent J 2002; 192:215. superficial caries lesions on primary molar teeth with resin infiltration and fluoride varnish versus fluoride varnish only: efficacy after 1 year. Caries 23. Drummond BK, Davidson LE, Williams SM, Moffat SM, Ayers KM. Res 2010;44:41-6. Outcomes two, three and four years after comprehensive care under general 40. Milgrom P, Tanzer, JM Perspectives on PACS: Where is caries anaesthesia. NZ Dent J 2004;100:32-7. prevention clinical research going? J Dent Res 2012;91:122-124. 24. Foster Page LA. Retrospective audit of Taranaki children undergoing Address for correspondence: dental care under general anaesthetic from 2001 to 2005. NZ Dent J Preventive and Restorative Dentistry 2009;105:9-13. Department of Oral Rehabilitation School of Dentistry, 25. Vila Verde A, Ramos MMD, Stoneham AM. Benefits in cost and University of Otago reduced discomfort of new techniques of minimally invasive cavity Dunedin, New Zealand treatment. J Dent Res 2009; 88:297-9. [email protected] 26. Paris S, Meyer-Lueckel H. Inhibition of caries progression by resin Editor’s note: Owing to illness Professor Bernadette infiltration in situ. Caries Res 2010; 44:47-54. Drummond presented this paper on Dr Foster Page’s behalf. 27. Nuttall NM, Pitts NB. Restorative treatment thresholds reported to be used by dentists in Scotland. Br Dent J 1990;169:119-26. 28. Elderton R. Overtreatment with restorative dentistry: when to intervene? Int Dent J 1993;43:17-24. 29. Davilia JM, Buonocre MG, Greeley CB, Provenza DV. Adhesive penetration in human artificial and natural white spots. J Dent Res 1975;54:999-1008. 30. RobinsonC, Hallsworth AS, Weatherall JA, Kunzel W. Arrest and control of carious lesions; a study based on preliminary experiments with resorcinol-formaldehyde resin. J Dent Res 1976;55:812-8. 31. Rodda JC. Impregnation of caries-like lesions with dental resins. NZ Dent J 1983;79:114-7.

Ann Roy Australas Coll Dent Surg 2012;21:56-57 MOLAR INCISOR HYPOMINERALIZATION Erin Mahoney, BDS, MDSc, PhD, FRACDS, MRACDS (Paeds)* Dr Mahoney is a Paediatric Dentist at the Hutt Valley District Health Board and Honorary Clinical Lecturer, Department of Paediatrics, University of Otago, Wellington, New Zealand. Abstract Molar Incisor Hypomineralization (MIH) is a common condition in New Zealand children and children around the world and can result in a significant defect in first permanent molars. This condition inevitably leads to a large amount of dental treatment for young children and may even result in the removal of their first permanent molars. This lecture will outline the understanding of the physical properties of these teeth and provide an evidence based review of the treatment options for affected teeth. Molar incisor hypomineralization (MIH) is a common TABLE 1. condition in New Zealand children. A recent NZ study has Summary of restorative material choice found that approximately 15% of Wellington children have this condition.1 MIH is defined as a hypomineralization for molars with MIH of systemic origin of one to four permanent first molars frequently associate with affected incisors.2 The defects Material choice Reasoning usually appear as demarcated opacities or after eruption GIC breakdown can occur resulting in a defect which mimics a Good as fissure sealants or as hypoplastic defect (Fig. 1). Composite resin temporary restoration No studies on effectiveness as a The treatment options for molars affected with MIH are Amalgam long term restoration different from a carious lesion as the general outline of the Stainless steel crown hypomineralized lesion does not follow the classic caries Appropriate for replacement of pattern. In addition, due to the inherent weakness of the Cast restorations small hypomineralized defects in affected enamel and the lack of classical etching patterns3 Extraction non load bearing areas different restorative materials often need to be chosen. Helpful to have some Although the choices made about restorative treatment will ‘unaffected’ enamel for bonding depend on the extent of the hypomineralized lesion, the cooperation level of the child affected, the tooth sensitivity Not indicated in most situations and the wishes of the child, the choices of materials can be summarized in Table 1. The table indicates that removal Excellent long term restoration of affected teeth is often required and can be a successful for moderate to extensive lesions treatment if the timing of the extraction is accurate. When Will need replacement in teenage contemplating extraction, the overall state of the dentition, years the age of the child and orthodontic considerations should be taken into account. If the clinician is uncomfortable with Appropriate for moderate lesions suggesting this option then referral for consultation from an with cuspal involvement in older orthodontic or paediatric dental colleague is warranted. children After the treatment options have been discussed and Appropriate in many cases with decided upon with a child and its parents, the biggest issues appropriate work up- usually for the clinician when faced with dealing with affected teeth between the ages of 8 and 10 is figuring out how to get a young child to cope, often with years. Orthodontic considerations extensive treatment. Jälevik and Klingberg showed that must be taken into account. children with severe MIH had nearly ten times more dental treatment than a control group.4 The affected children had (b) more dental fear and anxiety than the controls and this may have been because much of the treatment on these affected (a) teeth was done without local anaesthetic. Teeth with MIH are more sensitive and with patients with increased anxiety, Fig. 1. – Molar incisor hypomineralization of a) first permanent molar and dental treatment is difficult for children. Some clinical tips to b) incisors. help with treating these teeth are included in Table 2. * Presented at the Twenty-first Convocation of the Royal Australasian College of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012

ERIN MAHONEY 57 Tip TABLE 2. Rubber dam Clinical tips for treating molar teeth with MIH. Orthodontic Reasoning Separators Rubber dam as this will isolate the rest of the mouth and other affected teeth that may Radiographs be sensitive to the air and water used to restore the isolated tooth. Prior to placement of stainless steel crown, placement of orthodontic separator to limit Adequate the amount of tissue removal proximally Local Panoramic radiographs are important if contemplating extraction. Radiographs often Anaesthetic underestimate the extent of the hypomineralized enamel. Definitive Affected teeth are often sensitive and require adequate local anaesthetic. The use of treatment Articaine may be useful although no studies have been done on the different local anaesthetics available Sedation: Placement of multiple temporaries such as the use of GIC can be used if very small Nitrous oxide/ hypomineralized lesion but if extensive treatment needed, carrying out definitive oral etc… treatment as soon as possible will minimise sensitivity and number of appointments General for child. Children and their parents do not like having multiple appointments for a Anaesthesia single tooth! Although will not reduce pain and adequate LA is needed, sedation can reduce anxiety significantly in this group of children. Young children who require extensive treatment such as multiple extractions or stainless steel crowns and are unable to cope can have this treatment under GA. Incisor teeth are often affected with MIH (Fig. 1). Post 2. Weerheijm KL. Molar Incisor Hypomineralisation (MIH). Eur J eruptive breakdown is uncommon but does occur. Opacities Paediatr Dent 2003; 4: 114-20. are usually full thickness and although bleaching of these 3. Mahoney EK, Rohanizadeh R, Ismail FS, Kilpatrick NM, Swain MV. defects has been proposed, in general when a child requests Biomaterials 2004; 25: 5091-5100. that the opacities be restored for aesthetic reasons, the lesion 4. Jälevik B and Klingberg GA. Dental treatment, dental fear and must be removed down to dentine. Some of the more modern behaviour management problems in children with severe enamel resin composites with opaquers may be used with varying hypomineralization of their permanent first molars. Int J Paediatr Dent success if you do not wish to remove the entire opacity. 2002; 12: 24-31. Overall the treatment of teeth with MIH is complex but Address for correspondence: managing the patient as well as the teeth appropriately will Department of Dentistry minimize the distress and maximize the clinical outcome for Hutt Valley DHB the patient. High Street Lower Hutt References Wellington, New Zealand [email protected] 1. Mahoney EK, Morrison DG. Further examination of the prevalence of MIH in the Wellington region. N Z Dent J 2009; 107:79-84

Ann Roy Australas Coll Dent Surg 2012;21:58-59 ADVANCES IN GASTROENTEROLOGY - OPPORTUNITIES AND CHALLENGES FOR THE DENTAL PRACTITIONER. Anita Nolan, MB, BCh, BAO, BA, B Dent Sc, MD,FFDRCSI, LLM* Dr Nolan is Associate Professor of Oral Medicine at the University of Otago, New Zealand. She is qualified in medicine, law and dentistry and holds a Fellowship of the Faculty of Dentistry RCSI, a Doctorate in Medicine and accredited specialist training in Oral Medicine from the UK. Abstract As the oral cavity marks the beginning of the gastrointestinal tract (GIT), it is not surprising that it frequently mirrors disease that occurs lower in the GIT. Increasingly, clinical signs in the oral cavity are recognized as future predictors and prognostic indicators of GIT and, indeed, other systemic disease. This paper discusses recent advances in the overlap area of Oral Medicine and Gastroenterology and the significant role of the dental practitioner in the management of these patients. The oral cavity is the uppermost and most easily the submandibular salivary duct orifices (staghorning). visualized part of the gastrointestinal tract. Some systemic The palate is rarely involved but the tongue can be fissured diseases manifest in the mouth. Gastrointestinal diseases, (lingua plicata) and, if associated with recurring facial palsy in particular, fall into this category and oral lesions may and swelling of lips, has been described as Melkersson- be either a primary or secondary marker of gastrointestinal Rosenthal syndrome.5 disease. The condition termed Orofacial Granulomatosis (OFG) Gastrointestinal diseases may give rise to nutritional was first described by Wiesenfeld in 1985.6 These orofacial deficiencies as a result of malabsorption or chronic bleeding. appearances, with histological evidence of oral granulomas, Orofacial disease commonly occurs as a result of deficiencies may present specifically in the absence of any recognized of Iron, Vitamin B12 and Folic acid.1 Gastrointestinal systematic condition. However, many patients with OFG, Diseases that are associated with primary oral lesions include when investigated, have been found onto have subclinical Crohn’s Disease(CD), Coeliac Disease and Ulcerative intestinal CD, whilst in others, OFG may precede the Colitis. Liver disease is classified as a Gastrointestinal development of intestinal CD. Disease and Hepatitis C, for example, is associated with oral complications.2 The reported prevalence of disease specific oral lesions in CD varies from 0.5%7 to 48%.8 The presence of oral lesions This paper discusses the oral aspects of these presents the gastroenterologist with two issues, namely, gastrointestinal diseases, but concentrates particularly on the management of troublesome oral lesions in a patient Oral Crohn’s Disease (OCD) in terms of oral manifestations, with intestinal disease, and, secondly, how to interpret the oral complications of management and recent research in prognostic significance of oral lesions in a patient with this field. Inflammatory Bowel Disease (IBD). Whereas this second point is less clear, Harty9 reported a 41.7% prevalence of Crohn’s Disease (CD) is known to affect any part of the OCD in a prospective study of children with CD. There was gastrointestinal tract from the mouth to the anus. Dudeney, in a statistically significant association of OCD with perianal 1969, first reported a case of a 36 year old male with intestinal disease compared with those children who had CD, but did CD, who presented with a lesion of the buccal mucosa that not manifest OCD. Additionally, regardless of whether the macroscopically demonstrated a “cobblestone” appearance child continued to suffer from OCD or OCD occurred only at and was histologically identical to intestinal CD.3 Since the time of initial presentation of CD, those children in whom then, the connection between specific oral lesions and CD OCD was present at the time of diagnosis of CD suffered has been widely reported. There is, however, considerable a much more severe disease burden during the follow up debate on the clinical significance of such oral lesions in CD. period. This small study proposed that the presence of OCD in children at the time of diagnosis of CD is a marker for a The typical clinical of Oral Crohn’s Disease (OCD) is more severe CD phenotype. The authors emphasized the need one of a spectrum of orofacial signs, of which some or all to incorporate oral examination into the diagnostic protocol may be present at any one time.4 These include recurrent for CD, in view of the possible prognostic significance of persistent lip swelling, oral ulceration, particularly in the OCD. buccal sulcus (the lower “folds” of the inner cheek), a “full- width” gingivitis, which is a widespread erythema of the The OFG group presents different diagnostic and gums, cobblestoning of the buccal mucosa (inside of the management challenges for the Dental Surgeon. OFG cheek), oral mucosal tags, cracks at the corners of the mouth, patients present with orofacial lesions alone. OFG can known as angular cheilitis and characteristic swelling of precede the onset of CD by up to 10 years.10 Plauth11 reported that oral signs preceded CD in 60% of patients in a case * Presented at the Twentiy-first Convocation of the Royal Australasian College series of 79 patients. It is difficult to state what proportion of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012

ANITA NOLAN 59 of OFG cases progress to intestinal CD, as much of the 5. Levenson MJ, Ingerman M, Grimes C, Anand KV. Melkersson- literature on the topic comprises of case reports. A recent Rosenthal Syndrome. Arch Otolaryngol 1984;110:540-2. study by Campbell12 estimated the risk of progression to CD 6. Wiesenfeld D, Ferguson MM, Mitchell DN, Mac Donald DG, Scully C, in a relatively large series of cases of OFG was 20% over a Cochran K, et al. Oro-Facial Granulomatosis — a Clinical and Pathological median follow up of 5 years, which concurs with the earlier Analysis. QJM. 1985;54:101-13. report by Field13 on the 10 year follow-up of small cohort 7. Connes A, Dupuy A, Revuz J et al. Long term evolution of oral of OFG patients. Campbell12 also reported that lesions of localisation of Crohn’s Disease.Gastroenterology. 1998;114:A596. the buccal sulcus were predictive of likely future intestinal 8. Williams AJK, Wray D, Ferguson A. The clinical entity of orofacial CD. A London study demonstrated that when endoscoped, Crohn’s Disease. Q J Med 1991;79:451-8. OFG patients demonstrated low grade gut inflammation, 9. Harty S, Fleming P, Rowland M, Crushell E, McDermott M, Drumm B, insufficient to define as CD and unlikely to progress to CD.14 et al. A prospective study of the oral manifestations of Crohn’s disease. Clin Gastroenterol Hepatol 2005;3:886-91. The precise significance of oral lesions as a predictor of 10. Ghandour K, Issa M. Oral Crohn’s disease with late intestinal future CD and the prognostic value of oral lesions in CD manifestations. Oral Surg Oral Med Oral Pathol 1991;72:565-7. patients at the time of diagnosis are still uncertain due to the 11. Plauth M, Jebss H, Meyle J. Oral manifestations of Crohn’s disease. An lack of a clear evidence base. However, these very topics are analysis of 79 cases. J Clin Gastroenterol 1991;13:29-37. currently being investigated in prospective research projects 12. Campbell H, Escudier M, Patel P, Nunes C, Elliott TR, Barnard K, which will hopefully clarify the nature of the relationship et al. Distinguishing orofacial granulomatosis from Crohn’s disease: Two between the mouth and the remainder of the gastrointestinal separate disease entities? Inflamm Bowel Dis 2011;17:2109-15. tract in CD in the very near future. 13. Field EA, Tyldesley WR. Oral Crohn’s disease revisited--a 10-year- review. Br J Oral Maxillofac Surg 1989;27:114-23. References 14. Sanderson J, Nunes C, Escudier M, Barnard K, Shirlaw P, Odell E, et al. Oro-facial granulomatosis: Crohn’s disease or a new inflammatory 1, Field EA, Allan RB. Review article: oral ulceration – aetiopathogenesis, bowel disease? Inflamm Bowel Dis 2005;11:840-6. clinical diagnosis and management in the gastrointestinal clinic. Aliment Pharmacol Ther 2003;949-62. Address for correspondence Faculty of Dentistry 2. Carrozzo M, Gandolfo S. Oral diseases possibly associated with HCV. University of Otago Crit Re Oral Biol Med 2003;14:115-27. PO Box 647 Dunedin 9054 3. Dudeney TP, Todd IP. (1969) Crohn’s Disease of the Mouth. Proc Roy [email protected] Soc Med 1969;62:1237. 4. McCartan BE, Healy CM, McCreary CE et al. Characteristics of patients with orofacial granulomatosis; Oral Disease 2011doi:10.11111.1601- 0825.2011.01826.x

Ann Roy Australas Coll Dent Surg 2012;21:60-62 DIAGNOSIS AND MANAGEMENT OF POTENTIALLY MALIGNANT ORAL DISORDERS H. L. De Silva, BDS(Peradeniya), MS(Colombo), FDSRCS(England), FFDRCS(Ireland)* Mr Harsha De Silva is Senior Lecturer in the Department of Oral Diagnostics and Surgical Sciences at the Faculty of Dentistry at the University of Otago, Dunedin, New Zealand Abstract The optimum management strategy for potentially malignant disorders remains a constant challenge as our present knowledge is still short of being conclusive. In spite of its shortcomings as an accurate predictive marker, the assessment of the severity of epithelial dysplasia continues to be useful in risk assessment. It is important to use a combination of epidemiological, clinical and histopathological input when deciding on the most appropriate management for an individual patient. Advanced research exploring molecular markers for diagnosis and risk predictions appear to be promising. However, these tests have not evolved to a stage that they could be used for routine diagnostics at the clinical setting. Introduction is a major cause, heavy smokers being 4-7 times more likely to be affected compared with non-smokers.3,6 Alcohol, while It is well known that many oral cancers may have clinically being a risk factor on its own, may synergistically enhance the identifiable forerunners. Recently a group of experts found risk when combined with concurrent tobacco consumption.7 that the widely used terms precancer, precancerous lesion In fact the alcohol content in antiseptic mouth- washes could and premalignant condition to be somewhat misleading be a concern if they are used regularly over a lengthy period since, not all lesions and conditions progressed to cancer in a of time.8 Betel quid chewing is a major aetiological factor definable period of time. Further, cancer sometimes occurred for most PMDs seen in the South-East Asia and in the Indian in apparently normal mucosa outside the boundaries of sub-continent.9,10 There is conflicting evidence to the role of the clinically diagnosed premalignant lesion. The group human papilloma virus in the aetiology of PMDs.11 felt that the term “Potentially Malignant Disorder”(PMD) would better identify the risk state and should replace both Diagnosis premalignant lesions and conditions.1 Leukoplakia, the most commonly seen PMD was redefined as “white plaque of Most PMDs and even early stage carcinomas could questionable risk having excluded (other) known disorders often remain asymptomatic for long periods. It is common that carry no increased risk for cancer”. Erythroplakia, palatal for them to be detected as an incidental finding at a routine lesions in reverse smokers, Oral Submucous Fibrosis (OSF), dental check-up. Unfortunately, 1.1% to 17.5% of PMDs Oral Lichen Planus (OLP), oral lesions of Discoid Lupus will progress to oral cancer over a period of time.3 Therefore Erythematosus (DLE) and Actinic Keratosis constitute the the most important goal in the management of PMDs would other well known PMDs. be to halt this progression. Clinicians should be able to prevent or if not decrease the high morbidity and mortality Epidemiology and aetiology associated with Oral Squamous Cell Carcinoma (OSCC) if they could detect the PMDs, identify those which would The prevalence of oral PMDs vary significantly in progress to cancer and treat them at an early stage. published studies. Petti (2003)2 performed a meta-analysis of 23 carefully selected studies from 17 countries which Health education using mass media and clinical used internationally accepted criteria. Using a statistical examination in population based screening has been shown calculation, he estimated a global prevalence of 2.6% to be an effective tool for identification of PMDs particularly for PMDs while conceding the existence of a significant when undertaken for the high risk groups.12 In developed heterogeneity between different studies. The large population countries where the incidence is comparatively low an based studies generally come from the developing countries opportunistic screening by dentists and general medical while those from the developed world tend to be mostly from practitioners could be of value. institution based samples.3 Oral leukoplakia which is the most common PMD probably has 0.5% prevalence.4 Males appear PMDs of similar clinical appearance could have to be at a higher risk for PMD development.3,5 PMDs tend varying histopathology. Some PMDs may demonstrate the to occur more frequently among the middle aged population, presence of dysplastic changes in the epithelium. In general, particularly in the developed countries.2 Albeit many PMDs erythroplakias and non-homogenous leukoplakias tend to failing to display an association with an aetiological factor5 have more dysplastic features compared with leukoplakias it is widely believed that both smoked and chewed tobacco with homogenous appearance.13 For a long period, the light microscopic assessment of the presence and grading * Presented at the Twenty-first Convocation of the Royal Australasian College of severity of dysplastic features continued to be the of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012 most reliable marker to predict the liklihood of malignant transformation.14 However, many studies have cast doubts on

HARSHA DE SILVA 61 the reliability of this approach by demonstrating significant of a PMD may provide an opportunity to detect an OSCC in intra and inter-examiner variability in dysplasia grading15 its very early stage and pave the way for initiating prompt and also by the fact that OSCC being shown to develop in treatment. previously non-dysplastic epithelium.13 Further, in some PMDs the dysplastic features were found to have regressed Not all PMDs are amenable to surgical excision. Large completely or partially with both active treatment or more lesions and more generalized conditions may warrant a importantly with no treatment. Research has focussed on non-surgical approach for management. Chemoprevention molecular biology techniques to explore molecular markers both topical and systemically administered is a non-surgical in PMDs which could be used to predict their behaviour. A treatment strategy used in the management of PMDs. multitude of molecular markers have been studied and the Topical bleomycin, ketorolac as a mouth wash, systemic results are encouraging. However, these tests have not evolved betacarotenes, Vitamin A, retinoids and many other agents to a stage where they could be used for routine diagnostics have been tried as medical treatment for PMDs but none has at the clinical setting.16 In spite of the shortcomings in its achieved consistent treatment outcomes to be of significant predictive value, assessment of the degree of dysplasia value to prevent malignant transformation.20 Most of these from a specimen obtained through an incisional biopsy medical measures have been shown to encounter high still remains the most valuable investigation to indicate the recurrence.23 Medical management is more applicable for relative risk for a malignant transformation. Since most patients with OLP, DLE and OSF since the disease process treatment decisions are likely to be based on the severity is more generalized. However, a recent Cochrane review of dysplasia, a two tier system featuring a “low risk” and a on treatment of oral lichen planus failed to identify any “high risk category” has been proposed recently, to reduce treatment as being significantly superior to others.24 the ambiguity of dysplasia grading..14 An alternative approach may be to simply place the Management PMD under strict clinical and histopathological surveillance and to intervene at the earliest possible stage should a Management strategies can be broadly classified as malignancy develop. This approach is usually combined surgical, medical and observational. Decision to treat with encouragement to abandon any adverse health habits actively is usually made on the basis of extent and the like tobacco, betel quid or alcohol use. In a group of patients clinical appearance of the lesion, presence or absence of who were using smokeless tobacco, cessation of the habit risk behaviours like smoking, betel chewing and alcohol was rewarded with a 97.5% resolution rate for leukoplakia.25 consumption, and on the degree of severity of dysplastic changes determined by the light microscopic examination of Conclusion an incision biopsy specimen.14 To date there is no definitive treatment capable of A complete surgical excision provides an opportunity reliably eliminating the risk of malignant transformation of to enhance the accuracy of detecting the presence of oral PMDs. The effective management of PMDs are somewhat epithelial dysplasia and grading its severity. The site crippled by the lack of consistent, reliable and predictable of incisional biopsy is usually determined by clinical indicators to identify those lesions which will progress to an examination. It is well known that an incision biopsy may OSCC. Until more accurate molecular biological predictors not provide a true representative sample of a lesion and more emerge through research and become available for use in severe changes may lie in an area outside the domain of the routine clinical setting, a histopathological diagnosis the sample obtained.17 Such inaccuracies may prevent the to grade the severity of epithelial dysplasia is likely to clinician from appreciating the true risk and may lead to over remain the favoured investigation to formulate and underpin treatment or inadequate treatment. subsequent management plans. Following diagnosis and risk assessment, a regime of counselling to eliminate any adverse Both, scalpel excision and laser ablation are widely used health habits present, a complete surgical excision of the with each having its merits and demerits.18,19 Laser ablation lesion when feasible to do so and an aggressively monitored permits excision of more widespread areas of leukoplakia periodic follow-up constitutes a feasible approach in the with lesser side effects, but histopathological examination present context of knowledge. The newer developments in could be compromised. Cryo-ablation has been reported but optical spectroscopy, molecular biology and photodynamic has failed to gain acceptance to the same level, largely due to therapy hold promise for the future. the frequent side-effects.20 References However, it has been shown that surgical excision of a lesion by whichever method may not eliminate the risk of 1. Warnakulasuriya S, Johnson NW, van der Waal I. Nomenclature and developing a malignancy or a recurrence of the lesion.21 Yet, classification of potentially malignant disorders of the oral mucosa. J Oral a complete excision, if possible to be performed, still has Pathol Med 2007: 36; 575-80. value in that it provides the entire lesion for histopathological assessment and eliminates the risk of under assessment of 2. Petti S, Pooled estimate of world leukoplakia prevalence: a systematic the severity including the possibility of missing out on an review. Oral Oncology 2003: 39; 770-80. early invasive carcinoma within the lesion. The prognosis of OSCC is markedly influenced by the clinical stage at initial 3. Napier SS, Speight PM. Natural history of potentially malignant oral diagnosis, the presence or absence of lymphovascular spread lesions and conditions; an overview of the literature. J Oral Pathol Med and cervical lymph node metastasis.22 The complete excision 2008; 37: 1-10. 4. van der Waal I. Potentially malignant disorders of the oral and oropharyngeal mucosa; terminology, classification and present concepts of management. Oral Oncology 2009: 45; 317-23. 5. Axell T. Occurrence of leukoplakia and some other oral white lesions

62 POTENTIALLY MALIGNANT ORAL DISORDERS among 20333 adult Swedish people. Comm Dent Oral Epidemiol 1987; 17. Holmstrup P, Vedtofte P, Reibel J, Stoltze K. Oral premalignant 15:46-51. lesions: Is a biopsy reliable? J Oral Pathol Med 2007: 36; 262-66. 6. Lim K, Moles DR, Downer MC, Speight PM. Opportunistic 18. Marley JJ, Cowan CG, Lamey PJ, Linden GJ, Johnson NW, screening for oral cancer and precancer in general dental practice: results of Warnakulasuriya KA. Management of potentially malignant oral mucosal a demonstration study. Br Dent J 2003; 194: 497-502. lesions by consultant UK oral and maxillofacial surgeons. Br J Oral Maxillofac Surg 1996; 34: 28-36. 7. Hasibe M, Mathew B, Kuruvilla B, Thomas G, Sankaranarayanan R, Parkin DM, Zhang ZF. Chewing tobacco, alcohol and the risk of 19. Ishi J, Fujita K, Komori T. Laser surgery as a treatment for oral erythroplakia. Cancer Epidemiol Biomarkers Prevention 2000; 9: 639-45. leukoplakia. Oral Oncology 2003: 39; 759-69. 8. McCullough MJ, Farah CS. The role of alcohol in oral carcinogenesis 20. Porter S, Lodi G. Management of potentially malignant disorders: with particular reference to alcohol-containing mouth-washes. Aust Dent J evidence and critique. J Oral Pathol Med 2008: 37; 63-69. 2008; 53: 302-305. 21. Saito T, Sugiura C, Hirai A, Notani K, Totsuka Y, Shindoh M, 9. Amarasinghe AAHK, Usgodaarachchi US, Johnson NW, Lalloo R, Fukuda H. Development of squamous cell carcinoma from pre-existent oral Warnakulasuriya S. Betel-quid chewing with or without tobacco is a major leukoplakia: with respect to treatment modality. Int J Oral Maxillofac Surg risk factor for potentially malignant disorders in Sri Lanka: a case-control 2001; 30: 49-53. study. Oral Oncology 2010: 46(4); 297-30. 22. Huang TY, Hsu LP, Wen YH, Huang TT, Chou YF, Lee CF, Yang 10. Chung CH, Yang YH, Wang TY, Warnakulasuriya S. Oral MC, Chang YK, Chen PR. Predictors of locoregional recurrence in early precancerous disorders associated with areca quid chewing, smoking and stage oral cavity cancer with free surgical margins. Oral Oncology 2010; 46: alcohol drinking in Sothern Taiwan. J Oral Pathol Med 2005: 34; 460-66. 49-55. 11. Bagan JV, Jimenez Y, Murillo J, Gavalda C, Poveda R, Scully C, 23. Lodi G, Sardella A, Bez C, Demarosi F, Carrassi A. Interventions for Alberola TM, Torres-Puente M, Perez-Alonso M. Lack of association treating oral leukoplakia. Cochrane Database Syst Rev 2006; CD001829. between proliferative verrucous leukoplakia and human papillomavirus infection. J of Oral Maxillofac Surg 2007; 65: 46-49. 24. Thongprasom K, Carrozzo M, Furness S, Lodi G. Interventions for treating oral lichen planus. Cochrane Database of Systematic Reviews 2011, 12. Eadie D, MacKintosh AM, MacAskill S, Brown A. Development and Issue 7. Art. No.: CD001168. DOI: 10.1002/14651858.CD001168.pub2. evaluation of an early detection intervention for mouth cancer using a mass media approach. Br J Cancer 2009; 101(Suppl 2): S73-S79. 25. Martin GC, Brown JP, Eifler CW, Houstan GD. Oral leukoplakia status six weeks after cessation of smokeless tobacco use. J Am Dent Assoc 13. Shafer WG, Waldron CA. Erythroplakia of the oral cavity. Cancer 1999; 130: 945-954. 1975; 36: 1021-28. Address for correspondence 14. Warnakulasuriya S, Reibel J, Bouquot J, Dabelsteen E. Oral epithelial Department of Oral Diagnostics and Surgical Sciences dysplasia classification systems: predictive value, utility, weaknesses and Faculty of Dentistry scope for improvement. J Oral Pathol Med 2008: 37; 127-33. University of Otago Dunedin, New Zealand 15. Fischer DJ, Epstein JB, Morton TH, Schwarts SM. Interobserver [email protected] reliability in the histopathologic diagnosis of oral-premalignant and malignant lesions. J Oral Pathol Med 2004: 33; 65-70. 16. Pitiyage G, Tilakaratne WM, Tavassoli M, Warnakulasuriya S. Molecular markers in oral epithelial dysplasia. J Oral Pathol Med 2009; 38: 737-52.

Ann Roy Australas Coll Dent Surg 2012;21:63 THE MULTIDISCIPLINARY MANAGEMENT OF OBSTRUCTIVE SLEEP APNOEA Alister Neill, MbChB, FRACP,BSc, MD* Dr Alister Neill is an Associate Professor of Medicine at the University of Otago, Wellington School of Medicine and Health Sciences and Director of the WellSleep Laboratory and Research Group. He is a Respiratory and Sleep Physician at the Wellington Hospital, Capital and Coast Health in New Zealand. Synopsis for patients presenting with symptoms of a sleep disorder. Training pathways have been developed for physicians Obstructive sleep apnoea syndrome (OSAS) and bruxism wanting to specialize in sleep medicine. Sleep services are the sleep disorders most relevant to dentistry. OSAS are now looking to bring together clinicians with a broad affects 4% of adults and up to 2% of children.1 Although range of expertise. Currently the Sleep Physician and 40% of OSAS can be attributed to maxillofacial/dental Sleep Investigation Centre are central to the model of care. risk factors an epidemic of obesity has led to a significant In future, the field will be best served by structures that rise in OSAS prevalence, particularly in New Zealand successfully harness multi-disciplinary expertise. Maori, Pacific Islanders and lower socio-economic groups.2 The assessment pathway begins with a thorough clinical References assessment by a sleep medicine clinician who completes a sleep history, examination and determines the optimum 1. Neill AM, McEvoy RD. Obstructive Sleep Apnoea and other sleep investigation strategy. Portable/home sleep testing pathways breathing disorders - Essentials of Clinical Practice Series. Med J Aust are being increasingly used3,4 for diagnosis in patients 1997;167: 376-81. with high pre-test probability and to monitor the treatment 2. Mihaere, KM Harris R; Gander PH, Reid PM, Purdie G, Neill A. response. Continuous positive airway pressure (CPAP) is Obstructive Sleep Apnoea in New Zealand Adults: Prevalence and Risk a first line therapy for moderate to severe OSAS. Success Factors among Māori and non-Māori. Sleep 2009; 32:949-56. is highest when delivered as part of a clinical pathway. 3. Campbell A, Neill AM. Home set-up polysomnography in the Acceptance is lower in Maori and disadvantaged socio- assessment of suspected obstructive sleep apnoea. J Sleep Res 2011; economic groups.5 20:207-13. 4. Collop NA; Anderson WM; Boehlecke B; Claman D; Goldberg R; Oral appliances are being successfully used to treat mild Gottlieb DJ; Hudgel D; Sateia M; Schwab R. Clinical guidelines for the use to moderate OSAS and snoring in selected patients. Clinical of unattended portable monitors in the diagnosis of obstructive sleep apnoea predictors of MAS success include positional or mild OSAS, in adult patients. J Clin Sleep Med 2007;3:737-47. lower weight (BMI < 32 kg/m2), and adequate dentition. 5. Bakker JP, O’Keeffe KM, Neill AM, Campbell AJ. Ethnic Disparities Tongue stabilizing devices also have a role but retention is in CPAP Adherence in New Zealand: Effects of Socioeconomic Status, an issue. Follow-up studies are recommended to objectively Health Literacy and Self-Efficacy. Sleep 2011; 34:1595-603. assess the response. Funding levels, a lack of workforce 6. ADA Policy Statement 6.7, April 10, 2008 from ADA website. planning and inflexible service structures represent a significant barrier to accessing treatment options. The Address for correspondence: ADA’s policy statement (6.7)6 provides a useful summary of Department of Medicine professional issues in the use of Dental appliances promoting Wellington School of Medicine and Health Sciences the view that medical and dental expertise are both required P.O. Box 7343 to manage patients who are candidates for dental appliance Wellington South 6242 therapy for snoring and sleep apnoea. New Zealand [email protected] Clinicians with specialized interests and training in the field of sleep are needed to provide appropriate care * Presented at the Twenty-first Convocation of the Royal Australasian College of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012

Ann Roy Australas Coll Dent Surg 2012;21:64-65 OBSTRUCTIVE SLEEP APNOEA Investigations, diagnostic techniques and predicting surgical success Wayne Gillingham, BDS, MBChB, FRACDS, FDS RCS(Eng), MDS(OMS), FRACDS(OMS)* Dr Gillingham is an oral and maxillofacial surgeon working as a consultant for Hutt Valley Health and Midcentral District Health Boards in New Zealand. He consults and operates in private practice from a number of sites in the Wellington Region. Abstract Obstructive sleep apnoea (OSA) is diagnosed using a sleep study or Polysomnogram. The paper discusses the role of imaging and other examination techniques to assess the nature of OSA and what treatment you can offer a patient. When should a patient be offered a mandibular advancement splint? What type should be used? How do we know it is working? Surgical treatment of OSA is a controversial area. This paper provides an understanding of which patients may benefit from surgery and when is an appropriate time to refer. An overview of the three main types of surgery and their outcomes are discussed. Less experienced practitioners will feel better able to talk to patients about OSA and for those with a special interest in OSA there is new material to stimulate further discussion. Introduction rapidly becoming a useful tool for OSA imaging. Alternative imaging such as MRI and sleep fluoroscopy are useful as a There are three main objectives of this paper: research tool but do not add to the information required for day to day practice. 1. Investigations and diagnostic techniques for OSA apart from a sleep study or Polysomnogram (PSG) Manometry and Acoustic Reflection 2. Summary of Interventions for OSAexcluding Continuous Manometry helps identify upper airways resistance Positive Airways Pressure (CPAP) machines. syndrome and gives different data on wake and sleep. Acoustic reflection is a rapid means of assessing volumes. 3. Treatment protocol for OSA when patients do not wish Both measures are used predominantly in research and not to use CPAP clinical practice.4 Investigations and Diagnostic Techniques Pharyngoscopy Cephalometrics Flexible nasal endoscopic examination gives no OSA relevant information apart from seeing collapse or The role cephalometrics plays in diagnosing OSA is narrowing of the lateral pharyngeal walls. This information minimal. It is not a diagnostic tool for OSA and cannot be is also available from a CBCT. Hence there is no role for used as a screening tool.1 Airway changes before and after pharyngoscopy in the assessment and treatment decisions for surgery to not correlate with success of surgery to treat OSA. OSA.4 The role of cephalometrics is to identify those people who have a craniofacial disproportion. Patients with an abnormal Interventions for OSA skeleton will fail to respond to most surgical techniques for treatment apart from maxillomandibular advancement. Surgical cure is defined as an Apnoea Hypopnea Index Patients with a normal facial skeleton will have standard (AHI) < 5; surgical success is defined as AHI < 20 with > success rates for the range of surgical procedures that are 50% reduction.5 There are three groups of surgical procedure: available for OSA. Therefore cephalometrics predicts which group of patients will fail treatment, unless treatment is 1. Airway bypass or tracheostomy aimed at correcting their facial skeleton.2 2. Soft Tissue Surgery 3D Volumetric Analysis 3. Hard Tissue Surgery Volumetric analysis is the gold standard of airways assessment for OSA. There is variation in airway anatomy Tracheostomy provides a mortality benefit but does not when a patient is awake, asleep, upright, supine, mouth result in a surgical cure or success. open or closed and the timing of the ventilatory cycle but standardized imaging still gives useful data. Location of Soft tissue surgery has a variable rate of outcomes, the obstruction, analysis of craniofacial disproportion and procedures will be successful in some patients but it is a range of volume and fluid dymanics can be calculated. unknown what the selection criteria are. In summary, nasal Unlike cephalometrics, volume changes before and after procedures have no role to play in OSA surgery apart from surgery correlate with success.3 Conebeam CT imaging is allowing easier CPAP use. Uvulopalatopharyngoplasty (UPPP) has a success rate of 52% and cure rate of 16% but * Presented at the Twentiy-first Convocation of the Royal Australasian College 50% of patients will relapse to their pre-surgical AHI within of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012 four years of surgery. Transpalatal advancement is a hard tissue variant of the UPPP and carries a higher cure rate of

WAYNE GILLINGHAM 65 Fig. 1. – Management protocols (% values are OSA cure rate.) • Fitting of a mandibular advancement splint and titration to maximal advancement. 35% with likely longer lasting effect. Surgical procedures on the tongue have a variable outcome but are generally • Repeat of the sleep study three months after splint unpredictable and poor. With all soft tissue procedures insertion. relapse is a major complicating factor and initial successes will relapse over some years to the pre-surgical AHI.6 A decision tree is followed (Fig. 1). Seventy-five per cent of patients will achieve a cure and most will decide to Hard Tissue Surgery is more stable with reliable long continue with wearing a MAS. Some will decide to undergo term outcomes. Genioglossus advancement is a commonly surgery and the MAS is used as a surgical guide to provide used procedure usually combined with UPPP with a cure rate certainty of surgical outcomes. Some patients may only need of 52% but only in selected patients. Maxillary expansion a mandibular advancement if the guide demonstrates a cure cures 70% of cases when the patient has a narrow palate. and the shift is within the bounds of the dental occlusion. Twenty per cent of patient will achieve a partial response Maxillomandibular advancement (MMA) is now seen and most will respond well to MMA due to both jaws being as the gold standard treatment for OSA. With adequate advanced. Some may decide to continue wearing the MAS advancement and work up the cure rate is > 95%. When and supplementing their treatment with CPAP set at a much patients have undergone a UPPP and MMA, most patients lower and tolerable pressure. The final 5% group of patients report the MMA as preferable in terms of recovery, pain and are an unknown and no certainty can be given to successful certainly efficacy; 95% of patients are satisfied with surgery surgical outcomes. and no deaths have been reported over the past 60 years.7 Conclusion Mandibular advancement splints (MAS) Obstuctive Sleep apnoea must be diagnosed by a sleep There are three basic designs – titratable, fixed and or respiratory physician using a polysomnogram. Once the tongue suction devices. Fixed appliances give a 56.5% cure diagnosis is made then treatment falls into three areas. CPAP, rate vs titratable devices with a 74% cure rate due to the mandibular advancement splint or surgery. 3D volumetric ability to advance the jaw further over a number of weeks.8 analysis indicates which treatments will not work and helps The decision to stop advancing the device is made by what determine the nature of the airway narrowing. Mandibular the patient can tolerate. Laboratory controlled titratable advancement splints play a role in treatment but also in devices allow rapid assessment of a patient’s response to predicting success of skeletal surgery. From a checkered an advancement splint but do not reliably give a measure of past, surgery for Obstructive Sleep Apnoea has entered a advancement required to cure apnoea.9 new era of predictability and long term success utilising maxillomandibular advancement as the gold standard Advancment splints can be used as a treatment in treatment. themselves instead of CPAP. They are also a useful guide for surgical intervention. Determining the advancement required References to cure OSA can then be used to determine the surgical shifts required to treat OSA. This method gives a reliable and 1. Sher AE, Schechtman KB, Piccirillo JF. The effcacy of surgical modifi- predictable way of surgically treating OSA. cations of the upper airway in adults with obstructive sleep apnea syndrome. Sleep 1996;19:156-77. OSA Management Protocol 2. Riley RW, Powell NB, Guilleminault C. Maxillofacial surgery and ob- • Diagnosis and assessment at a sleep clinic with use of structive sleep apnea: a review of 80 patients. Otolaryngol Head Neck Surg Polysomnogram (Sleep Study). 1989;101:353-61. • Patient may trial CPAP and decide if an alternative is 3. Abramson et al. Three dimensional computed tomographic airway wanted. analysis of patients with obstructive sleep apnea treated by Maxilloman- dibular Advancement. J Oral Maxillofac Surg 2011;69:677-86. • Consultation with an oral and maxillofacial surgeon with a special interest in OSA. 4. Thakkar Kunal. Diagnostic Studies in Obstructive Sleep Apnea. Oto- laryngol Clin N Am 2007;40:785–805. • Conebeam CT or suitable alternative for 3D volumetric analysis. 5. Hseuh-Yu Li et al. Use of 3-dimensional computed tomography scan to Evaluate upper airway patency for patients undergoing Sleep-disordered breathing surgery. Otolaryngol Head Neck Surg 2003;129:336-42. 6. JE Holty, C Guilleminault. Surgical Options for the Treatment of Ob- structive Sleep Apnea. Med Clin N Am 2010;94:479–515. 7. JE Holty, C Guilleminault. Maxillomandibular advancement for the treatment of obstructive sleep apnea: A systematic review and meta-analy- sis. Sleep Medicine Reviews 2010;14:287–97. 8. Almeida FR et al. Effect of a titration polysomnogram on treatment success with a mandibular repositioning appliance. J Clin Sleep Med 2009;15:198–204. 9. Dieltjens M et al. Current opinions and clinical practice in the titra- tion of oral appliances in the treatment of sleep-disordered breathing. Sleep Medicine Reviews 2012;16:177-85. Address for correspondence: Dental Department Hutt Valley Health Hutt Hospital, Wellington, New Zealand [email protected]

Ann Roy Australas Coll Dent Surg 2012;21:66-69 THE CHANGING COMPLEXITY OF GERIATRIC HEALTH CARE AND THE IMPLICATIONS FOR ORAL HEALTH CARE FOR THE INDIVIDUAL AND COMMUNITY Warren Shnider, BDSc FRACDS(SND)* Dr Shnider is the Clinical Academic Lead in Special Needs Dentistry at LaTrobe University School of Rural Health. He is a staff specialist in Special Needs Dentistry at DHSV and has a private specialist practice in Melbourne. Abstract Geriatric healthcare has already changed. We are living longer and we are enduring those additional years with more severe chronic disease and a greater number of chronic diseases. Current mechanisms to improve oral health care for individuals and the community are considered in this paper. We are still yet to measure the effectiveness of these changes. Even more complex is the confusion and conjecture about what we should be measuring and whether what we measure actually has an impact on the quality of life. We are living longer period of time. Ettinger3 and Dolan4 note that in the United States, initiatives launched in the 1990s resulted in a white This simple observation and measurable fact is paper on oral health,4 which made specific recommendations, something that is so very much of our lifetime1(Table 1). As identified expected outcomes and set up a timetable to achieve suggested by the Australian Bureau of Statistics:1 “High life these goals. Some of these recommendations include: expectancy at birth indicates low levels of infant mortality, a • Develop, implement, and evaluate geriatric dentistry safe environment in which to live, a good health care system, clinical competencies and education standards sufficient food, and the adoption of preventative health • Require dental school accreditation standards for measures.” geriatrics education • Establish core competencies in national dental and We are more moribund dental hygiene boards and regional/state licensure board examinations Our longevity is not a particularly attractive place • Educate all health professional students in the principles to be when we experience more severe chronic disease of interdisciplinary team management and include the oral over an extended period of time.2 There is a demonstrable needs of older patients increase in morbidity and disability with increasing age. • Employ continuous quality improvement in dental This has implications for the individual and consequences education and in the dental care of older patients. for the community. There is a spiralling increase in the These goals have been further developed by the International workload of the health care system and demand for suitable Association of Disability and Oral health Education accommodation. The cost to meet these demands is a burden Committee. In a recent report,5 the Committee identified that governments and the private sector cannot continue to specific Aims and Objectives: afford. • To develop core consensus curricula in Special Care Dentistry for countries planning to develop undergraduate We have to change and postgraduate programmes • To encourage IADH member countries to develop We know that there has been a dramatic change in educational programmes sensitive to local needs the ageing population in our lifetime. It is axiomatic that • To present undergraduate and postgraduate core these changes cannot continue unchecked. We must look consensus Curricula to the IADH Congress in 2012 at changing the way we prepare future dental practitioners • To develop Special Interest Groups in Special Care while they are still in undergraduate training programs. We Dentistry. must examine the dental workforce and look at the roles that non-traditional dental providers may provide. Service What, exactly a core consensus curriculum will look like delivery models should be investigated, with the view to is yet to be determined.6,-10 MacEntee11 has suggested that “the assist dentists to work outside traditional dental practice ontology and theory of science, which provides definitions settings. Governments and private sector providers should of health and disease, legitimizes research methods, and work collaboratively to provide services in partnership. influences the role of the clinician”, yet the very nature of geriatric practice must address the psychosocial aspects of Undergraduate Training Programs disability and chronic disease. Geriatric education programs are very likely to embrace a coalescence of the science and The importance of introducing geriatric training programs the humanities if dentists are to effectively address the needs at pre-doctoral or undergraduate level, while dental students of an ageing population. are still at dental school has been recognized for a long * Presented at the Twenty-first Convocation of the Royal Australasian College of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012

WARREN SHNIDER 67 TABLE 1 Population aged 65 and over, by age and sex, 2006 to 2036 Age (years)/Sex 2006* 2016† 2026† 2036† Females 730,000 1,091,000 1,368,000 1,498,000 547,000 624,000 957,000 1,207,000 65–74 225,000 330,000 418,000 75–84 653,000 85+ Total females 65+ 2,045,000 1,502,000 2,744,000 3,357,000 Total females 10,330,000 11,441,000 12,469,000 13,306,000 Males 65–74 700,000 1,057,000 1,294,000 1,424,000 75–84 425,000 536,000 849,000 1,057,000 85+ 108,000 191,000 272,000 456,000 Total males 65+ 1,233,000 1,784,000 2,416,000 2,937,000 Total males 10,225,000 11,368,000 12,405,000 13,230,000 Persons 1,430,000 2,147,000 2,663,000 2,922,000 65-74 972,000 1,160,000 1,806,000 2,264,000 75-84 333,000 1,108,000 85+ 521,000 690,000 6,294,000 Total persons 65+ 2,735,000 3,829,000 5,159,000 26,536,000 Total persons 20,555,000 22,808,000 24,873,000 Census-adjusted estimated resident population, 30 June 2006. † Projections based on 2001 Australian census data. Source: ABS 2006t, 2007b. Dental Workforce significant difficulties for general dental practitioners to incorporate out-of-surgery practice as part of their usual Dentists, Dental Specialists, Dental Prosthetists, Dental routine. Hygienists, Dental Therapists and Oral Health Therapists provide clinical care within a defined scope of practice Some of the obstacles to domiciliary care pertain to the to dental patients in Australia.12 The role of these dental providers themselves.24,25 Wilwert et al.24 in a recent study of workforce members, both here and in other countries, has provision of dental care to a group of Iowa residents notes a wide range of variation13 and is the subject of ongoing that the dentists surveyed indicated that their professional debate.14 Even the most resistive countries, the most notable education did not adequately train them to meet the clinical, being the United States,15,16 are creating training programs psychosocial, communication, or spiritual needs of hospice and defining clinical competencies for complimentary dental patients. health care providers. These more recent developments have occurred because of the realization that dentists alone cannot There is a perceived difficulty as to the availability provide adequate and timely care to vulnerable populations,17 of appropriate domiciliary equipment and difficulties including geriatric patients, now or in the future without transporting it, but in reality the great majority of general additional support. Whether these additional dental providers practice work can be done with a minimum amount of extra should operate independently of a traditional provider or not expense, effort and outlay. is beyond this paper, but there is already published evidence that, albeit in a pilot study, there is a potential for allied Other issues that have been identified include: dental health providers to provide treatment independently • Poor financial remuneration27 with a highly acceptable understanding of the clinical risks • Lack of time28 involved.18,19 • Inability to provide a high standard of work29 • Concerns about adequate infection control30 Practice Settings • Concerns about access to emergency drugs30 Domiciliary oral healthcare has been described as a These difficulties, barriers and issues, although accurate service that reaches out to care for those who cannot reach enough in terms of current concerns, are not insurmountable a service themselves.20,21 Certainly in the United Kingdom, and therefore appear as a collection of excuses to deny the there has been a number of publications and guidelines on isolated frail elderly access to appropriate care. One solution domiciliary care22,23 but anecdotally, there continues to be to address these barriers is to further develop public-private partnership schemes.

68 CHANGING COMPLEXITY OF GERIATRIC HEALTHCARE Collaborative Partnerships 7. Ettinger RL. Meeting oral health needs to promote the well-being of the geriatric population: Educational Research Issues. J Dent Educ 2010;74:29- Partnerships between Governments, communities 35. and health providers are well established. There has been a long and well documented collaboration between 8. Shah N. Teaching, Learning, and assessment in geriatric dentistry: key stakeholders and fluoridation of water supplies.31 Researching models of practice. J Dent Educ 2010;74:20-27. Government administered dental funding schemes for private sector providers, such as The Australian Government 9. Best H. Educational systems and the continuum of care for the older Department of Veteran’s Affairs Dental Scheme32 are adult. J Dent Educ 2010;74:7-12. well utilized. Providers become familiar and comfortable with the idea that a collaborative arrangement exists for 10. Gezzi EM. The development of the Coalition for Oral Health for the certain groups within the population. However, we need to Aging. Spec Care Dent 2011;31:147-149. develop more intricate systems to provide clinical support that is more tailored to the frail elderly population and less 11. MacEntee MI. The Educational Challenge of Dental Geriatrics. J Dent focussed solely on the funding to support such a scheme. Educ 2010;74:13-19. The United States’ Surgeon General’s report on America’s Oral Health33,34 published over ten years ago, suggested 12. Dental Board of Australia. Scope of practice registration standard. a continuing importance to participate in private/public Undated. http://www.dentalboard.gov.au/Registration-Standards.aspx. partnerships35-37. These ideas were based on successful delivery models such as The Central Massachusetts Oral 13. Nash DA, Friedman JW, Kardos TB, Kardos RL, Schwarz E, Satur J, Health Initiative (CMOHI)38 and others. To date, there are a Berg DG, Nasruddin J, Mumghamba EG, Davenport ES, Nagel R. Kentucky, number of ad-hoc, pilot and more sophisticated partnerships USA Dental therapists: a global Perspective Int Dent J 2008;58:61-70. throughout Australia but on the whole they are dislocated and isolated from one another and have not been assessed 14. Hellyer PH. The older dental patient – who cares? Br Dent J 2011; 211: for their effectiveness in the delivery of oral care to specific 109-11. geriatric population groups. Private-Public Partnerships offer real challenges and opportunities to provide oral care 15. Evans C. The principles, competencies, and curriculum for educating to the home-bound frail elderly in the future. dental therapists: a report of the American Association of Public Health Dentistry Panel J Public Health Dent 2011;71:S9-S19. Change for the future 16. Edelstein BL. Training new dental health providers in the United States We have achieved our goal of longevity, and will probably J Public Health Dent 2011;71:S3-S8. continue on that path for the foreseeable future. Our next goal is quality. Our first challenge in that goal is to establish 17. Gallagher JE, Kleinman ER, Harper PR. Modelling workforce skill- what this quality is going to look like. How will we measure mix: how can dental professionals meet the needs and demands of older it? What exactly is “Quality of life”? Various authors have people in England? Br Dent J 2010;208:E6. conducted studies exploring the relationship between oral health and quality of life (OHRQOL)39 but what is actually 18. Hopcraft MS, Morgan MV, Satur JG, Wright FAC. Utilizing dental being measured, and what that measurement means to hygienists to undertake dental examination and referral in residential aged geriatric oral health has been challenged by other authors.40,41 care facilities. Community Dent Oral Epidemiol 2011;39:378-84. Once we have identified quality, we can then measure lack of quality. As dentists, we will be held accountable to observe 19. Calache H, Hopcraft MS. Provision of oral health care to adult patients and record this poor quality, which at some time will be by dental therapists without the prescription of a dentist .J Public Health recognized as elder neglect and abuse.42 Dent 2012;72:19-27. References 20. Fiske J, Lewis D. Domiciliary Dental Care. Dent Update 1999;26:396- 404. 1. Australian Social Trends March 2011 Life expectancy trends - Australia www.abs.gov.au/socialtrends© Commonwealth of Australia 2011 21. Fiske J, Lewis D. Domiciliary Oral Healthcare Dent Update 2011;38:231-44. 2. 4430.0 - Disability, ageing and carers, Australia: summary of findings, 2009 22. Fiske J, Lewis D. Guidelines for the delivery of a domiciliary oral healthcare service. British Society of Disability and Oral Health. 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Newsletter. care in North and West Belfast. Prim Dent Care 2008; 15: 105–11. January 2012. http://www.iadh.org/pdf/2012Winter.pdf. 26. Wilwert MM,Watkins CA, Ettinger RL, Cowen HJ, Fang Qian. 6. Bullock AD, Berkey D, Smith BJ. International education research The involvement of Iowa dentists in hospice care. Spec Care Dentist issues in meeting the oral health needs of geriatric populations: An 2011;31:204-9. introduction. J Dent Education 2010;74:5-6. 27. Sweeney M, Manton S, Kennedy C, Macpherson LM, Turner S. Provision of domiciliary dental care by Scottish dentists: a national survey. Br Dent J 2007;202: E23. 28. De Visschere LM, Vanobbergen JN. Oral healthcare for frail elderly people: actual state and opinions of dentists towards a well-organised community approach. Gerodontology 2006;23:170-6. 29. Freeman R. Adams E. The prediction of dentists’ work behaviour; factors affecting choice or intention in the treatment of special needs patients. Community Dent Health 1991;8:213–9. 30. Sweeney M, Manton S, Kennedy C, Macpherson LM, Turner S. Provision of domiciliary dental care by Scottish dentists: a national survey. Br Dent J 2007;202: E23. 31. Australian Research Centre for Population Oral Health, Dental School, The University of Adelaide, South Australia. The use of fluorides in Australia: guidelines Aust Dent J 2006;51:195-9.

WARREN SHNIDER 69 32. The Australian Government Department of Veteran’s Affairs Dental 40. MacEntee MI, Quality of life as an indicator of oral health in older Scheme. http://www.dva.gov.au/service_providers/dental_allied/dental/ people. J Am Dent Ass 2007;138(9 supplement):47S-52S. 41. Locker D, Allen F. What do measures of ‘oral health-related quality of Pages/dental.aspx life’ measure? Community Dent Oral Epidemiol 2007;35:401-11. 42. Katz RV, Smith BJ, Berkey DB, Guset A, and O’Connor MP. Defining 33. Evans CA, Kleinman DV., The Surgeon General’s report on America’s oral neglect in institutionalized elderly : A consensus definition for the oral health: Opportunities for the dental profession. J Am Dent Ass protection of vulnerable elderly people. J Am Dent Ass 2010;141:433-40. 2000;131:1721-8. Address for correspondence: 34. Lawrence HP, Leake JL.The U.S. Surgeon General’s report on oral Clinical Academic Lead, Special Needs Dentistry health in America: A Canadian Perspective. J Can Dent Assoc 2001; 67:587- Department of Dentistry and Oral Health 96. School of Rural Health La Trobe University Bendigo Campus 35. Chalmers JM, Ettinger RL, Public health issues in geriatric dentistry in Edwards Road the United States. Dent Clin N Am 2008;52:423-46. Flora Hill Victoria 3550 [email protected] 36. Robinson LA. Council on Access, Prevention and interprofessional relations, private sector response to improving oral health care access. Dent Clin N Am 2009;53:523-35. 37. Allukian M Jr, Adekugbe O.The practice and infrastructure of dental public health in the United States. Dent Clin N Am 2008;52:259-80. 38. Silk H, Gusha J, Adler B, Sachs Leicher E, Finison LJ, Huppert ME, Stille S, Yost JB. The Central Massachusetts Oral Health Initiative (CMOHI): a successful public-private community health collaboration. J Public Health Dent 2010;70:308-12 39. Mariño R, Schofield M, Wright C, Calache H, Minichiello V. Self- reported and clinically determined oral health status predictors for quality of life in dentate older migrant adults. Community Dent Oral Epidemiol 2008;36:85-94.

Ann Roy Australas Coll Dent Surg 2012;21:70-71 MANAGEMENT OF THE MEDICALLY COMPROMISED ELDERLY Kerrie Punshon, BDSc, FRACDS (SND)* Dr Punshon is a Specialist in Special Needs Dentistry. She runs a private practice restricted to Special Needs Dentistry in Melbourne, and works one day a week in the Special Needs Department at the Royal Dental Hospital of Melbourne. She teaches Special Needs Dentistry at both Post Graduate and Undergraduate level, at the University of Melbourne, RMIT University, and La Trobe University. With advances in Health Care and our standard of Frail and functionally dependent older adults often have living, we are living longer than ever before. The number physical and cognitive disabilities, and rely on carers to of people who are alive as a result of sophisticated medical assist or provide oral health care, and nutrition. This makes interventions is ever increasing, and people are living longer preventive oral health care much more complex. There have after these interventions. been initiatives to help provide information, support and training to carers in oral health, but currently the oral health Some return to a quality of life similar to their life before status of frail and dependent older adults remains poor.3 the medical intervention. For many however, they continue to live longer with higher levels of disability and dependency. The incidence of edentulism in the community as a whole is dropping, and this is also reflected in projected edentulous We also have a population of developmentally disabled rates for the elderly. It is estimated3 that the incidence of adults who are aging, and also have an increasing life edentulism will drop in 70-74 year olds from 23.3% in 2004- expectancy. 6 to 7.5% in 2021 and 0.3% in 2041. Amongst Australians 85+ years old, the percentages will drop from 42.7% to 23.3 This poses many challenges for oral health professionals. and 3.9% respectively. We are learning more about the interplay between oral In respect to aged care facility residents,4 there are high and general health. We are challenged by the oral effects of levels of oral disease and conditions experienced by many of our patients’medical conditions. This affects daily preventive these residents, including coronal and root caries, gingivitis, oral care as well as the way we provide professional dental plaque accumulation, oral mucosal lesions and denture services to this group of patients. Clinical treatment planning problems. becomes more complex. Many of these problems are evident soon after admission, Our patients may have physical disabilities, movement meaning that the deterioration in oral health has often started disorders, or cognitive disabilities in addition to their prior to admission to aged care facilities. medical and medication issues. Our clinics will require good disabled access, and a willingness to treat patients in a variety There is a trend towards providing support services to of settings. In the clinic, some patients will require a more keep frail and dependent elderly people in their homes for upright position in the dental chair. Our patients may need to as long as possible, and this group also suffer from increased be treated in a wheelchair, or a domiciliary setting. While the oral health problems.4 Perhaps of most concern were the very primary relationship is between the dentist and the patient, high levels of plaque accumulation on residents’ natural teeth we also find ourselves increasingly working with families, and dentures, which places them at high risk for developing carers, residential care facilities, other health care providers, aspiration pneumonia. third party providers, and legal representatives. Barriers that frequently impede residents’ access to dental It is helpful to classify elders in respect to their level of treatment, involve dental professionals, administrators, functioning, rather than by their chronological age. Higher nurses and care staff barriers. levels of dependency, as well as the patient’s medical conditions change the way we approach managing our There has been a great variety of oral hygiene care patients. strategies, programs and staff educational/training initiatives. However, very little of this research has shown long-term The three groups commonly used in classification are maintenance or improvement of residents’ oral health status. Functionally Independent Older Adults, Frail Older Adults, and Functionally Dependent Older Adults.1 Many dental professionals continue to struggle to provide dental treatment, institute preventive oral care Patients will be managed differently depending on which recommendations, and reduce the progression of caries and category they fall into, even though they may have the same other oral diseases and conditions for their institutionalized medical diagnoses. We also live in an age of Minimum patients, especially those with dementia. Intervention Dentistry. This means that increasingly we are using preventive methodologies to manage dental disease.2 There are three components common to all the strategies: oral hygiene care, dental treatment and regular oral * Presented at the Twenty-first Convocation of the Royal Australasian College assessment. of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012 There is a need to delineate the responsibilities for these three key components, to avoid perceived confusion.

KERRIE PUNSHON 71 The solution to high-quality oral health services in long- 3. Spencer AJ, Roberts-Thomson KF 8.5 Projections of prevalence of term care facilities may be considerably more complex than complete tooth loss. In: Slade GD, Ed. Australia’s dental generations: the simply providing on-site services, routines, and resources. National Survey of Adult Oral Health. 2004–06. AIHW cat. no. DEN 165. Attention is needed to the individual facility organizational Canberra: Australian Institute of Health and Welfare. (Dental Statistics and culture, philosophical values and communication patterns. A Research Series No. 34). 2007:234 more prominent role for dental personnel on the health-care 4. Chalmers JM, Spencer AJ, Carter KD, King PL & Wright C 1.1 Oral team of the facility probably offers the greatest likelihood health in residential care. Caring for oral health in Australian residential of improving oral health through increased visibility, active care. Dental statistics and research series no. 48. Cat. no. DEN 193. participation, and regular evaluation of results. Canberra: AIHW.2009: pg 1-2. 5. Aged Care Accreditation Standards 2.15 Oral and dental care. The need to monitor residents’ oral health is also reflected Residents’ oral and dental health is maintained. Produced by the Aged and in the Australian Commonwealth Residential Care Standard Community Care Division of the former Commonwealth Department of 2.15 Oral and Dental Care, which requires that residents’ Health and Family Services (now the Department of Health and Ageing) oral health must be maintained.5 05/03/2008. In conclusion, medically compromised older adults Address for correspondence: comprise an increasing proportion of our population. This PO Box 89 group is an increasingly dentate population and as a group, Blackburn they have a disproportionately high level of oral health needs. Victoria 3130 They are living longer in a disabled state, and their level [email protected] of disability and dependency, in addition to their medical problems pose us with challenges about how to adequately provide for their dental care. References 1. Ettinger RL. Meeting oral health needs to promote the well-being of the geriatric population: educational research issues. J Dent Educ 2010;74:29-35. 2. Mount GJ, Hume WR, eds. Preservation and Restoration of tooth structure. Australia: Knowledge Books and Software, 2005:66.

Ann Roy Australas Coll Dent Surg 2012;21:72-76 INFORMED CONSENT, DEMENTIA AND ORAL HEALTH CARE PROVISION Graeme Ting MSc, MDS, FRACDS, DABSCD, FICD Dr Ting graduated from Otago University and is on long service leave from his post as a Special Needs Dentistry Specialist for Auckland District Health Board. This year he is helping the International Association for Disability and Oral Health, investigating undergraduate and postgraduate curricula for teaching Special Needs Dentistry worldwide Abstract Managing patients with dementia requires a practitioner to exercise diverse skills. Communicating with the patient (as their dementia allows), relatives, caregivers and medical personnel are essential elements in the care process. Diagnosis of oral health problems may not be straightforward, clinical examination and treatment planning may be hampered by poor cooperation from the person with dementia. Practitioners must view any treatment from the patient’s perspective and balance this with the requirements for sound clinical care. The consent process must be approached in a manner that fulfils the ethical responsibilities that acknowledge patient rights. This can be difficult when managing a patient with dementia. This paper will explore issues surrounding the consent process and the provision of oral health care to people suffering from dementia. It is hoped that readers will be stimulated to review their practice; especially related to informed consent, whether they routinely manage patients with dementia or not. Such practice evaluation should consider the wants and needs of patients and families on a broader than clinical basis and thus enhance the care that is brought to this group of interesting and often challenging patients. Introduction disorders affecting the brain become apparent. People diagnosed with dementia have impaired cognitive function This paper is intended to provoke thought related to that in some way impacts on normal living and personal issues surrounding consent and the provision of oral health relationships. Affected people lose analytical ability and can care to people suffering from dementia. It is not intended to be emotionally labile. They may become agitated, delusional be an extensive treatise on law related to informed consent and suffer from hallucinations. Importantly for the oral and dementia, since there are specific publications devoted health team they may have behavioural problems that can to this. It is also not intended to be a cookbook for dementia affect home care, the delivery of care at the dental surgery care since all patients are individuals whose circumstances and the people associated with this aspect of daily living. A are different and constantly changing. Much of what has diagnosis of dementia is made if more than two intellectual been written here on oral health and dementia is a result of functions, for example: cognitive skills – analysis, reasoning more than 10 years of experience by the author, in caring for and judgment; language skills – speech and comprehension; dementia sufferers. It is hoped that readers will be stimulated or memory, are significantly impaired. Memory loss is a to think over their practice, the wants and needs of their common symptom of dementia, but memory loss per se does patients and families and use this paper as a stimulus to not indicate dementia. evaluate their practice related to care provision for this group of challenging patients. Classification of Dementia Background Dementia may be classified based on the part of the brain affected and the progressiveness of the disease. A patient’s The phenomenon of the ageing population is well diagnosis of dementia may involve several aspects of the described. The age demographic of our population is classification system; for example: Alzheimer’s disease is changing when compared with the past. People are living thought of as a progressive and cortical disorder. The table longer and with more complex medical conditions than below provides a broad overview of the thought process before. Advances in health care and medical technology behind the classification systems currently in use (Table 1). along with improved social and living conditions have contributed to this. Other conditions with associated dementia are listed below for completeness but since it is outside the brief of this As the proportion of older people in our population paper to describe dementia in detail, will not be discussed increases so will the proportion of older people with further. The interested reader is encouraged to source further dementia in this cohort. Oral health practitioners are likely information on the topic (Table 2). to be increasingly asked for advice on the management of a person with dementia or they may even be asked to provide The responsibility of assuming the perspective of care. treatment for such a person. What are the key components of good oral health care for Dementia - a brief overview a patient? In particular what are the key components of good care for a patient with dementia and do these differ from care Dementia is not a disease in its own right but is a provided to patients without dementia? It is essential to ask diagnosis that is invoked after the effects of a number of these question when caring for people with dementia because very often these patients cannot communicate their wants or * Presented at the Twentiy-first Convocation of the Royal Australasian College of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012

GRAEME TING 73 TABLE 1 complaints against care providers, there is greater patient Classification of dementia cooperation with care plans and more efficiency in healthcare delivery due to better outcomes achieved in concert with an Primary Dementia: a dementia such as Alzheimer’s “engaged” patient. disease that is not the result of trauma or any other disease. In 2004 Judith H. Hibbard, from the University of Secondary dementia: arises secondarily to trauma or Oregon and colleagues, presented a concept involving other pathology. primary care, patient activation and trust in the physician.1 What does this mean? It means that a care provider views Cortical dementia: affects the cortex of the brain and the health interventions from the patient’s perspective. This manifests itself in problems with memory, language, means that when patients review the intervention they feel cognitive function and social interaction. they have been listened to since the approach, process and outcome are in line with their expectations. Hibbard and Subcortical dementia: affects the brain below the cortex colleagues found the following key points were identified causing changes in emotion, movement and can be by both patients and care providers as key components for accompanied by memory loss. optimum “engagement” and thus the best outcomes (Table 3). Progressive dementia: each of these dementias may TABLE 3 or may not be slowly or rapidly progressive resulting in increasing loss of brain function with time. Hibbard criteria for successful patient engagement TABLE 2 Transfer of knowledge Conditions associated with dementia and dementia-like Ability to self-manage problems symptoms Ability to maintain function and prevent decline Alzheimer’s Disease, Vascular (Multi-Infarct) Dementia, Lewy Body Dementia; Frontotemporal Dementia; HIV- Underlying successful engagement is the practitioner’s associated Dementia, Huntington’s Disease, Dementia ability to transfer knowledge to the patient so the patient Pugilistica, Corticobasal degeneration, Creutzfeldt-Jakob can self-manage problems, maintain function and prevent Disease. decline and thus have an element of control over the health outcomes. This implies that the practitioner has ensured the Dementia or dementia-like symptoms may also be patient’s knowledge is coupled with an appropriate skill set associated with: side effects to medications; metabolic in these areas. The practitioner must also assess and ensure problems and endocrine abnormalities such as the patient has the skills to appropriately collaborate with the thyroid disease, hypoglycaemia, hyponatraemia or provider in order to ensure treatment success. Significantly, hypercalcaemia, or the inability to absorb vitamin B12 it was acknowledged by both patients and practitioners that (pernicious anaemia); nutritional deficiencies such as the patient plays the key role in achieving this. thiamine (vitamin B1), B6, or B12 and severe dehydration; infections such as meningitis, encephalitis, untreated For patients with neurological impairment, it is essential syphilis, and Lyme disease; subdural haematomas; that the care team be sufficiently informed, trained and poisoning such as exposure to lead or other heavy metals, motivated to provide these core skills and carry out appropriate alcohol, recreational drugs or other poisonous substances; “home” management. In 2008, Edwards confirmed other brain tumours; anoxia/hypoxia for example myocardial earlier studies that have shown that providing oral health and cerebral infarction. training for carers in nursing home situations, greatly improves oral health outcomes.2 It is essential that family needs. Sometimes it is a family member who is requesting and caregivers of people with dementia are trained and able treatment, other times a treatment need may be perceived to provide the best oral care possible in the home setting. by a care-worker or a medical practitioner. Therefore the dentist/oral health practitioner takes on the responsibility Informed Consent of assuming the patient’s perspective to determine what good care is and what are valid and reasonable treatment This concept of choices centred on a course of care as options or courses of treatment. In some instances, this is outlined above, melds deeply with the principles of informed straight forward but in many cases (even for patients without consent. Informed consent can be problematic for patients dementia) our training to select from the clinician’s point of with dementia who may rely on other people for appropriate view, the “best” treatment, may not coincide with what the decision-making and “self-management” of health issues. patient perceives as the most appropriate course of care. Of Unfortunately the consent process is often viewed as a course, this becomes more complicated when the patient has mechanical procedure involving getting the patient to sign dementia. a consent form. Informed consent is more than this. The consent signing process is the endpoint that acknowledges Contemporary thinking for optimum patient-practitioner a process has taken place. It is essential that this process has relationships is that a health practitioner should embrace provided the patient with sufficient information enabling an “patient engagement” and this will allow the clinician to informed decision to be made about the treatment. Through view care from the patient’s perspective. If this is done, then this communication process, a patient has been able to patients perceive they have been listened to, there are fewer rationalize the treatment options and their risks and benefits,

74 INFORMED CONSENT, DEMENTIA AND ORAL HEALTH CARE PROVISION choose and agree to a procedure. This should be a patient- and failure to comply with these requirements may be centred process which results in the patient feeling confident considered as medical misconduct. In New Zealand, all that enough information has been given to make a choice and dentists and doctors must be familiar, and comply with, the thus agree to undergo a specific medical intervention. Often Code of Health and Disability Services Consumers’ Rights patients with dementia cannot do this. 1999, its amendment in 2003 and subsequent reviews in 2004 and 2009.5 In Australia, practitioners should follow What were once purely ethical obligations for the Australian Charter of Health Care Rights that while not practitioners in the informed consent process are now legal legally enforceable, mirrors generally accepted common requirements in many places. This acknowledgement of law standards. Australian practitioners should also be aware fundamental patient rights appreciates the independence of the Consent to Medical Treatment and Palliative Care of the patient and that doctor-patient interaction is for the Act,1995. The rights of people with a mental incapacity are patient’s well-being. Complaints against practitioners and governed by the Guardianship and Administration Act, 1993. aspects of their practice have set legal precedents that have moved the consent process from one of ethics to law.3 In addition to this legislation Australian practitioners should also be aware of the regulations in their own state along For an appropriate choice to be made by a patient, a with specific regulations and practices for their workplace.6 practitioner is obliged to discuss as best as possible, the risks, In both Australia and New Zealand, practitioners should also benefits and costs of treatment. This information should be be aware of guidelines published by their governing Dental given at the level of competence and understanding of the Council and Dental Association. patient and so it is necessary that the practitioner is aware of their patient’s level of comprehension. For patients with When is informed consent not necessary? dementia this may be impossible. In this case, the practitioner is obliged to undertake this discussion with whoever is acting There may be rare occasions when it is not necessary for the patient and is signing the consent form. to get informed consent. Practitioners should be aware of the statutes in their practising country. In New Zealand, If a treatment is experimental or part of a research legislative requirements about patient rights and consent project, or the patient will be under a general anaesthetic, or are summarized nicely in a document on the NZ Medical there is significant risk of adverse effects, then the consent Council website.7 For example: some treatments under the must be in writing. Other than in extreme emergencies it is Mental Health Compulsory Treatment Act 1992 , and under also a requirement of the World Health Organisation Patient the Health Act 1956 to prevent the spread of infectious Safety Checklist to ensure a written and signed consent form disease. is completed prior to any operative procedure. The checklist is likely to be introduced into all New Zealand hospitals. Right 7 Section (4) of the Code of Health and Disability Services Consumers’ Rights specifies the circumstances During the discussion process, patients must be given when it is possible to proceed with treatment without the chance to ask questions to improve their understanding consent.5 Every consumer must be presumed competent to and clarify any areas of uncertainty. It is best practice for the make an informed choice and give informed consent, unless operator (and not a delegated representative) to inform and there are reasonable grounds for believing that the consumer discuss the following (Table 4): is not competent.5 The standard for informed consent is that which Where a consumer has diminished competence, that a reasonable patient might expect rather than what a consumer retains the right to make informed choices and reasonable doctor might think (Rogers v Whitaker 1992),4 give informed consent, to the extent appropriate to his or her level of competence.5 TABLE 4 Good practice in discussion with patients and patient rights Where a consumer is not competent to make an informed choice and give informed consent, and no person entitled to during informed consent consent on behalf of the consumer is available, the provider may provide services where: Practitioners should discuss with the patient: A diagnosis (if known); the nature and purpose of the (a) it is in the best interests of the consumer; and treatment or procedure; the risks and benefits of the proposed treatment or procedure; any alternatives to (b) reasonable steps have been taken to ascertain the this treatment or procedure (regardless of their cost or views of the consumer; and availability) and the risks and benefits of the alternative treatment as far as you know them; and the risks and (c) either benefits of not receiving or undergoing a treatment or procedure. (i) if the consumer’s views have been ascertained, and having regard to those views, the provider Patients have the right to: Consider the information believes, on reasonable grounds, that the provision given; ask for clarification and ask for time to consider the of the services is consistent with the informed information; consult with family and others; give consent choice the consumer would make if he or she were or decline to give consent; waive the right to discuss the competent; or details of treatment; after having given consent, change their mind and withdraw the consent. (ii) if the consumer’s views have not been ascertained, the provider takes into account the views of other suitable persons who are interested

GRAEME TING 75 in the welfare of the consumer and available to and xerostomia all have a negative impact and reduce the advise the provider.5 likelihood of a person with dementia maintaining good oral health. Who can give consent on behalf of another? Assessing the treatment needs and treatment planning In New Zealand the only individuals who are entitled for a person with dementia relies on more than just the to grant consent on behalf of a patient are legal guardians traditional intra-oral examination and accompanying (welfare guardians under the Protection of Personal and special tests such as radiographs. While some patients with Property Rights Act, or parents/guardians under the Care dementia may be cooperative for such assessments, in others of Children Act 2004 or someone with enduring power of a clinical examination is not so straightforward. Determining attorney). A spouse or next of kin cannot consent to or refuse if a person with dementia has dental pain can be very medical treatment on behalf of an incompetent person unless problematic. an enduring power of attorney is held or they are their welfare guardian. The individual with that authority can make all The person’s behaviour and the family and caregivers’ healthcare decisions, except for the legal ability to refuse perceptions of treatment needs are also key to treatment consent for lifesaving treatment or medical experimentation. planning. For example, for non-verbal, poorly cooperative Section 18(1) ( c) of The Protection of Personal and Property persons with dementia; they may seem to lose their appetite, Rights Act 1988 specifically forbids the person who has become restless, hit out or become more vocal, not wear enduring power of attorney from refusing consent “to dentures that were previously worn or not allow mouth care the administering ... of any standard medical treatment or such as tooth brushing where they previously did. These procedure intended to save [the patient’s] life or to prevent factors along with a thorough intra-oral examination all serious damage to that person’s health”.8 contribute to making a diagnosis and to treatment planning for care. When dealing with patients with dementia, it is important to reiterate that where they have diminished competence, Commonly, with patients with severe dementia, an they still retain the right to make informed choices and give anaesthetic assessment by an anaesthetist is required to informed consent, to the extent appropriate to their level of ensure the patient is fit enough for general anaesthesia. competence.5 Usually though, a practitioner is prudent to Sometimes, with poorly cooperative patients with dementia, determine if they have an enduring power of attorney. This family and caregivers may be required to wait adjacent to the power of attorney can have powers in relation to property, operating rooms so that treatment planning can be discussed or personal care, or both. A delegated person with enduring after intra-oral examination and x-rays have been performed. power of attorney over personal care is the most appropriate This should be planned, discussed and allowed for in the person to approach in regard to giving consent for health consent process. care. Patients with dementia and some degree of cooperation If, in emergency, immediate action must be taken to can be treated in a conventional dental setting. These preserve the life or health of a patient, then you can provide treatment sessions often need to be short since a patient’s the key services without consent. Only those treatments that attention span may be limited and sometimes treatment are necessary to preserve life or health should be done at this needs to be postponed if the patient is having an “off” time. Any procedure that can reasonably be delayed should day. Communication techniques such as prompting, event be delayed until an opportunity can be given for the patient and concept linking are effective for some patients with to consent. dementia and can facilitate treatment provision and home care. Planning for review and follow up is also an integral Occasionally, when a patient is unable or refuses to part of the treatment sequence. consent to treatment, a legal opinion should be sought with a view to seeking authority from the High Court. Important treatment aims are to eliminate pain, allow the patient to eat and drink, prevent acute problems and Oral Health Care encourage stable long term oral health. This minimizes the need for acute intervention, repeated general anaesthetics and One of the most important factors influencing oral health thus the risks associated with general anaesthesia. Providing in persons with dementia is the severity with which they dental treatment that allows for easy home maintenance, is are affected by dementia. A person with severe cognitive durable, prevents relapse of caries and periodontal problems impairment often lacks the insight and ability to communicate are important clinical goals. Caregiver education, motivation a treatment need, consent to a procedure, cooperate with care and assistance with home care are important for successful and often requires complex care provision under general outcomes. anaesthesia. They also have problems receiving important home care on a daily basis. This, coupled with potential Summary problems of high carbohydrate intake and the xerostomic effects of medications can result in a rapid decline in oral At the core of good oral care is a practitioner with good health status. The motivation, knowledge and willingness communication skills. These skills are used to interact with of care workers to provide daily oral hygiene is also an family, caregivers and other health care providers such as important factor. nurses and medical practitioners to ensure the best outcome for patients with dementia. In particular, families have a key Past interventions (for example, a heavily restored part to play in long-term dementia care since they are often dentition), poor diet, untreated periodontal disease, caries

76 INFORMED CONSENT, DEMENTIA AND ORAL HEALTH CARE PROVISION aware of the spiritual and cultural history of the person with 3. Gore D. Ethical, professional, and legal obligations in clinical practice: a dementia and can provide valuable insight into the patient’s series of discussion topics for postgraduate medical education. Introduction life and alongside other care providers contribute to their and topic 1: informed consent. Postgrad Med J 2001;77:238-9. loved one’s care. 4. Rogers v Whitaker [1992] HCA 58; 175 CLR 479 (19 November 1992). High Court of Australia (1992). When these communication skills are used to create a 5. Website of the Health and Disability Commissioner, New Zealand. situation where all parties agree on sound treatment goals; http://www.hdc.org.nz/the-act--code/the-code-of-rights (Accessed: January this enables the practitioner to execute the best treatment 2012). options. The result is predictable, stable and maintainable 6. Website for the Legal Services Commission of South Australia; oral health for our patients with dementia. http://www.lawhandbook.sa.gov.au/ch28s01.php (Accessed: January 2012). 7. Website for the Medical Council of New Zealand. http://www.mcnz. Acknowledgments org.nz/portals/0/publications/2011%20-%20Information%20and%20 Consent.pdf. (Accessed January 2012). Grateful acknowledgement is made to all of the staff 8. Fyfe J, Connolly A, Bond B. Chapter 9: Informed Consent in Cole’s of the Oral Health Regional Service, the Department of Medical Practice in New Zealand 2011, 10th Edition. Editor: St. George, I. Anaesthesia, and the Operating Theatres at Auckland and Pages 85-91. ISBN 978-0-9582792-7-7. Published by the Medical Council Green Lane Hospitals, Auckland District Health Board, of New Zealand, August 2010. Auckland, New Zealand. Their outstanding assistance has helped me to manage patients with many different Address for Correspondence presentations of dementia and provide them with oral health Abraham Kuyperplein 9 care that they otherwise may not have received. 2314EW Leiden The Netherlands References [email protected] 1. Hibbard J, Stockard J, Mahoney E, Tusler M. Development of the Patient Activation Measure (PAM): Conceptualising and Measuring Activation in Patients and Consumers. Health Services Research, 2004; 39. 2. Edwards M. Staff training improved oral hygiene in patients following stroke. Evid Based Dent 2008; 9:73.

Ann Roy Australas Coll Dent Surg 2012;21:77-80 WORKFORCE EDUCATION – THE CO-ORDINATION OF ORAL HEALTH CARE FOR THE ELDERLY – THE ROLE OF THE DENTAL PROFESSION Gelsomina L. Borromeo, BDSc, MScMed, PhD, FFPMANZCA, FRACDS(SND)* Dr Borromeo is Convener of and Specialist in Special Needs Dentistry at the Melbourne Dental School of the University of Melbourne. Abstract It is a well-understood fact that the world’s population is ageing. Concomitant with that is an increase in the chronicity of disease including dental disease. The challenges faced by the dental profession in managing patients as they age are becoming increasingly important. What do we know and understand about diseases and their impact on dental health in the elderly? What role do salivary dysfunction and biofilms play and how are these integrated with general and oral health? Are we really prepared to manage the impact of these factors and what is the profession doing to better equip itself for the inevitable change to dental practice that is likely to ensue? Dental education in Special Needs Dentistry and in particular geriatric care expands beyond the realms of the University setting. There is potential to expand knowledge in dental care amongst the elderly through continuing professional development that is now mandatory across Australia and New Zealand. Training should not be limited to University curricula. It should extend to include medical and allied health staff, staff in aged care facilities and all those involved in policy and decision making for the elderly. The aim of this paper is to address where education in geriatric oral health is currently placed and the role to be played by all key stakeholders from University to Community arenas. Introduction Geriatrics is concerned with the health care of the elderly and includes clinical, preventive, remedial and social aspects We live in an ageing population where chronicity of of illness.10 Ageing impacts on cellular function leading to disease will increase over the coming years. The impact of disrupted organ function and ultimately cessation of life.11 dental status on oral health related quality of life shows quite Older individuals can be subdivided according to the older clearly that for example the ability to chew or the perception adult, the frail elderly and the functionally dependent all of dry mouth are significant in ones overall general well of whom can have complex dental needs. In general, if being.1,2 There is clear evidence to support the link between an individual ages and has little or no medical issues then oral health and general health with aspiration pneumonia routine dental treatment should pose no extended challenges being one of the key causes of comorbidity in the elderly for the dental profession.12 However if medical issues arise which is linked directly to oral status.3-7 Together with this it or individuals becomes physically disabled or cognitively is well documented that individuals are retaining their teeth impaired as they age then this impacts on oral health and in longer.8 Hence there is a significant need today and into the turn dentistry. future to address issues related to aged care and in particular dental care from both medical and dental perspectives. Geriatric dentistry itself pertains to dental care for those Dental health in the elderly is unique. It is influenced by with “one or more chronic, debilitating, physical or mental multiple factors such as complex and chronic medical illness with associated medications and/or psychosocial histories, polypharmacy, impaired or limited mobility, frailty problems”.12 and variations in cognitive ability. It is also important to consider inclusion of individuals who are chronologically Workforce education young and have significant medical comorbidities such that they have fall into the criteria of geriatric. The oral health needs of individuals as they age are the responsibility of the whole dental profession. Ettinger The focus of dentistry is also changing to a more and Beck classified individuals and the respective levels integrated medical and social model where medicine and of dental care required and reported that the older adult dentistry must be more closely aligned. Education at all should be managed by the general dentist, the frail elderly levels needs to keep up to speed with all these changes. It was by those with further training and the functionally dependent recognized 20 years ago that geriatric dental education itself by those specifically trained to meet the complex needs of needed to be interdisciplinary in order to be able to meet hospitalized, home bound and institutionalized individuals, the potential challenges for this group of patients.9 Dental perhaps today, the Special Needs Specialist.12 This task is not professionals need to be more involved in interdisciplinary difficult as long as we have an understanding of rational care education in order to ensure optimal oral health care of their and treatment planning. Part of the role we as a profession patients as they age and as such education needs to impact at need to engage in is educating all key stakeholders involved all levels where oral health is a factor. in the care of these patients. Furthermore we need to address ways of measuring competency in dental geriatric education * Presented at the Twentiy-first Convocation of the Royal Australasian College at all levels to ensure consistency across all domains. of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012 Teaching should not be limited to a classroom setting as we all have different learning styles. Information can be

78 CO-ORDINATION OF ORAL HEALTH CARE FOR THE ELDERLY disseminated through a range of formats including lectures, material regarding dental needs of the ageing were covered interactive multimedia, videoconferencing, role plays, in other CPD courses.26 webcasting, internet broadcasting and virtual simulations.13 There is considerable variability worldwide in terms University dental curricula of types and delivery of CPD in dentistry and whether it should constitute attendance at courses or simply reading of Education in geriatric dentistry is fundamental to dental scientific literature.27-29 Buck and Newton showed that the practice especially as we are living in an ageing population majority of those surveyed in a single UK study reported and individuals are retaining teeth well into their senior that the main form of CPD (87%) consisted of reading of years. If we are to consider educating our non-dental journals.28 Reading, together with informal interactions with colleagues we need to first look at our own current level of colleagues, has also been shown to be the main methods for understanding. Dental students should be exposed to ageing keeping up to date with dentistry where CPD requirements patients and be given sufficient didactic training to manage were not mandatory.30 Interestingly, those surveyed chose to them and have insight into the importance of caring for this read local journals, maybe due to language barriers, rather patient cohort.14,15 than international journals thereby questioning the quality of what Italian dentists were reading.30 A number of dental schools worldwide offer varied didactic and clinical training in geriatric dentistry and core The level of CPD one undertakes is also governed by competencies have been identified in some Centres.16-21 At whether the CPD is mandatory or voluntary with lower the Melbourne Dental School undergraduate dental students uptake in the latter case.31 In addition, it is unclear whether and Bachelor of Oral Health students are taught geriatric CPD in and of itself produces change in overall dental dentistry as part of Special Needs Dentistry. Other dental practice or guarantees competence or improved standards schools support the concept of geriatric dentistry as part of of practice and what form of CPD produces better clinical the dental curriculum but the amount of teaching is restricted outcomes or in fact one’s overall motivation for participating by staffing levels, competing curricula and financial in such programs. It has been shown in some countries constraints.22,23 This is no different at the Melbourne Dental CPD is only considered beneficial in terms of improving School and would be the case at all Dental Schools globally. promotion capabilities rather than being seen as improving In some circumstances, geriatric dentistry is considered a better clinical outcomes.29 lower priority compared with other dental disciplines.24 In contrast, some Universities offer a Doctor of Philosophy In the context of mandatory CPD it is also worth qualification specific to geriatric dentistry.16 considering the next level, that is, within this framework what individual courses should be mandatory. One study Continuing Professional Development reporting that only CPR and infection control should fall into this category.32 This however makes it difficult when In order to ensure adequate oral health care exists determining how CPD marries with clinical practice. A range in the ageing population it is essential to determine the of different CPD courses are offered but what governs topics level of understanding of all key stakeholders. The dental and contents is unclear other than to assume it is driven by team includes dentists, oral health practitioners, dental current trends in clinical practice. Topics often range from prosthetists, dental assistants and practice mangers and these popular areas such as Restorative Dentistry and Endodontics are certainly key persons in the delivery of dental services with hands on components to improve clinical skills in to the elderly. However, they are not the only individuals favour of less popular areas such as Special Needs Dentistry involved in the management of the elderly patient. Medical including geriatric oral health.31,32 It is impossible to do practitioners, geriatricians, Directors of Nursing, carers, every CPD course available, however perhaps they should nurses, nursing assistants, aids, kitchen staff, pastoral care be categorized with dental health professionals having to workers and family members also play a key role in ensuring choose a set number in different categories. This would allow individuals maintain good oral health well into old age. The for a broader case mix of the types of course one selects. level of knowledge amongst each of these groups is varied but it is important that commonalty exists in order to ensure Whilst CPD within the profession is essential, oral that the individual’s oral health is optimal. health education should not be restricted to us alone. Those at the forefront of managing aged patients should also have Continuing professional development (CPD) would access to oral health education with the converse following be the optimal method of delivery of appropriate material that oral health practitioners should acquire knowledge in dental aged care. Such courses should be available to regarding overall medical and allied health care. An all facets of the dental profession.13 There is however very interdisciplinary approach to improving oral health care for little information on the level of CPD offered across the the elderly would benefit all key stakeholders and result in dental profession. For instance, little is know regarding improved care for patients.33 Not all are in agreement with CPD activities amongst prosthetists with one pilot study this concept. Physicians for example reported that dentists unable to determine consensus on CPD policy let alone were not relevant in patient care centred discussions despite course content.25 Kress analysed the role of CPD in geriatric pushes for interdisciplinary integrated health care models dentistry and reported that lack of demand was the greatest on a broader platform.34,35 Interestingly, a survey on inter- barrier to geriatric CPD amongst dentists.26 Lack of professional education highlighted geriatric care clinics as appropriately trained teachers and avoidance of the elderly one of the most common interdisciplinary clinics involving were also cited. Interestingly some respondents reported that

GELSOMINA BORROMEO 79 dentists.35 Disappointingly also was the admission of a lack 4. Terpenning MS, Taylor GW, Lopatin DE, Kerr CK, Dominguez BL, of willingness by some health care professions in academia Loesche WJ. Aspiration pneumonia: dental and oral risk factors in an older to move to inter-professional education citing reasons such veteran population. J Am Geriatr Soc. 2001;49:557-63. as lack of scientific evidence for its effectiveness.35 As with CPD in the dental profession and dental education at 5. Pace CC, McCullough GH. The association between oral the university level, issues of time management, crowded microorgansims and aspiration pneumonia in the institutionalized elderly: curricula, infrastructure and expertise in content delivery review and recommendations. Dysphagia 2010;25:307-22. are issues that face delivering such courses within aged care facilities and the community at large.35 6. Oh E, Weintraub N, Dhanani S. Can we prevent aspiration pneumonia in the nursing home? J Am Med Dir Assoc 2004;5:174-9. There have been recommendations that oral health education be integrated into in-service training at aged 7. Langmore SE, Terpenning MS, Schork A, Chen Y, Murray JT, Lopatin care facilities.36 In aged care facilities the amount of oral D, et al. Predictors of aspiration pneumonia: how important is dysphagia? care provided is governed by the mindset of the staff and, Dysphagia 1998;13(2):69-81. in particular, the priorities set by the directors.37-39 In aged care facilities Directors of Nursing felt less informed about 8. Berkey D, Berg R. Geriatric oral health issues in the United States. Int the oral health needs of residents and oral health care was Dent J 2001;51:254-64. often left to nursing assistants or registered nurses with tooth brushing being by far the most performed dental 9. Dolan TA. Is dental education in step with current geriatric health intervention.34,40 Oral health care was less important where promotion initiatives? J Dent Educ 1992;56:632-5. time constraints, finances or physical limitations were an issue.37,39,40 Furthermore, the role played by nursing assistants 10. Medicine Io. Ageing and Medical Education: National Academy of and aids in oral health care of residents in aged care facilities Sciences; 1978. revealed concerns for oral care centring around behavioural issues with time constraints and staffing levels significant 11. Izaks GJ, Westendorp RG. Ill or just old? Towards a conceptual factors in provision of oral care.34,41,42 Despite this, however, framework of the relation between ageing and disease. BMC geriatrics. most nursing assistants felt able to provide oral care despite 2003;3:7. some having no oral health education.34 Some nursing staff (54%) reported poor knowledge of current oral health whilst 12. Ettinger RL, Beck JD. Geriatric dentistry: is there such a discipline? others reported lack of available education in oral health Aust Dent J 1984;29:355-61. care as well as poor communication between themselves and dentists.34,37 It is unclear how knowledge is measured or what 13. Shah N. Teaching, learning, and assessment in geriatric dentistry: training if any the nursing assistants receive or what ongoing researching models of practice. J Dent Educ 2010;74:20-8. training is available. 14. Ettinger RL, Beck JD. Geriatric dental curriculum and the needs of the Another key stakeholder in geriatric patient care is the elderly. Spec Care Dentist 1984;4:207-13. physician. Despite this, however, their understanding of the oral cavity and its links with general health can be varied. 15. Anehosur GV, Nadiger RK. Evaluation of understanding levels of One study reported that only 17% of physicians felt the “the Indian dental students’ knowledge and perceptions regarding older adults. oral cavity was primarily an integrated part of the body” and Gerodontology 2010 ePub. 22% felt it was not “part of their profession”.34 Interestingly, a large number felt oral health training would be of value in 16. Kitagawa N, Sato Y, Komabayashi T. Graduate and undergraduate managing these patients.34 geriatric dentistry education in a selected dental school in Japan. Eur J Dent Educ 2011;15:231-5. Conclusion 17. Preshaw PM, Mohammad AR. Geriatric dentistry education in Oral health care for the elderly is a multifactorial European dental schools. Eur J Dent Educ 2005;9:73-7. issue involving key stakeholders across a broad range of disciplines. CPD aimed at improving knowledge and better 18. Chavez EM, LaBarre EE. A predoctoral clinical geriatric dentistry dental health care for the elderly should be delivered at a rotation at the University of the Pacific School of Dentistry. J Dent Educ number of differing forums. It is imperative that oral health 2004;68:454-9. education for elderly citizens keeps pace with current trends including the evidence base for clinical practice. 19. Dolan TA, Lauer DS. Delphi study to identify core competencies in geriatric dentistry. Spec Care Dentist 2001;21:191-7. References 20. MohammadAR, Preshaw PM, Ettinger RL. Current status of predoctoral 1. Brennan DS, Spencer AJ, Roberts-Thomson KF. Tooth loss, chewing geriatric education in U.S. dental schools. J Dent Educ 2003;67:509-14. ability and quality of life. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation 2008;17:227- 21. Nitschke I, Muller F, Ilgner A, Reiber T. Undergraduate teaching in 35. Epub 2007/12/14. gerodontology in Austria, Switzerland and Germany. Gerodontology 2004;21:123-9. 2. Willumsen T, Fjaera B, Eide H. Oral health-related quality of life in patients receiving home-care nursing: associations with aspects of dental 22. Saunders RH, Yellowitz JA, Dolan TA, Smith BJ. Trends in predoctoral status and xerostomia. Gerodontology. 2010;27:251-7. education in geriatric dentistry. J Dent Educ 1998;62:314-8. 3. Paju S, Scannapieco FA. Oral biofilms, periodontitis, and pulmonary 23. Mann J, Bomberg TJ, Holtzman JM, Berkey DB. Current status of infections. Oral Dis 2007;13:508-12. Geriatric Dentistry Educational Activities in U.S. dental schools. J Dent Educ 1987;51:705-8. 24. Berkey DB. Geriatric dentistry at the crossroads. J Dent Educ 1996;60:939-42. 25. Reeson MG, Jepson NA. Professional development for dental technicians; a pilot study. Br Dent J 2007;202:685-9. 26. Kress G. An analysis of the supply of and demand for continuing education in geriatric dentistry. Spec Care Dentist 1991;11:151-4. 27. Schleyer T, Eaton KA, Mock D, Barac’h V. Comparison of dental licensure, specialization and continuing education in five countries. Eur J Dent Educ 2002;6:153-61. 28. Buck D, Newton T. Continuing professional development amongst dental practitioners in the United Kingdom: how far are we from lifelong learning targets? Eur J Dent Educ 2002;6:36-9. 29. Wu ZY, Zhang ZY, Jiang XQ, Guo L. Comparison of dental education and professional development between mainland China and North America. Eur J Dent Educ 2010;14:106-12. Epub 2010/06/05. 30. Nieri M, Mauro S. Continuing professional development of dental practitioners in Prato, Italy. J Dent Educ 2008;72:616-25. Epub 2008/05/03.

80 CO-ORDINATION OF ORAL HEALTH CARE FOR THE ELDERLY 31. Abbott P, Burgess K, Wang E, Kim K. Analysis of dentists’ participation 39. Rabbo MA, Mitov G, Gebhart F, Pospiech P. Dental care and treatment in continuing professional development courses from 2001-2006. Open needs of elderly in nursing homes in Saarland: perceptions of the homes Dent J 2010;4:179-84. Epub 2011/02/23. managers. Gerodontology 2011. 40. Pyle MA, Jasinevicius TR, Sawyer DR, Madsen J. Nursing home 32. Hopcraft MS, Marks G, Manton DJ. Participation in continuing executive directors’ perception of oral care in long-term care facilities. Spec professional development by Victorian dental practitioners in 2004. Aust Care Dentist 2005;25:111-7. Dent J 2008;53:133-9. 41. Chalmers JM, Levy SM, Buckwalter KC, Ettinger RL, Kambhu PP. Factors influencing nurses’ aides’ provision of oral care for nursing facility 33. Coleman P. Opportunities for nursing-dental collaboration: addressing residents. Spec Care Dentist 1996;16:71-9. oral health needs among the elderly. Nursing outlook 2005;53:33-9. 42. Pyle MA, Nelson S, Sawyer DR. Nursing assistants’ opinions of oral health care provision. Spec Care Dentist 1999;19:112-7. 34. Chung JP, Mojon P, Budtz-Jorgensen E. Dental care of elderly in nursing homes: perceptions of managers, nurses, and physicians. Spec Care Address for correspondence: Dentist 2000;20:12-7. Melbourne Dental School 720 Swanston Street .35. Rafter ME, Pesun IJ, Herren M, Linfante JC, Mina M, Wu CD, et Victoria, 3010, Australia al. A preliminary survey of interprofessional education. J Dent Educ [email protected] 2006;70:417-27. 36. McKelvey VA, Thomson WM, Ayers KM. A qualitative study of oral health knowledge and attitudes among staff caring for older people in Dunedin long-term care facilities. N Z Dent J 2003;99:98-103. 37. Logan HL, Ettinger R, McLeran H, Casko R, Dal Secco D. Common misconceptions about oral health in the older adult: nursing practices. Spec Care Dentist 1991;11:243-7. 38. Smith BJ, Ghezzi EM, Manz MC, Markova CP. Perceptions of oral health adequacy and access in Michigan nursing facilities. Gerodontology 2008;25:89-98.

Ann Roy Australas Coll Dent Surg 2012;21:81-84 PERIODONTAL TREATMENT AND SYSTEMIC CONDITIONS Saso Ivanovski, BDSc, BDentSt, MDSc (Perio), PhD, FICD* Saso Ivanovski is Professor of Periodontology, School of Dentistry and Oral Health, Griffith University, Gold Coast, Australia. Abstract It has been reported that patients with periodontal disease have a greater prevalence of systemic disease than the general population. Furthermore, we are faced with an ageing population that is retaining its teeth for longer, and tends to present for periodontal management with a variety of systemic conditions. There is ample evidence to show that periodontal treatment results in a systemic response, which includes bacteraemia and systemic inflammatory cytokine release. Certain systemic conditions present unique challenges in the treatment of periodontal disease. These conditions include cardiovascular disease, diabetes mellitus and cancer. The various treatment modalities for these systemic diseases can impact on periodontal treatment, and conversely periodontal treatment can influence systemic conditions and their management. Close collaboration with the treating physician and timely provision of periodontal treatment are important considerations of managing the systemically compromised patient. Introduction practices in Brisbane, periodontal patients were found to have a higher prevalence of systemic diseases.6 Furthermore, Periodontitis is a highly prevalent chronic inflammatory patients with periodontitis also took more medications and disease. The prevalence of periodontitis and the extent were more likely to suffer from multiple conditions compared of attachment loss both increase considerably with age.1 with the general dental population. The association of periodontitis with a variety of systemic conditions, including cardiovascular disease, diabetes Systemic effects of periodontal treatment mellitus and adverse pregnancy outcomes, has been established, although a causative relationship is yet to be It is recognized that periodontal treatment can lead to confirmed.2 bacteraemia, with even the process of full mouth probing inducing bacteraemia in 40% of patients with periodontitis.7 Periodontitis progression is characterized by periodontal Furthermore, the incidence and magnitude of bacteraemia attachment loss and apical extension of epithelium, after scaling was significantly higher in periodontitis than in creating a periodontal ‘pocket’. In untreated periodontitis, gingivitis patients and healthy control individuals.8 the epithelium in the periodontal pocket is ulcerated and permeable. During periodontal treatment, which involves Subjects with periodontitis present with elevated levels of mechanical debridement of the root surface, the ulcerated inflammation in their bloodstream as demonstrated by higher epithelium lining is disturbed resulting in bacteraemia and numbers of circulating neutrophils or a higher concentration systemic inflammatory cytokine release. Given that the of acute-phase markers such as C-reactive protein (CRP).9 total area of ulcerated epithelium in untreated periodontitis The magnitude of this difference is clinically significant as may be up to 4000 mm2, it is biologically plausable it is large enough to shift subjects between the identified that periodontal treatment may have a systemic effect.3 classes of CRP-associated cardiovascular risk. Furthermore, periodontal treatment may be influenced by systemic diseases, such as cardiovascular disease, cancer and It has been shown that periodontal therapy can result in diabetes, or the therapeutic management of these diseases. a dose-dependent improvement in systemic inflammatory This review examines issues related to the bi-directional markers.10,11 Furthermore, the better the clinical outcome of relationship between periodontal treatment and systemic periodontal therapy, the larger the magnitude of the decrease disease, with a particular emphasis on the management of in systemic markers of inflammation.11 These findings medically compromised patients. reiterate the positive systemic effects of periodontal treatment on systemic health. However, although the ultimately lower Incidence of systemic disease in periodontally levels of inflammation may result in decreased incidence of systemic disease, the short term increases in inflammatory compromised patients burden is a consideration particularly in systemically compromised patients. Several studies have investigated the incidence of systemic disease in patients with periodontal disease. When considering the interaction of periodontal and Generally, it has been reported that approximately 50% of systemic health, an over-arching paradigm is that periodontal these patients suffered from a systemic disorder, and the treatment, consisting of professional debridement, good frequency of systemic diseases increased with increasing personal oral hygiene and regular supportive periodontal age.4,5 In a study comparing general practice and specialist therapy, results in periodontal disease resolution and reduced periodontal practice patients from both private and public inflammation, and hence is paramount in mitigating the effects of periodontal disease and treatment on systemic * Presented at the Twenty-first Convocation of the Royal Australasian College disease. of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012

82 PERIODONTAL TREATMENT AND SYSTEMIC CONDITIONS Treatment of Systemically Compromised Patients comprehensive review of the literature, only one case-control study met the inclusion criteria, and no significant effect Cardiovascular disease of penicillin prophylaxis on the incidence of endocarditis could be seen. The authors concluded that there was no The primary management goal for the patient with evidence about whether penicillin prophylaxis is effective cardiovascular disease during periodontal therapy is to or ineffective against bacterial endocarditis in people at risk ensure that the cardiovascular capacity of the patient is not who are about to undergo an invasive dental procedure. exceeded as a result of periodontal treatment.12 This is best achieved by minimizing the impact of treatment on alterations Following a revision of UK and USA guidelines in 2006 of blood pressure, heart rate, heart rhythm, cardiac output, and 2007 respectively, which considerably reduced the and myocardial oxygen demand. Additionally, psychological categories of cardiac conditions which required antibiotic and physiological stress during periodontal treatment has prophylaxis for dental or other mucosally invasive procedures, the potential to significantly alter haemodynamic stability. new Australian guidelines for the prevention of infective Consequently, a stress reduction protocol should be endocarditis were published in July 2008.14 These guidelines implemented for patients with significant cardiovascular outline a limited list of conditions that require antibiotic disease. This approach could include shorter appointments prophylaxis: a) prosthetic cardiac valves, b) previous preferably in the morning when the patient is well rested, the infective endocarditis, c) congenital heart disease but only if use of adequate local anaesthesia to minimize discomfort, it involves unrepaired cyanotic defects, completely repaired preoperative and/or intraoperative conscious sedation, and defects with prosthetic material during the first six months adequate postoperative analgesia. The above guidelines are after the procedure, and residual defects at or adjacent to the recommended for patients with hypertension, stable angina, site of a prosthetic patch or device, d) cardiac transplantation and treatments undertaken more than six months following with the subsequent development of cardiac valvulopathy, myocardial infarction. It is noteworthy however that these and e) rheumatic heart disease in Indigenous Australians recommendations present a ‘common sense approach’ only. The guidelines also outline dental procedures which based on consensus opinion established by experience and always, sometimes and never require antibiotic prophylaxis informed clinical judgment, and have not necessarily been for the abovementioned procedures. Notably, several validated by controlled clinical trials. procedures commonly carried out in periodontal practice are in the category where prophylaxis is always required There are certain severe cardiovascular conditions and these are periodontal procedures including surgery, which contraindicate elective periodontal therapy. These subgingival scaling and root planing, as well as extractions include severe/uncontrolled hypertension, uncontrolled and implant placement. Dental procedures where prophylaxis angina, uncontrolled arrhythmias and treatment within is recommended only in the presence of periodontal disease six months following myocardial infarction. If emergency include full periodontal probing and supragingival calculus dental care is needed in these patients, the treating physician removal/cleaning. should be consulted. It may be necessary to provide preoperative anxiolytic medication for stress reduction, Anticoagulant Therapy closely monitor the patient’s haemodynamic status and oxygen saturation before and during treatment, administer Anticoagulant therapy is widely used for the prevention supplemental oxygen and provide intravenous access for and complications of cardiovascular disease. These the administration of intraoperative sedative agents. This medications can influence surgical periodontal treatment therapy may best be provided in a controlled medical by increasing post-operative bleeding. However, decisions environment such as a hospital setting. Acute dental needs to change anticoagulant therapy regimes should be taken should be addressed definitively, since continued pain may with care as a key issue is to balance the risk of bleeding potentiate haemodynamic alterations or dangerous cardiac from a dental wound compared with the risk of intravascular arrhythmias. thrombi and emboli leading to stroke. Close consultation with the treating physician is important, with consideration Prophylactic Antibiotic Therapy of the coagulation status of the patient as measured by the ‘prothrombin time’ and reported as an International Antibiotic prophylaxis has been routinely used in the past Normalised Ratio (INR) value. to prevent infective endocarditis in patients with valvular disease, and post-operative infection in patients receiving Commonly utilized anti-platelet drugs, such as aspirin, hip prostheses. However, these prophylactic guidelines do not affect the INR but can increase bleeding times. They were not based on controlled clinical studies. Indeed, there do not usually require changes to the normal routine prior to has never been a blind, placebo-controlled human study on periodontal treatment, although care should be taken with antibiotic prophylaxis for the prevention of endocarditis. surgical techniques. More elaborate planning is necessary Furthermore, evidence for the use of prophylactic antibiotic for patients taking the commonly utilized anti-coagulant therapy in the joint replacement patient is primarily in the warfarin and requiring periodontal surgery or extractions.15 form of case reports. In these cases, an INR reading should be obtained within 24 hours of the surgical procedure. If the INR is less than A Cochrane Systematic review published in 2008 2.2, the patient can be treated as per normal routine, while examined the question ‘Does prophylactic antibiotic if the INR is over 4, surgery is contraindicated. If the INR is administration before invasive dental procedures in people between 2.2 and 4, surgery can be carried out with appropriate at increased risk of bacterial endocarditis influence mortality, serious illness or endocarditis incidence?’.13 Despite a

SASO IVANOVSKI 83 planning and care, adequate suturing and possibly the use of being preferable. Orthodontic extrusion is also an option a local haemostatic agent. Additionally, an antifibrinolytic for tooth removal in these patients. Notably, the incidence (tranexamic acid) mouthwash is prescribed to be used four of BRONJ in patients taking oral doses of bisphosphonates times daily for 2 minutes, for up to 5 days. (e.g., Fosamax taken once weekly) for the management/ prevention of osteoporosis is relatively rare, and likely linked Cancer treatment to the duration of bisphosphonate treatment and local factors such as the quality of self-performed oral hygiene. Informed As the population ages, an increasing number of cancer consent, risk assessment and careful surgical technique are patients will require dental treatment to maintain oral important considerations in these patients. health. Both chemotherapy and radiation therapy produce a wide range of oral complications.12,15,16 Patients undergoing Diabetes Mellitus radiation therapy may develop dermatitis, mucositis, loss of taste, xerostomia, radiation-induced caries, hypovascularity, There is a strong association between both diabetes osteoradionecrosis, and a variety of bacterial, fungal, and mellitus types I and II and periodontitis.18 Therefore, viral infections. Due to the cytotoxicity of the agents used, evaluation of the potential impact of diabetes mellitus on mucositis may be even more severe during chemotherapy. periodontal treatment planning requires accurate assessment Chemotherapy may also cause xerostomia, but, unlike that of the level of metabolic control, duration of disease and associated with radiation therapy, it is generally reversible types of medications used. The advent of ‘at-home’ blood following administration of chemotherapeutic agents. glucose monitoring and glycosylated haemoglobin assays Secondary infection of areas with ulceration or mucositis have improved the ability to objectively determine the degree may lead to septicaemia. of both short- and long-term metabolic control. However, the mere existence of diabetes does not necessarily result in a It is critical that dental treatment needs be assessed less favourable response to periodontal therapy, nor does it as soon as a definitive diagnosis has been rendered and a suggest an absolute need for alterations in the periodontal decision is made to initiate a radiation or chemotherapy treatment plan. The well-controlled diabetic patient is similar protocol. Early involvement by the periodontist in the to non-diabetic individuals relative to treatment planning overall treatment protocol provides particular benefit to and expected response to therapy. On the other hand, patients patients undergoing cancer therapy. Patients embarking on with poorly controlled diabetes experience significantly chemotherapy or radiation therapy protocols need a complete greater periodontal attachment loss compared with patients dental examination and treatment to eliminate potential with well-controlled diabetes or those without diabetes. sources of infection and establish a personal oral hygiene regimen compatible with long-term health. Notably, there is emerging evidence of a two-way relationship between periodontitis and diabetes—diabetes Once dental extractions become unavoidable after can lead to poor periodontal health, and poor periodontal radiotherapy they can be performed by specialists with health can make it difficult to control diabetes.19 Indeed, appropriate surgical techniques, adjuvant therapies and periodontal treatment intervention studies in diabetes rigorous follow-up after the surgical procedures. In general, patients have shown that treatment for periodontitis may hyperbaric oxygenation and antibiotics have been considered improve glycaemic control; however, further studies are favourable when used as adjuvants in dental extractions needed to confirm these findings. after radiotherapy, contributing to a low frequency of complications,16 If periodontal treatment is needed during Conclusions chemotherapy, it is best done the day before the drugs are given, when white cell counts are relatively high. Thus, There is a well established association between coordination with the oncologist is critical. periodontal status and a variety of systemic conditions, especially cardiovascular disease and diabetes. Periodontitis Drugs which have received increasing attention in recent has been shown to increase the systemic inflammatory years belong to the bisphosphonate group, which are ‘bone- ‘burden’, and periodontal treatment aimed at achieving sparing’ medications used in the treatment of osteoporosis, periodontal health is paramount in our efforts to mitigate the bone cancers and Paget’s disease. Bisphosphonate use, effect of periodontitis on systemic disease. Close interaction especially intravenously, has been associated with the with treating physicians, timely management of periodontal condition ‘Bisphosphonate Related Osteonecrosis of the Jaw problems prior to embarking on ‘immunosuppressive’ (BRONJ)’.17 This newly emerging condition usually occurs treatment, and control of factors which may influence the following tooth extraction in patients being treated with outcome of periodontal treatment (such as glycaemic control intravenous nitrogen-containing bisphosphonates and the in diabetes patients), are all important considerations in the osteonecrosis that results is usually untreatable. The treatment periodontal treatment of medically compromised patients. approach to the prevention of BRONJ is similar to that taken with patients about to undertake radiotherapy for cancer, References in that early involvement of a dental practitioner/specialist as part of a multi-disciplinary team is paramount, and 1. Albander JM, Rams TE. Global epidemiology of periodontal diseases: definitive treatment is indicated. If extractions are required an overview. Periodontol 2000 2002;29:7-10. after a patient commences intravenous bisphosphonates, then this should be carried out with minimal trauma and 2. Cullinan MP, Ford PJ, Seymour GJ. Periodontal disease and systemic antibiotic prophylaxis, with full coverage of the socket health: current status. Aust Dent J 2009;54:S62-9. 3. Nesse W, Abbas F, van der Ploeg I, Spijkervet FK, Dijkstra PU, Vissink A. Periodontal inflamed surface area: quantifying inflammatory burden. J Clin Periodontol 2008;35:668-73.

84 PERIODONTAL TREATMENT AND SYSTEMIC CONDITIONS 4. Brasher WJ, Rees TD. Systemic conditions in the management of 14. Daly CG, Currie BJ, Jeyasingham MS, Moulds RF, Smith JA, periodontal patients. J Periodontol 1970;41:349-52. Strathmore NF, et al. A change of heart: the new infective endocarditis prophylaxis guidelines. Aust Dent J 2008;53:196-200. 5. Peacock ME, Carson RE. Frequency of self-reported medical conditions 15. Oral and dental expert group. Therapeutic guidelines: Oral and Dental. in periodontal patients. J Periodontol 1995;66:1004-7. 1st ed. Victoria, Australia: Therapeutic Guidelines Ltd, 2007. 16. Koga DH, Salvajoli JV, Alves FA. Dental extractions and radiotherapy 6. Georgiou TO, Marshall RI, Bartold PM. Prevalence of systemic in head and neck oncology: review of the literature. Oral Dis 2008;14:40-4. diseases in Brisbane general and periodontal practice patients. Aust Dent J 17. Rayman S, Almas K, Dincer E. Bisphosphonate-related jaw necrosis: A 2004;49:177-84. team approach management and prevention. Int J Dent Hygiene 2009;7:90-5. 18. Lakschevitz F, Aboodi G, Tenenbaum H, Glogauer M. Diabetes and 7. Daly CG, Mitchell DH, Highfield JE, Grossberg DE, Stewart D. periodontal diseases: interplay and links. Curr Diabetes Rev 2011;7:433-9. Bacteremia due to periodontal probing: a clinical and microbiologic 19. Lalla E, Papapanou PN. Diabetes mellitus and periodontitis: a tale of investigation. J Periodontol 2001;72:210-4. two common interrelated diseases. Nat Rev Endocrinol 2011;7:738-48. 8. Forner L, Larsen T, Kilian M, Holmstrup P. Incidence of bacteremia Address for correspondence: after chewing, tooth brushing and scaling in individuals with periodontal School of Dentistry and Oral Health inflammation. J Clin Periodontol 2006;33:401-7. Gold Coast Campus Griffith University 9. Paraskevas S, Huizinga JD, Loos BG. A systematic review and meta- Queensland 4222 analyses on C-reactive protein in relation to periodontitis. J Clin Periodontol Australia 2008;35:277-90. s.ivanovski@griffith.edu.au 10. Tonetti MS, D’Aiuto F, Nibali L, Donald A, Storry C, Parkar M, et al. Treatment of periodontitis and endothelial function. N Engl J Med 2007;356:911-20. 11. Tonetti MS. Periodontitis and risk for atherosclerosis: an update on intervention trials. J Clin Periodontol 2009;36(Suppl 10):15-9. 12. Mealey BL. Periodontal Implications: Medically Compromised Patients. Ann Periodontol 1996;1:256-321. 13. Oliver R, Roberts GJ, Hooper L, Worthington, HV. Antibiotics for the prophylaxis of bacterial endocarditis in dentistry. Cochrane Database Syst Rev 2008;(4):CD003813.

Ann Roy Australas Coll Dent Surg 2012;21:85-87 THE ROLE OF THE DENTIST IN THE MANAGEMENT OF SYSTEMIC CONDITIONS Mary Cullinan, BDS, MSc, FADI, FICD* Dr Cullinan is an Associate Professor in Periodontics at the School of Dentistry, University of Otago. Abstract The rates of lifestyle-related diseases are increasing. Worldwide there is an obesity epidemic, one of the consequences of which is an overwhelming increase in type 2 diabetes, not only in adults, but also in children and adolescents. Many cases are currently undiagnosed resulting in serious complications and placing individuals at increased risk for cardiovascular disease. As many diseases share common risk factors, the current emphasis is on primary prevention and risk assessment by all health care providers to enable detection and early intervention. Lifestyle factors that impact on oral health can also have an impact on general health, and lifestyle behaviours that promote better oral health can decrease the risk for chronic disease. In this context, changing oral health behaviour to promote better oral health may directly impact on improving general health for all age groups. Risk assessment for systemic diseases in the dental setting is explored to provide dental professionals with a framework for promoting better overall health for their patients. Introduction Australia diabetes is the fastest growing chronic disease with approximately 1 million people currently diagnosed Should the dentist become involved with risk assessment, with diabetes and 100,000 new diagnoses per year.5 It is also primary prevention or risk management of systemic diseases? recognized that there are many people with undiagnosed Whilst our primary role is the treatment and prevention of diabetes and pre-diabetes. Indigenous Australians are at oral diseases and conditions, a recent survey has shown that greater risk than non-Indigenous Australians, as are those dentists in the United States are indeed willing to screen for from North Africa, the Middle-East and Asian countries medical conditions.1 In terms of oral diseases dentists already compared with their Australian born counterparts.6 Estimates address risk assessment and risk reduction strategies for of expenditure likely to be incurred in the not too distant lifestyle factors that are also risk factors for obesity, diabetes future on treating diabetes and its consequences are causing and cardiovascular disease, such as diet and smoking. Thus concern worldwide. This further highlights the need for reinforcement of the healthy lifestyle message by dentists widespread early screening for diabetes and pre-diabetes to may also have broader ramifications in reducing risk for prevent, detect and manage these conditions, particularly as obesity, diabetes and cardiovascular disease.2 many cases can be prevented or the onset delayed. Dentists are recognized by the medical profession for Astudy by Ellison et al.7 reported on HbA1c (glycosylated having a long history of prevention, with patients accepting haemoglobin) screening for undiagnosed diabetes in New of this preventive approach and accustomed to regular Zealand. HbA1c reflects glycaemic levels over the lifespan dental recalls. Dentists are also in a position to reach many of the erythrocytes (2 - 3 months), as in the presence of patients who are unaware of their overall health status, as chronic hyperglycaemia glucose attaches to haemoglobin. traditionally medical consultation is often only sought after In non-diabetics the HbA1c level should be ≤ 6% which the appearance of symptoms. For this very reason and due to equates with a mean plasma glucose level of 7.5 mmol/L. the enormous projected future financial and societal burden In this study 50,000 individuals who were not known to of the consequences of diabetes and cardiovascular disease, have diabetes were screened and 12% were found to have dentists and other primary health care practitioners are being HbA1c levels > 6%. These authors concluded that HbA1c encouraged to assist in identifying those at increased risk for can be used as an opportunistic screening test for diabetes these diseases. and glucose intolerance. Diabetes The Department of Health and Ageing in Australia has put out a risk assessment tool, The Australian type 2 diabetes Currently it is estimated that more than 200,000 New risk assessment tool (AUSDRISK), that was developed Zealanders have Type 1 or Type 2 diabetes with the highest from the findings of the national Australian Diabetes prevalence among Pacific people (10.1%), followed by Asian (8.4%), Maori (8%) and Europeans (2.9%).3 Maori and Obesity and Lifestyle study (AusDiab).8 AusDiab examined Pacific people have a high prevalence of risk factors such as obesity, physical inactivity, insulin resistance and metabolic approximately 6,000 Australian adults on two occasions five syndrome.4 It is estimated that by 2021 approximately years apart. AUSDRISK is aimed at assisting patients and 15% of the health budget will be spent on treating the health professionals to assess the risk of developing type 2 complications of Type 2 diabetes in New Zealand.3 In diabetes within the next five years. The tool is a relatively simple, straightforward questionnaire that is suitable for * Presented at the Twenty-first Convocation of the Royal Australasian College use in the dental setting. Patients can complete it either of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012 with or without the assistance of a health professional,

86 THE ROLE OF THE DENTIST IN THE MANAGEMENT OF SYSTEMIC CONDITIONS therefore patients who may be resistant to such screening A recent study by Lalla et al.12 in which they examined in the dental setting can be given a copy to complete at new dental patients (n = 601) without a history of diabetes their leisure. AUSDRISK can be downloaded from the or pre-diabetes found that 535 of them had at least one of the Diabetes Australia website (http://www.diabetesaustralia. following self-reported diabetes risk factors: family history com.au/en/Understanding-Diabetes/Are-You-at-Risk/) or of diabetes, hypertension, high cholesterol, overweight/ used as an online interactive tool (http://www.health.gov. obese. These patients then had a periodontal examination au/internet/main/publishing.nsf/Content/chronic-diab-prev- and an HbA1c test followed by fasting plasma glucose at aus). Based on the total score, risk level is graded as low, their next visit. Interestingly, the presence of at least 26% intermediate or high with intermediate risk indicating that pockets of 5 mm or more, or four or more missing teeth an improvement in lifestyle may help reduce the risk of identified 73% of the true diabetes cases. With the addition developing type 2 diabetes. Those scoring in the high risk of HbA1c ≥ 5.7%, 92% of diabetes cases were identified. category are advised to see their doctor for a fasting blood Similarly, Table 1 shows data from a study conducted in a low glucose test as they may have undiagnosed diabetes or be at socioeconomic area near Brisbane with all the determinants high risk of developing diabetes. It is important that dentists of poor oral and general health. Over 500 individuals on a refer or encourage these patients and those with diabetes public dental clinic waiting list or attending for emergency to consult their medical practitioner and adhere to medical dental care were tested for HbA1c level and lipid profile. recalls. It is recommended that all adults over 40 years use Approximately 15% were found to have HbA1c values above AUSDRISK every three years. Others considered to be at the normal reference range, with some being new diagnoses high risk for undiagnosed type 2 diabetes are Aboriginal and of diabetes and others having uncontrolled diabetes. Further, Torres Strait Islanders aged 35 years or more, Maori, Pacific up to 40% of these patients were also found to be at risk for Islanders, people from the Indian subcontinent, people of cardiovascular disease with elevated lipid profiles. Chinese origin and those 40 years or older who are obese, Patients with diabetes are now encouraged to take an or have hypertension or cardiovascular disease (myocardial active role in the management of their diabetes. The dental infarction, angina, stroke or peripheral vascular disease). team is also well positioned to support them in this. Whilst Obese women with polycystic ovarian syndrome and people treating any oral infection will contribute to improved on antipsychotic drugs are also considered to be at high risk. glycaemic control, so too will the dietary advice customarily Antipsychotic drugs can interfere with glucose metabolism. given within the dental setting regarding reducing dietary Several studies have now shown that the dental setting intake of high energy snacks and beverages. Any reduction provides an opportunity to identify undiagnosed diabetics, in energy intake may result in weight loss and many studies with the best predictors being waist circumference and age, have shown that even weight loss of around 5 to 20% can together with self-reported oral health, self-reported weight improve glycaemic control, blood pressure and lipid profiles. and self- reported race or ethnicity. Further information Dentists are also well positioned to encourage diabetic on periodontal status and family history of diabetes was patients to adhere to medical recalls as dental practices have also found to be helpful.9-11 The probability of diabetes traditionally had more efficient recall systems than medical was increased in periodontal patients over 45 years with a practices. family history of diabetes, history of hypertension and high cholesterol and the probability increased with increasing Cardiovascular Disease age.9 Therefore, these patients should be referred for medical assessment. A recent study by Touger-Decker2 supports the concept of CVD risk reduction in dental practices due to the relationship Dentists also have the opportunity to identify and refer between diet, CVD and oral health. Again, the dietary advice for medical assessment individuals at risk for impaired aimed at improving oral health may also help reduce obesity fasting glucose (IFG) and impaired glucose tolerance (IGT). and the risk of developing CVD. It is generally accepted These patients are likely to be over 40 years, overweight that even a modest change in risk can lead to a significant (with central adiposity), hypertensive, have cardiovascular change in disease burden. Obesity itself is a risk factor for disease, and a family history of diabetes or history of type 2 diabetes, hypertension, dyslipidaemia, coronary heart gestational diabetes. disease and stroke. There is some evidence that it may also TABLE 1 Diabetic control and lipid profiles of dental patients in a low socioeconomic area HbA1c (%) Reference Minimum Maximum Mean (SD) % above % below Range reference reference TC (mmol/L) 4.3 13.6 5.6 (0.9) LDL (mmol/L) < 6.0 1.0 11.8 5.3 (1.1) range range HDL (mmol/L) < 5.5 0.8 6.5 3.1 (0.9) 14.8 TG (mmol/L) 2.0-3.4 0.4 2.9 1.4 (0.4) 8.7 0.9-1.6 0.4 20.4 1.9 (1.5) 40.5 4.1 < 2.0 33.1 20.8 32.5

MARY CULLINAN 87 be a risk factor for periodontitis in young individuals (18-34 7. Ellison et al. HbA1c screening for undiagnosed diabetes in New years),13 reduced salivary flow, and caries.14,15 The Australian Zealand Diabetes/Metabolism Research and Review 2005;21:65-70. National Heart Foundation (NHF) Guidelines recommend that overweight or obese adults without known CVD or 8. Chen L, Magliano DJ,mBalkau B, Colagiuri S, Zimmet PZ, Tonkin already known to be high risk should be assessed for absolute AM, Mitchell P, Phillips PJ, Shaw JE. AUSDRISK: an Australian Type CVD risk, as obesity is a strong independent risk factor for 2 Diabetes Risk Assessment Tool based on demographic, lifestyle and cardiovascular events and death. These guidelines are for use simple anthropometric measures. Med J Aust 2010; 192:197-202. by primary care health professionals to assess the absolute CVD risk of adults before they show any symptoms of CVD. 9. Borrell LN, Kunzel C, Lamster I, Lalla E. Diabetes in the dental office: Absolute CVD risk predicts the risk of a cardiovascular using NHANES III to estimate the probability of undiagnosed disease. J event over the next 5 years and is also recommended for Periodont Res 2007; 42: 559–565. all adults aged 47 - 74 years who are not already known to be at increased risk. Web-based calculators can be found 10. Strauss SM, Russell S, Wheeler A, Norman R, Borrell LN, Rindskopf at www.cvdcheck.org.au or www.nzgg.org.nz. However, in D . The dental office visit as a potential opportunity for diabetes screening: diabetics under 60 years and obese individuals not already an analysis using NHANES 2003-2004 data. J Public Health Dent known to have CVD or to be at high risk, the risk may be 2010;70:156–162. underestimated, therefore these patients should be referred for medical assessment. 11. Li S, Williams PL, Douglass CW. Development of a clinical guideline to predict undiagnosed diabetes in dental patients. J Am Dent Assoc Lifestyle behaviours that promote oral health, such as 2011;142:28-37. improved diet and tobacco cessation, also decrease the risk for chronic disease. It has been shown that by following a 12. Lalla et al. Identification of unrecognised diabetes and pre-diabetes in single healthy behaviour, disease risk can be reduced by a dental setting J Dent Res 2011;90:855-60. approximately 50%.16 Therefore, by providing advice on diet and smoking cessation dentists can help patients optimize 13. Al-Zahrani MS, Bissada NF, Borawskit EA. Obesity and periodontal their oral health and prevent systemic disease. While the disease in young, middle-aged, and older adults. J Periodontol 2003;74:610- nature of the association between oral disease and CVD is 5. controversial17 and remains to be fully elucidated, the role of the dentist as a primary health care provider in risk assessment 14. Flink H, Bergdahl M, Tegelberg A, Rosenblad A, Lagerlöf F. for systemic disease is being increasingly recognized. In this Prevalence of hyposalivation in relation to general health, body mass index context dentists should be actively engaged with medical and remaining teeth in different age groups of adults. Community Dent Oral practitioners in providing the best possible outcomes for Epidemiol 2008;36:523–531. their patients. 15. Modéer T, Blomberg CC, Wondimu B, Julihn A, Marcus C. Association References between obesity, flow rate of whole saliva, and dental caries in adolescents. Obesity 2010; doi:10.1038/oby.2010.63 1. Greenberg BL, Glick M, Frantsve-Hawley J, Kantor ML. Dentists’ attitudes toward chairside screening for medical conditions. J Am Dent 16. Ford ES, Bergmann MM, Kröger J, Schienkiewitz A, Weikert C, Assoc 2010;141;52-62. Boeing H. Healthy Living Is the Best Revenge: Findings From the European Prospective Investigation Into Cancer and Nutrition–Potsdam Study. Arch 2. Touger-Decker R. Diet, cardiovascular disease and oral health: Intern Med 2009;169:1355-62. Promoting health and reducing risk. J Am Dent Assoc 2010;141:167-70. 17. Lockhart PB, Bolger AF, Papapanou PN, Osinbowale O, Trevisan M, 3. Diabetes New Zealand. www.diabetes.org.nz/ Accessed 29/03/2012. Levison ME, Taubert KA, Newburger JW, Gornik HL, Gewitz MH, Wilson WR, Smith SC Jr, Baddour LM. Periodontal disease and atherosclerotic 4. Joshy G, Simmons D. The epidemiology of diabetes in New Zealand: vascular disease: Does the evidence support an independent association? Revisit to a changing landscape. NZ Med J 2006;119:1235. : A scientific statement from the American Heart Association. Circulation 2012;125: published online April 18, 2012. http://circ.ahajournals.org DOI: 5. Diabetes Australia. http://www.diabetesaustralia.com.au/en/Under 10.1161/CIR.0b013e31825719f3 Downloaded from http://circ.ahajournals. standing-Diabetes/Diabetes-in-Australia/ Accessed 29/03/2012. org/ on April 18, 2012. 6. Australian Institute of Health and Welfare: Thow AM, Waters A-M. Address for correspondence: Diabetes in culturally and linguistically diverse Australians: Identification Faculty of Dentistry, of communities at high risk. AIHW cat. no. CVD 30. Canberra: Australian University of Otago, Institute of Health and Welfare. PO Box 647, Dunedin 9054, New Zealand [email protected]

Ann Roy Australas Coll Dent Surg 2012;21:88-90 NON-PRESCRIPTION MEDICATIONS: CONSIDERATIONS FOR THE DENTAL PRACTITIONER. Angus Kingon MDSc, FRACDS, FDSRCS(Eng), FICD* Angus Kingon is an oral surgeon in private practice. He was formerly Senior Lecturer in Oral Surgery at Sydney University but has been in full-time private practice since 1995. He is a member of the Australian Dental Association’s Dental Therapeutics Committee. ABSTRACT The widespread availability of non-prescription medications has a significant potential impact on dental practice. Dentists are trained to provide scientifically-based advice on the appropriate use of medications, but it is not uncommon for patients to take matters into their own hands, especially if it is felt that the treatment provided is not solving a specific problem, or is insufficient. Well-meaning but often ill-informed family and friends frequently have an opinion as to what should be done. Not only may the suggested treatment not be effective, it may also be harmful. Over-the-counter medications can easily be obtained, and there is nothing to stop individuals exceeding recommended doses, and if this occurs, there could be adverse medical sequelae. Patient compliance in taking prescription medications is known to be problematic, and when combined with the ready availability of complementary medications, probiotics and illicit drugs, the risk of self-harm can be seen to be a distinct possibility. To compound the position, sometimes there seems to be, in a practical sense, little regulation on the advertising and marketing of non-prescription medications, which can leave consumers not only confused but potentially vulnerable. While complementary medicines may not have a significant role in dental practice in 2012, that may not always be the case as research continues, and reference is made to some aspects of ongoing work. Non-prescription medications are discussed, and some effects on oral health are considered. In many households, over-the-counter analgesics are kept where there is a medically diagnosed problem, yet the to deal with contingencies of discomfort such as headaches, widespread and occasionally aggressive marketing of from which everyone suffers from time to time. To control multivitamin preparations by commercial enterprises (and dental pain, paracetamol, codeine and ibuprofen are widely outside conventional medical practice) appears to proceed used, and many preparations of these drugs are available without restriction. This arguably sows the seeds of doubt without prescription. Therefore the opportunity for misuse into the minds of many consumers regarding what they need or abuse is always present, although probably, in percentage and what they do not. Reference ranges vary as knowledge terms, the risk is relatively small. Paracetamol is hepatotoxic, and technology improves, but it is a moot point to consider and a common cause of acute liver failure. Codeine, whose whether or not economic interests ever play a part. Whatever efficacy in clinical trials has been shown to be modest1 and the reasons, it is well documented that the complementary yet continues to be widely recommended for dental pain, has medicines’ industry is worth very large sums of money so a number of well- known side-effects. Ibuprofen is arguably many people believe it to be beneficial. There is however the best drug to control dental pain, but is contraindicated good reason for caution with these preparations - the Iowa in patients with peptic ulcers and some asthmatics. Further, Women’s Health Study has reported on just under 40,000 a recent report documented morbidity with over-the-counter individuals followed over 20 years and found an increased codeine-ibuprofen analgesics.2 mortality with taking multivitamins, vitamin B6, folic acid, iron, magnesium and copper. Calcium was the only The compound most closely implicated in causing dental supplement associated with decreased risk in this study.5 caries, sugar, is, ironically, a component of most paediatric medications.3 It is included in antacid tablets, antifungal There is another group of products which accounts for agents, many liquid medications, cough drops and chewable billions of dollars in global revenue, and which is poised tablets including vitamins.4 While it is important to make for rapid and continued expansion: probiotics (therapeutics preparations palatable for this age group, it is clearly consisting of live micro-organisms). However, no probiotic desirable for them to be composed of substances which will product was, as at early 2011, licensed in the United States as not cause collateral harm. The problem is magnified when it a biological drug product for use in the treatment, prevention, is necessary for them to be taken long-term. cure, mitigation or diagnosis of a specific human disease.6 The claimed benefits are made on the basis of limited or The effects of deficiency of individual vitamins are controversial data.7 However, it is important not to eliminate well-known and have been for many years. Rectification probiotics as being beneficial in the future as it has been by eating a healthy and balanced diet is usually effective found that the bacterium Lactobacillus rhamnosus (which is used as a nutritional supplement in yoghourt) secretes a * Presented at the Twentiy-first Convocation of the Royal Australasian College soluble protein which prevents the death of mouse intestinal of Dental Surgeons, Queenstown, New Zealand, 31 March -4 April 2012

ANGUS KINGON 89 cells. It is not known if the same occurs in humans.8 TABLE 1 Eight commonly used herbal productss Clinical experience has shown that antiseptic mouthwashes are widely used. Many contain substantial Echinacea Immunosuppression quantities of alcohol, and a possible link with oral cancer has Poor wound healing been suggested.9 Further, while they are claimed to destroy Opportunistic infection pathogenic bacteria, they are not selective in their actions Hepatotoxic and thus must have some effect on commensals, upsetting the balance of the oral environment. If used over long Ephedra Cardiac toxicity periods, it is in effect similar to the chronic administration Central Nervous System effects of antibiotics – there is increasing awareness of the problem Garlic Enhances noradrenaline release from of antibiotic resistance. A former Nobel Prize winner pointed Gingko biloba sympathetic neurons. In 2002, over out the magnitude of the latter problem, noting that 100,000 Ginseng 1070 episodes of sympathomimetic succumbed to MRSA each year, more than AIDS.10 Yet Kava effects were reported to USA Food antiseptic mouthwashes are not only available over-the- and Drug Administration (FDA), some counter without prescription, they are heavily promoted St John’s Wort fatal. Hence there is concern with by their manufacturers, and while they may have a role in, general anaesthesia and arrhythmias. for example, those unable to care for their mouths, e.g., the Valerian Interacts with Monoamine Oxidase elderly in nursing homes, they are unnecessary for healthy Inhibitors individuals where mechanical cleansing (tooth brushing, flossing) is effective. Platelet aggregation inhibitor Many texts address the practice of Phytotherapy (the Platelet inhibitor. Care with use of plants or plant extracts for medicinal purposes). For periodontal surgery, root planing etc. example, one11 includes a number of references to remedies for oral conditions, such as citrus seed extract as a mouthwash Platelet aggregation and other to treat oral bacteria and to reduce plaque and tooth decay,12 coagulation problems licorice as being beneficial for plaque reduction, and the number and healing of mouth ulcers,13 and thymol having, Potential to enhance effects of sedative first, the ability to kill cariogenic and pathogenic bacteria and general anaesthetic agents and, second, having been recorded as resolving Kaposi’s Has been the subject of a warning by Sarcoma.14 While some of these claims have been referenced, FDA none has been accepted as conventional treatments and has Banned in some countries not, to date, been taught to dental students. Further, there (hepatotoxicity). have been concerns with the use of herbal products – prior to surgical procedures, 22% were found to be taking herbal Alters drug metabolism medications, 32% of patients in an ambulatory medical Photosensitivity. setting admitted to using herbal medications regularly, and Care with dental sedation e.g., 70% of herbal users did not describe their use to their health benzodiazepines. care provider.15 Eight commonly used herbal products have Also may affect warfarin, digoxin, been identified as having the potential to cause adverse non-steroidal antiinflammatory drugs effects when undergoing medical-surgical procedures (Table (NSAIDs) 1). Advice regarding surgical procedures has been suggested which includes ceasing Ephedra a minimum of 24 hours Potential to enhance effects of sedative before surgery, Gingko biloba a minimum of 36 hours before and general anaesthetic agents surgery, and Garlic and Ginseng, 7 days before surgery. In summary, care in dental practice is necessary, especially with (After Ciancio SG. Herbal agents and oral health. Biol Ther Dent respect to post operative bleeding, impaired wound healing, 2002;18:1-2) and drug interactions (notably sedatives). (a) check hepatic and renal function before the first A considerable number of compounds contain coumarin, prescription is issued, and 3-monthly after that, including arnica, celery and chamomile. Therefore they may potentiate warfarin activity. Others may interact with (b) check blood pressure at least fortnightly, warfarin, for example, St John’s Wort, some Chinese herbs, papaya and green tea.16 (c) inform patients of the early side effects of treatment, and if they occur, cease taking the herbal preparation, and Herbal Medicines caused at least 10 deaths in Japan then contact the prescribing doctor.17 in the two-year period 1994-1996 (Japanese Ministry of Welfare). Side effects caused by herbal therapies are The need to consider specifically modifying dental common elsewhere in Asia, but are overlooked. There are treatment for patients on herbal supplements has been a number of problems with herbal preparations, and doctors highlighted.18 are advised to:- It is not as though there has been no attempt by herbal medicine professionals to address the safety of these therapies and the issues have been summarized.19 It seems reasonable to expect that proponents of the herbal therapies must be able to prove a specific treatment is at least equal to, and preferably better than, conventional medical management,

90 NON-PRESCRIPTION MEDICATIONS and by being subject to the same rigorous testing as Acknowledgement prescription drugs are before release onto the market. It is perplexing to read that one authority appears to suggest that The advice of Josie Gruber of the Australian Dental the benefit-risk ratio which is applied to modern drugs should Association (NSW) Centre for Professional Development not be applied to herbal therapies20 – it is not so much that all for providing references on complementary medicines is treatments should immediately be discarded simply because much appreciated. they are herbal, more that, as in all therapies, it is important to be able to demonstrate clinical benefit. Indeed, there is References potential in one clinical problem very topical in dentistry in the early part of the 21st century: the risk of Bisphosphonate 1. Iedema J. Cautions with codeine. Australian Prescriber 2011;34:133-5. Induced Osteonecrosis of the Jaws, and this condition has 2. Frei MY, Nielsen S, Dobbin MDH, et al. Serious morbidity associated had a significant impact on dental practice. Four hundred with misuse of over-the-counter codeine-ibuprofen analgesics: a series of 27 herbal products have been screened in Japan with a view to cases. Med J Aust 2010;193:294-6. providing a possible alternative approach to the management 3. Shaw L, Glenwright HD. The role of medications in dental caries of osteoporosis, and three (Melia azedarach, Corydalis formation: need for sugar-free medication for children. Paediatrician turtschaninovii, and Cynanchum atratunich) were found to 1989;16:53-5. have growth-inhibitory and/or apoptosis-inducible effects on 4. Ciancio SG. Medications’ impact on oral health. J Am Dent Assoc osteoclasts, but none on osteoblasts or chondrocytes.21 While 2004;135:1440-8. this is early work, it shows there could be a future clinical 5. Mursu J, Robien K, Harnack LJ, et al. Dietary Supplements and application in the management of osteoporosis. Mortality Rate in Older Women. The Iowa Women’s Health Study. Arch Intern Med 2011;171:1625-33. Illicit drug use is widespread and causes many problems, 6. Probiotic development and regulation: the science of supplements. The both social and medical. The adverse effects on the oral cavity New York Academy of Sciences Magazine; 2011 Spring:6. of some of the commoner substances include the following: 7. Deconstructing a probiotic. Science 2011;332:1243 cannabis (dry mouth, oral malignancy), cocaine (dry mouth, 8. Yan F, Cao H, Cover TL, et al. Colon-specific delivery of a probiotic- bruxism, tooth erosion, gingival ulceration), ecstasy (dry derived soluble protein ameliorates intestinal inflammation in mice through mouth, bruxism), heroin (dry mouth, bruxism, craving for an EGFR-dependent mechanism. J Clin Invest 2011;121:2242-53. sweet foods leading to caries), and methamphetamines (dry 9. McCullough MJ, Farah CS. The role of alcohol in oral carcinogenesis mouth, bruxism, caries).22 with particular reference to alcohol-containing mouthwashes. Aust Dent J 2008;53:302-5. In summary, over-the-counter preparations provide 10. Steitz T. Nature 2011;478:S2-3 significant support to enable the public to obtain medications 11. Mills S, Bone K. Principles and practice of phytotherapy. Elsevier, without attending healthcare professionals, and also when 2000 (reprinted 2010). problems occur outside normal business hours, e.g., weekends 12. Mills S, Bone K. Principles and practice of phytotherapy. Elsevier, and late nights. It does nonetheless require individual 2000 (reprinted 2010):341. personal responsibility to ensure appropriate usage – the 13. Mills S, Bone K. Principles and practice of phytotherapy. Elsevier, lack of restrictions as to the quantity of non-prescription 2000 (reprinted 2010):472. drugs that can be obtained provides the opportunity for 14. Mills S, Bone K. Principles and practice of phytotherapy. Elsevier, misuse, abuse and consequent self-harm. With respect to 2000 (reprinted 2010):564. many complementary medicines, it is difficult not to think 15. Ciancio SG. Herbal agents and oral health. Biol Ther Dent 2002;18(1):1-2. that some of the science behind the therapies has not been 16. National Prescribing Newsletter (Australia); October 2003. sufficiently rigorous, and when this is considered alongside 17. Samurai M. Herbal dangers. Nature 2011;480:S97. the monetary value of the industry, it does not compute in 18. Abebe W. Herbal supplements may require modifications of dental the age of evidence-based medicine. This may change in treatments. Dent Today 2009;28:136-7. the future, but although the public are increasingly well- 19. Mills S, Bone K. The essential guide to herbal safety. Elsevier 2005 educated, clinical practice reveals this does not extend to an (reprinted 2008):3-7. extensive understanding of healthcare. Clinical practice also 20. Mills S, Bone K. Principles and practice of phytotherapy. Elsevier reveals the vast majority of people worry about their health, 2000 (reprinted 2010): xiii. so it theoretically provides an opportunity for commercial 21. Kondo S, Mukudai Y, Yazawa K, et al. Effects of 3 herbal products on interests to exploit that fear. Whether or not that occurs is osteoclasts, osteoblasts and chondrocytes as novel drugs for osteoporosis. for each of us to judge, but it is incumbent on all healthcare Abstracts of the 20th International Conference on Oral and Maxillofacial workers to ensure high ethical standards, without interference Surgery, 1-4 November, 2011, Santiago, Chile. Int J Oral Maxillofac Surg from those with vested interests, and affirm the professional 2011;40:1214, (abstract 374). trust given, so the well-being of those who seek advice can 22. Teeth and drug use. http:// www.better health.vic.gov.au be improved. Address for correspondence: 45 Grandview Street Pymble, NSW, 2073 [email protected]

Ann Roy Australas Coll Dent Surg 2012;21:91-93 ADVERSE DRUG REACTIONS: ORAL AND DENTAL MANIFESTATIONS AND COMPLICATIONS M. Schifter, BDS, MDSc (Oral Med), MSNDRCSEd, MOMed RCSEd, FFDRCSI (Oral Med), FRACDS (Oral Med)* Clinical A/Professor Mark Schifter is a Staff Specialist in Oral Medicine and Head, Department of Oral Medicine, Oral Pathology and Special Care Dentistry, Westmead Centre for Oral Health, Westmead Hospital, Westmead (Western Sydney), Australia. Professor Schifter is the Convenor DClinDent (Oral Med/Oral Path) Specialist Training Program and Acting Head of the Discipline of Special Care Dentistry, Faculty of Dentistry, University of Sydney. Professor Schifter is also in specialist private practice, with the Skin and Cancer Foundation Australia (SCFA), Darlinghurst (Sydney) and the Westmead Hospital Specialist Dental Centre (WHSDC), Westmead, NSW. Abstract Adverse, that is unintended untoward effects of medications, are increasing in incidence and their severity, given the aging of the Australian and New Zealand population and associated drug use. Not only are the number of agents that our patients are using increasing, including the increased use of “alternate” or “complimentary” medications, but also their complexity, with the advent of potent, targeted, biological agents. The result is an increasing number of our patients will be at greater risk of adverse effects from their medications. These adverse effects include the impeding of the safe delivery of dental treatment and the adverse oral and dental manifestations and complications related to the use of medications. Key words: adverse drug reactions (ADRs), classification, identification, prevention. Introduction can occur with any of the drugs administered during the course of the dental care to patients. Oral health practitioners Adverse Drug Reactions (ADRs) have been defined as “a can prevent ADRs by having and developing good history taking skills, to identify previous ADRs, as reported by response to a drug that is noxious and unintended and occurs the patient, thereby avoiding administering the causative drug, or addressing the adverse reactions by interventions, at doses normally used in man for the prophylaxis, diagnosis such as additional drugs, so as to prevent or lessen their severity, and especially those that are known to have an or therapy of disease, or for modification of physiological adverse impact on the oral and/or dental health. Importantly, function”.1 A more recent definition defines ADRs as: “An dental/oral health practitioners, in knowing what drugs their patients are taking, and being aware of their established appreciably harmful or unpleasant reaction, resulting from ADRs appropriately modify the dental treatment the patient requires, to ensure it is delivered safely, with no harm to the an intervention related to the use of a medicinal product, patient. A current and topical example is the ADR seen with the use of potent bisphosphonate agents, given to prevent which predicts hazard from future administration and bony complications of malignancy, such as metastases and pathological fractures. Caution is required in undertaking warrants prevention or specific treatment, or alteration of dental extractions in patients taking bisphosphonate agents the dosage regimen, or withdrawal of the product”.2 Both these definitions emphasize that ADRs are, in general, TABLE 1. initially unpredictable, but once such ADRs are known Classification of Adverse Drug Reactions their occurrence is predictable and therefore avoidable, by the knowledgeable, educated clinician not using drugs (Rosenheim ML, Moulton R. 1958).2 associated with severe ADRs, or by the clinician putting in place measures to ameliorate, or prevent such ADRs from 1. Overdosage occurring.3 ADR’s range in their severity from mild to troublesome, but can be life threatening, or even fatal. 2 Intolerance ADR’s have been classified into eight broad categories 3. Side-Effects (Table 1). 4. Secondary Effects The dental/oral health practitioners’ role in regards to the management of ADRs, is firstly to maintain a high level of 5. Idiosyncratic Reactions clinical awareness and acumen in recognizing and diagnosing ADRs, especially when such reactions have distinct oral 6. Teratogenic Effects and dental manifestations. This is particular concern in recognizing and then administrating vital first aid in cases 7. Hypersensitivity of immediate hypersensitivity reactions (anaphylaxis) that 8. Drug Interactions * Presented at the Twenty-first Convocation of the Royal Australasian College of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012

92 ADVERSE DRUG REACTIONS given the risk of them developing osteonecrosis of the jaws is “Point of Care (PoC) Testing” ensuring that patients are (ONJ). Another role for dental/oral health practitioners that achieving the intended therapeutic targets with respect to should be further developed and encouraged, is Point of Care the medications they need to take to maintain their health. Testing, to ensure patient compliance with their medications The ever-improving sophistication of these testing devices and ensure the agents’ intended medical benefit for the and their increasing affordability, entails that all oral health patient has been satisfactorily achieved.4 Examples include practitioners need to consider providing this service to checking if patients International Normalised Ratio (INR) their patients.4 Common examples include, PoC Testing is within the required therapeutic range for patients taking for patients taking the anti-coagulant medication, warfarin, warfarin, monitoring of patients’ blood pressure, for those to ensure patients are within the required therapeutic range patients who are taking antihypertensive agents and patients’ (as measured by the International Normalised Ratio (INR)). BSL for patients who require oral anti-glycaemic agents and/ Patients who are over-coagulated, in general are thought or insulin, in the setting of diabetes mellitus. to be of greater concern, given the risk of uncontrolled haemorrhage, especially if undertaking invasive dental Adverse drug reactions: Specific oral/dental procedures such as extractions. However, patients who are under-coagulated, as identified by a sub-therapeutic INR, manifestations and/or complications. TABLE 2. Epidemiology ADRs Effect on the Stomatognathic System All drugs, whether they be prescribed, over the counter, (oral and dental tissues and structures). herbal (complimentary) 5 or illicit, commonly give rise to a great range of specific oral/dental manifestations and/ 1. DIRECT EFFECTS OF ADRs or complications, of which the most frequent is that of a dry mouth (xerostomia and/or salivary hypofunction).6-8 Immunological ADRs Dysgeusia (taste disturbance) is less common, as is the 1.1. - Types I-IV Hypersensitivity Reactions development of stomatitis, that is oral mucosal ulceration. (not “hard” or “soft” tissue specific) The incidence of ADRs is increasing and is expected to further increase with the ageing9 of the Australian population 1.2.1. ADRs Effect on the “Hard Tissues” and consequent associated need for medical intervention, especially for the chronic diseases, such as hypertension, • Impairment of calcification coronary artery disease, heart failure, diabetes mellitus and - impaired bone turnover/formation osteoarthritis, as well improved survival of patients who - impaired odontogenesis have had cancer.10 • Extrinsic Staining of teeth Classification Given the range and extent of ADRs and their impact on 1.2.2. ADRs Effect on the “Soft” Tissues the oral and dental structures, classification is difficult. ADRs • Mucositis can manifest oral and/or dentally “directly” as to their site of presentation, or by the adverse effect such reactions can have • Alteration in Pigmentation on the oral and dental tissues and structures. ADRs can also - hyperpigmentation affect the stomatognathic system and tissues “indirectly” - hypopigmentation by one of two mechanisms: firstly, by complicating and/or adversely affecting the safe provision and undertaking of • neurological disturbances dental treatment; thereby impairing the maintenance and - disturbances of motor (muscle) innervation health of the oral and dental structures and tissues; and, - sensory disturbances (general sensory and special sensory, secondly, by adversely affecting the cells, tissues, secretions (principally saliva), and organs that protect and/or maintain for example taste) the integrity and health of the stomatognathic system. 2. INDIRECT EFFECTS OF ADRs These ADRs can also be further classified by the effects on either the “hard” tissues, of the stomatognathic system, Adversely Affect/Complicate Dental Treatment comprising the dentition, periodontium and supporting jaw bones - the maxilla and mandible, and temporomandibular - impeding the provision of safe and routine dental care joints (TMJ) and/or the “soft” tissues. The soft tissues, consist of the lips, gingiva, oral mucosa, salivary glands (major and - thereby impairing the prevention of disease and the minor), the collagenous constituents of the periodontium maintenance of the health of the stomatognathic system and and TMJ’s, muscles used in the functions undertaken by the tissues mouth and teeth (including the gag and swallow reflexes), nerves, including the special sensory system that conveys 2.1 Examples taste, lymphatic system and the vasculature (Tables 2and 3). - adverse drug interactions 11 Point of Care (PoC) Testing - anti-coagulant drugs - immune-suppression/pancytopenia secondary to cytotoxic An aspect of ADRs that oral health professionals need chemotherapy agents to increasingly consider in their day-today clinical practice Adverse Effect on the cells, tissues, secretions (saliva), and organs that protect/maintain the stomatognathic system Examples - drug-induced salivary gland hypofunction 2.2. - immune-suppression/pancytopenia secondary to cytotoxic chemotherapy agents resulting in opportunistic infections of the oral cavity - immune-suppression/pancytopenia secondary to cytotoxic chemotherapy agents resulting in opportunistic infections of the oral cavity

MARK SCHIFTER 93 TABLE 3. Conclusions Immunological (Hypersensitivity Reactions) ADRs: effect All oral health practitioners, but especially dentists, need on the stomatognathic system and tissues. to be aware that with the increasing drug use, of prescribed, illicit, over the counter and herbal (complimentary) ADR Pharmacologi/ Class(es) of Examples medications, the incidence of ADRs is increasing and will Pathogenic Drugs continue to increase. These ADRs will have a direct effect anaphylaxis Mechanisms beta-lactams and indirect effects on the tissues and structures of the ALL - penicillins stomatognathic system, as well as having the potential to angioedema Type I - cephalo- dangerously complicate the delivery of dental treatment and Histamine angiotensin- sporins care. Good history taking and awareness of ADRs, will lead Pemphigus/ release (IgE/ converting ramipril to the appropriate treatment planning and the modification Pemphigoid- mast cell enzyme (Tritace®) of treatment so that it can be undertaken safely, with little Like interaction) (ACE) risk of morbidity or mortality to the patient, and ensure the Reactions inhibitors Tegretol® provision of a dentition, that can be easily maintained by the Erythema Type II (carba- patient. Multiforme Antibody anti- mazepine) Mediated epileptics References Type III 1. WHO. International drug monitoring: the role of national centres. Tech Immune- Rep Ser WHO 1972, no 498. Complex 2. Rosenheim ML, Moulton R. Council for International Organizations of Medical Sciences 1958 Springfield, Ill., Thomas. Sensitivity reactions Lichenoid Type IV, non- to drugs; a symposium organized by the Council for International Reactions Cell-Mediated steroidals Organizations of Medical Sciences, established under the joint auspices of Immunity UNESCO and WHO [held in Liège, July 9-12, 1957] Eds. (CD4 T-cell hypo- 3. Edwards RI, Aronson JK. Adverse drug reactions: definitions, mediated) glycaemic diagnosis, and management. Lancet 2000;356:1255-59. agents 4. Shephard M. Point-of-care testing comes of age in Australia. Aust Prescr 2010;3:6–9. are at risk of potentially fatal, thrombo-embolic events, such 5. Shankland II, WE. Four Common Herbs Seen in Dental Practice: as stroke. Other examples include monitoring of patient’s Properties and Potential Adverse Effects. Cranio 2009;27;118-24. blood pressure that need anti-hypertensive medications 6. Smith RG, Burtner AP. Oral side-effects of the most frequently and patient’s blood sugar level (BSL) for those patients prescribed drugs. Spec Care Dentist 1994; 4:96-102. being treated for diabetes mellitus. In regards to the latter 7. Scully C, Bagan J-V. Adverse drug reactions in the orofacial region. example, hypoglycaemia, with a BSL less than 2.8 mmol/L Crit Rev Oral Biol Med 2004;14:221-39. is associated with the imminent risk of coma, and possibly 8. Fure S. Ten-year cross-sectional and incidence study of coronal and root death.12 caries and some related factors in elderly Swedish individuals. Gerodontol 2004;21;130-40. However, if committed to providing PoC Testing, 9. McCreary C, Ni Riordáin R. Systemic Diseases and the Elderly. Dent practitioners need to be conscientious in recording the Update 2010;37:604–7. results of such testing and acting appropriately on the finding 10. Brindley MJ, Longman LP, Randall C, Field EA. Drug Profile of Adult of abnormal results. The finding of a patient with severely Patients Attending Five General Dental Practices in Merseyside: oral side- abnormal, or potentially, immediately life-threatening effects and potential interactions with dentally prescribed medication. abnormal results on PoC Testing, requires the patient to be Primary Dent Care 2003;10:113-8. directed straightaway to the Emergency Department of the 11. Pemberton MN, et al. Derangement of warfarin anticoagulation by nearest hospital, and it is best that the patient is accompanied miconazole oral gel. Brit Dent J 1998;184: 68-9. by a letter briefly highlighting the abnormal results and 12. Service FJ. Cryer PE. Overview of hypoglycemia in adults. Up to the concerns regarding the health of the patient. Abnormal date.http://www.uptodate.com/contents/overview-of-hypoglycemia-in- results that are less severe, and pose no immediate concern to adults?source=search_result&selected Title=2%7E150. the patient’s wellbeing, also need to be acted on, by directing the patient to see their treating physician or their regular Address for correspondence: general medical practitioner, but again an accompanying Department of Oral Medicine, Oral Pathology and letter flagging the abnormal results and concerns should Special Care Dentistry, accompany the patient. This practice of acting on the finding Level 3, Westmead Centre for Oral Health, of abnormal results on PoC Testing is not only sensible, but Westmead Hospital. it can be argued is a medico-legal necessity, that also serves PO Box 533 Wentworthville NSW 2145. to protect the practitioner. The development of simple, “form [email protected] letter” with “tick-a-box” features to identify the abnormal results, and what actions the patients has been directed to undertake, with the inclusion of the practice contact details, may readily attend to this issue.

Ann Roy Australas Coll Dent Surg 2012;21:94-96 ATTRITION AND EROSION: ASSESSMENT AND DIAGNOSIS Ian Meyers, BDSc, FICD,FADI, FPFA, FRACDS* Dr Meyers is currently in private general practice in Brisbane and holds honorary professorial positions at the University of Queensland School of Dentistry and James Cook University School of Medicine and Dentistry. Abstract The management of patients with extensively worn and badly broken down dentitions presents a difficult challenge in dental practice and restorative treatments are often complex, time consuming and costly to implement, so careful case selection and treatment planning is essential. Ultimately the success of any restorative intervention is very dependent on the stability of the oral environment and the status of the remaining tooth structure. Prior to the commencement of any restorative treatment an understanding of the importance of the disease process, the risk factors in the mouth, and the intrinsic and extrinsic factors which affect the oral balance is critical. While there is a growing range of materials and techniques available for cost effective and conservative management of these cases, failure to take a systematic approach to assessment and stabilization may result in early restorative failure, rapid recurrence of the problems and a repeat restoration cycle. Therefore successful management of these patients must include an appropriate mix of preventive and restorative strategies. Despite the overall trend towards improved oral health at greater risk, and frequently are those demonstrating signs and reduced dental caries incidence over the last decades, of tooth erosion.12-15 Hyposalivation is a growing concern epidemiological evidence is supporting the contention that in dental practice and may be due to a multitude of factors tooth wear is increasing in severity and prevalence, not only including diet and lifestyle factors, medication side effects amongst older people who are living longer and retaining or underlying systemic conditions.16,17 As our population more teeth, but also amongst those in the early decades of ages and individuals keep their teeth longer we are faced their adult life.1-3 This growing incidence of tooth wear has with the ever increasing geriatric dentate population with increased the demand on dental practitioners to provide a a greater risk of hard tissue dental disease. Combine this range treatment alternatives for the replacement of the lost with an increasing number of medications being provided tooth structure to cater for the range of individuals presenting to this older population and the overall hyposalivation with varying degrees of tooth wear. In recent years there has and xerostomia concerns become more pronounced.18 been an increasing trend toward the restoration of severely Consequently the potential for irreversible tooth surface loss, worn and broken down dentitions using more conservative other than by caries, becomes an important aspect of patient approaches with adhesive restorative materials.4-6 These oral health management. approaches aim to preserve as much remaining tooth structure as possible and provide a cost effective management option Thorough patient risk assessment is essential and for patients. It is essential however that any restorative requires that all predisposing factors are considered and treatment is only undertaken after careful diagnosis of the risks minimized. There are many diagnostic templates causative factors, stabilisation of the oral environment and and proformas available to assist in this process,19-21 but prevention of further tooth destruction, and remineralisation it is important to be aware that no two individuals will be of the remaining tooth structure to enhance adhesive the same and consideration must be given to individual bonding.7,8 circumstances. As such it is important to accept that there is no, one single ‘off the shelf’ treatment suitable for all In the diagnosis and treatment planning phase it is patients, but similar strategies of management can be important to understand and take into consideration the employed. It is essential to not only recognize the presence differences in the process of demineralization and tooth of tooth wear, but more importantly to determine the activity material loss in tooth wear cases compared with dental caries. status of the process. Many patients will present with tooth While dental caries is a localized event with plaque producing surface loss and, while for the sake of record taking it can be relatively weak acids which demineralize tooth tissue over classified as showing patterns of erosion, abrasion, attrition a prolonged period of time, tooth erosion from stronger or abfraction, there is often no knowledge of how or when extrinsic or intrinsic acids usually occurs in relatively short this occurred. Determining if tooth wear is a result of past periods of time and can be quite extensive.9-11 Prevention history and now stabilized, or if it is currently still actively of this acidic demineralisation in the absence of plaque is occurring becomes central to determining management very dependent on the ability of saliva to stabilize and buffer strategies. Most patients will demonstrate a range of factors the acidic challenges in the mouth. Patients with reduced contributing to their overall wear, and while many long salivary flow or reduced salivary buffering capacity will be standing concepts of ‘tooth brush abrasion’ or ‘bruxism’ have been linked with tooth wear, these are often only part * Presented at the Twenty-first Convocation of the Royal Australasian College of the problem and there is frequently an underlying erosive of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012 process which accelerates the process beyond the normal

IAN MEYERS 95 physiological range.22 While there are a number of proposed associated with this extensive work. Consequently many tooth wear indices and scoring criteria published,23-26 there is patients look at less costly options using direct and semi- currently no real consensus on an ideal method of recording direct tooth coloured adhesive restoratives and these can and evaluating tooth wear, so it falls on individual operators often be a quite successful and conservative option. These to make their own clinical decision on when and how to less invasive treatments can also follow on from the initial evaluate, record and determine management options. stabilization phase and be used to evaluate long term patient compliance prior to undertaking more complex indirect There are however a number of clinical indicators for procedures.4,5,8,35 active tooth wear and these should be carefully assessed prior to the commencement of any restorative treatment.7 References Visual clues such as decreased surface lustre on enamel can be an indicator of acid dissolution of the tooth surface, 1. Van’t Spijker A, Rodriguez JM, Kreulen CM, Bronkhorst EM, similar to tooth etching. In active erosion cases, exposed Bartlett DW, Creugers NHJ. Prevalence of tooth wear in adults. Int J Pros dentine is often quite sensitive due to dissolution of any 2009;22:35-42. protective smear layer and the opening of dentine tubules thereby allowing tubule fluid flow and sensitivity to 2. Kelleher MG, Bomfim DI, Austin RS. Biologically based restorative stimulus. Patients with active tooth erosion often complain management of tooth wear. Int J Dent 2012; Article ID: 742509. of tooth sensitivity, particularly after consuming certain acidic foods or beverages, and this should be taken as a clear 3. Lee A, He LH, Lyons K, Swain MV. Tooth wear and wear investigations indicator of a shift in oral balance from remineralization to in dentistry. J Oral Rehabil 2012;39:217-25. demineralization and removing the surface protection on dentine.27,28 The presence of calculus, particularly on the 4. Meyers IA. Diagnosis and management of the worn dentition: lingual of the lower incisors teeth, should always be assessed conservative restorative options. Ann R Australas Coll Dent Surg in patients with tooth wear as the absence of calculus may 2008;19:31-4. be an indicator of unsaturated saliva with insufficient ability to mineralize. The formation of calculus is a mineralizing 5. Burke FJ, Kelleher MG, Wilson N, Bishop K. Introducing the concept event and will not occur when there is a balance towards of pragmatic esthetics, with special reference to the treatment of tooth wear. demineralization in the mouth. The evaluation of salivary J Esthet Restor Dent 2011 Oct;23:277-93. flow, viscosity, pH and buffering capacity becomes critical in these cases, not just for the clinician, but for the patient 6. Dietschi D, Argente A. A comprehensive and conservative approach for to assist them in developing an understanding of the risks the restoration of abrasion and erosion. part II: clinical procedures and case present.29 Placement of restorations in an oral environment report. Eur J Esthet Dent 2011;6:142-59. where there are uncontrolled risks will undoubtedly lead to early restoration failure. 7. Meyers IA. Diagnosis and management of the worn dentition: risk management and pre-restorative strategies for the oral and dental Active tooth erosion will produce a demineralized tooth environment. Ann R Australas Coll Dent Surg 2008;19:27-30. surfaces which will not provide a reliable or predictable bond with adhesive restorative materials. A severely 8. Dietschi D, Argente A. A comprehensive and conservative approach compromised tooth surface may in fact be more prone to for the restoration of abrasion and erosion. Part I: concepts and clinical cohesive failure of the tooth rather than adhesive failure rationale for early intervention using adhesive techniques. Eur J Esthet Den. at the restoration tooth interface. To ensure the maximum 2011;6:20-33. benefits from adhesive restorative materials it is essential that the oral environment is stabilized, risk factors reduced, 9. Zero DT, Lussi A. Erosion-chemical and biological factors of and the tooth surface remineralized to the best possible importance to the dental practitioner Int Dent J 2005;55(Suppl 1):285-90. condition prior to repair.7,30 Strategies for remineralization should include reduction of acids and underlying risk factors 10. Eisenburger M. Degree of mineral loss in softened human enamel after where possible, and the inclusion of various remineralization acid erosion measured by chemical analysis. J Dent 2009;37:491-4. agents. Fluoride has been accepted as an effective agent for enhancing remineralisation and reducing demineralization, 11. Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion-an but it must be remembered that its action is very dependent overview with emphasis on chemical and histopathological aspects. Caries on the availability of sufficient calcium. Most current Res 2011;45 Suppl 1:2-12. remineralization strategies include recommending the used of calcium and phosphate enhanced remineralization 12. Mulic A, Tveit AB, Songe D, Sivertsen H, Skaare AB. Dental erosive products.31-34 wear and salivary flow rate in physically active young adults. BMC Oral Health 2012 Mar 23;12:8. Once stabilized the technical task of rehabilitating a severely worn dentition can proceed, and the range of available 13. Jager DH, Vieira AM, Ligtenberg AJ, Bronkhorst E, Huysmans MC, restorative materials enables the selection on a number of Vissink A. Effect of salivary factors on the susceptibility of hydroxyapatite different approaches. While complex reconstructions with to early erosion. Caries Res 2011;45:532-7. ceramics, crowns, bridges and implants may be considered the best option, many patients are unable to afford the cost 14. Piangprach T, Hengtrakool C, Kukiattrakoon B, Kedjarune-Leggat U. The effect of salivary factors on dental erosion in various age groups and tooth surfaces. J Am Dent Assoc 2009;140:1137-43. 15. Bavbek AB, Dogan OM, Yilmaz T, Dogan A. The role of saliva in dental erosion and a prosthetic approach to treatment: a case report. J Contemp Dent Pract 2009;10:74-80. 16. Navazesh M. Dry mouth: aging and oral health. Compend Contin Educ Dent 2002;23(10 Suppl):41-8. 17. Hopcraft MS, Tan C. Xerostomia: an update for clinicians. Aust Dent J 2010;55:238-44. 18. Gerdin EW, Einarson S, Jonsson M, Aronsson K, Johansson I. Impact of dry mouth conditions on oral health-related quality of life in older people. Gerodontolog. 2005;22:219-26. 19. Saliva Assessment, GC ASIA , http://www.gcasia.info/brochures/pdfs/ saliva_pad.pdf 20. Caries Risk Assessment Form, CariFree, essology http://www.essology. com/PDF/CariesRiskAssessment-Adult.pdf 21. Oral Health Risk Assessment and Management, 3M ESPE, http:// solutions.3m.com/wps/portal/3M/en_US/3M-ESPE-NA/dental- professionals/solutions/dental/preventive/oral-health-risk/

96 ATTRITION AND EROSION: ASSESSMENT AND DIAGNOSIS 22. Harpenau LA, Noble WH, Kao RT. Diagnosis and management of 32. Llena C, Forner L, Baca P. Anticariogenicity of casein phosphopeptide- dental wear J Calif Dent Assoc. 2011;39:225-31. amorphous calcium phosphate: a review of the literature. J Contemp Dent Pract 2009;10:1-9. 23. Smith BGN, Knight JK. An index for measuring the wear of teeth. Br 33. Cochrane NJ, Cai F, Huq NL, Burrow MF, Reynolds EC. New Dent J 1984;156:435-8. approaches to enhanced remineralization of tooth enamel. J Dent Res 2010;89:1187-97. 24. Bartlett D. BEWE: basic erosive wear examination. Br Dent J 34. Gupta R, Prakash V. CPP-ACP complex as a new adjunctive agent for 2010;208:204-9. remineralisation: a review. Oral Health Prev Dent 2011;9:151-65. 35. Robinson S, Nixon PJ, Gahan MJ, Chan MF. Techniques for restoring 25. Bartlett D, Harding M, Sherriff M, Shirodaria S, Whelton H. A new worn anterior teeth with direct composite resin. Dent Updat. 2008;35:551- index to measure tooth wear-methodolgy and practical advice. Community 2, 555-8. Dent Health 2011;28:182-7. Address for correspondence: 26. Young WG, Kahn F. (eds) Toothwear – The ABC of the Worn Dentition School of Dentistry Wiley-Blackwell, UK 2011 University of Queensland Turbot Street 27. Chu CH, Lam A, Lo EC. Dentin hypersensitivity and its management. Brisbane Gen Dent 2011;59:115-22 Queensland 4000 [email protected] 28. Addy M, Smith SR. Dentin hypersensitivity: an overview on which to base tubule occlusion as a management concept J Clin Dent 2010;21:25-30. 29. Ngo H, Gaffney S. Risk Assessment in the Diagnosis and Management of Caries. in Preservation and Restoration of Tooth Structure, Knowledge Books and Software, Australia, 2005. 30. Curtis DA, Jayanetti J, Chu R, Staninec M. Decision-making in the management of the patient with dental erosion. J Calif Dent Assoc 2011;39:259-65. 31. Reynolds EC. Calcium phosphate-based remineralization systems: scientific evidence? Aust Dent J 2008;53:268-73.

Ann Roy Australas Coll Dent Surg 2012;21:97-100 ATTRITION AND EROSION: RESTORATIVE PLANNING AND PERFORMANCE Michael F. Burrow, BDS, MDS, PhD, MEd, MRACDS (Pros), FRACDS, FICD* Michael Burrow is a Clinical Associate Professor in the Faculty of Dentistry at the University of Hong Kong, and an Honorary Professorial Fellow in the Melbourne Dental School at the University of Melbourne. Abstract The number of patients presenting with severe attrition and associated erosion is increasing in frequency. Treatment of this patient group is very challenging as it is simply not just a case of replacing lost tooth tissue, but also trying to identify and then eliminate the aetiological factors responsible for the loss of tooth structure. In most cases restorative treatment involves extensive rehabilitation of the dentition to restore the aesthetics and function and also to prevent further tooth loss. Such treatment often involves a multidisciplinary approach to eliminate and/or reduce causative factors prior to definitive restoration of teeth. Treatment needs to focus on quick intervention when the problem has been identified and diagnosed. Restorative treatment involves careful if not complex planning culminating in the establishment of a well defined and ongoing maintenance plan. Long-term success of treatment is centred on the maintenance phase. Current restorative options include the use of extensive resin composite build-ups. This is often the best initial starting point as it allows for adjustments, as well as being a reversible and more conservative procedure. The use of indirect restorations is likely to provide a longer lasting outcome after initial stabilization, whether it is metal- or ceramic-based or a combination. Introduction The one question that must be answered is when should the tooth wear be considered excessive compared with the The attrition and erosion of teeth is becoming an ever physiological wear, which we all experience. Often the increasing problem for practitioners to manage.1,2 This determination of normal or pathological tooth loss is based loss of tooth structure was once relegated to more mature on a patient’s attendance to a dental practice desiring an patients but recently has become almost independent of age. aesthetic solution for unattractive anterior teeth or problems Often these patients were left in the “too hard basket” for associated with function and/or tooth sensitivity.5 The other treatment, thus allowing the problem to continue. However, aspect for diagnosis of tooth loss is based on the dentist’s as there is an ever-increasing number of young adults observation that the degree or extent of wear is excessive for presenting with erosive loss of tooth structure, treatment has the patient’s age. become essential to ensure they can maintain a long lasting dentition as well as to uphold current treatment philosophies Once is has been determined that the tooth wear is greater of minimal intervention dentistry. Thus one of the critical than ‘normally’ expected for the patient’s age, then the next points for treatment is to first identify patients exhibiting a step is to determine the cause. Clinically, it is most likely tooth loss problem. The research is still sorely lacking,1 thus the cause is not due to one factor alone but a combination making treatment somewhat experimental and published of factors working simultaneously. The systematic review reports are mostly anecdotal rather than controlled treatment paper by Van’t Spilker et al.6 concluded that the number studies. of adults presenting with severe tooth wear at age 20 years was approximately 3% and increased to 17% at 70 years of The aetiology of tooth loss is usually multifactorial being age. Hence, it is expected that tooth wear will be observed a combination of abrasion, erosion, bruxism or some other in older patients, which is an increasingly larger patient pool parafunctional occlusal habit. Identifying the individual needing more complex care. factors causing the tooth loss is possibly the most important aspect of treatment as a means to slow the loss of hard It has been noted, however, that there seems to be an tissues. Abrahamsen3 published a useful table outlining increased observation of younger patients presenting with some of the factors that will aid diagnosis of tooth loss. It erosion.5 This is due to increased consumption of carbonated is generally thought that all patients should be considered drinks as well as other causes. at risk. Therefore any new patient should be assessed not only for all aspects of the oral cavity we now examine, but Management observation for tooth wear/loss should be included.1 It can also be said that once identified, tooth wear can be halted or The management of a patient who presents with what at least slowed considerably.4 could be termed ‘pathological’ tooth wear is complex from the starting point of a diagnostic decision, then determination * Presented at the Twentiy-first Convocation of the Royal Australasian College of aetiological factors, modifying these factors before of Dental Surgeons, Queenstown, New Zealand, 31 March - 4 April 2012 undertaking any definitive treatment to replace lost tooth structure. It is also necessary to note the extent of the wear,

98 ATTRITION AND EROSION: RESTORATIVE PLANNING AND PERFORMANCE as this will influence how extensive and complicated the Often the early phase of treatment will include the use treatment plan may need to become. Tooth loss or wear of splint therapy, especially if TMJ symptoms are present. can range from just one or two teeth, to the whole anterior Care must be taken if the patient has gastric reflux or has segment with little posterior wear or vice versa, or the whole an ‘erosive’ diet. It must be ensured that the splint does not dentition. become a reservoir for the acidic fluids and hence exacerbate the problem. It can also be useful to use the splint as a vehicle The recent series of papers by Mehta et al.5,7-9 provides to expose teeth to remineralizing agents, thus serving a dual a comprehensive overview of assessing a patient who purpose.5 presents with tooth wear and how it can be managed. They reiterate the importance of obtaining an excellent history and Once the conservative phase and stabilization of the examination and ensuring the patient is made to understand patient’s condition has been achieved then the rehabilitative exactly what the problem is. Monitoring is also an important phase of treatment should commence. This usually means part of the overall treatment, especially during the period prior the replacement of lost tooth structure often associated to undertaking restorative rehabilitation. This monitoring is with increasing the vertical dimension. This is especially necessary to determine if the aetiological factors have been the case where the anterior teeth have been severely worn controlled, without which, any rehabilitation will be less but compensated by continued eruption. In such a case the successful. posterior teeth have often changed little. There is currently little research on the clinical longevity of restorations placed in One aspect that must be determined at examination is this group of patients. In the past, treatment often incorporated the occlusal vertical dimension (OVD) of the patient.10 In the preparation of teeth to receive indirect restorations such some cases the teeth will continue to erupt to compensate as pinledges, onlays and crowns. Fortunately with the advent for the loss of tooth structure. Hence, the freeway space and great improvement of adhesive restorative materials a and rest vertical dimension should be obtained as part of much more conservative and potentially reversible treatment the diagnosis. It will also provide a wealth of information options can now be implemented.12 with respect to how any restorative management may be undertaken, and from when to start to plan the rehabilitation In the case where a few teeth have been affected by phase of treatment. wear and have an existing enamel margin with loss of the dentine surface, typically seen on lower incisors, and there To develop a comprehensive treatment plan this patient is no reduction in OVD, then a conservative approach group will need an extensive examination beyond that which aimed at protecting the exposed, and occasionally sensitive, we may do for the ‘average’ patient. Points mentioned dentine is to cover it with either glass ionomer cement or above, such as OVD, the occlusal relationship, TMJ resin composite. The longevity of such restorations is often function, and articulated study casts, intra-oral radiographs, limited and patients should be informed of this. However, it sensibility tests, analysis of the saliva and diagnostic wax- is a very simple and quick method to solve the problem. The up are all needed before a treatment plan is presented to the glass ionomer cements tend to wear and chip at the margins patient.11 One of the current drawbacks is the distinct lack more frequently than resin composite but can often be longer of a classification system and a screening tool that may lasting due to chemical adhesion to the underlying sclerotic aid practitioners to determine if the wear is in, or close to, dentine. When a good enamel margin exists, then bonded the ‘pathological’ range. This would be a great aid in the resin composites are a good alternative. Should chipping treatment planning process and at which point to intervene. of the composite occur they can be easily repaired. Either a three-step etch and rinse or two-step self-etching adhesive Treatment to aid prevention of further tooth loss includes system is preferred based on the clinical evidence showing conservative means such as prescribing the use of fluoride these two groups of adhesives bond well to sclerosed dentine. mouthwashes and now remineralizing agents such as casein A recent laboratory study did show that in the case of a self- phosphopeptide amorphous calcium phosphate (CPP-ACP) etching adhesive it may be useful to lightly roughen the to modify tooth surfaces to become more acid resistant, dentine to enhance the adhesion if it has been eroded.13 This thus reducing the effects of erosive agents. The fluoride and has not been tested clinically, but there are studies of bonding CPP-ACP containing agents will also assist with eliminating to non-carious cervical lesions with the more recent all-in- sensitive teeth. Hypersensitivity can also be managed to one adhesives where only the tooth surface has been cleaned some extent by modification of tooth-brushing habits, use with pumice and water. The retention rate of the restorations of desensitizing toothpastes or even the application of resin- has been shown to be very good with this treatment.14 based adhesives. In this latter case, the self-etching materials However, should the tooth surface be burnished and glassy in are likely to be simpler to apply to the tooth surface. appearance, then it would be advisable to roughen this tooth surface prior to bonding. Another alternative is the use of a Once the aetiological factors of the individual patient’s resin-modified glass ionomer adhesive and resin composite. tooth loss have become better understood, then it is also The author has had some clinical success with this method. important to educate the patient about the effects of diet.5 This technique combines the adhesion of glass ionomer and The consumption of low pH foods should be avoided, but strength and wear resistance of composite. when this is not possible then the patient must be taught how to reduce the effects of demineralization from such foods A number of papers have appeared in recent times and beverages. This can be as simple as rinsing the mouth outlining the clinical processes of how to restore patients’ after consuming acidic food/fluids, or chewing sugar-free gum, which may also contain CPP-ACP.