Annals Vol 24 (2018)

ANNALS 2018 Volume 24



ANNALS OF THE ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS Proceedings of the Twenty-Fourth Convocation of the Royal Australasian College of Dental Surgeons Thursday 20 to Sunday 23 September 2018 Published by THE ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS Incorporated Level 13/37 York Street, Sydney, New South Wales 2000 Australia All rights reserved

Contents Royal Australasian College of Dental Surgeons Council 2016-2018 4 Founders & Honorary Fellows of the College 5 Elected Members of Council 5 Office Bearers 6 Convocation Committee 6 Convocations of the College 7 Twenty-Fourth Convocation, Royal Australasian College of Dental Surgeons Adelaide. South Australia – Opening Ceremony 20 September 2018 Presidential Address 8 Dr Patrtick Russo 10 11 Opening Address Govenor of South Australia, Prof Hieu Van Le AC New Fellows and Members HONOURS BESTOWED Meritorious Service Award 12 13 A/Prof Jocelyn Shand 13 Dr Leone Hutchinson 14 15 Dr Bruce Emery Taylor 16 Admission as an Honorary Fellow Dr David Sykes OAM Emerging Lecturer Award Eighteenth Robert Harris Oration Executive Director of South Australian Health and Medical Research Institute, Prof Steve Wesselingh 2 RACDS ANNALS 2018

SCIENTIFIC PROGRAM – PAPERS AND ABSTRACTS Surgical Management of Temporomandibular Joint Disorders 19 Dr George Dimitroulis 20 21 Emergency Endodontic Management 22 Dr Daniel Farmer 23 24 Who Owns Your DNA? 25 Ms Julie Brooke-Cowden 26 The New Era in Prosthodontics 29 Dr Philip Tan 31 33 Esthetic Outcomes and Digital Technology in Implant Prosthodontics Dr German Gallucci 38 Digital Approach to Implant Dentistry Dr German Gallucci Success Criteria for Implant-Prosthodontic Rehabilitations Dr German Gallucci The Pathophysiology of Orthodontic Tooth Moment: Role of Endoplasmic Reticulum Stress Dr Fiona Firth Digital Planning for Mandibular and Maxillary Reconstruction Prof Jonathan Clark and Dr Georg Haymerle Who Benefits from New Technologies in Dentistry? Dr Suzanne Hanlin Psychosocial Considerations for Temporomandibul Disorders Drs Ramesh Balasubramanium, Lalima Tiwari and Amanda Phoon-Nguyen 2017 WHO Classification of Odonteogenic Cysts and Tumours Dr Alison M Rich EMERGING LECTURER AWARD PAPERS Paediatric Dentistry - Don't brush us aside 41 Dr Gwendolyn Huang 42 43 The Oral Mycobiome in Children with and without Dental Caries Dr Jacquelyn Fechney 44 45 Silver Diamine Fluoride: An integrated, evidence-based approach to arrest 46 dental caries for vulnerable children Dr Jilen Patel Pacific Oral Health in New Zeland: Realities and The Exciting Way Forward Dr Mowafaq Amso Azithromycin in the Treatment of Periodontitis Dr Meredith Owen CONTRIBUTOR’S INDEX & SPONSORS RACDS ANNALS 2018 3

Council RACDS Council 2016-18 Back row (L to R) – Dr David Sykes OAM (Immediate Past President), Prof Ian Meyers OAM, Dr Peter Gregory, Dr Chris Callahan, Dr Denise Lawry, Dr Albert Lee, A/Prof Richard Widmer and A/Prof Peter Duckmanton Seated (L to R) – Dr Hugh Trengrove MNZM, A/Prof Nicky Kilpatrick, Dr Patrick Russo (President), Dr Paul Sambrook, (President Elect) and Dr Warren Shnider President COUNCIL APPOINTMENTS Dr Patrick Russo, BDSc, FRACDS, FPFA Registrar, General Dental Practice President–Elect Prof Liz Martin, BDS(Hons), MDS, PhD, FRACDS, FPFA, FADI, FICD Dr Paul Sambrook, MBBS, MDS, FRACDS(OMS) Registrar, Specialist Dental Practice Executive Officer Adj A/Prof Neil Peppitt, BDS, MDSc, A/Prof Nicky Kilpatrick, BDS, PhD, FDS, RCPS, FRACDS(Paed) MRACDS(Pros),FRACDS Honorary Treasurer Dr Hugh Trengrove MNZM, BDS, MDS, FRACDS Registrar, Oral Maxillofacial Surgery Dr Julia Dando, BDS (Wales), MMedSci, MRACDS(Ortho), Censor- in- Chief Dr Warren Shnider, BDSc, FRACDS(SND), FICD OrthRCS (Eng), FDSRCS (Ed) Immediate Past-President Assistant Registrar, General Dental Practice Dr David Sykes OAM, BDS(Lond), MDS(Syd), LDSRCS(Eng), Dr Catherine Prineas, BDS(Hons), FRACDS, GradDipClinDent(Sedation and Pain Control) MRACDS(Pros), FRACDS Assistant Registrar, Specialist Dental Practice Councillors A/Prof Werner Bischof, BDSc, MDSc, FRACDS, Dr Chris Callahan, BA, BDSc, FRACDS, FADI, FICD A/Prof Peter Duckmanton, BDS, MDSc, FRACDS, FICD, FPFA MRACDS(Perio), FICD, FPFA Dr Peter Gregory, BDSc, MDSc, , MRACDS(Paed), FRACDS Dr Albert Lee, BDS(Adel), MSc(Lond), FRACDS, FCDSHK(Paed Honorary Editor, Annals A/Prof Menaka Arundathi Abuzar PhD, Dent), FHKAM(Dental Surgery), FICD Dr Denise Lawry, BDSc(Melb), LDS(Vic), MDSc(Melb), MDSc(Prosthodontics), MRACDS, FACDS(Orth), FPFA, FADI, Grad Dip(Arts) French (Melb) Prof Ian Meyers OAM, BDSc, FRACDS, FICD, FPFA, FADI Honorary Editor, College News Prof Clive Wright AM, MDS, PhD, FICD, MRACDS(DPH) 4 RACDS ANNALS 2018 Chief Executive Officer Dr Karen Luxford

FOUNDERS OF THE COLLEGE Committee appointed by the Australian Dental Association to investigate ways and means of establishing an Australian College of Dental Surgeons Alfred Gordon Rowell, Chairman William Alan Grainger Kenneth Thomas Adamson Robert Harris Alwyn James Arnott H Roy Cash William Keith Ross Mackenzie K Robertson 1. Subscribers to the Initial Constitution 2. Interim Council, elected 14 March, 1965 3. First Council, elected 5 November, 1966 Kenneth Thomas Adamson Alwyn James Arnott President A G Rowell President A G Rowell William Alan Grainger Robert Harris Vice-President K T Adamson Vice-President K T Adamson William Keith Ross Mackenzie Alfred Gordon Rowell Censor-in-Chief W A Grainger Censor-in-Chief W A Grainger *Did not serve. Honorary Secretary R Harris Honorary Secretary R Harris 1965 Arthur Amies* Honorary Treasurer W K R Mackenzie Honorary Treasurer J S Lyell 1965 John Hall Best* 1966 Alwyn James Arnott* Councillors: H R Cash* Councillors: G Christensen 1966 T Draper Campbell* 1966 Sidney Firth Lumb* J F Lavis J F Lavis 1966 John Walsh* 1968 Robert Bradlaw* R L Taylor 1968 Terence Ward* 1968 Frank Clare Wilkinson* HONORARY FELLOWS 1970 Gerald Leatherman* 1 9 7 1 Neil William George Macintosh* 1 9 7 8 Ivor Robert Horton Kramer 1 9 9 8 John Kenneth Harcourt 197 3 Alan Docking* 1 9 7 9 Robert Harris* 1 9 9 8 George Henry Hewitt 1 974 William Alan Grainger* 1 9 7 9 John Frederic Lavis* 2000 Sydney Charles Warneke 1976 Kenneth Adamson* 1 9 7 9 Alfred Gordon Rowell* 20 01 John Hugh Sinclair* 1976 Kenneth Wollaston Cleland* 1 9 8 2 Paul Anthony Bramley 2003 Kenneth Howard Wendon 197 7 Percy Raymond Begg* 1 9 8 3 Kenneth Joseph George Sutherland 2005 Ross Jan Bastiaan 197 7 George Neville Davies 1 9 8 5 Henry Gordon Lamplough* 2007 David Henry Thomson 1 9 8 5 Warwick Olver Read* 2009 Neil John Joseph Peppitt *Deceased. 1 9 8 7 Earle Harold Bastian* 2010 Eric Charles Reynolds 1 9 8 7 Stanley George Kings* 2 0 1 1 Bernadette Kathleen Drummond 1 9 8 7 John Alfred Sagar* 2 0 1 4 Werner Hans Bischof 1989 Richard Manning King* 2 0 1 5 Braham Anthony Pearlman* 1989 Robert York Norton* 2 0 1 5 Francis So Wah Chau 1 9 9 1 George Wing 2 0 1 5 Martin John Tyas 1 9 9 3 John Henry Muller 2 0 1 7 David Sykes 1 9 9 3 Diana, Princess of Wales* 1 9 9 5 Reginald William Hession ELECTED MEMBERS OF COUNCIL 1966 – 1969 F G Christensen* 1982 – 1996 P W McKerracher 2004 – 2012 W H Bischof 1986 – 1996 G H Hewitt 1966 – 1971 R L Taylor 1986 – 1999 S C Warneke 2004 – 2014 F S W Chau ‡ 1988 – 2000 J H Sinclair 1966 – 1973 W A Grainger* 1988 – 19 96 B Feiglin 2006 – 2012 J P Fricker 1990 – 2002 K H Wendon 1966 – 1975 J S Lyell* 1990 – 2004 R J Bastiaan 2010 – 2014 R A Whyman † 1990 – 2004 J P H Rogers 1966 – 1976 K T Adamson* 1990 – 2002 G A Thomas 2012 – 20 14 R Nair 1992 – 2006 D H Thomson 1966 – 197 8 R Harris* 1994 – 2004 A N Goss 2008 – 20 12 B Pearlman* 1996 – 2005 R G Cook 1966 – 1978 J F Lavis * 1996 – 2008 S C Daymond 2006 – 2016 D G Sykes 1996 – 2002 E D Kingsford-Smith 1966 – 1978 A G Rowell * 1996 – 2008 N J J Peppitt 2008 – 20 18 P Russo 2000 – 2010 B K Drummond 1969 – 1973 G B Ferguson* 2000 – 2002 M D Suthers 2010 – 2018 W H Shnider 2000 – 2012 M J Tyas 1970 – 1982 T B Lindsay 2002 – 2012 S M Hanlin 2010 – 2018 P J Gregory 2002 – 2010 R D Story 1971 – 1982 H G Lamplough * 2002 – 2006 B M Woodhouse 2010 – 2018 A M P Lee ‡ 2004 – 2010 D D Bambery † 1971 – 1982 W O Read* 2012 – 20 18 P Duckmanton 1974 – 1986 S G Kings * 2012 – 20 18 P Sambrook 1974 – 1986 J A Sagar* 2013 – 20 18 N Kilpatrick 1975 – 1988 R Y Norton* 2014 – 20 18 C M Callahan 1976 – 1988 R M King 2014 – 20 16 J P Fricker 1978 – 198 9 P Hastie 2014 – 20 18 H G Trengrove † 1978 – 199 0 G Wing 2014 – 20 18 R P Widmer 1978 – 1979 D E Poswillo 2016 – 20 18 D Lawry 1979 – 1992 J H Muller 2016 – 20 18 I Meyers 1982 – 1996 J K Harcourt 1982 – 1994 R W Hession *Deceased †Representing the New Zealand Region ‡Representing the Asian Region RACDS ANNALS 2018 5

OFFICE BEARERS President 1966 – 1968 Vice-President Honorary Treasurer 1966 – 1968 A G Rowell 1970 – 1972 K T Adamson 1966 – 1968 J S Lyell 1968 – 1970 K T Adamson 1970 – 1972 W A Grainger 1968 – 1970 J F Lavis 1968 – 1970 W A Grainger 1972 – 1974 J F Lavis 1970 – 1971 R L Taylor 1972 – 1974 J F Lavis 1974 – 1976 J S Lyell 1971 – 1974 H G Lamplough 1974 – 1976 J F Lavis 1976 – 1978 J A Sagar 1974 – 1976 W O Read 1976 – 1978 J A Sagar 1978 – 1980 W O Read 1976 – 1980 R Y Norton 1978 – 1980 W O Read 1980 – 1982 H G Lamplough 1980 – 1982 S G Kings 1980 – 1982 H G Lamplough 1982 – 1984 R Y Norton 1982 – 1988 J H Muller 1982 – 1984 R Y Norton 1984 – 1986 S G Kings 1988 – 1994 S C Warneke 1984 – 1986 S G Kings 1986 – 1988 R M King 1994 – 1996 J H Sinclair 1986 – 1988 R M King 1988 – 1990 G Wing 1996 – 1998 R J Bastiaan 1988 – 1990 G Wing 1990 – 1992 J H Muller 1998 – 2002 J P H Rogers 1990 – 1992 J H Muller 1992 – 1994 R W Hession 2002 – 2004 N J Peppitt 1992 – 1994 R W Hession 1994 – 1996 J K Harcourt 2004 – 2012 S McE Hanlin 1994 – 1996 J K Harcourt 1996 – 1998 S C Warneke 2012 – 2014 R Whyman 1996 – 1998 S C Warneke 1998 – 2000 J H Sinclair 2014 – 2016 P Sambrook 1998 – 2000 J H Sinclair 2000 – 2002 K H Wendon 2016 – 2018 H Trengrove 2000 – 2002 K H Wendon 2002 – 2004 R J Bastiaan 2002 – 2004 R J Bastiaan D H Thomson Registrar 2004 – 2006 D H Thomson (General Dental Practice) 2006 – 2008 N J Peppitt 2004 – 2006 President-Elect 1996 – 2000 E D Kingsford Smith 2008 – 2010 B K Drummond 2006 – 2008 N J Peppitt 2000 – 2008 B A Pearlman 2010 – 2012 W H Bischof 2008 – 2010 B K Drummond 2008 – 2012 E Martin 2012 B A Pearlman 2010 – 2012 W H Bischof 2012 – 2018 E Martin 2012 – 2014 F S W Chau 2010 – 2014 B A Pearlman 2014 – 2016 D G Sykes 2014 – 2016 D G Sykes Registrar 2016 – 2018 P J Russo 2016 – 2018 P J Russo (Specialist Dental Practice) P Sambrook 1996 – 2004 C G Daly 2004 – 2013 A C Cameron 1966 – 1968 Censor-in-Chief 1966 – 1978 Honorary Secretary 2014 – 2018 N J Peppitt 1968 – 1972 W A Grainger 1978 – 1984 R Harris 1972 – 1974 J S Lyell 1984 – 1990 G Wing Assistant Registrar 1974 – 1978 W O Read 1990 – 1998 R W Hession (General Dental Practice) 1978 – 1980 H G Lamplough 1998 – 2006 K H Wendon 1998 – 2002 A C Cameron 1980 – 1984 S G Kings 2006 – 2008 S C Daymond 2002 – 2004 H M Cameron 1984 – 1986 R M King 2008 – 2012 W H Bischof 2008 – 2018 C Prineas 1986 – 1992 G Wing F S W Chau 1992 – 1996 J K Harcourt Assistant Registrar 1996 – 2002 P W McKerracher 2012 – 2014 Executive Officer (Specialist Dental Practice) 2002 – 2004 D H Thomson 2014 – 2016 Patrick Russo 2002 – 2004 A C Cameron 2004 – 2006 A N Goss 2016 – 2018 P Gregory 2004 – 2013 A F Georgiou 2006 – 2008 B K Drummond N Kilpatrick 2014 – 2018 W H Bischof 2008 – 2012 R D Story 2012 – 2018 M J Tyas Registrar Assistant Registrar W Shnider 1966 – 1980 R Harris (Oral Maxillofacial Surgery) 1980 – 1988 G Wing 2009 – 2018 J Dando 1988 – 1996 G H Hewitt 1997 – 2006 S C Daymond Convocation Committee 2018 Scientific Program Chairs Dr Louise Brown A/Prof Richard Widmer Arrangements Committee Chair Dr David Sykes Organising Committee Dr Patrick Russo A/Prof Nicky Kilpatrick 6 RACDS ANNALS 2018

Convocations Date Venue Annals 31 August – 1 September 1967 Canberra, Australia Vol. 1 13 – 16 August 1969 Sydney, Australia Vol. 2 11 – 13 August 1971 Sydney, Australia Vol. 3 3 – 6 March 1974 Adelaide, Australia Vol. 4 20 – 23 February 1977 Melbourne, Australia Vol. 5 13 – 16 May 1979 Christchurch, New Zealand Vol. 6 9 – 12 November 1981 Sydney, Australia Vol. 7 2 – 5 April 1984 Brisbane, Australia Vol. 8 30 October – 3 November 1986 Melbourne, Australia Vol. 9 25 February – 2 March 1989 Hong Kong, SAR China Vol. 10 21 – 24 September 1991 Rotorua, New Zealand Vol. 11 16 – 19 April 1994 Canberra, Australia Vol. 12 26 – 30 April 1996 Sydney, Australia Vol. 13 23 – 27 October 1998 Adelaide, Australia Vol. 14 20 – 24 October 2000 Auckland, New Zealand Vol. 15 17 – 20 October 2002 Melbourne, Australia Vol. 16 14 – 17 October 2004 Darwin, Australia Vol. 17 31 August – 3 September 2006 Sydney, Australia Vol. 18 30 May – 2 June 2008 Hong Kong, SAR China Vol. 19 11 – 14 March 2010 Perth, Australia Vol. 20 31 March – 4 April 2012 Queenstown, New Zealand Vol. 21 10 – 13 April 2014 Surfers Paradise, Australia Vol. 22 30 March – 2 April 2016 Hobart, Australia Vol. 23 20 - 23 September 2018 Adelaide, Australia Vol. 24 RACDS ANNALS 2018 7

Presidential Address Address by the President of the Royal Australasian College of Dental Surgeons Dr Patrick Russo, BDSc, FRACDS, FPFA at the Opening Ceremony 8 RACDS ANNALS 2018

Since 1969, Fellowship of the College has been gained by .Certainly dentistry has benefited by his labours, but it is equally Examination in either General Dental Practice or Specialist Dental important that many people in the professional as well as general Practice. Fellowship of the Royal Australasian College of Dental community felt the hand of kindness that he so readily proffered. Surgeons is the highest qualification the College bestows denoting He was an extraordinary practitioner to achieve the status of a highly skilled and proficient practitioner and is assessed by Fellowship in the College. He served the College in the formative rigorous examination in the basic dental sciences and clinical years as a Councillor, lecturer, examiner and Chairman of the evidence-based practice. Queensland Regional Committee. Tonight, we have with us 25 successful candidates for Fellowship It is not surprising therefore, that his death did not mean an end in General Dental Practice” to his endeavours for he ensured that a tangible expression of his interests should persist in the form of a Prize for the successful The list of Fellows in General Dental Practice by Examination candidate with the highest marks and outstanding proficiency includes those candidates who have been successful at the Final at the Primary Examination held by the College. I do not need Examination in the past two years or who have not previously to remind you of the high standard of this Examination, and the been formally presented. international reputation that it has achieved. Membership of the Royal Australasian College of Dental Surgeons The F.G Christensen Memorial Prize consists of a Medal and a is awarded to those candidates who have shown high competency monetary Award. and knowledge relevant to the practice of dentistry with a comprehensive breadth of skill and understanding in evidence The influence of Robert Harris on this College is well known. He based clinical practice. Membership in General Dental Practice is was an inaugural member of Council and served the maximum achieved through an exacting program of assessment modules term of 12 years. undertaken by the successful candidate. As Honorary Secretary and Registrar of the College from 1965- Tonight, we have with us successful candidates for Membership in 1978 he must take a large share of the credit for the shaping of the General Dental Practice. College to its present status, its recognition throughout the world, its relationship with the Royal Colleges of England, Scotland and The list of Members in General Dental Practice by Examination Ireland and its relationship with its own Fellows. The College, in includes those candidates who have been successful at the naming the Oration to be given at the time of Convocations 'The Examinations in the past 2 years or who have not previously been Robert Harris Oration', recognises the great debt it owes to this formally presented. Founding Father. I call on the Censor-in-Chief to please present the candidates , for This year’s Robert Harris Orator is Professor Steve Wesselingh admission to Membership in General Dental Practice” Professor Wesselingh initially trained as an Infectious Diseases By virtue of the authority vested in me as President, I formally Physician and then completed a PhD titled “Response of admit to Membership in the College these candidates who have Astrocytes to Viral Infections”. In 1991 he was awarded an NHMRC been successful in the Examinations for Membership in General Neil Hamilton Fairley Fellowship to continue the study of the neuro- Dental Practice. immunology of HIV at the Neurovirology Unit in the Department of Neurology, Johns Hopkins Hospital, Baltimore. Fellowship in Specialist Dental Practice, in line with the standard for Fellowship in General Dental Practice, is the highest qualification In 1993 he was appointed to the faculty of the Johns Hopkins bestowed by the College in the various specialist dental disciplines. School of Medicine as Assistant Professor. Professor Wesselingh An equally high standard of knowledge and proficiency is required returned to Australia in 1994 to set up the Neurovirology Research to be demonstrated by the successful candidate. Unit within the Department of Microbiology and Infectious Diseases, Flinders University, continuing a close collaboration with Tonight we have with us successful candidates for Fellowship in Neurology Department at Johns Hopkins. He was then appointed Specialist Dental Practice in the category of Oral and Maxillofacial Professor and Director of the Infectious Diseases Unit at the Alfred Surgery. Hospital which incorporated the Victorian State-wide HIV/AIDS service and the Victorian HIV palliative care unit. I call on the Censor-in-Chief to please present the candidate for admission to Fellowship in Specialist Dental Practice in Oral and Professor Wesselingh has been Dean of the Faculty of Medicine, Maxillofacial Surgery. Nursing and Health Sciences at Monash University and is now the inaugural Executive Director of the South Australian Health Membership of the College in Specialist Dental Practice has been and Medical Research Institute. His research has encompassed gained either by College examination or by conjoint examination the neuro-immunology of HIV and, more recently, examining with our partners in Universities or sister Colleges or by recognition the human role of the microbiome in immune development; of prior training and standing as a registered specialist. particularly examining the bacteria that colonise us and how they impact upon us. Tonight we have with us successful candidates for Membership in Specialist Dental Practice by examination and candidates for The College places great importance on the 'Oration' and considers Membership by prior recognition. it one of the highlights at the Opening Ceremony. It chooses its Orator with great care. Tonight, our choice of Orator has been The list of Members in Specialist Dental Practice includes exceptional and I congratulate you, Professor Steve Wesselingh, those candidates who have been successful in satisfying the on a fine Oration, one which we, as a College, will be proud to requirements for granting of Membership in Specialist Dental record in our 'Annals'. Practice in the past two years or who have not previously been formally presented. As a tangible expression of our thanks I would like to present to you this Medallion which has been purposely struck in order that I call on the Censor-in-Chief to please present the candidates for you may have a permanent record of the occasion on which you admission to Membership in Specialist Dental Practice by both delivered this Oration. examination and prior recognition. RACDS ANNALS 2018 9 Frederick George Christensen died on July 17th 1969. There are few people who, “in the ordinary course of events, have the tenacity of purpose, the energy, the capacity and capability to accomplish in three score years and ten”, what George Christensen did in his fifty four years.

Opening Address Official Opening Remarks by His Excellency Professor The Honourable Hieu Van Le AC, Governor of South Australia I acknowledge that we meet on the traditional lands of the Kaurna people and that we respect their spiritual relationship with their country. Thank you Suzanne Russell for your Welcome to Country. It is an honour to address the 24th Convocation today. To our interstate guests here today, welcome to Adelaide the City of Churches and to South Australia, the Festival State. I hope that you will enjoy our outstanding food and wine and also experience our wonderful heritage, spectacular coastline and landscapes. To the new inductees and those who have completed specialist accreditation, I offer my congratulations. You have shown passion, skill and dedication to your profession. The ceremony today is a testament to your hard work and is an important milestone. Ladies and gentlemen. In South Australia we are proud of the Adelaide Dental School at the University of Adelaide. Its reputation as a centre of excellence in education, research and service is built on nearly 100 years of history. Dentistry undoubtedly touches people’s lives. After all, good dental health is essential for our wellbeing and quality of life. A person’s smile, condition of teeth and mouth can boost self-esteem. How we look, how we eat, how we speak, how we drink are all integral to how we feel about ourselves and how others see us. I was concerned to learn that in 2010, 55% of six year olds I was interested to learn that your Convocation sessions in Australia had experienced decay in their baby teeth… will explore the digital era; it’s opportunities and challenges. And 48% of 12-year-olds had experienced decay in their Technology has great potential to further enhance permanent teeth. In 2013, about 19% of adults aged 65 and diagnostic tools, record keeping and share cutting-edge over had no natural teeth. Three in 10 adults aged 25-44 have information. In a country like Australia, with vast distances untreated tooth decay. The College is to be commended for and remote communities, harnessing technology can break your role in supporting improved dental care. down barriers and enable greater access to services. In particular I commend you for becoming a partner in the To all here today, I congratulate you for your commitment to Rethink Sugary Drink alliance. Greater education; engaging the profession. As dental surgeons, Fellows and Members of the community on the importance of diet, regular dental the Royal Australasian College of Dental Surgeons, you do check-ups and the benefits of building a relationship with “let knowledge conquer disease”. dental health professionals will lead to better dental health. I wish you well for the Convocation and the future. It gives Ladies and gentlemen. Through your commitment to a me great pleasure to open the ceremony to admit the professional college you are ensuring professional standards Fellows and Members. as well as a forum for life-long learning and development in a collegiate way. 10 RACDS ANNALS 2018

- ORDER OF PROCEEDINGS - Presentation of Fellows Admitted to the College in General Dental Practice Mowafaq Amso 2018 Errol Kilov 2017 Farhana Pethani 2018 Joshua Ch'ng 2017 Atin Kundu 2017 Helena Ryan 2011 Fiona Firth 2017 Wai Jean Lim 2018 Annabelle Shalders 2018 Catherine Moe Moe Htet Fu 2017 Zanab Malik 2018 Wan Jiun Tan 2018 Finn Gilroy 2017 David McKelvey 2016 Arun Prabu Velusamy 2018 Aakriti Goel 2018 Nur Awanis Mohamed Alang 2018 Yuk Chi Wong 2017 Brenna Holmes 2018 Arun Mohan 2018 Michael Wylie 2017 Laura Ichim 2016 Lydia Oi Ying Ng 2016 Ji Tchung Jong 2018 Farhana Omar 2018 Presentation of Members Admitted to the College in General Dental Practice Mamta Arya 2017 Edmund Kwong 2018 Nicholas Taft 2017 Nirosha Balasubramaniam 2017 Jonathan Lo 2017 Fiona Thuy 2016 Trupta Desai 2018 Tafadzwa Mabheju 2017 Dushyanti Umakhanthan 2017 Gideon Dhinakaran 2017 Girish Nanoo Sasidharan 2018 Ahmed Wahba 2018 Deborah Elijah 2017 Patanjali Pandey 2016 Stephanie Walls 2017 Angela Gurner 2018 Prathayini Puvanakumar 2018 Andrew Young 2018 Vivek Jain 2018 Rangi Sooriyaarachchi 2017 Augustine Kim 2018 Barry Subramani 2016 Presentation of Fellows Admitted to the College in Oral and Maxillofacial Surgery Frank Chang 2018 Tran-Lee Kaing 2017 Presentation of Members Admitted to the College in Specialist Dental Practice Discipline Darryl Beresford 2018 - Prosthodontics Joao Camacho 2017 - Paediatrics Fiona Firth 2018 - Orthodontics Maansi Juneja 2018 - Paediatrics Nik Mukhriz Nik Mustapha 2017 - Orthodontics Emily Meredith Owen 2018 - Periodontics John Perry 2017 - Orthodontics Benlee Yap 2017 - Orthodontics Presentation of Members Admitted to the College via Prior Recognition in Specialist Dental Practice Rajvinder Dhaliwal 2017 - Dental Public Health Robert Gan 2017 - Orthodontics Howard Holmes 2017 - Orthodontics Susan Needham 2017 - Orthodontics Manjunath Rajashekhar 2016 - Dental Public Health Presentation of F.G Christensen Memorial Award Dr Matheel Zohair Yousif Alrawas 2017 Presentation of Kenneth J G Sutherland Prize & Award Dr Joshua Ch'ng 2017 Dr Annabelle Shalders 2018 Presentation of Meritorious Service Award Dr Leone Hutchinson 2017 A/Prof Jocelyn Shand 2017 Dr Bruce Emery Taylor 2017 Presentation of Honorary Fellowship Dr David Sykes OAM 2017 RACDS ANNALS 2018 11

Presentation of Meritorious Service Award A/Prof Jocelyn Shand Associate Professor Shand gained her Bachelor Degree in dentistry from the University of Otago in 1990 and then commenced her journey towards her goal of a career in Oral and Maxillofacial Surgery by gaining a Fellowship from the Royal College of Surgeons of England in 1994, a Bachelor of Medicine and Surgery in 1999 and a Masters of Dental Science in 2003; both from the University of Melbourne, then Fellowship in Oral and Maxillofacial Surgery from our College, also in 2003. A/Prof Shand has worked in Oral and Maxillofacial surgery positions in Australia, New Zealand, the United Kingdom and in the USA charting an illustrious career in her specialty which has encompassed research, teaching and clinical practice. She has been awarded several prizes and awards from the Australian and New Zealand Association of Oral and Maxillofacial Surgeons, for whom she served as President between 2009 and 2011, and was recognised with a Distinguished Service Award from the Australian Dental Association, Victorian Branch. The College Council wishes to acknowledge A/Prof Shand’s notable long service to the Board of Studies for Oral & Maxillofacial Surgery. Specifically for her service as a Board member culminating in Board Chair for 4 years; for her service on several Committees of the Board; for her development of Surgical training curriculum; for her teaching, examining and, especially, her leadership in the re-accreditation of the OMS Training Program. This particular contribution was paramount in the successful re-accreditation of the programme for a further 5 years by the Medical & Dental Councils of both Australia and New Zealand. A/Prof Jocelyn Shand has made a significant and important contribution to the specialty of Oral Maxillofacial Surgery, both within the College and to the specialty as a whole. 12 RACDS ANNALS 2018

Dr Leone Hutchinson Dr Leone Hutchinson gained her Bachelor Degree in dentistry from the University of Sydney in 1980 and gained a Bachelor of Arts in 1988 and a Graduate Diploma in Arts in 1989; also from the University of Sydney. Dr Hutchinson was awarded Fellowship of the Pierre Fauchard Academy in 2001 and the International College of Dental Surgeons in 2009. Dr Hutchinson was elected to Fellowship of the College by examination in 1989 and joined the NSW Regional Committee 3 years later. She served on the Regional Committee for 20 years including six years as the Chair. Dr Hutchinson has served the College in many other areas including as a member of the Organising Committee for two previous Convocations, as an assistant Examiner in the Primary examination, and as a mentor in the MRACDS programme. She also held positions on the fund-raising committee for the College Foundation including as a Director and as Secretary. In addition to her roles with the College, Dr Hutchinson has represented the profession as a Councillor for the Australian Dental Association NSW Branch and on the Federal body. Dr Hutchinson has provided an important, dedicated and innovative contribution to the College since her election as a Fellow to the present day. Dr Bruce Taylor Dr Taylor gained his Bachelor Degree in Dental Science from the University of Melbourne in 1974 together with a Licentiate in Dental Surgery. He worked, initially, as a general dentist and then undertook a Masters programme in orthodontics which he completed in 1981. He has worked in specialist orthodontic practice from then until his retirement in 2015. Dr Taylor was admitted as a Fellow of the College in 1978. During his professional life, he served the profession in many roles; as a teacher and demonstrator in Orthodontics for Melbourne and La Trobe Universities; as an elected Council member of the Australian Dental Association (Victorian Branch), serving as President in 1987; and as a Director of the Australian Dental Council, the Australian Dental Research Foundation and the Medical Indemnity Protection Society. Dr Taylor held significant roles in all these organisations and made substantial contributions to the development of each institution. Dr Taylor’s commitment to teaching dental students, both at an undergraduate and postgraduate level, has extended for over 30 years. From a College perspective, his involvement commenced with final year dental student tutorials in the area of orthodontics organised by the RACDS Victoria and Tasmania Regional Committee. Dr Taylor’s commitment and dedication to this teaching role on behalf of the College and his support for the College over many years have enhanced the learning experience of countless dental students, both undergraduate and postgraduate. RACDS ANNALS 2018 13

Admission of Honorary Fellows Dr David Sykes OAM Dr David Sykes gained his Bachelor Degree in dentistry On his retirement as President, Dr Sykes has continued to from the University of London in 1975. After a period as a support the College to Chair the Convocation Organising general dentist in the UK, he moved to Australia gaining a Committee for the 2018 Convocation. position as Registrar in Prosthodontics at Westmead Clinical Dental School, Sydney. During this time, he was admitted Dr David Sykes has represented the College as a Councillor, as a Fellow of the College by examination in 1984. Dr Sykes as President, and as a member of the New South Wales completed a Masters degree in Dental Surgery in 1987 and Regional Committee and he has represented the profession was listed as a Specialist Prosthodontist by the Dental Board as a whole in Australia, to a commendably high standard. of New South Wales in 1990. His broad involvement in many aspects of dentistry was recently recognised in the Queen’s Birthday honours with Dr Sykes has supported the profession in a variety of an award of the Medal in the Order of Australia for his organisational and teaching roles over many years. He was service to dentistry and in particular Prosthodontics. elected to the Council of the Australian Dental Association (NSW Branch) in 1986 and served as Branch President between 1992 and 1993. He was elected to the Dental Council of New South Wales in 1995 and continued on the Board until 2010. Dr Sykes has been a Reserve Dental Officer in the Royal Australian Navy and Specialist Consultant at HMAS Kuttabul for many years. He is currently a Board member of the Australian Dental Council and continues to teach as Senior Clinical Associate on the Specialist Prosthodontic training programme at the University of Sydney. For the College, Dr Sykes was elected to the New South Wales Regional Committee of the College in 1987 and served as its Secretary and its Chair until he was elected to College Council in 2006. As a College Councillor he acted in various roles culminating by serving as President from 2014 to 2016. During his term as President, Dr Sykes furthered initiatives of the previous President, Dr Francis Chau, in strengthening relationships in the Asia Pacific Region, particularly with the College of Dental Surgeons of Hong Kong and the College of Dental Surgeons Singapore. The College enhanced its relationship with the Royal College of Surgeons Edinburgh by hosting diets of the RCSEd Diploma in Implant Dentistry. It was during his tenure that the College reflected its maturity as an organization by transitioning from an entity incorporated under the Associations Act in the ACT to a public company limited by guarantee under the Corporations Act. 14 RACDS ANNALS 2018

Emerging Lecturer Award The Emerging Lecturer Award has established itself as an important part of College Convocation. Once again it was a well received part of the scientific program. The College is grateful to Colgate for their continued support of this award. Gratitude is also extended to our panel of judges, Dr Paul Sambrook, Dr Patrick Russo and Prof Bill Scarfe. This year’s candidates presented on topics from diverse disciplines and provided the judges with the difficult task of deciding a winner. The candidates and the titles of their presentations were: • Dr Gwendolyn Huang, Paediatric Dentistry – Don’t brush us aside • Dr Jacquelyn Fechney, The Oral Mycobiome in Children with and without Dental Caries • Dr Jilen Patel, Silver Diamine Fluoride: An integrated, evidence-based approach to arrest dental caries for vulnerable children • Dr Mowafaq Amso, Pacific Oral Health in New Zealand - Realities and The Exciting Way Forward • Dr Meredith Owen, Azithromycin in the Treatment of Periodontitis The winner was Dr Jilen Patel from the University of Western Australia. He was awarded a certificate and a cheque from Colgate. The other lecturers were awarded a Certificate of Achievement. The judges noted that all presentations, in both content and delivery, were of a high standard. Convocation delegates were left in no doubt as to the value of the Emerging Lecturer Award in fostering emerging presenters and their research, which bodes well for the future of our profession. Clin A/Prof Richard Widmer Convener, Emerging Lecturer Award RACDS ANNALS 2018 15

The Eighteenth Robert Harris Oration Address by Prof Steve WESSELINGH, BMBS, PhD, FRACP, FAHMS, Executive Director of The South Australian Health and Medical Research Institute (SAHMRI), Adelaide Dean of the Faculty of Medicine, Nursing and Health Sciences at Monash University, Australia. Thank you for that terrific welcome to country. like Robert Harris, have built the fence at the top of cliff. Robert recognised the need for preventing the onset of dental disease, I would also like to acknowledge the traditional custodians of the land. rather just treating it. Understanding the reasons for rampant caries and developing measures of control. Being asked to give the Robert Harris Oration is a great honour from a great Australian College. He also understood the importance of peer review and the peer reviewed literature. He was involved in the development of the Robert Harris was an outstanding Australian. national Australian Dental Journal and was editor for more than 30 years. As I am sure you are all aware, he was a significant player in the development of the college, but he also understood the I believe the themes I am going to talk about today would resonate importance of research and the integration of research into clinical with Robert Harris. practice - the themes I am going to talk about today. I also want to acknowledge what a terrific meeting you have coming up and that a lot of the speakers know far more on the In addition, he championed the importance of prevention, issues of digital health than I do. something that dental medicine has done much better than the rest of medicine. We are still at the bottom of the cliff waiting with Firstly, I want to take a step back and ask. What does the community the ambulance, while you and your colleagues lead by people want, what are its expectations around health? 16 RACDS ANNALS 2018

I believe the community wants, health reform. They want better, What’s the most rapid uptake in the collection of health data? more accessible, equitable and affordable health. However, health reform is highly dependent on the ability of the ‘system’ to rapidly • Shopping data identify, develop and introduce innovation, research and work • Electrical data force change into health care. • Movement data • iPhone apps It currently takes more than 17 years to move research and • Wearable health devices innovation into health care delivery. That is obviously way too • Even tooth brushes and floss devices that measure usage! long. Why does it take so long? There are multiple reasons, but I • New iPhone want to highlight a few: • FDA-cleared ECG, too fast or too slow • Falls monitor, SOS call • Dichotomy of funding streams. • Dichotomy of expected KPI. Rapid uptake obviously has potential consequences of excessive • Health funding based on outputs and transactions, rather screening and false positive rate. Dangers may extend to medical conspiracies, misdiagnosis, drug compliance. But there is a need than outcomes and quality measures, i.e. diagnostic tests. to encourage discussion. • Evaluation not linked to research, again measuring However, there will be huge risks and concerns. transactions, not quality, not potential improvements. • Lack of links between primary (including dental care) with Two key issues we need to keep at front of mind always as we inevitably go down this path, are that it must be consumer-led, tertiary care, no opportunity for a system wide approach to or patient-centred. And we must always keep the issue of equity health care improvement. front and centre. The risk increasing inequity is high, i.e. Aboriginal • And importantly high impact bioscience and computation Health. development not linked to health care innovation, which goes back to the issue of impact vs other more traditional The digital experience must be a humane experience. Technology metrics, on both sides, research and health care delivery. should increase the time spent with patients and the quality of the patient experience, i.e. pitfalls of EMRs. There are four critical words: integration, translation, impact and speed. Prof Sir Malcolm Grant Chairman of the NHS England said, “It is difficult to imagine the historic model of a general practitioner, One of the ways we are trying to deal with the integration, which is after all the foundation stone of the NHS… being able to translation and speed issues is through the development AHSC cope with the increasingly complex wealth of data… The answer or translation centres. These aim to integrate Universities, MRIs to how we can best reform historic models to enable better, more and health care delivery etc. They are accredited by NHMRC and cost-effective and faster outcomes lies in digital technology, data funded by the MRFF. and patient demand.” Examples are Monash Partners, Health Translation SA, Sydney Health Partners. We have brought them all together in AHRA, We can integrate research with clinical care more rapidly, we can covering 95% of all Australian health research. move innovation into health care more quickly, by utilising digital And MRFF with $20 billion investment is leading to doubling of health developments, by understanding and harmonising data health research, i.e. genomics, health services, digital medicine, sources and by using AI and machine learning to analyse complex and opportunity for Dental Health Research. data sources. Major integration issues still exist. However, over the last decade And maybe, with the combination of collaborative research efforts we have seen some significant changes and leaps forward that across all sectors, a precision medicine approach and optimal use may have unprecedented impact. of all available data, we can reduce the current 17 years to 2-3 years or even shorter. We have seen the growth of: • Major advances in computing science, AI and machine I hope your conference leads to further discussion about this exciting digital future in front of researchers and health care learning, particularly in the areas of computational biology, providers. bioinformatics and health informatics. • Sequencing technology has improved and reduced in price Thanks for asking me to give the Robert Harris oration and I also at an amazing rate, leading to truly deliverable precision hope Robert would have been interested in tonight’s discussions. medicine and personalised prevention. Thanks. And I believe that these advances utilized appropriately, may allow us the leap over some of the barriers mentioned. Email address for correspondence: [email protected] As examples: • Rapid cheap WGS, giving us cancer precision medicine, metagenomics allowing the analysis of the microbiome. • Genomics, proteomics, metabolomics linked to imaging and other metadata. • Imaging link to 3D printing. • Health Informatics leading to digital hospitals i.e. QLD and Digital Patients, including immediate and automated access to world-wide data. • Personalised prevention. However, to deliver digital experience you need free flowing content and data; Easily shared patient data; My Health record; State EMRs cost-benefit. Are we? Why aren’t we? Is the health care industry moving fast enough? Almost certainly not. RACDS ANNALS 2018 17

ANNALS OF THE ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS SCIENTIFIC PROGRAMME PAPERS AND ABSTRACTS FROM THE TWENTY-FOURTH CONVOCATION OF THE ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS ADELAIDE, SOUTH AUSTRALIA, AUSTRALIA, 20 – 23 SEPTEMBER 2018 Readers are advised that since the Annals reports the Proceedings of Convocation, none of the scientific papers has been peer reviewed.

SURGICAL MANAGEMENT OF TEMPOROMANDIBULAR JOINT DISORDERS George DIMITROULIS, MDSc, PhD, FRACDS(OMS), FDSRCS(Eng), FFDRCS(Irel) Dr George Dimitroulis is a Consultant Oral & Maxillofacial Surgeon at the Maxillofacial Surgery Unit, Department of Surgery, St.Vincent’s Hospital, Fitzroy, Australia. ABSTRACT While temporomandibular joint (TMJ) surgery is often considered as an option of last resort, there are instances where surgery is the definitive and sometimes the only treatment option, such as in rare cases of TMJ ankyloses and tumours. In a fundamental sense, surgery is used to restore and repair damaged tissue or remove tissue that cannot be salvaged. Surgery is also used to promote healing of tissues by replacing missing tissues with grafts.1 The literature has shown that about 5 - 10 per cent of all patients undergoing treatment for temporomandibular disorders require surgical intervention.2 There is a spectrum of surgical procedures currently used for the treatment of temporomandibular disorders, ranging from TMJ arthrocentesis and arthroscopy to the more complex open joint surgical procedures, referred to as arthrotomy. Oral & Maxillofacial Surgeons with a special interest in this field will often prefer to see patients undergo a period of non-surgical therapy prior to seeking a surgical opinion. The benefits and limitations of each of the surgical procedures are readily determined on an individual case basis.3 A clear understanding of joint pathology and the role that surgery plays in the management of joint disease are indispensable requirements for all dental practitioners.1 The right combination of symptomatic history, clinical features and radiological signs will readily reveal whether the TMD patient is an appropriate candidate for surgery.2 It is crucial that all dental practitioners familiarise themselves with every treatment option available, and not forget that TMJ surgery is one essential treatment modality that must never be overlooked.1 REFERENCES 1. Dimitroulis G. Temporomandibular joint surgery: what does it mean to the dental practitioner? Aust Dent J 2011;56:257-64. 2. Dimitroulis G. The role of surgery in the management of disorders of the temporomandibular joint: a critical review of the literature; Part 1 Int J Oral Maxillofac Surg 2005;34:107-13. 3. Dimitroulis G. The role of surgery in the management of disorders of the temporomandibular joint: a critical review of the literature; Part 2 Int J Oral Maxillofac Surg 2005;34:231-73. Email address for correspondence: [email protected] RACDS ANNALS 2018 19

EMERGENCY ENDODONTIC MANAGEMENT Daniel S FARMER BDS, MDS (Endo), FRACDS, FADI, FICD Dr Daniel Farmer is a Specialist Endodontist, North Terrace, Adelaide, South Australia, Australia ABSTRACT Managing the emergency patient can be challenging and stressful for both the clinician and the patient. Patients suffering from acute dental pain are often added to the clinician’s day list, resulting in a myriad of challenges for the clinician, including time management and providing the correct level of care to ensure the patient is rendered pain free. Dental pain can loosely be classified as either related to acute inflammation (irreversible pulpitis or acute / symptomatic apical periodontitis), or acute infection (acute periapical abscess). Although the acute inflamed pulp tissue is caused by infection, its management provides different challenges to that of the necrotic and infected pulp space that has resulted in the development of a periapical abscess. These changes to the pulp nerve supply result in two major challenges to the clinician. The first is in diagnosing the origin of the pain. Judicious use of the tests available, including both CO2 and electric pulp testing, percussion and palpation of the adjacent soft tissues and the isolation of the teeth with rubber dam before exposing the tooth to extremes of temperature, will aid in diagnosing the tooth responsible for the pain. The use of local anaesthetic (LA) to help isolate the tooth responsible for the pain should be considered a last resort, as no further testing can be reliably achieved after its administration. The second challenge is in providing adequate anaesthesia. There are several theories for the failure to satisfactorily anaesthetise an inflamed pulp. Tissue changes occur in the inflamed pulp, resulting in a drop in pH in the immediate area (approx. 6.0). This results in a state known as ‘tissue acidosis’. An acidic environment causes a shift in balance towards the ionised form of the LA solution. Nerve cell membrane penetration will be impaired, resulting in less effective LA. A greater proportion of LA is caught in ionised form and therefore unable to cross the cell membrane, known as ‘ion trapping’. LA solutions with a lower pKa value are relatively resistant to ion trapping. Inflammation causes localised vasodilation, resulting in an increased rate of systemic absorption of the LA. This is more applicable for failure following infiltration anaesthesia. The use of LA containing a vasoconstrictor aids in overcoming this localised vasodilatory effect. When the pulp becomes infected, these nociceptive nerve endings undergo structural changes due to the release of a number of immune cells and inflammatory mediators. Two such changes include nerve sprouting caused by the release of inflammatory growth factors and a decreased sensory threshold caused by the release of prostaglandins. This will result in two main changes in the response pattern of pulp nociception during pulp inflammation to occur: 1) Allodynia - a sensitisation of neurons e.g. ‘throbbing’ pulpal pain caused by sensitised pulp nociceptors firing in response to the patient’s heartbeat. Prostaglandin E2 (PGE2) reduces the threshold for firing of nociceptors to the point where gentle stimuli can activate the neurons. 2) Hyperalgesia - inflammatory growth factors alter the structural properties, e.g. nerve sprouting, which increases the size of the receptive field. Terminal ends of peripheral nerves in the pulp literally grow into the inflamed pulp, resulting in an increase in nerve terminals in inflamed tissue, which increases the size of the receptive field. Theories involving anatomical causes for the failure of local anaesthetic include the erratic distribution of LA within the pterygomandibular space and accessory innervation from the mylohyoid nerve, lingual nerve, buccal nerve and transverse cervical nerve. Following the administration of LA, keeping the patient’s mouth open will help maintain the anaesthetic solution in the desired location and decrease the chances of a more erratic distribution. Block anaesthetic techniques, including the Gow Gates and the infra-orbital techniques can be utilised to help resolve many of the issues experienced with more traditional anaesthetic administration techniques. There are two types of swellings that manifest as a result of endodontic infection: (1) Cellulitis is a serious diffuse swelling which spreads through adjacent soft tissues, dissecting fascial planes, and is caused by an inability of the host’s defence systems to localise the lesion. A cellulitis must be aggressively treated and monitored. Cases not responding to treatment (seen by elevated temperature, increased swelling, pain and malaise), should be hospitalised. (2) Space Infections are less common, and the type of space infection must be identified and managed locally and systemically. Space infections can be life threatening and if unable to be arrested and stabilised, then hospitalisation should be considered. Drainage of the infection is essential, either through the tooth by apical trephination, through adjacent soft tissue by incision, or through hard tissue by cortical trephination. Systemic medication including the use of intravenous, intramuscular or oral antibiotics, needs to be considered when such a cellulitis or space infection presents. 20 RACDS ANNALS 2018 Email address for correspondence: [email protected]

WHO OWNS YOUR DNA? Julie BROOKE-COWDEN, BSc, LLM Ms Julie Brooke-Cowden is an Accredited Specialist Defendant Personal Injury Law, and Adjunct Lecturer School of Medicine, University of Notre Dame, Sydney, Australia. ABSTRACT The traditional common law concept of there being no property in the human body has been transformed by recent advances in medical science, such as in vitro fertilisation, organ transplantation and gene mapping. Components of the human body, such as blood, organs, gametes and DNA are now recognised as having great commercial value. Whilst the concepts of self-determination and bodily autonomy support the notion that each individual owns their DNA, the current reality is very different. Unfortunately, it appears that commercial exploitation of the vulnerable groups in society continues - although the Australian Courts have somewhat departed from this trend by refusing to allow the genes which code for the BRCA1 breast cancer gene to be patented. This presentation examines the transformation of legal thinking, from the view that the human body has no value, to it being characterized as a commodity of potentially great value. Cautionary tales in relation to the exploitation of DNA, are discussed. Email address for correspondence: [email protected] RACDS ANNALS 2018 21

THE NEW ERA IN PROSTHODONTICS Philip Leong Biow TAN, BDSc, Grad Dip Clin Dent, MSD(Iowa), Cert Grad Pros (Iowa), FPFA, MRACDS Dr Philip Tan is a Specialist Prosthodontist. He works in private practice, and as a Consultant at the Royal Children’s Hospital Melbourne, Australia. ABSTRACT All areas of prosthodontic care have been impacted by digital technologies, including the preliminary stages of patient management which include patient evaluation, diagnosis and treatment planning, as well as treatment methods in the areas of fixed and removeable prosthodontics. The preliminary stages are being revolutionised by the use of intra-oral scanning, digital radiography, digital photography and digital occlusal analysis. Individually, the digital devices allow for greater insight into the patient’s condition, as well as the ability to collect the information in less invasive and more predictable ways. A second and equally valuable advance has been the development of computer software that allows combination and integration of digital information. This allows for the merging of separate pieces of information to enable a new perspective on how different but related entities within the same patient interact. Two common examples of such combination are in implant planning and digital smile design. Digital implant planning typically involves the combination of the patient’s existing dental condition in the form of an intra-oral scan as well as a cone beam computed tomography (CBCT) scan. The proposed restoration shape is then determined, and finally, the available hard and soft tissue is assessed for the possibility of implant placement with or without grafting. Such a process gives the clinician a better understanding of the scope of the treatment and degree of complexity, and can be used as a communication tool between dental colleagues as well as with the patient. The plan can then be enacted with the aid of a surgical guide which accurately transfers the information from the virtual world into the patient’s mouth. Digital smile design typically involves the combination of digital photos of the patient with a model of the patient’s teeth. Initial iterations of this process involved a purely 2D analysis of the photo and calibration so that a 2D design could be transferred onto a physical model of the patient’s teeth. This has been superseded by a completely digital and 3D process in which the 3D face scan is combined with a 3D intra-oral scan. The new tooth shapes are created with reference to both the face scan and intra-oral scan. This allows both the aesthetic and functional outcomes to be established simultaneously. Fixed and removeable prosthodontic treatment has been affected at the stages of impression taking, restoration design and restoration manufacture. Once again, intra-oral scanning has played a significant role by creating a 3D digital rendering directly from the patient, rather than relying on a more traditional stone model. Most restoration types are now being designed and manufactured digitally with advances in digital data manipulation, computer aided design and then finally computer aided manufacturing, with both additive and subtractive manufacturing methods. Making changes to incorporate digital technology could be seen as a daunting task, given the large number of changes required to practice processes, the requirement to make significant purchases of equipment and the bewildering array of commercially available products with different technical specifications. A recommended path to follow is to first assess what type of patient management is carried out at the practice. Then a staged introduction of change should be implemented to allow for mastery of each stage prior to progressing to the next. This always allows for the maintenance of a high standard of care. For the typical dental practice that already has a basic level of digitisation and familiarity, a sensible place to start would be an intra-oral scanner. The scanner is useful for patient assessment, diagnosis, education and planning, as well as for treatment modalities such as fixed and removeable prosthodontics, and other areas such as orthodontics. Once basic proficiency and training has been attained with the intra-oral scanner, it needs to be applied to a variety of patient scenarios. It is best to start with simple scenarios with compliant patients, who understand there may be extra time involved in the treatment process. In the area of fixed prosthodontics, managing single crowns (on either implants or natural teeth) would be appropriate. In the area of removeable prosthodontics, doing intra-oral scanning for occlusal splints, bleaching trays and mouthguards would be appropriate. With experience, confidence grows, and with success in basic procedures, the clinician can start to embark on larger fixed restorative cases, short span bridges, upper complete dentures and partial dentures for removeable cases. Finally, the clinician can undertake complete mouth rehabilitation if it is possible, using digital technology. There has to be sufficient clinical experience, high quality and high technology laboratory support and an understanding that the technology will be pushed to the limit and predictability in outcomes will be compromised. If the clinician is not willing to accept some failures it is best not to embark on complete mouth rehabilitation with an intra-oral scanner. Overall, the digitisation of prosthodontics heralds a new and exciting era, which gives all involved the opportunity to challenge themselves and offer more treatment options at a higher level of care for their patients. 22 RACDS ANNALS 2018 Email address for correspondence: [email protected]

ESTHETIC OUTCOMES AND DIGITAL TECHNOLOGY IN IMPLANT PROSTHODONTICS German O. GALLUCCI, DMD, PhD Dr German Gallucci is Raymond J. and Elva Pomfret Nagle Associate Professor and Chair in the Department of Restorative Dentistry and Biomaterials Sciences at the Harvard School of Dental Medicine, Harvard University, Boston, USA. ABSTRACT During this lecture, clinical considerations and indications for dental implants are analysed in the context of their direct application to aesthetic implant-prosthetic rehabilitations. Risk assessment, treatment planning, surgical protocols and aesthetic/prosthodontic rehabilitations are discussed in detail according to different clinical situations. Recommended planning steps and treatment procedures are presented through scientific evidence. Modern implant-prosthetic restorations using different implant designs and digital technology call for a harmonious aesthetic integration with the pre-existing environment. A scalloped gingival line with distinct papillae, free of any abrupt vertical differences in clinical crown length between anterior implants, is paramount. In this context, biologic considerations affecting normal peri-implant soft tissue integration are discussed as a major aesthetic parameter. OBJECTIVES Upon completion of this lecture, the participant should be able to: • Familiarise with current trends in aesthetic implant dentistry. • Assess associated risk factors for suitable treatment planning. • Widen treatment planning options using a selective approach. Email address for correspondence: [email protected] RACDS ANNALS 2018 23

DIGITAL APPROACH TO IMPLANT DENTISTRY German O. GALLUCCI, DMD, PhD Dr German Gallucci is Raymond J. and Elva Pomfret Nagle Associate Professor and Chair in the Department of Restorative Dentistry and Biomaterials Sciences at the Harvard School of Dental Medicine, Harvard University, Boston, USA. ABSTRACT The translation from digital (CBCT, Intraoral Scanning, and Laboratory Scanners) into the clinical field opens an unaccounted number of treatment possibilities at the surgical and prosthodontic level. The incorporation of such technologies calls for an update on implant-prosthodontic workflows, to successfully achieve a full digital approach to implant dentistry. OBJECTIVES Upon completion of this lecture, the participant should be able to: • Familiarise with the use of Dental Digital Technology in implant dentistry. • Understand the potential of Intraoral scanning in implant dentistry. • Evaluate implant-prosthetic protocols in a fully digital workflow. Email address for correspondence: [email protected] 24 RACDS ANNALS 2018

SUCCESS CRITERIA FOR IMPLANT-PROSTHODONTIC REHABILITATIONS German O. GALLUCCI, DMD, PhD Dr German Gallucci is Raymond J. and Elva Pomfret Nagle Associate Professor and Chair in the Department of Restorative Dentistry and Biomaterials Sciences at the Harvard School of Dental Medicine, Harvard University, Boston, USA. ABSTRACT Success in implant dentistry should ideally evaluate the long-term primary outcome of an implant-prosthetic complex as a whole. During this lecture, clinical considerations for dental implants are analysed in the context of their application to esthetic implant rehabilitations. Risk assessment, treatment planning, surgical protocols and aesthetic/prosthodontic rehabilitations are discussed in detail, according to different clinical situations. In particular, this presentation examines the most frequently used criteria to define treatment success for implant rehabilitations in the aesthetic zone. Parameters at the implant, peri- implant soft tissue, prosthetic, and patient satisfaction level are discussed as indicators of treatment success. OBJECTIVES Upon completion of this lecture, the participant should be able to: • Familiarise with current trends in aesthetic implant dentistry. • Assess associated risk factors for suitable treatment planning • Widen treatment options using a selective approach. Email address for correspondence: [email protected] RACDS ANNALS 2018 25

THE PATHOPHYSIOLOGY OF ORTHODONTIC TOOTH MOVE- MENT: ROLE OF ENDOPLASMIC RETICULUM STRESS Dr Fiona FIRTH, BDS, FRACDS (GDP), DClinDent(Ortho), MRACDS (Ortho), MOrth RCSEd Dr Fiona Firth is affiliated with the Department of Oral Sciences, Faculty of Dentistry, University of Otago, Dunedin, New Zealand. ABSTRACT Mechanical forces associated with orthodontic tooth movement (OTM) influence cell regulation (including protein synthesis and cell death). The endoplasmic reticulum (ER) maintains cellular homeostasis, with ER stress activating the unfolded protein response (UPR), potentially resulting in apoptotic cell death. To investigate the relationship between ER stress and mechanically-strained periodontal ligament (PDL) cells, primary PDL cell cultures were seeded in 3-D hydrogel and subjected to 24 hours of static mechanical strain. Cell viability, caspase activity and the relative expression of mechanical strain- and UPR-related genes were assessed. A tendency to reduced cell viability was observed after mechanical strain. There was no difference in caspase activity. Some UPR-related genes were differentially upregulated in the strained cells including CREB3L3 (an acute inflammatory response gene), and the pro-apoptotic factor DDIT3. While a reduction in cell viability was observed following strain, an increase in caspase activity was not evident, thus the reduction in viability appears to be mediated via caspase-3/7-independent mechanisms. INTRODUCTION towards biology. This may allow the potential development of biomarkers for at-risk patients, e.g. IL-1β gene polymorphisms Following the exposure of a tooth to mechanical force, tooth can predispose orthodontic patients to increased root movement occurs via remodelling of the periodontal ligament resorption, and is also associated with periodontitis.5 (PDL), dental pulp, alveolar bone and gingival tissues. Orthodontic • Root resorption occurs when the reparative capacity of force results in physical strain on the PDL, extra-cellular matrix cementum is exceeded due to pressure, leading to exposure (ECM) and alveolar bone cells, which in turn elicits biochemical of dentine and its potential degradation7. The macrophages effects leading to orthodontic tooth movement (OTM). With an involved in this process are followed by odontoclasts, which ever-increasing shift in focus in orthodontics from biomechanics resorb cementum and then dentine. The expression of to biology to tailor results to individual patients, multiple genes to induce the production of odontoclasts is induced hypotheses regarding the mechanism of tooth movement have by M-CSF and RANKL.8 been presented – most dominantly the pressure/tension in the • Reduced treatment duration is of benefit to both orthodontic PDL theory, and the alveolar bone bending theory. Debate still patients and practitioners, particularly in the prevention of exists regarding these hypotheses, likely due to the wide variety of time-related adverse effects such as root resorption and experimental techniques adopted in investigating these theories the development of enamel white spot lesions. The biologic particularly in the magnitude, type and time period of force rationale for accelerated tooth movement techniques is the application. production of increased numbers and function of osteoclasts – allowing the rapidity of the rate-limiting step in OTM (bone The pressure-tension theory outlines that following the application resorption at the compression side) to be increased.9 of force, a tooth moves through a periodontal space with one side • Orthodontic relapse is a phenomenon that is disappointing of the PDL in tension, and the other in compression. In areas of to both practitioners and patients. Relapse may occur due to PDL compression, fibres become disorganised, production of new physiological tooth movement (reorganisation of supporting fibres ceases, and vascular constriction contributes to reduced cell tissues), neuromuscular imbalance, the presence of inherent replication1. In areas of PDL cell tension, cell replication is stimulated dental factors and continued facial growth.10 PDL changes by stretching of fibre bundles, and tension-associated osteoblasts during relapse are consistent with those during experimental differentiate from PDL progenitor cells.1, 2 The bone-bending theory tooth movement, with increased gene expression of markers outlines that orthodontic force is transmitted to all nearby tissues, of bone formation (alkaline phosphatase, collagen-1) on bending the bone, tooth and surrounding PDL, and as bone is the the prior pressure side, while markers of bone resorption most elastic of these tissues, it is thus the most responsive.3 The decrease10. It has been hypothesised by Maltha, et al. (2015) stretch of periodontal fibres at the side of the tooth under tension that relapse is initiated by mechanical stimuli, similar to the reduces the radius of the alveolar wall i.e. bending the bone4. initiation of OTM, as these forces are able to maintain tooth The piezoelectric model of OTM purports that the movement movement. In mice, apoptosis of PDL tissue has been of charged particles also plays a role in OTM by electric polarity identified during relapse in areas under compressive force.11 being created in bone crystals due to deformation, leading to the creation of an electric current.5 With growing information Apoptosis is a form of programmed cell death, occurring regarding complex cell-cell and cell-matrix interactions, it is more under necessary or particular circumstances. Apoptosis is likely that electrical potentials are a by-product of mechanical involved physiologically in the maintenance of homeostasis, in deformation, rather than being directly stress-generated.6 embryological development and healing.12 While the effects of mechanical loading of the PDL have been examined in relation to A thorough understanding of the biological mechanisms involved oxidative stress, there is little known information about its effects in tooth movement allows for increased knowledge of: on another important cellular stress mechanism – endoplasmic • The concept of individualised treatment. Orthodontics is reticulum (ER) stress. The ER organelle is required for intracellular protein synthesis and folding, and its normal function is essential currently undergoing a shift from a focus on biomechanics 26 RACDS ANNALS 2018

in the maintenance of homeostasis. ER stress occurs when the (test) plates were subjected to static equibiaxial tensile strain, at protein-folding capacity of the ER is exceeded, resulting in the a level of 18% substrate elongation for 24 hours, while unstrained accumulation of poorly matured and unfolded proteins within the control plates were housed within the same incubator for the ER. entire duration of the straining period. The process of OTM involves an acute inflammatory response, Cell viability and caspase-3/7 activity were measured using the in which the unfolded protein response (UPR), known to have CellTiter-Glo 3-D Cell Viability Assay (Promega) and the Caspase- crucial functions in inflammation, may play a role. The UPR may Glo 3/7 Assay (Promega). Both assays result in the conversion of act as an inflammatory nidus, with ER stress directly initiating luciferin to light. cDNA was synthesised from RNA samples for real- inflammatory pathways and pro-inflammatory factors such as time quantitative polymerase chain reaction, to measure the mRNA cytokines, and reactive oxygen species.13 Due to the involvement expression level of three mechanical strain-responsive and 25 of UPR in inflammation, there is interest in the UPR of mechanically UPR-related genes. Two unstrained control and two mechanically strained PDL cells as the UPR may be involved in OTM, as well strained test samples were analysed for each of the three cell lines. as in the balance of immune-mediated disease states, for which A custom TaqMan 96-well (3 x 32 genes) array (Life Technologies) pharmaceutical potential may exist. was designed, with the inclusion of three housekeeping genes (GAPDH, B2M and RPL13A). In vivo, PDL cells are entrenched in an extracellular three- dimensional (3-D) matrix composed of collagenous and non- RESULTS collagenous proteins. To mimic this environment, in which a complex extracellular network surrounds cells, in vitro, hydrogels Following the application of mechanical strain, cell viability have been developed to function as scaffolds for 3-D tissue (compared to that of unstrained controls) was found to be constructs. Traditional 2D cellular models have been reported as significantly reduced in one cell line and showed a tendency to being unlikely to be representative of the complex environment.14 reduce in the other two cell lines. When results from all cell lines were combined, the overall trend was for a reduction in cell viability Hydrogels possess material properties that simulate the natural post-strain, with mean relative luminescent values being 73.1% of cellular environment, being composed of a class of polymer that the control values (SD = 12.7%), however this difference was not allows absorption of water without dissolution of the gel. The use significant (p = 0.098). The differences in caspase-3/7 activity of hydrogels in gene expression experiments has been identified between strained and control samples within cell lines were more as being beneficial in mimicking the natural environment, as well variable and not statistically significant. A number of genes were as improving cell morphology, phenotype and adhesion – each found to be differentially regulated – of interest are CREB3L3 of which plays an important role in investigations regarding the (mean fold-regulation = 1.91, p = 0.063), and pro-apoptotic factor response of the PDL to mechanical strain.15, 16 DDIT3 (mean fold-regulation = 17.0, p = 0.438). AIMS AND METHODS DISCUSSIONS AND CONCLUSIONS The study briefly described below was carried out to examine cell This study was the first to investigate the relationship between the viability and apoptosis following the application of mechanical application of mechanical strain to PDL cells and UPR as affected strain to PDL cells in 3-D cultures, and to examine the expression by ER stress with the additional facet of the use of 3-D cell/gel of ER stress- and UPR-related genes following the application of constructs, aiming to better represent the in vivo environment mechanical strain to PDL cells in 3-D culture. of PDL cells. CREB3L3 is a membrane bound transcription factor, localised to the ER, belonging to the cyclic AMP response element The experimental sample comprised cultured human PDL cells. binding protein transcription factor family.18 CREB3L3 has been Following obtaining informed consent, PDL cells were collected identified as playing a key role in the activation of the acute from healthy premolar teeth, free of caries and periodontal inflammatory response, as occurs during OTM.19, 20 Additionally, disease, which were extracted from three healthy, non-smoking ER stress may negatively regulate osteoblast differentiation individuals for orthodontic reasons. through the expression of CREB3L3, with suppression of alkaline phosphatase and osteocalcin, which has been shown to be The premolar teeth were treated following the protocol described related to OTM.21-23 DDIT3 encodes for a protein that is a potent by Somerman et al (1998) in order to prepare a primary culture of transcription factor that potentiates apoptosis and autophagy and PDL cells. Following extraction under local anaesthesia, PDL tissue is a well-established pro-apoptotic factor in the UPR.24, 25 Enhanced explants were collected from the premolar teeth by instrumenting synthesis of the DDIT3 protein leads to increases in oxidative the middle third of the root surface using a scalpel blade. Explants stress and cell death.24 This study demonstrated a tendency were placed into tissue culture plates with supplemented culture towards high upregulation of DDIT3 following the application of medium and incubated at 37 °C in a humidified atmosphere with mechanical strain to cell/gel constructs, indicating its potential role 5% carbon dioxide/95% air. The tissue samples were routinely in the PDL response to strain. examined under a light microscope to assess outgrowth of cells from the explants. The Hystem-C Hydrogel Kit (Esi-Bio, USA), a To conclude, a 3-D model has been developed in which to culture thiol-modified hyaluronan-gelatin, PEDGA cross-linked hydrogel, human PDL cells and allow the application of mechanical force. was selected as the scaffold in which to culture PDL cells in three- There is a potential role of ER stress and the UPR during OTM – dimensions. this study provides a context and potential UPR targets for future research, which could examine further strain parameters. The cells were mechanically strained using a computer- regulated bioreactor, the Flexercell FX-4000TM strain unit (Flexcell ACKNOWLEDGEMENTS Corporation, USA), which utilises vacuum pressure to apply controlled, validated strain at a precise level to cultured cells. The Professor Mauro Farella, Dr Trudy Milne and Dr Benedict Seo unit allows the user to select the frequency and time period of of the University of Otago. The New Zealand Dental Research strain, as well as the strain level – defined by the elongation of the Foundation provided funding for this study. substrate surface. Strain is applied to cells via vacuum deformation of the flexible silicone elastomer base of specially designed culture RACDS ANNALS 2018 27 plates. A compressor is required to create the vacuum. Strained

REFERENCES 14. Baker BM, Chen CS. Deconstructing the third dimension - how 3D culture microenvironments alter cellular cues. J Cell 1. Krishnan V, Davidovitch Z. Biology of orthodontic tooth Sci. 2012;1:3015-24. movement: The evolution of hypotheses and concepts in Biological Mechanisms of Tooth Movement. 2nd ed. 15. Hoffman RM. To do tissue culture in two or three dimensions? Chichester, West Sussex: John Wiley & Sons Inc.; 2015. That is the question. Stem Cells. 1993;11:105-11. 2. Masella RS, Meister M. Current concepts in the biology of 16. Cukierman E, Pankov R, Stevens DR, Yamada KM. Taking cell- orthodontic tooth movement. Am J Orthod Dentofacial matrix adhesions to the third dimension. (Reports). Science. Orthop. 2006;129:458-68. 2001;294:1708-12. 3. Krishnan V, Davidovitch Z. Cellular, molecular, and tissue- 17. Somerman MJ, Archer SY, Imm GR, Foster RA. A comparative level reactions to orthodontic force. Am J Orthod Dentofacial study of human periodontal ligament cells and gingival Orthop. 2006;129:469.e1-.e32. fibroblasts in vitro. J Dent Res. 1988;67:66-70. 4. Epker B, Frost H. Correlation of bone resorption and 18. Omori Y, Imai J, Watanabe M, Komatsu T, Suzuki Y, Kataoka formation with the physical behavior of loaded bone. J Dent K, et al. CREB-H: a novel mammalian transcription factor Res. 1965;44:33-41. belonging to the CREB/ATF family and functioning via the box-B element with a liver-specific expression. Nucleic Acids 5. Masella RS, Chung P. Thinking beyond the wire: emerging Res. 2001;29:2154-62. biologic relationships in orthodontics and periodontology. Semin Orthod. 2008;14:290-304. 19. Cooper SM, Sims MR. Evidence of acute inflammation in the periodontal ligament subsequent to orthodontic tooth 6. Meikle MC. The tissue, cellular, and molecular regulation of movement in rats. Aust Orthod J. 1989;11:107-9. orthodontic tooth movement: 100 years after Carl Sandstedt. Eur J Orthod. 2006;28:221-40. 20. Zhang K, Shen X, Wu J, Sakaki K, Saunders T, Rutkowski DT, et al. Endoplasmic reticulum stress activates cleavage of 7. Reitan K. Initial tissue behaviour during apical root resorption. CREBH to induce a systemic inflammatory response. Cell. The Angle Orthodontist. 1974;44:68-82. 2006;124:587-99. 8. Abass SK, Hartsfield JK. Orthodontics and external apical root 21. Han XL, Meng Y, Kang N, Lv T, Bai D. Expression of osteocalcin resorption. Semin Orthod. 2007;13:246-56. during surgically assisted rapid orthodontic tooth movement in beagle dogs. J Oral Maxillofac Surg. 2008;66:2467-75. 9. Huang H, Williams RC, Kyrkanides S. Accelerated orthodontic tooth movement: molecular mechanisms. Am J Orthod 22. Jang WG, Kim EJ, Koh JT. Tunicamycin negatively regulates Dentofacial Orthop. 2014;146:620-32. BMP2-induced osteoblast differentiation through CREBH expression in MC3T3E1 cells. BMB reports. 2011;44:735-40. 10. Maltha JC, Ramachandran R, Krishnan V. The biological background of relapse of orthodontic tooth movement 23. Jang WG, Jeong BC, Kim EJ, Choi H, Oh SH, Kim DK, et al. in Biological Mechanisms of Tooth Movement. 2nd ed. Cyclic AMP response element-binding protein H (CREBH) Chichester, West Sussex: John Wiley & Sons Inc.; 2015. mediates the inhibitory actions of tumor necrosis factor alpha in osteoblast differentiation by stimulating Smad1 11. McManus A, Utreja A, Chen J, Kalajzic Z, Yang W, Nanda R, et al. degradation. J Biol Chem. 2015;290:13556-66. Evaluation of BSP expression and apoptosis in the periodontal ligament during orthodontic relapse: a preliminary study. 24. Rashid H-O, Yadav RK, Kim H-R, Chae H-J. ER stress: Autophagy Orthod Craniofac Res. 2014;17:239-48. induction, inhibition and selection. Autophagy. 2015;11:1956-77. 12. Elmore S. Apoptosis: a review of programmed cell death. 25. Lurlaro R, Munoz-Pinedo C. Cell death induced by endoplasmic Toxicol Pathol. 2007;35:495-516. reticulum stress. The FEBS journal. 2016;283:2640-52. 13. Grootjans J, Kaser A, Kaufman RJ, Blumberg RS. The unfolded Email address for correspondence: protein response in immunity and inflammation. Nature [email protected] Reviews Immunology. 2016;16:469-84. 28 RACDS ANNALS 2018

DIGITAL PLANNING FOR MANDIBULAR AND MAXILLARY RECONSTRUCTION Dr Georg HAYMERLE, MD, PhD and Jonathan R. CLARK, MBBS, MBiostat FRACS Prof Jonathan Clark (Presenter) and Dr Georg Haymerle are affiliated with the Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O’Brien Lifehouse, Sydney, Australia. In addition, Prof Clark is affiliated with the Central Clinical School, The University of Sydney, Australia. ABSTRACT Mandibular and maxillary reconstruction using osseous microsurgical tissue transfer following ablative surgery is common practice in head and neck cancer treatment.1 One of the fundamental components of mandibulomaxillary reconstruction is the technique of bone modelling. This has a direct influence on correct bone-to-bone contact, dental occlusion and facial contour. Traditional techniques can be imprecise regarding exact angles and location of osteotomies. Various methods have been introduced to minimize human error, including pre-bending a reconstruction plate prior to bone resection. However, this is not suitable in cases where the bone is significantly eroded or missing, or for large exophytic tumours, around which the plate cannot be bent. Options to compensate for this include intraoperative templates or sterolithographic models, which can be fashioned to recreate normal anatomy. The utilisation of virtual surgical planning (VSP) is a relatively recent development that allows surgeons to plan every step of the resection and reconstruction, prior to the operating theatre. This has been shown to reduce operating times, simplify highly complex reconstructive procedures and improve accuracy.2-4 VSP consists of pre-operative image acquisition and modelling of both the facial and the donor-site skeleton, resulting in a patient-specific surgical plan adapted to surgeon’s preference.5 The technology allows for 3D-printed models, bone cutting-guides and custom-made titanium plates to be manufactured during the planning process instead of contouring the bone graft ‘free-hand’ to the intra-operative defect. A recent multi-centre study highlights the benefits of adopting the VSP technology.6 These include more accurate pre-operative planning, allowing the patient to better visualise and understand the procedure prior to surgery and streamlining multiple surgical steps. VSP furthermore reduces the length of stay6 and improves functional as well as aesthetic outcomes.7 Usually, the entire process of virtual planning is outsourced to an external company (Figure 1). In our department, however, patients can be reconstructed with external or in-house planning. The outsourced option is proprietary-VSP (P-VSP) provided by DePuy Synthes® (DePuy Synthes - Umkirch, Germany), including a reconstructive 3D-model (showing the bone graft inset to the facial defect), cutting guides for the donor and ablative sites, and a customised titanium plate, provided by Materialise® (Materialise, Leuven, Belgium/DePuy Synthes) and Trumatch® (Synthes GmbH - Oberdorf, Switzerland), which is printed titanium. The institutional-VSP (I-VSP Group) developed by the Surgical Innovation Research Officer at the Institute of Academic Surgery at the Royal Prince Alfred Hospital, consists of 3D models and cutting- guides processed and printed according to a locally developed process.8 Generic titanium reconstruction or mini-plates are pre-bent to the patient specific model prior to the surgery and re-sterilised for intraoperative use. VSP can ultimately be combined with a two-stage prefabricated approach for osseous reconstruction, enabling the patient to be fitted with an implant supported denture at the same time as the cancer removal (Figure 2). In a first stage operation, the osseointegrated implants are placed into the donor site bone, most commonly the fibula, according to exact virtual plans and covered with split thickness skin graft. The second stage involves removal of the tumour and insetting of the free flap containing the osseointegrated implants covered with the skin graft, hence permitting dentures to be fixed to the implants. The combination of these two techniques facilitates highly accurate mandibulomaxillary reconstruction and early dental rehabilitation. REFERENCES 1. Hayden RE, Mullin DP, Patel AK. Reconstruction of the segmental mandibular defect: current state of the art. Curr Opin Otolaryngol Head Neck Surg 2012;20(4):231-6. 2. Wilde F, Hanken H, Probst F, Schramm A, Heiland M, Cornelius CP. Multicenter study on the use of patient-specific CAD/CAM reconstruction plates for mandibular reconstruction. Int J Comput Assist Radiol Surg 2015;10(12):2035-51. 3. Toro C, Robiony M, Costa F, Zerman N, Politi M. Feasibility of preoperative planning using anatomical facsimile models for mandibular reconstruction. Head Face Med 2007;3:5. 4. Hirsch DL, Garfein ES, Christensen AM, Weimer KA, Saddeh PB, Levine JP. Use of computer-aided design and computer-aided manufacturing to produce orthognathically ideal surgical outcomes: a paradigm shift in head and neck reconstruction. J Oral Maxillofac Surg 2009;67(10):2115-22. 5. Bell RB. Computer planning and intraoperative navigation in cranio-maxillofacial surgery. Oral Maxillofac Surg Clin North Am 2010;22(1):135-56. 6. Erben C, Vitt KD, Wulf J. First statistical analysis of data collected in the Phidias validation study of stereolithography models. Phidias Newsl 2000;5:6-12. RACDS ANNALS 2018 29

7. Valentini V, Agrillo A, Battisti A, Gennaro P, Calabrese L, Iannetti G. Surgical planning in reconstruction of mandibular defect with fibula free flap: 15 Patients. J Craniofac Surg 2005;16(4):601-607. 8. Smithers F, Jayaram R, Cheng K, Murkherjee P, Clark JR. Maxillofacial reconstruction using in house virtual surgical planning. ANZ J Surg 2018;88(9):907-912. Email address for correspondence: [email protected] Figure 1. PROPLAN CMF® virtual surgical planning (VSP) for complex reconstruction of the left maxilla. Figure 2. Two-stage prefabricated fibula flap technique for maxillary reconstruction combined with analogue surgical planning. 30 RACDS ANNALS 2018

WHO BENEFITS FROM NEW TECHNOLOGIES IN DENTISTRY? Dr Suzanne HANLIN, MDS(Otago), PGDipHealInf, FRACDS, MRACDS(PROS) FPFA, FADI, FICD Dr Suzanne Hanlin is the Joint Associate Dean (Clinical) in the Department of the Dean. She is a Prosthodontist and a Senior Lecturer in the Department of Oral Rehabilitation, Faculty of Dentistry, University of Otago, Dunedin, New Zealand. ABSTRACT Digital dentistry includes any dental technology or device that incorporates digital or computer-based components.1 Major benefits are said to accrue from digital technologies in dentistry, however recent research has focused largely on comparisons between traditional and digital processes and there is still very little information about the benefits to overall cost of care or oral health outcomes. The shift from analog to digital workflows in dentistry impacts on the whole dental community and concerns have been raised that the most important interaction that must survive this technological revolution is between the patient and the dentist.2 We must also re-evaluate and strengthen the relationships between dental technicians and dentists, as new responsibilities are developed and ethical questions are raised around accountability, data transfer, data storage and patient privacy. Our difficulty is to understand who is currently gaining real benefit from the digital revolution. More research is required to explore the benefits of technological expansion using broad measures of impact to determine the true effects on oral healthcare provision. Exploration of accountability and new ethical considerations around data management and patient rights will challenge the profession in coming years. INTRODUCTION dental air-turbine hand piece, can become quickly integrated into standard dental practice because it fulfils a widely perceived need. The digital age started with the development of the computer The porcelain fused to metal (PfM) crown experienced a rapid post-WW2 and we have lived and changed with the newly uptake in as little as 5 years to be universally accepted by the emerging technologies that have followed. Digital dentistry profession. Other innovations, including digital radiography and includes any dental technology or device that incorporates digital implant dentistry and computer aided design and manufacturing or computer-based components.1 Dental Informatics by contrast (CADCAM), have had a much slower passage over a variable time embraces the applications of computers and information science frame from 10 to 25 years and are still not adopted by all dentists.1 to improve dental practice, research, education and management. Major benefits are said to accrue from digital technologies in A recent evaluation of the progress in adoption of implants noted dentistry and include; earning potential and efficiency,3 less that implant placement increased until the global financial crisis invasive procedures and greater affordability,2 standardised work (GFC) of 2007, and that growth in the implant market has been protocols, improvements in predictability and reproducibility of moderated by cost to the patient since that time.9 A review of outcomes,4 reduction in both clinical and laboratory work time available industry data has indicated that there are currently a with the simplified workflows,5 improved quality of care, improved limited number of new technologies in the pre-production process efficiency and ease of use.6 Recent research has focused on for possible release before 2040 and although new technologies comparisons between traditional and digital processes and there will continue to make the dentist more efficient, they will also is still very little information about the benefits to overall cost of potentially reduce the need to train more dentists. The emergence care or oral health outcomes. of a break-through product is likely to still be viewed sceptically by the profession and take a lengthy period of time to become widely The shift from analog to digital workflows in dentistry impacts on established.9 the whole dental community and concerns have been raised that the most important interaction that must survive this technological BARRIERS revolution is between the patient and the dentist.2 We must also re-evaluate and strengthen the relationships between dental The enablers and barriers to adoption of recent and emerging technicians and dentists as new responsibilities are developed technologies in dentistry have been widely discussed in the dental and ethical questions are raised around accountability, data literature.6,10-13 High levels of adoption of digital dental radiography transfer and data storage and patient privacy. Our difficulty is to (75% of views) were shown in France by 2010 and demonstrated understand who is currently gaining real benefit from the digital the impact of healthcare reimbursement encouraging adoption revolution. of emerging technology.11 This was in contrast to the New Zealand experience, where a 2012 survey of general dentists and specialists INNOVATION found only fifty eight percent were using digital radiography and a major barrier to adoption was cost.14 More recent surveying Using a five point classification of diffusion of new innovations, of New Zealand dentists and dental specialists indicated a rise, first formulated by E.M Rogers in 1962, dentists have variably with 88 percent of practitioners surveyed having adopted been thought of as innovators, early and late majority or laggard digital radiography.6 When compared to a similar 2013 study (late) adopters of new technologies6,7,8 and it can take several of Netherland dentists,13 there was a higher percentage of New decades for new technologies to be adopted in a meaningful Zealand dentist than in the Netherlands using intraoral cameras, way by the profession.9 The uptake of new innovations into while a smaller percentage were using intraoral radiography and clinical dental practice is said to follow a sequence of diffusion practice websites.6 Non-adopters cited their satisfaction with (passive and unplanned), dissemination (active and planned), and the existing radiographic process, patient potential discomfort, implementation (putting into practice).10 and diagnostic error as reasons for not adopting digital imaging at that time.14 Other barriers to adoption included training, the The social influence of peers and external groups is an important requirement to demonstrate improved efficiency and accuracy factor in this diffusion. A disruptive technology, for example the and a need for a high level of predictability in outcomes.9 Adoption RACDS ANNALS 2018 31

of digital radiography in other countries was also found to be into practices in the developed world and eHealth and mHealth slow with cost, practice norms and reimbursement as factors.11 are preferred vehicles for many initiatives in the developing world. The adoption of CADCAM technologies has followed a similar More research is required to explore the benefits of technological course to implants, with a long delay from the original release of expansion using broad measures of impact to determine the true milling capacity in dentistry until significant industry and clinical effects on oral healthcare provision. Exploration of accountability adoption was noted. Developments in the technologies, opening and new ethical considerations around data management and of access, development in material science and reduction in establishment cost and the societal effect of peers are all likely patient rights will also challenge the profession in coming years. factors in the current revolution we are currently discussing. In a survey of 760 dental technicians in the UK and Ireland, most REFERENCES technicians reported using digital technologies in some form 1. Child P. Digital dentistry. Is this the future of dentistry? Dental within their normal workflow.15 Large laboratories were more likely to use technologies without outsourcing, leading to an increase Economics 2011;101: https://www.dentaleconomics.com/ in the use of zirconia and a decrease in the use of noble alloys. articles/print/volume-101/issue-110/features/digital-dentistry-is- Within New Zealand, anecdotal reports indicate that it is becoming this-the-future-of-dentistry.html more common for smaller laboratories to subcontract to larger 2. Marinello C. Editorial: The digital revolutions impact on laboratories where costly technologies are involved in production. prosthodontics. International Journal of Prosthodontics Interestingly most of the training provided to laboratories came 2016;29(5):431-433. from companies15 and this may well be similar amongst dental 3. Tay K, Wu J-Y, Yet M-S, Thomson W. The use of newer practitioners, where product training and product-lead study clubs technologies by new zealand dentists. N Z Dent J 2008;104:104- are provided only to purchasers of proprietary technologies. From 108. a laboratory perspective, there appears to be a varying impact 4. Abduo J, Lyons K, Bennamoun M. Trends in computer aided on staffing. Working relationships were unaffected with CADCAM manufacturing in prosthodontics: A review of the available workflows15,16 however there has been little investigation of these streams. Int J Dent 2014:1-15. specific issues. 5. Joda T, Zarone F, Ferrari M. The complete digital workflow in fixed prosthodontics: A systematic review. BMC Oral Health OUTCOMES 2017;17:1-9. 6. van der Zande MM, Hong CL, Gorter RC, Wismeijer D, It has been suggested that scientific validation of the biological Broadbent JM. Use of newer technologies by dentists in New outcomes and economic analyses of benefits accruing from digital Zealand. N Z Dent J 2018;114:107-115. technologies in dentistry is required.5 Various methods have been 7. Barnett M, Hyman J. Challenges in interpreting study results: used in healthcare to analyse the economic impact of different The conflict between appearance and reality. J Am Dent Assoc treatments and allow comparisons between costs and benefits 2006;137:32S-36S. to be made.17 It has been recommended that an evaluation of 8. Chambers D. Technology innovation. J Am Coll Dent outcomes of innovation (treatment and technologies) should 2001;68(2):41-45. factor in survival, physiological impact, psychological effects 9. Milgrom P, Horst J. The need of new oral care technologies and economic factors to accommodate both patient concerns on the need for dentists in 2040. Journal of Dental Education and the interests of the healthcare provider.18 Reduced industry 2017;81:126-132. contribution to research is expected to impact sources of new 10. Matthews D C, McNeil K, Brillant M, Tax C, Maillet P, McCulloch CA, products. While there is an anticipated move towards greater Glogauer M. Factors influencing adoption of new technologies productivity and efficiencies in dentistry, this will impact on the into dental practice: A qualitative study. International and uptake of all new technologies. The demand for oral health care will American Association of Dental Research 2016;1(1):77-85. be less in the groups with low disease activity and higher in lower 11. Lamster I, Collins F. Are dentists using new clinical income groups with high disease rates and levels of edentulism.9 technologies? Colgate Oral Health Network 2018: https://www. For many dentists, the digital CADCAM revolution seems currently colgateoralhealthnetwork.com/article/are-dentists-using-new- to reside within dental laboratories. The educational sector is clinical-technology/ also addressing the impact of the digital revolution in dentistry, 12. Parashos P, Messer H. The diffusion of innovation in dentistry: with the American College of Prosthodontists releasing its digital A review using rotary nickel-titanium technology as an curriculum framework and trialling this in five dental schools in example. Oral Surg Oral Med Oral Pathol Oral Radiol Endod the USA since 2017. A planned broader release to international 2006;101:395-401. universities is expected in coming years. Many other universities 13. van der Zande MM, Gorter RC, Aartman IHA, Wismeijer D. internationally are already integrating digital teaching into the Adoption and use of digital technologies among general curriculum and Australasia has been very proactive in developing dentists in the Netherlands. PLoS ONE 2015;10(3): e0120725. to meet the needs of new graduates. 14. Ting N, Broadbent J, Duncan W. Digital radiography in New Zealand: Digital versus film. N Z Dent J 2013;109:107-114. CONCLUSIONS 15. Blackwell E, Nesbit M, Petridis H. Survey on the use of CAD- CAM technology by UK and Irish dental technicians. Br Dent J Who is currently benefiting from new technologies? Well, to 2017;222(9):689-693. an extent, we all are. We tend to forget how pervasive digital 16. Alameri SS, Aarts JM, Smith M, Waddell JN. Dental technology technologies are in our modern lives. We access the web, services and industry trends in New Zealand from 2010 to text message and email every day, our media is digital and 2012. N Z Dent J 2014;110(2):65-73. in our practising lives, there are very few of us would not use 17. Walton TR, Layton DM. Cost satisfaction analysis: A novel a range of digital tools within our normal day. Existing and patient-based approach for economic analysis of the utility of emerging technologies have been shown to improve record fixed prosthodontics. J Oral Rehabil 2012;39(9):692-703. keeping accuracy, treatment planning, patient education and 18. Joda T, Ferrari M, Bragger U, Zitzmann NU. Patient reported communication, practitioner support, efficiency for patients, outcome measures (PROMs) of posterior single-implant clinicians and the laboratory and to improve patient comfort crowns using digital workflows: A randomized controlled and provide at least equivalent treatment outcomes.11 Electronic trial with a three-year follow-up. Clin Oral Implants Res 2018 health records and digital radiography have penetrated widely Sep;29(9):954-961. 32 RACDS ANNALS 2018 Email address for correspondence: [email protected]

PSYCHOSOCIAL CONSIDERATIONS FOR TEMPOROMANDIBULAR DISORDERS Dr Lalima TIWARI, Dr Amanda PHOON-NGUYEN, Dr Ramesh BALASUBRAMANIAM, BSc, BDSc (UWA), MS, Cert Orofacial Pain (UKy), Cert Oral Medicine (UPenn), MRACDS (OralMed) Dr Ramesh Balasubramanium (Presenter) is a Clinical Associate Professor at the UWA Dental School, University of Western Australia, Perth, Australia. Dr Lalima Tiwari and Dr Amanda Phoon-Nguyen are Trainees, Doctor of Clinical Dentistry in Oral Medicine, UWA Dental School, Perth, Australia. ABSTRACT The term Temporomandibular Disorders (TMD) comprises of a complex, multifactorial group of conditions that are associated with psychosocial factors. Current tools utilised for diagnosis and management of TMD apply concepts of the biopsychosocial model of pain to appropriately assess and manage TMD. Furthermore, strong evidence demonstrates associations between TMD patients and concurrent depressive disorders, anxiety, somatisation and catastrophising, with persistent TMD symptoms and increased pain. Assessment of psychosocial factors in patients presenting with TMD is crucial for the clinician to establish an accurate diagnosis and management plan. This narrative review discusses the current literature on psychosocial considerations pertaining to TMD in adults and children, as well as aiming to provide perspective into taking a psychosocial history. INTRODUCTION a purely ‘biological’ experience (cerebral activation, inflammation) to recognising its manifestation as a complex interaction of The influence of psychosocial factors in pain have been widely biological, psychological and social factors.5,6 This work was recognised in recent literature.1,2 As a result, the strong associations further enhanced by Dworkin and his colleagues, who presented of cognition and sociality, along with the concepts of the a comprehensive biopsychosocial model of chronic pain biopsychosocial model of pain are also now being reflected in the development, that was applicable to TMD and provided further definition of pain; ‘a distressing experience associated with actual understanding of TMD pain.7 The model recognises the variability or potential tissue damage with sensory, emotional, cognitive and in the individual expression of subjective pain experience and social components’.2 ‘Temporomandibular Disorders’ (TMD) is a pain behaviours, and highlights the dynamic nature of intrinsic collective term for a group of musculoskeletal and neuromuscular intrapersonal factors (nociception, pain perception), extrinsic conditions which includes several clinical signs and symptoms interpersonal factors (behaviour responses to pain, social roles involving the muscle of mastication, the temporomandibular joint for the person in pain, the workplace, the social welfare system), and associated structures.1 Of interest, chronic TMD represents and how these factors can be intensified or minimised throughout the most common chronic orofacial pain condition. Like other time, leading to chronic TMD pain and dysfunction.7 In the context chronic pain conditions, individuals with chronic TMD pain of management, the biopsychosocial model also encourages demonstrate greater psychological maladjustment, and poorer the clinician to recognise that the relative importance of each management outcomes compared to healthy controls.3 Similar set of factors and their interactions varies considerably across outcomes and psychosocial comorbidities have been seen in patients and over time, thereby requiring a treatment plan that children and adolescents with TMD pain.4 Furthermore, the dual appropriately addresses each factor, instead of utilising a standard axis diagnostic criteria; Diagnostic Criteria for TMD (DC/TMD) biomedical model of disease management.5 A classic example of has been developed to not only render physical diagnoses, the biomedical model in dentistry is the provision of splint therapy but also provide biobehavioural assessments of the patient’s to almost all patients diagnosed with TMD, regardless of each pain disorder.1 Interestingly, there is increasing evidence to patient’s specific diagnosis. suggest that premorbid psychosocial factors predict the onset and persistence of TMD, resulting in a seemingly bidirectional AETIOLOGY AND RISK FACTORS IN association and reflecting these factors as potentially important TEMPOROMANDIBULAR DISORDERS treatment targets.5 As patients with pain-related TMD often seek treatment with dentists, the recognition and assessment of the Historically, mechanisms related to dental or structural patient’s psychosocial functioning is an essential part of the abnormalities which could be readily identified during clinical diagnostic process, assisting the development of management examination were implicated in TMD pathology, with considerable plans (including referrals for further multidisciplinary assessment), controversy and little scientific evidence.8 Contemporary as well as determining patient prognosis.1 This review aims to evidence now points to an amalgamation of genetics, sensory discuss psychosocial considerations pertaining to TMD in adults processing, psychological and behavioural factors contributing to and children, aiding the clinician to take an adequate psychosocial the multifactorial aetiology of TMD.8 It is the interplay of these risk history of the TMD patient and allowing for appropriate TMD factors, as experiences prior to the onset of TMD (predisposing diagnosis and management factors), during TMD onset (initiating factors) or persistence throughout TMD (perpetuating factors), that makes this complex BIOPSYCHOSOCIAL MODEL OF PAIN disorder unique to the individual suffering from it.8 Understanding concepts of the biopsychosocial model of pain GENETICS remains crucial for adequate assessment of contributing factors in TMD and other pain conditions in general.6 The biopsychosocial In a landmark cohort study of 2737 individuals, five main gene model proposed by Engel transformed our approach to pain from polymorphisms from 368 genes linked to nociceptive pathways, RACDS ANNALS 2018 33

inflammation and affective distress were shown to have and are often used as a diagnostic label by clinicians when they associations with predicting TMD onset.9 Voltage-gated sodium do not have an explanation for the symptoms that the patient is channel-type 1-alpha subunit (SCN1A) and angiotensin I-converting reporting. Given the presence of high levels of somatic symptoms enzyme 2 (ACE2) displayed associations with non-specific orofacial in TMD patients, influence of underlying central mechanisms on symptoms, while prostaglandin-endoperoxide synthase 1 (PTGS1) autonomic tone is considered, further indicating a multidisciplinary and amyloid-beta precursor protein (APP) were associated with treatment approach, including psychological intervention, rather overall psychological symptoms and stress respectively.9 Finally, than peripherally based treatments alone.5 multiple PDZ domain protein (MPDZ) was shown to be associated with heat pain temporal summation.9 Interestingly, no genetic A cross-sectional study of 411 female patients with chronic markers were discovered which predicted TMD onset, rather, orofacial pain observed 23.6% with post-traumatic stress disorder several genetic risk factors for clinical, psychological, and sensory (PTSD) symptoms consistent with a diagnosis of PTSD.13 These phenotypes associated with TMD onset were observed.9 Further findings were further substantiated by the OPERRA study, which studies examining these gene associations are still required to demonstrated PTSD, perceived stress and recalled traumatic life build on the current evidence. events, along with general psychological symptoms and negative mood, to be predictive of TMD incidence.11 Furthermore, traumatic SENSORY PROCESSING stressors in patients with TMD conditions are also associated with pain severity, affective distress and disability.5 PTSD screening, Recent evidence suggests that risk of onset and chronicity of TMD as well as a thorough sleep evaluation, is therefore strongly is influenced by a state of pain amplification.10 Pain amplification recommended as routine assessment for orofacial pain patients. refers to alterations in peripheral and central nervous system Furthermore, treatment of PTSD symptoms should be considered processes that have the net effect of amplifying the perceptual part of the standard care.13 response to nociceptive stimuli.10 This can manifest as heightened responsiveness to sensory testing, as well as spontaneous pain Studies have also noted associations with catastrophising from deep tissues such as muscles, joints and visceral tissues.10 In and exacerbation of negative affect and cognitive distortions the context of TMD, studies have shown that the most consistent in chronic pain patients. These associations of maladaptive predictor of developing a chronic TMD was the presence of cognitive attributes have also been seen in patients with another chronic pain condition at baseline.10 These overlapping TMD.14 Interestingly, measures of catastrophising (rumination, conditions can be categorised as central sensitivity syndromes magnification, helplessness) are not significantly associated with and include chronic headache, fibromyalgia, interstitial cystitis, TMD onset.11 Rather, baseline catastrophising is strongly associated irritable bowel syndrome, lower back pain, chronic fatigue with increased pain intensity, and may in fact increase the risk for syndrome and vulvodynia, resulting in an overall hypersensitised transition from acute to chronic TMD pain, instead of predicting state.10 Such overlapping syndromes are seen particularly in TMD pain onset.11, 15 women of child bearing age and are considered a risk indicator for TMD-pain and dysfunction, as well as a predictor for lack of PSYCHOSOCIAL FACTORS IN CHILDREN response to treatment. The influence of certain adverse factors in childhood has long PSYCHOSOCIAL FACTORS been thought to have risk associations across a number of chronic pain conditions, which may manifest in childhood or adulthood. There is now substantial evidence demonstrating that people The list of childhood adversity risk factors associated with chronic with chronic pain conditions show greater levels of psychological pain is numerous, and those found relating specifically to TMD distress, environmental stress, catastrophising and somatic have been summarised in Table 1. Undoubtedly, psychosocial risk symptoms.11 Mental health disorders such as depression or anxiety factors in youth have far-reaching effects on health into adulthood. are more prevalent in patients with TMD (16% - 40%) than in the However, less well understood is the mechanism by which this general population (16%).12 Interestingly, females have reportedly occurs, and how it affects adult health. Does childhood adversity higher prevalence of mental health disorders than men, with accumulate and ‘prime’ an individual to be vulnerable later in life? prevalence of depression and generalised anxiety of 2.3% and Or perhaps early life adversity could set an individual off on an 4.4% among the general population and 8.8% and 12.8% among unfavourable life ‘trajectory’ on which they will accumulate and women, respectively.12 This bias is of particular importance, develop susceptibilities to certain pain conditions. Others have especially when assessing a female patient with TMD-related suggested a possible ‘biological programming’ effect, where early pain.12 Patients with TMD have been shown to be more likely to life adversity could lead a child to be less able to cope with later suffer from social isolation, sleep dysfunction, daytime sleepiness life stressors.4 A history of adversity could increase vulnerability and to have difficulty with concentration; characteristics which are to emotional distress, or increase the tendency to attend, amplify also present in major depressive disorders.5 Furthermore, patients and overinterpret somatic symptoms. However, the connection of with depressive disorders concurrent with anxiety symptoms this to clinical and psychosocial variables remains unclear. There is may exacerbate negative effect and amplify pain perception. As similarly an unclear relationship between when adversity occurs, a result, depression and anxiety are now considered predictors of and if/when chronic pain will manifest, and it is furthermore long-term persistence of TMD in patients with existing TMD, as well unknown whether the pain drives psychological symptoms or vice becoming important targets in the comprehensive management versa. While there are many unknowns, it is clear that associations of TMD.11 have been found between childhood adversity and chronic pain states, including fibromyalgia, headache/migraine, irritable bowel Findings from a large prospective cohort study assessing syndrome, TMD, interstitial cystitis, endometriosis, vulvodynia, psychological functioning prior to onset of TMD, also revealed a and chronic pelvic pain. It is also worth emphasising the inherent strong association between somatisation and TMD onset.11 Somatic difficulties and limitations of work in this area. Chronic pain, by its symptoms including pain, fatigue or neurological symptoms can very nature, is insidious in onset and it is sometimes impossible manifest as a cluster of disorders, resulting in significant disruption to measure disease onset with any precision. As most studies are to daily functioning in a suffering individual. Diagnostic criteria retrospective, there is seldom objective confirmation of adverse for somatic symptoms and related disorders include individuals childhood exposures, and often recall bias. experiencing excessive thoughts, feelings and behaviours related to their symptoms for at least six months.5 These symptoms While there are few studies of early life adversity and its relationship may or may not be associated with another medical condition, with TMD, it has been reported that a higher proportion of patients with temporomandibular disorders disclosed a history of 34 RACDS ANNALS 2018

physical and/or sexual abuse. Fillingim and colleagues compared Table 2. Taking a psychosocial history female TMD subjects and age-matched female control subjects, and found a slightly but not statistically significant greater Behavioural History percentage of TMD subjects (44.8%) reported a history of sexual or physical abuse compared to control subjects.16 They reported Sleep: their prevalence of physical/sexual abuse among TMD subjects • How many hours do you sleep at night? to be similar to that of other chronic pain populations.16 Another • Are you sleepy during the day? study by Riley et al. involving 139 subjects with TMD found 49% • Do you have trouble falling and/or staying asleep? reported a history of physical and/or sexual abuse.17 The abused Diet: subjects reported significantly higher levels of anxiety, depression, • Do you drink caffeinated beverages? If so, how much and and somatic symptoms than non-abused subjects.17 Similarly, the same group of researchers found that amongst 114 women with at what time of the day? TMD, those with a history of physical abuse, as ascertained by • Do you drink alcohol? If so, how much and at what time structured clinical interview, reported significantly more pain than those who reported a history of sexual abuse, or no abuse.18 of day? Tobacco/ Drugs: A large population study recruited 2000 eleven-year-old children, • Do you smoke? How many cigarettes do you smoke? and followed them up for 3 years, with the aim of investigating • Do you use any recreational drugs? predictors of TMD (and orofacial pain) in adolescence.19 Baseline risk factors included general health status, indicators of school Social History performance / school satisfaction, physical and sedentary activity levels, self-esteem, depression and somatisation. They found the Effect of pain on daily life: following baseline predictors in early adolescence were associated • How much does your pain problem interfere with your with clinically significant TMD pain: female gender [Odds Ratio (OR) = 2.0, 95% Confidence Interval (CI) = 1.2–3.3] and negative day to day activities? somatic and psychological symptoms including somatisation (OR Work: = 1.8, CI = 1.1–2.8), number of other pain complaints (OR = 3.2, CI = • Does your pain prevent you from working? 1.7–6.1) and life dissatisfaction (OR = 4.1, CI = 1.9–9.0).19 Surprisingly, • Are you experiencing financial stresses as a result? depression was not found to be an independent variable in this Home life: study, though a large study in Finland investigated the effects • Who do you live with at home? of parental depression.19 Pelkonen and colleagues interviewed • What are your support systems? the mothers of 12,058 children, with over 31 years of follow up • How supportive is your partner (significant other) to you via questionnaires, and found that parental depression during the offspring’s childhood was significantly associated with facial in relation to your pain? pain and temporomandibular joint pain at jaw rest.20 This was • How worried is your partner (significant other) about you not found in the offspring of antenatally depressed mothers. This study highlighted the importance of effective treatment of in relation to your pain? parental depression to avoid negative influences on the future • Has your pain changed your marriage and other family health of their children.20 relationships? There is clear consistency, across a number of studies, that both • Has your pain changed the amount of satisfaction you early life adversity, and a number of aspects of psychological vulnerability, are significantly associated with chronic pain get from family-related activities? conditions. Psychosocial factors and pain perpetuation are Social Life: inextricably linked, and consideration of such is imperative to the • How much has your pain changed the amount of overall and holistic management of the patient. satisfaction or enjoyment you get from participating in Table 1. Childhood risk factors associated with temporomandibular social and recreational activities? disorders Secondary gains: • Do you require a disability pension as a result of your Female Gender pain? Somatisation Emotional History Life dissatisfaction Affective: • How would you rate your mood during the past week? History of physical abuse • How severe has your pain been during the last week? • Do you feel sad, anxious, worried, frustrated or always History of sexual abuse tired? Parental depression during childhood • How much control do you feel that you have had over TAKING A PSYCHOSOCIAL HISTORY your life? • How much suffering do you experience because of your The importance of taking a psychosocial history as part of the diagnostic workup of the TMD patient cannot be overemphasised. pain? Tools such as the DC/TMD are reliable instruments that can be Self – Esteem: utilised in clinical practice for the diagnosis of TMD, providing both • Have you suffered from any previous childhood trauma? a physical and psychosocial assessment of the patient.1 However, • Has someone in your family recently passed away? dentists often feel inadequate to diagnose mental health disorders, • How is your relationship with your family? or unsure as to how to proceed with treatment planning.12 Table 2 Suicidal thoughts: provides a list of questions that may guide the clinician to target • Does the pain bring up suicidal thoughts? various psychosocial factors that are associated with TMD when assessing a patient. Interestingly, most mental health disorder screening is in paper form, time consuming and does not guide management.12Recently, a new electronic screening tool; IMPARTS (Integrating mental and physical: research training and services) was developed to RACDS ANNALS 2018 35

help non- specialists address common mental health problems reduce distress, change behaviour, and ultimately increase the in patients with TMD.12 Although it was developed to address therapeutic yield of therapies such as pharmacotherapy or budget constraints in the UK health system, this tool provides surgery. clear recommendations for guidance and predetermined referral pathways, making it easier for clinicians to care for patients CONCLUSION holistically.12 There is no doubt that psychosocial factors significantly influence MANAGEMENT the onset and persistence of TMD symptoms, as well as complicate TMD diagnosis and management. Taking a biopsychosocial Early consideration and identification of psychosocial factors are model viewpoint towards the condition and obtaining a thorough of the utmost importance in treating chronic pain states such psychosocial history will ensure the dentist appropriately as painful TMD. Painful TMD is sometimes perpetuated due to recognises not just a physical diagnosis, but possible underlying a complex interplay of multiple biological, psychological, social psychosocial dysfunctions in the TMD patient. Exploring and cultural factors, none of which can be ignored in order to contributory factors such as depressive disorders, somatisation, holistically manage chronic pain. While piecing together the PTSD and anxiety will ensure appropriate treatment planning, mosaic of a patient’s individual pain experience is no simple including a multidisciplinary team approach for the management matter, tailored treatments based on the individual’s risk factors of the TMD patient. is crucial to comprehensive, patient-centred management. Today, the majority of those researching and managing TMD REFERENCES understand that comprehensive and appropriate assessment and management requires consideration of the biopsychosocial 1. Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, model.21 Goulet J-P, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Figure 1. Tailored and multimodal approach to treating chronic recommendations of the International RDC/TMD Consortium temporomandibular disorders Network and Orofacial Pain Special Interest Group. J Oral Facial The purpose of a psychosocial assessment is not to diagnose Pain Headache 2014;28(1):6-27. psychiatric conditions, but rather to recognise psychosocial 2. Williams AC de C, Craig KD. Updating the definition of pain. Pain dysfunction in a TMD patient. This will facilitate early education of 2016;157(11):2420-3. the patient, encouraging principles of self-management, discussing the biopsychosocial model, and allow for a comprehensive 3. Fillingim RB, Ohrbach R, Greenspan JD, Knott C, Dubner R, treatment plan to be formulated with the patient, that employs a Bair E, et al. Potential Psychosocial Risk Factors for Chronic multidisciplinary input when required. TMD: Descriptive Data and Empirically Identified Domains from the OPPERA Case-Control Study. J Pain 2011;12(11, Pharmacotherapy had traditionally been the mainstay of pain Supplement):T46–60. treatment, though it is now recognised to play a lesser role in overall management and should be considered within a larger 4. Jones GT. Psychosocial Vulnerability and Early Life Adversity as context in order to maximise the potential of the medication to Risk Factors for Central Sensitivity Syndromes. Curr Rheumatol help the patient.21 Implementing and facilitating patient education, Rev 2016;12(2):140–53. self-management, and biobehavioural therapy, in addition to pharmacotherapy, is critical to a tailored and multimodal approach 5. Bartley EJ, Schmidt JE, Carlson CR, Fillingim RB. Psychosocial (Figure 1). Biobehavioural therapy is a broad term that has been Considerations in TMD. In: Gremillion HA, Klasser GD, editors. used to group a wide variety of techniques such as physical self- Temporomandibular Disorders: A Translational Approach regulation, mindfulness, biofeedback, and cognitive behavioural From Basic Science to Clinical Applicability [Internet]. Cham: therapy. These techniques are based on assessments of an Springer International Publishing; 2018 [cited 2019 Jan 13]. p. individual’s behaviour and symptoms, and employ social learning 193–217. Available from: https://doi.org/10.1007/978-3-319-57247- principles and skills training, to facilitate coping mechanisms, 5_10 6. Durham J, Raphael KG, Benoliel R, Ceusters W, Michelotti A, Ohrbach R. Perspectives on next steps in classification of oro- facial pain – part 2: role of psychosocial factors. J Oral Rehabil 2015;42(12):942–55. 7. Suvinen TI, Reade PC, Kemppainen P, Könönen M, Dworkin SF. Review of aetiological concepts of temporomandibular pain disorders: towards a biopsychosocial model for integration of physical disorder factors with psychological and psychosocial illness impact factors. Eur J Pain Lond Engl 2005;9(6):613–33. 8. Ohrbach R, Fillingim RB, Mulkey F, Gonzalez Y, Gordon S, Gremillion H, et al. Clinical Findings and Pain Symptoms as Potential Risk Factors for Chronic TMD: Descriptive Data and Empirically Identified Domains from the OPPERA Case-Control Study. J Pain 2011 Nov 1;12(11, Supplement):T27–45. 9. Smith SB, Mir E, Bair E, Slade GD, Dubner R, Fillingim RB, et al. Genetic variants associated with development of TMD and its intermediate phenotypes: the genetic architecture of TMD in the OPPERA prospective cohort study. J Pain Off J Am Pain Soc 2013;14(12 Suppl):T91-101.e1-3. 10. Maixner W, Diatchenko L, Dubner R, Fillingim RB, Greenspan JD, Knott C, et al. Orofacial Pain Prospective Evaluation and Risk Assessment Study – The OPPERA Study. 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11. Fillingim RB, Ohrbach R, Greenspan JD, Knott C, Diatchenko L, Dubner R, et al. Psychological Factors Associated with Development of TMD: the OPPERA Prospective Cohort Study. J Pain Off J Am Pain Soc [Internet]. 2013 Dec [cited 2019 Jan 13];14(12 0). Available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3855656/ 12. Yeung E, Abou-Foul A, Matcham F, Poate T, Fan K. Integration of mental health screening in the management of patients with temporomandibular disorders. Br J Oral Maxillofac Surg 2017 Jul 1;55(6):594-9. 13. Burris J, Cyders M, de Leeuw R, Smith G, Carlson C. Posttraumatic Stress Disorder Symptoms and Chronic Orofacial Pain: An Empir...: EBSCOhost. J Orofac Pain 2009;23(3):243-52. 14. Turner JA, Brister H, Huggins K, Mancl L, Aaron LA, Truelove EL. Catastrophizing is associated with clinical examination findings, activity interference, and health care use among patients with temporomandibular disorders. J Orofac Pain 2005;19(4):291- 300. 15. Velly AM, Look JO, Carlson C, Lenton PA, Kang W, Holcroft CA, et al. The effect of catastrophizing and depression on chronic pain--a prospective cohort study of temporomandibular muscle and joint pain disorders. Pain 2011 Oct;152(10):2377–83. 16. Fillingim RB, Maixner W, Sigurdsson A, Kincaid S. Sexual and physical abuse history in subjects with temporomandibular disorders: relationship to clinical variables, pain sensitivity, and psychologic factors. J Orofac Pain 1997;11(1):48-57. 17. Riley III JL, Robinson ME, Kvaal SA, Gremillion HA. Effects of Physical and Sexual Abuse in Facial Pain: Direct or Mediated? CRANIO® 1998 O;16(4):259-66. 18. Campbell LC, Riley JL, Kashikar-Zuck S, Gremillion H, Robinson ME. Somatic, affective, and pain characteristics of chronic TMD patients with sexual versus physical abuse histories. J Orofac Pain 2000;14(2):112-9. 19. LeResche L, Mancl LA, Drangsholt MT, Huang G, Von Korff M. Predictors of Onset of Facial Pain and Temporomandibular Disorders in Early Adolescence. Pain 2007 Jun;129(3):269-78. 20. Pelkonen ESJ, Mäki PH, Kyllönen MA, Miettunen JA, Taanila AM, Sipilä KK. Pain-related symptoms of temporomandibular disorders in the offspring of antenatally depressed mothers and depressed parents: a 31-year follow-up of the Northern Finland Birth Cohort 1966. Eur J Pain Lond Engl 2013 Aug;17(7):1048-57. 21. Ohrbach R, Durham J. Biopsychosocial Aspects of Orofacial Pain. In: Farah CS, Balasubramaniam R, McCullough MJ, editors. Contemporary Oral Medicine [Internet]. Cham: Springer International Publishing; 2017 [cited 2019 Jan 13]. p. 1-21. Available from: http://link.springer.com/10.1007/978-3-319-28100-1_37-1 Email address for correspondence: [email protected] RACDS ANNALS 2018 37

2017 WHO CLASSIFICATION OF ODONTOGENIC CYSTS AND TUMOURS Dr Alison M RICH, BDS, MDSc, PhD, FRACDS, FFOP (RCPA), FRCPath Dr Alison M Rich is a Professor in the Faculty of Dentistry, University of Otago, Dunedin, New Zealand. ABSTRACT The 4th edition of the World Health Organisation (WHO) classification of head and neck tumours was published in 2017. This article provides a summary of changes to the classification of odontogenic cysts and tumours. INTRODUCTION odontogenic tumour (KCOT) as per the 2005 classification. Whether this lesion is a developmental cyst, or a true benign cystic The new edition of the WHO classification of head and neck neoplasm has been debated for years. The rationale for designation tumours was released in early 20171 (updating the 2005 edition).2 It as a tumour related to its high recurrence rate and the presence was developed by consensus from a panel of invited international of mutation of the PTCH1 gene in some OKCs,10 but no single leaders in the fields of odontogenic and bone pathology3,4 genetic mutation defines neoplasia. Other cysts e.g. dentigerous and provides a standardised reference guide for clinicians and cysts, have PTCH mutations,11 not all sporadic OKC have PTCH pathologists, has an international focus, avoids over emphasis on mutations12 and they may resolve with decompression13,14 i.e. they rare and/or poorly defined entities, has a conservative approach do not necessarily show relentless growth (although surgical to recommendation relating to controversial and /or provisional intervention post-decompression is usual).15,16 entities and has a standardised nomenclature with other organ sites.5 Orthokeratinised odontogenic cyst (‘an odontogenic cyst that is entirely or predominately lined by orthokeratinised stratified The 2017 edition has three chapters of particular interest to squamous epithelium’) has been included in the list of development dentists and dental specialists: cysts as a distinct entity in its own right.17 Its distinction from OKC is important to recognise since it has a lower rate of recurrence.18 Chapter 4 – ‘Tumours of the Oral Cavity and Mobile Tongue’, Chapter 7 – ‘Tumours of Salivary Glands’, and Soft tissue gingival cysts (‘odontogenic cysts found in the alveolar Chapter 8 – ‘Odontogenic and Maxillofacial Bone Tumours’. mucosa’) comprise infant and adult forms. The histological features of the gingival cyst of adult mirror those of the lateral This presentation will concentrate on the odontogenic cysts and periodontal cyst, leading to the suggestion that gingival cyst of tumours included in Chapter 8.6 adult, lateral periodontal cyst, botyroid odontogenic cyst and even glandular odontogenic cyst (GOC) may be part of a spectrum of ODONTOGENIC CYSTS related lesions, with the latter lesions having greater potential to recur. GOC in particular may be extensive at presentation and Unlike the previous classification in 2005, the updated 2017 have a high recurrence rate. Although their odontogenic origin classification now includes odontogenic cysts. They are separated is proven, GOCs need to be differentiated from intraosseous into two categories; odontogenic cysts of inflammatory origin, and mucoepidermoid carcinomas, and this can be achieved by odontogenic and non-odontogenic cysts of developmental origin confirming the lack of mastermind-like (MAML)2 rearrangements (Table 1). in GOCs.19,20 Radicular cysts (‘an odontogenic cyst of odontogenic origin The new classification of odontogenic cysts includes calcifying associated with non-vital teeth’) encompass lateral radicular cysts odontogencic cysts (COC), ‘a simple cyst lined by ameloblastoma- and residual cysts. Inflammatory collateral cysts (ICC) ‘arise on the like epithelium, which contains focal accumulations of ghost cells’. buccal aspect of the roots of partially or recently erupted teeth COC is at one end of the spectrum of odontogenic ghost cell as a result of inflammation in the pericoronal tissues’.6 There are lesions. Its solid form, known as dentinogenic ghost cell tumour, two types of ICC, the paradental cyst, which is associated with is in the benign odontogenic tumour classification, while the mandibular third molars, and the mandibular buccal bifurcation malignant form is known as a ghost cell odontogenic carcinoma. cyst (MBBC), associated with the buccal aspect of mandibular first or second molars. While the behaviour of paradental cysts is well ODONTOGENIC TUMOURS known to clinicians who frequently extract third molars, MBBCs are less frequently encountered. These lesions occur in children Odontogenic tumours are derived from cells of the odontogenic with erupting mandibular first or second molars where there is apparatus and their remnants.6 They may be malignant or benign. inflammation in the overlying soft tissue.7 They may be bilateral. In the 2017 classification, the malignant list is simplified into three Generally, it is recommended that treatment is conservative categories, all of which are very rare (Table 2). enucleation, with retention of the adjacent teeth, with or without bone grafting,8 although there are reports of resolution without The classification of benign odontogenic tumours has also been intervention as the teeth erupt.9 simplified, with separation into tumours that are of epithelial origin, mesenchymal origin, or mixed, without describing the degree of With regard to developmental odontogenic cysts, the most induction of dental hard tissues (Table 3).4,6 significant change is the inclusion of odontogenic keratocyst (OKC) in this category rather than being known as keratocystic Conventional ‘solid/multicystic’ ameloblastoma is now known 38 RACDS ANNALS 2018

simply as ameloblastoma. Desmoplastic ameloblastoma has been Table 2. Classification of Malignant Odontogenic Tumours (From dropped from the classification since it behaves as a conventional Takata and Slootweg, 2017)6 ameloblastoma, but remains a histological subtype.3 Unicystic ameloblastoma (‘a variant of intraosseous ameloblastoma Odontogenic carcinomas that occurs as a single cystic cavity, with or without luminal proliferation’)21 still comprises intramural unicystic ameloblastomas, Ameloblastic carcinoma which many people consider should be managed in the same Primary intraosseous carcinoma way as conventional intraosseous ameloblastomas.4 Interest Sclerosing odontogenic carcinoma in the mutation profile in signalling pathways in all forms of Clear cell odontogenic carcinoma ameloblastoma remains strong, with potential for targeted Ghost cell odontogenic carcinoma molecular therapy.22-25 Odontogenic carcinosarcoma Table 1. Classification of Odontogenic Cysts (From Takata and Slootweg, 2017)6 Odontogenic sarcomas Odontogenic cysts of inflammatory origin Table 3. Classification of Benign Odontogenic Tumours (From Takata and Slootweg, 2017)6 Radicular cyst Inflammatory collateral cysts Benign epithelial odontogenic tumours Odontogenic and non-odontogenic cysts of developmental Ameloblastoma origin unicystic type extraosseous/peripheral type Dentigerous cyst metastasising ameloblastoma Odontogenic keratocyst Squamous odontogenic tumour Lateral periodontal cyst and botyroid odontogenic cyst Calcifying epithelial odontogenic tumour Gingival cyst Adenomatoid odontogenic tumour Glandular odontogenic cyst Calcifying odontogenic cyst Benign mixed epithelial and mesenchymal odontogenic Orthokeratinised odontogenic cyst tumours Nasoplatine duct cyst Ameloblastic fibroma Primordial odontogenic tumour is a newly described benign Primordial odontogenic tumour tumour which mostly occurs as a radiolucency in the posterior Odontoma mandible in children and young adults, associated with an compound type unerupted third molar. The histology shows tissue similar to the complex type dental papilla which is rimmed by cuboidal to columnar epithelium Dentinogenic ghost cell tumour resembling the inner enamel epithelium of the enamel organ.26,27 Benign mesenchymal odontogenic tumours Lesions like ameloblastic fibro-odontome are not included in the 2017 classification since the distinction between them as a distinct Odontogenic fibroma entity, as opposed to a developing odontome, is unclear, and Odontogenic myxoma/myxofibroma management is not affected. Cementoblastoma Cemento-ossifying fibroma The benign mesenchymal group is largely unchanged, but the term cementifying-ossifying fibroma (COF) is used instead of REFERENCES simply ossifying fibroma. Debate about these terms persists, 1. El-Nagger et al. eds. WHO Classification of Head and Neck but the decision was made for the 2017 edition to use COF for these particular fibro-osseous lesions associated with tooth roots Tumours. 4th ed. Lyon IARC 2017. since, in this situation, the lesion is of odontogenic origin having arisen from the periodontal ligament and the material includes 2. Barnes L et al. ed. WHO Classification of Tumours: pathology cementum. A similar lesion, distant from tooth roots, would be and genetics of head and neck tumours. 3rd ed. Lyon IARC included in the bone tumour section and be known as ossifying 2005. fibroma. 3. Wright JM, Vered M. Update from the 4th edition of the World It is incumbent on clinicians and pathologists to review WHO Health Organisation classification of head and neck tumours: classifications to ensure standardisation of diagnosis and odontogenic and maxillofacial bone tumours. Head Neck management across the globe, so that large population studies Pathol 2017;11:68-77. with uniform diagnoses are available for research, ultimately leading to advances in diagnosis and management. 4. Speight P, Takata T. New tumour entities in the 4th edition of the World Health Organization classification of head and neck tumours: odontogenic and maxillofacial bone tumours. Virchows Arch 2018;472:331-9. RACDS ANNALS 2018 39

5. Seethala RR. Update from the 4th edition of the World Health 17. Speight P, Fantasia JE, Neville BW. Orthokeratinised odontogenic Organisation classification of head and neck tumours: preface. cyst. In El-Nagger et al. eds. WHO Classification of Head and Head Neck Pathol 2017;11:1-2. Neck Tumours. IARC Lyon 2017;241. 6. Takata T, Slootweg PJ. Chpt 8 WHO classification of odontogenic 18. Macdonald-Jankowski DS. Orthokeratinised odontogenic cyst: and maxillofacial bone tumours, WHO Classification of Head A systematic review. Dentomaxillofacial Radiol 2010;39:455-67. and Neck Tumours. 4th ed. Lyon IARC 2017. 19. Bishop JA, Yonescu R, Batista DA, Warnock GR, Westra 7. Thurnwald GA, Acton CH, Savage NW. The mandibular WH. Glandular odontogenic cysts (GOCs) lack MAML2 infected buccal cyst-a reappraisal. Ann R Australas Coll Dent rearrangements: a finding to discredit the putative nature of Surg. 1994;12:255-63. GOC as a precursor to central mucoepidermoid carcinoma. Head Neck Pathol 2014;8:287-90. 8. Levarek RE, Wiltz MJ, Kelsch RD, Kraut RA. Surgical management of the buccal bifurcation cyst: Bone grafting 20. Greer RO, Eskendri J, Freedman P, Ahmadian M, Murakami- as a treatment adjunct to enucleation and currettage. J Oral Walter A, Varella-Garcia M. Assessment of biologically Maxillofac Surg 2014;72: 1966-73. aggressive, recurrent glandular odontogenic cysts for mastermind-like 2 (MAML2) rearrangements: histopathologic 9. Zadik Y, Yitchaky O, Neuman T, Nitzan DW. On the self-resolution and fluorescent in situ hybridization (FISH) findings in 11 cases. nature of the buccal bifurcation cyst. J Oral Maxillofac Surg J Oral Pathol Med 2018;47:192-7. 2011;69: e282-e284. 21. Vered M, Muller S & Heikinheimo K. Ameloblastoma, unicystic 10. Philipsen HP. Keratocystic odontogenic tumour. In Barnes type. In El-Nagger et al. eds. WHO Classification of Head and L et al (eds). WHO Classification of Tumours: pathology and Neck Tumours. IARC Lyon 2017;217-8. genetics of head and neck tumours. IARC Lyon 2005;306-7. 22. Brown NA, Rolland D, McHugh JB, Weigelin HC, Zhao L, Lim MS 11. Pavelić B, Levanat S, Crnić I, Kobler P, Anić I, Manojlović S et et al. Activating FGFR2-RAS-BRAF mutations in ameloblastoma. al. PTCH gene altered in dentigerous cysts. J Oral Pathol Med Clin Cancer Res 2014;20:5517-26. 2001: 30:569-76. 23. Kurppa KF, Caton J, Morgan PR, Ristimaki A, Ruhin B, 12. Gu XM, Zhao HS, Sun LS, Li TJ. PTCH mutations in sporadic and Kelllokoski J et al. High frequency of BRAF V600E mutations Gorlin-syndrome-related odontogenic keratocysts. J Dent Res in ameloblastoma. J Pathol 2014; 232492-8. 2006;85 859-63. 24. Gültekin et SE, Aziz R, Heydt C, Sengüven B, Zöller J, Safi AF 13. Pogrel M, Jordan R. Marsupialization as a definitive treatment et al. The landscape of genetic alterations in ameloblastomas for the odontogenic keratocyst. J Oral Maxillofac Surg 2004;62: relates to clinical features. Virch Arch 2018;472: 807-14. 651-5. 25. Heikinheimo K, Huhtala JM, Thiel A, Kurppa KJ, Heikinheimo H, 14. Morankar R, Bhatia SK, Goyal A, Gulia P. Conservative Kovac M et al. The mutational profile of unicystic ameloblastoma. management of keratocystic odontogenic tumour in a young J Dent Res 2018; doi: 10.1177/0022034518798810. child with decompression and an intraoral appliance: 5-year follow-up. BMJ Case Rep 2018;doi: 10.1136/bcr-2017-221563. 26. Mosqueda-Taylor A, Pires FR, Aguirre-Urizar JM, Carlos-Bregni R, de la Piedra-Garza JM, Martinez-Conde R et al. Primordial 15. Awni S, Conn B. Decompression of keratocystic odontogenic odontogenic tumour: clinicopathologic analysis of six cases of tumours leading to increased fibrosis, but without any change a previously undescribed entity. Histopathol 2014; 65 606-12. in epithelial proliferation. Oral Surg Oral Med Oral Pathol Oral Radiol 2017;123: 634-44. 27. Mosqueda-Taylor A, Neville BW. Primordial odontogenic tumour. In El-Nagger et al eds WHO Classification of Head and 16. Al-Moraissi EA, Dahan, AA, Alwadeai MS, Oginni FO, Al-Jamali Neck Tumours. IARC Lyon 2017;223-4. JM, Alkhutari AS et al. What surgical treatment has the lowest recurrence rate following the management of keratocystic Email address for correspondence: odontogenic tumour? A large systematic review and meta- [email protected] analysis. J CranMaxSurg 2017;45:131-44. 40 RACDS ANNALS 2018

Paediatric Dentistry – Don’t brush us aside Dr Gwendolyn Huang Dr Gwendolyn Huang was appointed as a Consultant (Paediatric Dentistry) at the Women’s and Children’s Hospital, Adelaide. She is involved with numerous multi-disciplinary clinics, including with the Australian Craniofacial Unit and Department of Haematology ABSTRACT Paediatric dentistry is an evolving speciality. No longer is the discipline about purely about little fillings on little teeth. There is an imperative shift towards minimal intervention dentistry, with a focus on ‘patient self-care’ in partnership with the patient’s families and other medical professionals involved in the child’s health environment. Pathology of the oral and maxillofacial region can be debilitating and sometimes fatal. Because of the region involved, dental professionals may not be the only health professionals involved in the diagnosis and management of such pathology. However, there insufficient knowledge of oral and maxillofacial pathology specific to paediatric patients. The epidemiological features and distribution of paediatric oral and maxillofacial pathology in Australia is sparsely reported. The medical and dental specialities involved in management of oral and maxillofacial pathology is also unreported. This study intended to audit oral and maxillofacial pathology specimens submitted for diagnosis in a paediatric tertiary-referral hospital setting, by assessing histopathological records during a sixteen-year period from January 1998 to December 2013. A total of 676 oral and maxillofacial pathology specimens were collected from patients aged 0-18 years. The majority of cases were benign, with malignancies accounting for 2.66% of cases. The most common type of pathology was mucosal pathology (22.34%), followed by connective tissue (19.82%). The lower lip was the most commonly affected site (26.64%), followed by the mandible (16.81%). The Department of Paediatric Dentistry submitted the most specimen (23.67%), followed by Department of Otolaryngology, the Australian Craniofacial Unit, the Departments of Paediatric Surgery and Plastics. The study reinforced there is a wide range of oral and maxillofacial pathology, and the importance of understanding their epidemiological features in paediatric patients. The study also showed that paediatric dentistry is in a strong position to facilitate both dental and medical disciplines to improve management of oral and maxillofacial pathology. RACDS ANNALS 2018 41

The Oral Mycobiome in Children with and without Dental Caries Dr Jacquelyn Fechney ABSTRACT Children's oral health is in a dire state, with dental caries being one of the most common chronic diseases. While the pivotal role of bacteria in the oral microbiome and its contribution to dental caries is established, the contribution of fungi is relatively unknown. The increased abundance of Candida albicans, is suggested to contribute to caries development. We assessed the oral mycobiome makeup in childhood (n = 16), to determine if the composition of fungi varies between children with and without caries. Oral mycobiome composition was assessed by amplifying the ITS2 region from supragingival dental plaque DNA extracts and sequencing these amplicons with Illumina MiSeq. This revealed the oral mycobiome in the investigated children contained 26 species from three phyla (Ascomycota, Basidiomycota and Zygomycota). Candida albicans was the most abundant species and was ubiquitous in all samples regardless of whether caries was present. While the overall diversity of fungi was similar, independent of whether caries was present (p > 0.05), we found that caries influenced the abundance of specific fungi. Children with healthy teeth had a significantly higher abundance of 15 species compared to children with caries, who had only four enriched species (p < 0.001). The ubiquity and dominance of Candida albicans in the oral microbiome of children with and without caries indicates this species may not be involved in caries development. However, the finding that several other fungal species were differentially abundant between children with healthy teeth and caries suggests fungi in the oral microbiome may influence oral health. Resolution of the aetiology of caries requires analysis of both fungal and bacterial communities in the oral microbiome. 42 RACDS ANNALS 2018

Silver Diamine Fluoride: An integrated, evidence-based approach to arrest dental caries for vulnerable children Dr Jilen Patel, BDSc (Hons) WA, DClinDent (Paed Dent), MRACDS, FADI, FICD Dr Jilen Patel is a specialist paediatric dentist who completed his specialist training at UWA and Princess Margaret Hospital for Children. ABSTRACT Whilst the majority of children face improvement in oral health standards, significant disparities in oral health continue to persist among children from vulnerable populations. Refugee children in particular face considerable disadvantage and continue to experience alarmingly high rates of untreated dental caries. The persisting barriers to dental care inevitably lead these children to present to hospital emergency departments requiring multiple dental extractions under general anaesthesia. This not only has a negative impact on the child’s quality of life, but also imposes a huge burden on the public health system; with estimates upwards of AUD $4,000 per child for emergency dental treatment conducted within the tertiary care setting. Silver diamine fluoride (SDF) has shown to be an effective, inexpensive and easy to apply cariostatic agent for use among high- risk children with limited access to comprehensive dental care. An integrated primary care program using remineralising agents such as SDF alongside oral health promotion strategies has the potential to address the fundamental needs of newly arriving refugee children. However, the existing literature raises concerns around the high concentrations of fluoride in commercial preparations as well as the potential of staining from silver fluoride compounds. Therefore, this study sought to first investigate i) the fluoride concentration and leachate profile of SDF and ii) the in vitro staining potential of SDF. The results of these studies were then used to design and implement a primary care program and a randomised controlled clinical trial integrated within a multidisciplinary medical framework aiming to improve oral health outcomes for refugee children. RACDS ANNALS 2018 43

Pacific Oral Health in New Zealand - Realities and The Exciting Way Forward Dr Mowafaq Amso, BDS BSc FRACDS MInstD ABSTRACT Dentistry and oral health worldwide is currently relishing in the digital transformation age. Sadly, however, not all patients have come to benefit from these advances. The Pasifika community in New Zealand has some of the lowest accessibility rates to oral health services in the whole country and it comes as no surprise that they also suffer from a multitude of preventable oral health conditions, such as dental caries and periodontal disease. This presentation will address the elephant in the room, and attempt to tackle the age-old question of why. The current challenges facing Pacific oral health will be highlighted as well a new proposed model for providing better care for Indigenous populations, with a focus on Pasifika. 44 RACDS ANNALS 2018

Azithromycin in the Treatment of Periodontitis Dr Meredith Owen ABSTRACT Aim The aim of this study was to compare the clinical and microbiological changes occuring in generalized stage III – IV periodontitis patients receiving subgingival debridement (SRD) alone or with systemically administered azithromycin (AZT)or with amoxycillin (AMX) and metronidazole (MET). Materials and Methods Forteen subjects with generalized stage III – stage IV periodontitis received one of the following treatments: SRD with placebo (n = 4), SRD with AZT (n = 5), or SRD with AMX/MET (n = 5). Probing pocket depths (PPD), clinical attachment level (CAL), and bleeding on probing (BOP) were recorded at baseline and after 3 months. Subginginval plaque samples were taken at baseline, immediately posttreatment, 2-weeks, 1-month, and 3-months post-treatment. Subgingival plaque samples were analyzed using real-time PCR for the major bacteria associated with periodontitis. Results In all groups, PPD, CAL, and BOP improved signigicantly after 3-months. The AZT and AMX/MET groups showed statistically significant clinical improvements over the placebo group (P < 0.0001). Statistically, no antibiotic regime was superior over another. Periodontal bacteria were significantly reduced after 3 months in the AZT and AMX/MET groups, however, in the placebo group, counts returned to baseline values. Conclusions The preliminary data of this study demonstrated that non-surgical periodontal therapy provides significant clinical benefits. The adjunctive use of systemic antibiotics provides a significant benefit over SRD alone. RACDS ANNALS 2018 45

PAPERS AND ABSTRACTS SPONSORS CONTRIBUTORS’ INDEX The Convocation Committee for the 24th Convocation extends its Contributor Page appreciation to the following sponsors for their commitment and support. Amso, Mowafaq 44 Bronze & Lecturer Award Sponsor Balasubramaniam, Ramesh 33 Bronze Sponsor Brooke-Cowden, Julie 21 Dimitroulis, George 19 Farmer, Daniel 20 Fechney, Jacquelyn 42 Firth, Fiona 26 Gallucci, German 23, 24, 25 Hanlin, Suzanne 31 Haymerlie, Georg 29 Huang, Gwendolyn 41 Owen, Meredith 45 Patel, Jilen 43 Phoon-Nguyen, Amanda 33 Rich, Alison 38 Tan, Phillip Leong 22 Tiwari, Lalima 33 The Organising Committee thanks the following Industry Exhibitors for their contribution to the Convocation Colgate Crown Dental and Medical Limited Dentavision Dental Protection Dynek Pty Ltd EMS Geistlich Biomaterials GC Hu-Friedy Henry Schein Ivoclar vivadent NSK OMX Solutions Straumann Zimmer Biomet



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