Annals Vol 22 (2014)

ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS Annals of the ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS Volume 22 April 2014

ANNALS OF THE ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS VOLUME 22 - APRIL 2014 The Organising Convocation Committee for the 22nd Convocation extends its appreciation to the following sponsors for their commitment and support. Silver Sponsors Young Lecturer Award Sponsor The Organising Committee thanks the following Industry Exhibitors for their contribution to the Convocation Biohorizons NSK Biomet3i Philips Zoom GC Straumann Griffith University Troll Dental Investec Specialist Bank Medifit

ANNALS OF THE ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS Proceedings of the Twenty-second Convocation of the Royal Australasian College of Dental Surgeons Thursday 10 April to Sunday 13 April 2014 Published by THE ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS Incorporated Level 13/37 York Street, Sydney, New South Wales 2000 Australia ISSN 0158-1570 All rights reserved

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 2 ANNALS OF THE ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS VOLUME 22 - APRIL 2014 CONTENTS ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS COUNCIL 2012-2014 ............................................................................. 4 FOUNDERS OF THE COLLEGE.................................................................................................................................................................... 6 HONORARY FELLOWS OF THE COLLEGE................................................................................................................................................. 6 ELECTED MEMBERS OF COUNCIL............................................................................................................................................................. 6 OFFICE BEARERS.........................................................................................................................................................................................7 CONVOCATION COMMITTEE.......................................................................................................................................................................7 CONVOCATIONS OF THE COLLEGE........................................................................................................................................................... 8 EDITORIAL – Professor Martin J Tyas AM................................................................................................................................................ 9 TWENTY-SECOND CONVOCATION, ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS GOLD COAST, AUSTRALIA – OPENING CEREMONY 10 APRIL 2014 PRESIDENTIAL ADDRESS – Dr Francis Chau............................................................................................................................................10 OPENING ADDRESS - Ms Leneen Forde AC, Chancellor, Griffith University........................................................................................13 NEW MEMBERS AND FELLOWS..................................................................................................................................................................16 HONOURS BESTOWED FELLOW BY ELECTION WITHOUT EXAMINATION – Dr John S Boucher.................................................................................................17 FELLOW BY ELECTION - Professor Lakshman Samaranayake...............................................................................................................18 MERITORIOUSSERVICEAWARD–A/ProfessorAngusCameron..............................................................................................................19 PRESIDENTIAL COMMENDATION – Professor Nicky Kilpatrick............................................................................................................... 20 SIXTEENTH ROBERT HARRIS ORATION - A/Professor Jill Sewell AM.................................................................................................21 IN MEMORIAM A/PROFESSOR BRAHAM PEARLMAN RFD.............................................................................................................................................24 ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS, YOUNG LECTURER AWARD..........................................25 SCIENTIFIC PROGRAM – PAPERS AND ABSTRACTS DETERMINING RISK FACTORS FOR PERIODONTAL DISEASES: A RISKY BUSINESS? – LF Brown.....................................................27 IMPLANT SUCCESS, COMPLICATIONS AND FAILURE – INDIVIDUAL PATIENT RISK – W Bischof......................................................33 MINIMALLY INVASIVE AESTHETIC RESTORATION WITH INNOVATIVE ADHESIVE MATERIALS – J Tagami.....................................39 HYPODONTIA – THE CHALLENGES OF RESTORATION IN THE YOUNG PATIENTS – K Harley............................................................45 GENETIC ANOMALIES OF THE CRANIOFACIAL SKELETON – AAC Heggie............................................................................................48 APPLICATION OF SWEPT-SOURCE OPTICAL COHERENT TOMOGRAPHY TO CARIES DIAGNOSIS – J Tagami.................................56 ROOT CARIES – THE EMERGING CHALLENGE IN DENTAL CARIES MANAGEMENT – LJ Walsh.........................................................60 THE RESTORATIVE MANAGEMENT OF DEVELOPMENTAL ENAMEL DEFECTS – K Harley...................................................................64

3 ELECTRONIC HEALTH RECORDS AND eHEALTH - THE PERSONALLY CONTROLLED ELECTRONIC HEALTH RECORD (PCEHR) – FS Fryer......................................................................................................................................................................................67 CONSTRUCTION OF FLUORIDE-CONTAINING PLLA NANOFIBRE SCAFFOLD FOR BONE REGENERATION – Q Ye..........................71 REPLACEMENT OF LOST ANTERIOR TEETH IN YOUNG INDIVIDUALS: AUTOTRANSPLANTATION OF PREMOLARS: THE JOINT ROLE OF THE PAEDIATRIC DENTIST, ORAL SURGEON AND ORTHODONTIST – FM Andreasen.................................74 PLANNING EARLY ORTHODONTIC TREATMENT – J Fricker....................................................................................................................77 GENES AND ENVIRONMENTAL INTERACTIONS IN ORAL AND OROPHARYNGEAL CANCER – NW Johnson..................................82 ADULT ORTHODONTIC TREATMENT – A VIEWPOINT – B Kerr.............................................................................................................86 ORAL HEALTH IN THE FIRST HALF OF LIFE: AN UPDATE ON THE DUNEDIN STUDY – JM Broadbent................................................88 THIRD MOLARS: INDICATIONS FOR INTERVENTION – DM Hyam.........................................................................................................91 MAJOR SURGERY IN THE ELDERLY: DOTTING THE Is AND CROSSING THE Ts. – MD Batstone.........................................................96 YOUNG LECTURER AWARD PAPERS PREPARING MALAYSIAN DENTAL GRADUATES TO PROVIDE CARE FOR PATIENTS WITH SPECIAL HEALTH CARE NEEDS - HOW DO WE COMPARE WITH AUSTRALIA? EDUCATION SPECIAL NEEDS DENTISTRY IN MALAYSIA – MS Ahmad.................98 HOW e-HEALTH STRATEGIES MAY ENHANCE DENTAL RESEARCH – R Lam....................................................................................102 DISTRACTION OSTEOGENESIS – A PANACEA FOR INFANT MICROGNATHIA WITH UPPER AIRWAY OBSTRUCTION? – A Adhikari................................................................................................................................................................................................107 DENTOFACIAL DEFORMITIES AND ORTHOGNATHIC SURGERY IN HONG KONG AND GLASGOW – C Lee......................................113 THE ORAL HEALTH OF CAMBODIAN PRESCHOOL AGED CHILDREN – K Bach..................................................................................116 AN INVESTIGATION INTO PERFORMANCE OF THREE TYPES OF IMPLANTS IN A NOVEL OVINE MANDIBLE CANINE MODEL – C Barker....................................................................................................................................................................................................117 ABSTRACTS OF PRESENTED PAPERS OROFACIAL DISEASE – GENES, GENETICS AND GERIATRICS – RM Logan............................................................................................118 ENDODONTIC ADVANCES – G Young........................................................................................................................................................119 ENDODONTIC OUTCOMES – J McNamara...............................................................................................................................................119 MINIMALLYINVASIVECERAMICS–REALLY?-DMRoessler...................................................................................................................120 MULTIPLE MISSING TEETH: WORKING TOGETHER AS A TEAM – L Ramalingam.................................................................................121 NATIONAL ORAL HEALTH PLAN 2014-2023 – A McAuliffe......................................................................................................................122 PERSONALISED GENETIC MEDICINE: IMPACT ON CLINICAL MEDICINE – R Savarirayan...................................................................123 THE ORAL MICROBIONE IN HEALTH AND DISEASE – L Samaranayake................................................................................................124 SCIENTIFIC PROGRAM – PAPERS AND ABSTRACTS CONTRIBUTORS’ INDEX...........................................................................................................................................................................125

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 4 ANNALS OF THE ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS VOLUME 22 - APRIL 2014 COUNCIL 2012 – 2014 Front Row: [L – R] Dr Patrick Russo (Executive Officer), Dr David Sykes (President-Elect), Dr Francis Chau (President), Dr Warren Shnider (Censor-in-Chief), Dr Robin Whyman (Honorary Treasurer) Second Row: [L – R] Dr Peter Gregory, Dr Albert Lee, Associate Professor Peter Duckmanton, Mr Paul Sambrook, Professor Nicky Kilpatrick, Associate Professor Werner Bischof, Associate Professor Raj Nair

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 5 ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS COUNCIL 2012 – 2014 President Dr Francis So Wah Chau, MDS, MRACDS(Pros), FRACDS, MRD RCS(Ed), LLB, MBA President–Elect Dr David G Sykes, BDS(Lond), MDS(Syd), LDSRCS(Eng), MRACDS(Pros), FRACDS Executive Officer Dr Patrick J Russo, BDSc, FRACDS, FPFA Honorary Treasurer Dr Robin A Whyman, BDS, MComDent, FRACDS, FRACDS(DPH), FICD, FADI Censor- in- Chief Dr Warren H Shnider, BDSc, FRACDS(SND) Past-President A/Professor Werner H Bischof, BDSc, MDSc, MRACDS(Perio), FRACDS, FPFA, FICD Councillors A/Professor Peter Duckmanton, BDS, MDSc, FRACDS, FICD, FPFA Dr Peter J Gregory, BDSc, MDSc, , MRACDS(Paed), FRACDS Professor Nicky Kilpatrick, BDS, PhD, FDS, RCPS, FRACDS(Paed) Dr Albert M P Lee, BDS(Adel), MSc(Lond), FRACDS, FCDSHK(Paed Dent), FHKAM(Dental Surgery), FICD A/Professor Dr Raj Nair, MSc (Oral Med, Lond) PhD(HK) MRACDS(OralMed) Dr Paul Sambrook, MBBS, MDS, FRACDS(OMS) COUNCIL APPOINTMENTS Registrar, General Dental Practice A/Professor Liz Martin, BDS(Hons), MDS, PhD, FRACDS, FPFA, FADI, FICD Registrar, Specialist Dental Practice (resigned September 2013) A/Professor Angus C Cameron BDS(Hons), MDSc, FDSRCS(Eng), FRACDS, FICD, FADI Registrar, Specialist Dental Practice (Interim) 2014 A/Professor Neil Peppitt, BDS, MDSc, MRACDS(Pros), FRACDS Assistant Registrar, General Dental Practice Dr Catherine Prineas, BDS(Hons), FRACDS, GradDipClinDent(Sedation and Pain Control) Assistant Registrar, Oral Maxillofacial Surgery Dr Julia Dando, BDS (Wales), MMedSci, MRACDS(Ortho), MOrthRCS (Eng), FDSRCS (Ed) Assistant Registrar, Specialist Dental Practice (resigned November 2013) Dr Anastasia Georgiou, BDS, MDSc, MRACDS(OralMed), FRACDS, FICD Assistant Registrar 2012-13 (term completed November 2013) Dr John Fricker OAM, BDS, MDSc, Grad Dip Ed(Adult), MRACDS(Orth), FRACDS, FADI, FPFA, FICD Honorary Editor, Annals Professor Martin John Tyas, AM, BDS, PhD, DDSc, GradDipHlthSc, FADM, FICD, FRACDS, FADI Honorary Editor, College News A/Professor Susan Buchanan, BDSc, MDS, FRACDS, MBA Chair, CPD Committee Professor Ian Meyers, BDSc, FRACDS, FICD, FADI, FPFA Chief Executive Officer Mr Gary Disher BBus, GAICD

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 6 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 Honorary Treasurer W K R Mackenzie Honorary Treasurer J S Lyell Councillors: H R Cash* Councillors: G Christensen J F Lavis J F Lavis R L Taylor HONORARY FELLOWS 1965 Arthur Amies* 1977 Percy Raymond Begg* 1989 Robert York Norton* 1965 John Hall Best* 1977 George Neville Davies 1991 George Wing 1966 Alwyn James Arnott* 1978 Ivor Robert Horton Kramer 1993 John Henry Muller 1966 T Draper Campbell* 1979 Robert Harris* 1993 Diana, Princess of Wales* 1966 Sidney Firth Lumb* 1979 John Frederic Lavis* 1995 Reginald William Hession 1966 John Walsh* 1979 Alfred Gordon Rowell* 1998 John Kenneth Harcourt 1968 Robert Bradlaw* 1982 Paul Anthony Bramley 1998 George Henry Hewitt 1968 Terence Ward* 1983 Kenneth Joseph George 2000 Sydney Charles Warneke 1968 Frank Clare Wilkinson* 2001 John Hugh Sinclair 1970 Gerald Leatherman* Sutherland 2003 Kenneth Howard Wendon 1971 Neil William George Macintosh* 1985 Henry Gordon Lamplough* 2005 Ross Jan Bastiaan 1973 Alan Docking* 1985 Warwick Olver Read* 2007 David Henry Thomson 1974 William Alan Grainger* 1987 Earle Harold Bastian* 2009 Neil John Joseph Peppitt 1976 Kenneth Adamson* 1987 Stanley George Kings* 2010 Eric Charles Reynolds 1976 Kenneth Wollaston Cleland* 1987 John Alfred Sagar* 2011 Bernadette Kathleen Drummond 1989 Richard Manning King* *Deceased. ELECTED MEMBERS OF COUNCIL 1966 – 1969 F G Christensen* 1982 – 1994 R W Hession 2002 – 2006 B M Woodhouse 1966 – 1971 R L Taylor 1982 – 1996 P W McKerracher 2004 – 2010 D D Bambery † 1966 – 1973 W A Grainger* 1986 – 1996 G H Hewitt 2004 – 2012 W H Bischof 1966 – 1975 J S Lyell* 1986 – 1999 S C Warneke 2004 – 2014 F S W Chau ‡ 1966 – 1976 K T Adamson* 1988 – 2000 J H Sinclair 2006 – 2012 J P Fricker 1966 – 1978 R Harris* 1988 – 1996 B Feiglin 2006 – 2014 D G Sykes 1966 – 1978 J F Lavis * 1990 – 2002 K H Wendon 2008 – 2012 B Pearlman* 1966 – 1978 A G Rowell * 1990 – 2004 R J Bastiaan 2008 – 2014 P Russo 1969 – 1973 G B Ferguson* 1990 – 2004 J P H Rogers 2010 – 2014 R A Whyman † 1970 – 1982 T B Lindsay 1990 – 2002 G A Thomas 2010 – 2014 W H Shnider 1971 – 1982 H G Lamplough * 1992 – 2006 D H Thomson 2010 – 2014 P J Gregory 1971 – 1982 W O Read* 1994 – 2004 A N Goss 2010 – 2014 A M P Lee ‡ 1974 – 1986 S G Kings * 1996 – 2005 R G Cook 2012 – 2014 P Duckmanton 1974 – 1986 J A Sagar* 1996 – 2008 S C Daymond 2012 – 2014 R Nair 1975 – 1988 R Y Norton* 1996 – 2002 E D Kingsford-Smith 2012 – 2014 P Sambrook 1976 – 1988 R M King 1996 – 2008 N J J Peppitt 2013 – 2014 N Kilpatrick 1978 – 1989 P Hastie 2000 – 2010 B K Drummond 1978 – 1990 G Wing 2000 – 2002 M D Suthers *Deceased 1978 – 1979 D E Poswillo 2000 – 2012 M J Tyas †Representing the New Zealand Region 1979 – 1992 J H Muller 2002 – 2012 S McE Hanlin ‡Representing the Asian Region 1982 – 1996 J K Harcourt 2002 – 2010 R D Story

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 7 OFFICE BEARERS President Vice-President Honorary Treasurer 1966 – 1968 1966 – 1968 1968 – 1970 A G Rowell 1970 – 1972 K T Adamson 1966 – 1968 J S Lyell 1968 – 1970 K T Adamson 1970 – 1972 W A Grainger 1972 – 1974 W A Grainger 1972 – 1974 J F Lavis 1968 – 1970 J F Lavis 1974 – 1976 J F Lavis 1974 – 1976 J S Lyell 1976 – 1978 J F Lavis 1976 – 1978 J A Sagar 1970 – 1971 R L Taylor 1978 – 1980 J A Sagar 1978 – 1980 W O Read 1980 – 1982 W O Read 1980 – 1982 H G Lamplough 1971 – 1974 H G Lamplough 1982 – 1984 H G Lamplough 1982 – 1984 R Y Norton 1984 – 1986 R Y Norton 1984 – 1986 S G Kings 1974 – 1976 W O Read 1986 – 1988 S G Kings 1986 – 1988 R M King 1988 – 1990 R M King 1988 – 1990 G Wing 1976 – 1980 R Y Norton 1990 – 1992 G Wing 1990 – 1992 J H Muller 1992 – 1994 J H Muller 1992 – 1994 R W Hession 1980 – 1982 S G Kings 1994 – 1996 R W Hession 1994 – 1996 J K Harcourt 1996 – 1998 J K Harcourt 1996 – 1998 S C Warneke 1982 – 1988 J H Muller 1998 – 2000 S C Warneke 1998 – 2000 J H Sinclair 2000 – 2002 J H Sinclair 2000 – 2002 K H Wendon 1988 – 1994 S C Warneke 2002 – 2004 K H Wendon 2002 – 2004 R J Bastiaan 2004 – 2006 R J Bastiaan D H Thomson 1994 – 1996 J H Sinclair 2006 – 2008 D H Thomson 2008 – 2010 N J Peppitt 1996 – 1998 R J Bastiaan 2010 – 2012 B K Drummond 2012 W H Bischof 1998 – 2002 J P H Rogers 2012-2014 B A Pearlman F S W Chau 2002 – 2004 N J Peppitt Censor-in-Chief 1966 – 1968 W A Grainger 2004 – 2012 S McE Hanlin 1968 – 1972 J S Lyell 1972 – 1974 W O Read 2012 – 2014 R Whyman 1974 – 1978 H G Lamplough 1978 – 1980 S G Kings President-Elect N J Peppitt Registrar (General Dental Practice) 1980 – 1984 R M King 2004 – 2006 B K Drummond 1996 – 2000 E D Kingsford Smith 1984 – 1986 G Wing 2006 – 2008 W H Bischof 2000 – 2008 B A Pearlman 1986 – 1992 J K Harcourt 2008 – 2010 B A Pearlman RFD 2008 – 2012 E Martin 1992 – 1996 P W McKerracher 2010 – 2012 D G Sykes 2012 – 2014 E Martin 1996 – 2002 D H Thomson 2010 – 2014 2002 – 2004 A N Goss Registrar (Specialist Dental Practice) 2004 – 2006 B K Drummond Honorary Secretary 2006 – 2008 R D Story 1966 – 1978 R Harris 1996 – 2004 C G Daly 2008 – 2012 M J Tyas 1978 – 1984 G Wing 2012 – 2014 W Shnider 1984 – 1990 R W Hession 2004 – 2013 A C Cameron 1990 – 1998 K H Wendon 1998 – 2006 S C Daymond 2014 N J Peppitt 2006 – 2008 W H Bischof 2008 – 2012 F S W Chau Assistant Registrar (General Dental Practice) 1998 – 2002 A C Cameron 2002 – 2004 H M Cameron 2008 – 2014 C Prineas Executive Officer Assistant Registrar (Specialist Dental Practice) 2012 – 2014 Patrick Russo 2002 – 2004 A C Cameron 2004 – 2013 A F Georgiou Registrar 1966 – 1980 R Harris Assistant Registrar (Oral Maxillofacial 1980 – 1988 G Wing Surgery) 1988 – 1996 G H Hewitt 2009 – 2014 J Dando 1997 – 2006 S C Daymond Convocation COLLege regional Committee committees, divisions, Chair standing Dr Francis Chau committees and Members boards of studies Associate Professor Peter Duckmanton (see the RACDS Handbook 2014) Associate Professor Raj Nair Dr Bill Kahler Young Lecturer Award Coordinator Dr Suzanne Hanlin Dr David Sykes Dr Patrick Russo Mr Gary Disher

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 8 CONVOCATIONS 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 Gold Coast, Australia Vol. 22

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 9 TWENTY-SECOND convocation royal australasian college of dental surgeons gold coast, australia, april 2014 EDITORIAL From genome to nursing home – everything new under the sun The Twenty-second Convocation on the Gold Coast, Queensland, was a great success. The Marriott Resort provided excellent facilities, with the lecture rooms, refreshment area and the industry display all on one level. The weather was warm and sunny throughout, apart from the final sessions on Sunday morning when the edge of the Cyclone Ita, having had a serious effect on Cooktown and Port Douglas further north, created cloudy conditions. The main Convocation was preceded by an Education Day, at which various aspects of the College’s award programs and educational strategies were discussed. The Convocation commenced with the customary Opening Ceremony, reported in detail below, but unfortunately Associate Professor Jill Sewell AM, who was scheduled to deliver the Robert Harris Oration, was detained in Melbourne because of adverse weather. Instead, three past Presidents (Dr George Wing AM, Dr Ross Bastiaan AM and Dr Neil Peppitt) were asked to reflect for five minutes each on their Presidencies, which they did so with insight and humour. The subsequent scientific program was a tribute to the hard work of the Continuing Professional Development Committee which embraced the theme ‘From genome to nursing home – everything new under the sun’. Local Australasian speakers were superbly supported by our international guests Dr Kathryn Harley (UK), Dr Frances Andreasen (Norway) and Prof Junji Tagami (Japan). Six presentations were given in the Colgate-supported Young Lecturer Award, a pleasing increase on the two presentations in 2004. The Annals will be distributed mainly in electronic format, with a short print run available for libraries and other organisations. I extend my thanks to those authors who provided their manuscripts in due time. My thanks are also due to staff in the College Office in Sydney who undertook most of the final formatting and production. In concluding, I would like to make special mention of Dr John Harcourt OAM, who edited the several previous Annals. John has been unfailingly helpful in providing advice and guidance for the editing of the 2014 Annals. Martin J Tyas, AM, BDS, PhD, DDSc, GradDipHlthSc, FRACDS, FADM, FICD, FADI Honorary Editor, Annals

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 10-12 TWENTY-SECOND convocation royal australasian college of dental surgeons gold coast, australia, april 2014 Address by the President of the Royal Australasian College of Dental Surgeons Francis Chau, MDS, MRACDS(Pros), FRACDS, MRD RCS(Ed), LLB, MBA at the Opening Ceremony Distinguished guests, Fellows and Members of the College, and a half days, both invited international and local renowned colleagues, dental healthcare practitioners, accompanying speakers will be presenting stimulating and informative persons and families, as President it is my honour, on behalf lectures across a broad spectrum of disciplines, sharing with of the Council and the Convocation Committee, to welcome delegates the latest evidence-based knowledge and cutting- you to the beautiful Gold Coast for the opening ceremony edge dental technology. I would like to take this opportunity to of the 22nd Convocation of the Royal Australasian College of thank the Scientific Program Chair, Professor Ian Meyers and Dental Surgeons. his committee members for organizing the exciting scientific program, I am sure this would be an enjoyable and rewarding I would like to extend my warmest welcome to our opening event for all participants. On behalf of the Council, I would address speaker Ms Leneen Forde, Chancellor of Griffith also like to thank the Honorary Editor, Professor Martin Tyas, University; the Robert Harris Orator, Associate Professor Jill for editing all the manuscripts of the presentations at this Sewell; Dr. John Boucher, President of the Australian Dental Convocation for publishing in the College Annals. Council; Dr. Andrew Heggie, President of the Australian and New Zealand Association of Oral and Maxillofacial Convocation also provides the opportunity at this Opening Surgeons; Dr. Louise Brown, President of Australian and New Ceremony to formally admit new Members and Fellows Zealand Academy of Periodontists; Dr. Kathryn Harley, Dr in both the general and specialist dental practice as well Frances Andreasen, and special invited speaker from Japan, as to recognize members of the profession through the Professor Junji Tagami; Professor Samaranayake, Dean of presentation of College Awards for their contribution to Faculty of Dentistry, University of Queensland; Professor the profession and to the College. This evening we have 42 Ward Massey, Dean of School of Dentistry and Oral health, Inductees presenting for admission from each of the College’s Griffith University. postgraduate programs. I would like to congratulate you all on your achievements and welcome you into the College. I would also like to welcome all the participants of this 22nd Convocation. The biennial Convocation is recognized as the As a new Member or Fellow of the College, you have flagship scientific meeting of the College. Over the next two demonstrated self-directed learning to enhance and extend

11 the knowledge, skills and standards that you have attained As the first President coming from outside Australia or New at university. These competencies have been benchmarked Zealand, there is a definite mission for me to strengthen by the relevant College qualification examinations, developed the College presence in the Asia Pacific Region. Another and reviewed through a collaborative process engaging the strategic priority of this Council is to form an alliance profession, specialist academies, local and international with the Colleges of Dental Surgeons of Hong Kong and universities and colleges. Singapore, and this initiative has been well received. The first collaboration activity by the three Colleges is well underway The College, since it was established in 1965 and after almost in organizing a joint collegiate scientific meeting to be held on half a century of its strong commitment to furthering the 7-8 December this year in Hong Kong. The main objectives of science and art of dentistry and to supporting the continuing this alliance include resource sharing where we would expect professional development (CPD), of the profession, now has a a much lower cost for members to attend conjoint scientific membership of almost three thousand. The rapid membership meetings, enhance support in CPD to members in the region growth in recent years is a reflection of the popularity across and increase exposure and promote growth of the College. all College programs for their reputation of high standards in structures and examination processes. On behalf of the The Council envisages future membership growth of the Council, I would like to thank the Registrars, examiners, College will be predominantly from the Asia Pacific Region. members of various boards of studies, the education and There are currently several developments in College examination teams for your contribution and committed activities in the region. A business plan to set up the Primary efforts in establishing and maintaining the high standard of Examination in Fellowship in General Dental Practice (GDP) in our postgraduate programs and examinations. Singapore is under review, and it is very likely that the first diet of examination will be available later this year. In Hong Today the College has an international footprint with members Kong, the first conjoint Membership examination in Specialist residing in 25 countries with the majority of our members Dental Practice (SDP) in the discipline of DPH is expected to be and active Regional Committees in Australia, New Zealand, held later this year pending on the signing of a Memorandum Hong Kong and Singapore. With such a wide geographic of Understanding between the College of Dental Surgeons representation, one of the endeavours of this Council is to of Hong Kong and the College. This year there will be more support members, regardless of their geographic location, than double the number of members coming through the with lifelong learning and access to high quality CPD courses conjoint Membership examination arrangement in GDP with and programs organized by the College or in collaboration the CDSHK than from the MRACDS (GDP) program in the with universities and dental associations. One of the means Australia-New Zealand region. is by on-line learning and this will be available for preview throughout Convocation at the College booth. In order to implement the strategic priorities identified by Council, manage the expanded College activities in both To enrich members’ experience in education activities and education and examination areas and allow sustainable continuing professional development, the Royal Australasian growth, it is of paramount importance for the College to have College of Dental Surgeons’ Centre for Learning, Education an organizational structure with the right human resources and Research was recently established, annexed to the for efficient administration and best governance practice. College office and we were honoured to have its opening Best governance is built on a corporate structure with good officiated by the Hon Tony Abbott, Prime Minister of Australia. systems and clear policies. In this last year we have an addition This Centre provides an additional facility equipped with the of more than ten policy documents approved by this Council latest audio-video digital technology enabling interactive for efficiency and risk management. On behalf of the Council I learning and strengthening the education and research would like to thank the Chief Executive Officer, Mr. Gary Disher, activities of the College. for his capability and leadership and his dedicated team of staff in managing the College office to a high professional standard, As the Council and I scan the horizon to ensure that we are making great progress in implementing strategic priorities in aware of the emerging challenges to the profession, what we all aspects of College activities. see in the international arena is a shift towards practitioners needing to revalidate their competencies within their defined As membership grows, it is necessary to have efficient scope of practice. It can be certain to say we are moving into communication between the College and its members. an era where we will be required to display certain levels of Council’s strategic priorities are now published in the proficiency in our practice. Newsletter. The transformed user-friendly website is another endeavour to enable users to navigate to an array of College It is not the number of mandatory hours of CPD alone that will information. Council has also resolved to standardize the help us demonstrate this proficiency. Continuing Professional descriptions of all College Membership and Fellowship Development is about self-directed, reflective learning, programs by adopting the nomenclature of General Dental measureable with multi-source feedback on healthcare Practice for the general discipline and Specialist Dental outcomes. In other words, it is qualitative learning. The Practice for all specialist disciplines. All the 19 College challenge for the College is to develop an education Regulations and Appendices governing education and framework of self-directed, reflective learning leading to all examination will be compiled into three handbooks for easy members of the College being able to meet future regulatory reference to all the necessary information: one handbook for requirements. To facilitate some of this work, the Education GDP, one for all disciplines in SDP and a separate one for the Policy Board has been renamed the Education Board to FRACDS (OMS) training program. These handbooks will be a appropriately reflect its nature of educational activities, very useful resource to assist candidates to make an informed which is more than just policy development. decision on the program they would like to pursue.

12 It is encouraging to see that this Council has achieved The College is moving into an exciting era as we are planning remarkable progress in a number of endeavours, only for the celebrations of its 50th Anniversary next year. What possible because the strategic priorities were built on the makes this College unique is that after almost 50 years of sound foundation established by past Presidents and their growth, the College has built a membership that is full of Councils. It is my honour to acknowledge a number of past talented and dedicated members. To best connect all the Presidents who are with us this evening: Associate Professor talents, this Council is building a membership directory which John Harcourt OAM, Professor George Wing AM, Dr. Kenneth will also be a powerful referral tool between members. Some Wendon, Dr. Ross Bastiaan AM, A/Professor David Thomson, of the strategic priorities may seem ambitious to achieve but A/Professor Neil Peppitt and A/Professor Werner Bischof. it is time to unleash the talents of the College. Ladies and I am also most fortunate to have a talented and dedicated gentlemen, we can do it. Council and I would like to thank my Councillors for their sage advice and unreserved support in my role as President. It now gives me great pleasure to invite our Guest of Honour, Professor Leneen Forde, Chancellor of Griffith University, to officially open the proceedings of the 22nd Convocation of the Royal Australasian College of Dental Surgeons.

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 13-14 TWENTY-SECOND convocation royal australasian college of dental surgeons gold coast, australia, april 2014 OPENING ADDRESS BY MS LENEEN FORDE AC CHANCELLOR, GRIFFITH UNIVERSITY I would like to acknowledge the traditional owners of the land to our overall health and wellbeing. Just as dental health is on which we meet and to pay my respects to the custodians of important, so is overall fitness, and a good personal exercise the world’s oldest living culture. regime is very important. It would be most unfortunate to have any of your members suffer injury as the result of over- It is my great pleasure on behalf of Griffith University and enthusiastically participating in, or even merely watching, the University’s Dental School to welcome you all to this bi- such vigorous exercise to which they were unaccustomed. annual convocation. At Griffith we pride ourselves on our commitment to community service and i know there is a I note that the College was founded in 1965, and thus will strong relationship between the College and many members reach a significant milestone next year by celebrating your of the Dental School. Our Medical and Dental Schools here 50th anniversary. This will be a great opportunity to reflect on at the Gold Coast campus are among our largest, and have how your profession has developed in those years. Speaking a well-deserved international reputation for the quality of as one of your patients through all those 50 years, let me both our teaching and the ground breaking research in many say to you that I am immensely grateful for the enormous related fields. strides you have made in diagnosis and treatment, not least in the area of anaesthetics! A visit to the dentist isn’t quite To those who haven’t been here before, welcome to the Gold yet something to be enjoyed, but it’s a lot more relaxing than Coast. The Coast provides a wonderful scenic backdrop for it used to be, and for that we can thank the developments in our campus, which enrols by far the greatest number of our both techniques and materials that have come about because students among the University’s five campuses. of the great research done by the academic schools and by you practitioners every day in your surgeries. The theme you have chosen for your convocation- ‘from genome to nursing home’ – is not only very “catchy” as the This Convocation is an important event in the life of the saying goes, it is also very appropriate. It reminds us that oral college. It is very impressive that the organisers have been and dental health should be a matter of lifelong interest to able to draw over 170 Members and Fellows of the College all of us. Unfortunately too many of us in the general public from all over Australia and internationally to attend. You don’t realise that until something goes wrong and we have come together as a fellowship to welcome those who are to seek treatment. I don’t need to tell this audience that being inducted into the College as well as recognise those there is overwhelming evidence of just how important this is

14 who have made significant contributions. I understand that Education is one of the two main levers for initiating and driving the college will be inducting 35 new members and presenting change, the other being policy. Indeed, it is a fundamental six awards. May I offer my personal congratulations to those vision of the College is to share education, training and new members and to the award winners. I am sure you will ongoing professional development among likeminded people. find great personal and professional value in membership of Importantly, the College is a postgraduate education body, organisations such as the College. It allows you to engage providing the skills and experiences for life-long learning. in the activities of the professional organisation and seek to You have some 3 000 Members and Fellows, one third living shape the future of the profession via its education programs. outside Australia and New Zealand, in Asia and the United Kingdom. You provide active education programs throughout This Convocation started with an education workshop Australia, New Zealand, Hong Kong, Singapore and Malaysia. that brought together Members and Fellows engaged in Wearing my University Chancellor’s hat, it is very pleasing the education and examination activities of the College. to see that the College is an early adopter of the rapidly Engagement in the College’s education programs is one of emerging tools and experiences that create lifelong learners the key benefits of College membership, helping to shape the through e-learning, audio and visual communications. These future of the profession and those who practice it. are the teaching tools of the future — indeed, of the present — and allow you to take the College to where the members and From the Opening Ceremony right through to the last day fellows live and work. and the College Forum, you have put together an impressive program of speakers and experiences that address some Again, on behalf of Griffith University it is my great pleasure of the key issues and developments in dentistry. You are to welcome you and I urge you to enjoy the next few days, particularly fortunate to have three international and keynote including the wonderful opportunities for relaxation that the speakers covering a variety of topics. Doctors Kathryn Harley Gold Coast offers. and Frances Andreasen will speak each day, and Professor Junji Tagami will speak on Friday and Saturday.

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 15 TWENTY-SECOND convocation royal australasian college of dental surgeons gold coast, australia, april 2014 MEMBERSHIP IN GENERAL DENTAL PRACTICE Keith BOND 2014 Alan MANN 2014 Mohamed ELFAR 2013 Patrick OXBROUGH 2013 William GIBLIN 2014 Krishanti MAHADEVAN 2014 David POWER 2014 Sumathini MANIARPILLAI 2012 Robert SALTMIRAS 2014 Shareif ELHOUFY 2014 MEMBERSHIP IN A SPECIALIST DENTAL PRACTICE DISCIPLINE Orthodontics Special Needs Dentistry Norman FIRTH 1989 David BASSER 2013 Al NAELI 2012 Matthew FRACARO 2014 FELLOWSHIP BY EXAMINATION Ashim ADHIKARI 2013 Raymond LAM 2013 Mahmoud AHMED 2013 Jennifer LAN 2014 Peter MANSOUR 2009 Qian AN 2013 Inoka MEDAGO 2013 Poppy ANASTASSIADIS 2013 Dumi MEDAGODA 2013 Deon NAICKER 2014 Christopher BARKER 2013 Hitesh NAVANI 2014 Eva CHAI 2013 Jodie OLIVIER 2014 Adam CHEN 2014 Pooja RAI 2014 Ajay COUTINHO 2013 Michael ROBINSON 2011 Simon FRANKS 2013 Sidrah SAMNAKAY 2014 Ashley FREEMAN 2012 Albert TRAN 2014 Krati GARG 2009 Wade HSU 2013 PRESENTATION OF FELLOWSHIP BY EXAMINATION IN A SPECIALIST DENTAL PRACTICE DISCIPLINE Paediatric Dentistry Oral and Maxillofacial Surgery John SHEAHAN 2005 George CHU 2014 2012 CHRISTENSEN MEMORIAL PRIZE Poppy HORNE 2013 CHRISTENSEN MEMORIAL PRIZE Marina KAMEL 2014 KENNETH J.G. SUTHERLAND PRIZE Ching Ching YEW in absentia

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 16 THE PRESIDENT WITH NEW MEMBERS AND FELLOWS ADMITTED AT CONVOCATION

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 17 TWENTY-SECOND convocation royal australasian college of dental surgeons gold coast, australia, april 2014 ADMISSION AS A FELLOW WITHOUT EXAMINATION DR JOHN S BOUCHER John Boucher graduated from the University of Melbourne He is a full time General Practitioner dentist of 35 years in 1978 with First Class Honours, First in Class, John Illiffe and has lectured to ADA State and National conferences Prize, Francis Gray Prize, Bertha Bennett Scholarship and on Dental Records, Restorative Dentistry and CAD CAM the Australian Society of Periodontology Prize. Dentistry. He is a former Senior Fellow of the University of Melbourne, He has made four trips to Vietnam as a volunteer providing having taught Clinical Dentistry for 26 consecutive years. dental services in regional areas to school age children with the Rotary Australia Vietnam Dental Health Project. He has served on the ADAVB Defence and other Committees and is a former co-chair of eviDent, Australia’s first ever He is a past president of the Dental Practice Board of dental practice based research network (UniMelb, ADAVB, Victoria and a past president of the Victorian Notifications CRC-OH). and Registration Committee of the Dental Board of Australia He has been a clinical examiner for the Australian Dental He is President of the Australian Dental Council. Council since its inception, having previously examined for ADEC since 1994.

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 18 TWENTY-SECOND convocation royal australasian college of dental surgeons gold coast, australia, april 2014 FELLOWSHIP BY ELECTION PROFESSOR LAKSHMAN SAMARANAYAKE Professor Lakshman Samaranayake assumed duties as Professor Samaranayake is a highly sought after speaker on the Head of the School of Dentistry, and Professor of Oral oral infections and infection control, and has addressed the Microbiomics and Infection at the University of Queensland, profession in more than 40 countries in all five continents. Brisbane, Australia in January 2014. Prior to this he served He is also the founding Editor-in-Chief of the Journal of at the University of Peradeniya, Sri Lanka, University of Investigative and Clinical Dentistry. Glasgow, Scotland, University of Alberta, Canada and The University of Hong Kong, China. He was the Dean of Dentistry Professor Samaranayake’s research interests are in infections at the latter institute for a decade, from 2004. in medically comprised individuals, mainly oral candidiasis, clinical oral microbiology and infection control in dental The author of over 430 research articles that are highly cited practice. (over 11,500 occasions), Professor Samaranayake has written eight books, some of which have been translated into five Professor Samaranayake has provided invaluable support languages. He has received many international accolades for for the College as an examiner at the Primary Examinations. his outstanding research, and services to dentistry including As part of the scientific program at this year’s Convocation, the IADR Distinguished Scientist Award in Oral Medicine and Professor Samaranayake will present on The Oral Microbiome Pathology, and the King James IV Professorship of the Royal in Health and Disease and sit on the judging panel for the College of Surgeons of Edinburgh, UK. He was also a Director Young Lecturer Award. of the FDI, as well as the Chairman of its Science Commission.

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 19 TWENTY-SECOND convocation royal australasian college of dental surgeons gold coast, australia, april 2014 MERITORIOUS SERVICE AWARD ASSOCIATE PROFESSOR ANGUS CAMERON Associate Professor Angus Cameron recently resigned from Prior to becoming Registrar, Associate Profesor Cameron his position of Registrar Specialist Dental Practice (Special held a number of significant positions with the College, Fields) after nearly 10 years in the role (2004 to 2013. In this including: time Associate Professor Cameron has contributed greatly to the College including: 1994 - 2013 Board of Studies, Paediatric Dentistry 1997 - 1999 Ad Hoc Publications Committee • Establishing the regulatory framework surrounding the 1998 - 2003 Assistant Registrar, General Stream MRACDS 1999 - 2001 RACDS representative, Westmead Dental Appointments Advisory Committee • Establishing valuable links to the Dental Faculties of the 1999 - 2000 Continuing Education Committee UK Royal Colleges of Surgeons 2002 - 2013 Examinations Committee 2003 - 2013 Assistant Registrar, Special Field Streams • Established the Conjoint MOrth examination with the Royal College of Surgeons of Edinburgh Such contribution has helped to strengthen the position of the College within the Profession and our sister organisations. • Chairs many of the College’s Boards of Studies (Specialist Dental Practice) The Council unanimously agreed to present Associate Professor Angus Cameron with the Meritorious Service Award.

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 20 TWENTY-SECOND convocation royal australasian college of dental surgeons gold coast, australia, april 2014 PRESIDENTIAL COMMENDATION PROFESSOR NICKY KILPATRICK Nicky Kilpatrick graduated from Birmingham University, At the meeting of Council on 20 May 2013 Council unanimously UK, in 1985. She completed her specialist paediatric dental resolved to invite Professor Kilpatrick to fill the casual training at the Eastman and Guy’s Hospitals, London. She vacancy on Council and, following her acceptance, Professor then completed her PhD on the management of dental caries Kilpatrick was appointed to the position. in children at the University of Newcastle-upon-Tyne, UK. Following a fellowship year at the Royal Children’s Hospital Professor Kilpatrick has been actively involved with College in Melbourne Australia she took up the position of Senior activities for a number of years, including terms served Lecturer in Paediatric Dentistry at the University of Sydney. as a member of the Board of Studies Paediatrics and the In 1999 she returned to the Melbourne as Director of the Continuing Professional Development Committee for this Department Dentistry at the Royal Children’s Hospital where year’s Convocation. Professor Kilpatrick has also supported she is also co-director of the Cleft Lip and Palate Service. She College examinations, acting as an examiner in the Final currently runs the Oral Health Research Unit at the Murdoch Exam for General Dental Practice. Children’s Research Institute, has over 60 publications and has lectured widely in Australia and overseas. For her services to the Royal Australasian College of Dental Surgeons, Professor Nicky Kilpatrick is awarded Presidential Her clinical interests centre on the oral health and Commendation. management of children with special healthcare needs whilst her research interests include integration of oral health in to general child health.

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 21-23 TWENTY-SECOND convocation royal australasian college of dental surgeons gold coast, australia, april 2014 THE SIXTEENTH ROBERT HARRIS ORATION Address by Associate Prof Jill Sewell AM FRACP FAICD DMedSci (Hon) President Francis Chau, inductees, Fellows and Members, heard in all languages of the world. From about nine months, distinguished guests, ladies and gentlemen. they respond to the sounds heard in their environment, and gradually shut down the capacity to make sounds that are Thank you for the honour of allowing me to deliver the Robert not relevant. This is also the reason why in most languages Harris Oration as you open this 22nd College Convocation. the first words to name parents and grandparents reflect the Robert Harris was an outstanding member of the dental syllabic utterances that infants make from about nine months, profession, being a founder of this Royal Australasian College of for example mama, dada, nana, papa. These names are similar Dental Surgeons, serving as honorary Secretary and Registrar all around the world because they start to develop just prior from 1965 to 1978, and an honorary Fellow from 1979. He also to the selection of sounds more relevant to the particular made a great contribution to the Australian Dental Journal language. Another example is language development in and to dental research. He was honoured as both a Member hearing-impaired children, which is severely delayed if the of the British Empire and a member of the Order of Australia. environmental sounds do not contribute to the language When made AM he was described as having two outstanding development area of the cortex. Yet another example is the characteristics: a desire to serve his profession, and a visual impairment called amblyopia if the neural pathway to determination to strive for excellence in all his undertakings. the visual cortex is interrupted, for example with congenital These are characteristics that we may all intend to strive for, cataracts. These are examples of the ‘use it or lose it’ but some demonstrate them to the greatest degree. It seems understanding of brain development, whereby brain cells are that Robert Harris was amongst them. pruned when not in use. A diagram of brain cell connections of a 6 month old looks like a maple tree in early spring, of a 6 When I had a coffee with your Chief Executive Officer Gary year old like an oak tree in late summer, and of a 60 year old Disher last year to discuss my invitation, I was immediately like a gumtree after a bush fire has swept through. taken by the title of your convocation, ’from genome to nursing home’. As a developmental behavioural paediatrician, More recent research has demonstrated that if children my main focus is on early childhood - significant in its own do not form attachments in the early months of life or are right, but even more significant as the beginning of the exposed to extreme stress, that frontal lobe development is developmental trajectory over the lifetime. This life course altered, and may set up very long-term behavioural responses perspective tells us that optimising health, development and with poor self-regulation, poor planning and organisation, wellbeing in the early years of life is very relevant to adult life, and poor capacity for understanding social mores. There both in reaching personal goals, in contributing to society, is also increasing research of the foetal environment, for and in long-term health. example when the foetus is exposed to particular music they are more likely to recognise it after birth. Not only do we As an individual, I recently attended my father’s 90th birthday now understand that brain development is affected by the party. Fortunately he is not in a nursing home, but this is a environment and that this occurs throughout life – I could ask time of reflection for me - how I want to live my remaining how many of the older members of this audience regularly do years intellectually, physically, and socially, preferably with crossword puzzles or sudoku in order to fend off the horrors of all my teeth, preferably with community support to avoid a dementia – we are now beginning to understand the science of nursing home, but if I need one, preferably one that respects epigenetics. This refers to external modifications to DNA that me as an individual and provides for all my needs, including turns genes on or off, that is, not changing the DNA sequence, general and dental health. but affecting how cells read genes. There is beginning evidence that some of these changes may be passed on Our work in early childhood at the Centre for Community through the generations, so for example inadequate maternal Child Health at the Royal Children’s Hospital in Melbourne diet or maternal stress in your pregnant grandmother may emphasises the period from 0 to 8 years, and the subsequent affect the ovaries of your mother as a foetus, and therefore developmental trajectory. These early years constitute the may affect you. This line of thinking is beginning to be greatest period of brain growth and development. There researched where there has been multigenerational effects has been an explosion of knowledge about the science of of poverty and deprivation, for example in some members brain development in recent years. We now know that this of our indigenous population. So there can be no doubt that development is directed not only by our genes, but by our genes interact with our environments to shape all outcomes, environment in a constantly changing and unfolding way. The and this is relevant right across the life span. environment has an effect on brain cell growth, cell linkage and cell migration. There are obvious examples which we have Our work at the Centre for Community Child Health known for generations. One is in language development; for includes clinical work in developmental and behavioural the first nine months of life babies use sounds that could be

22 paediatrics; research into common conditions childhood for in particular on entry to the profession as so many of you example behavioural problems, language and literacy delay, are here this evening. The Australian codes include: providing hearing and obesity; and in supporting and strengthening good care, working with patients or clients, working with community-based professionals and organisations in their other practitioners, working within the health care system, work with families - through service development and minimising risk, maintaining professional performance, evaluation, community programs, training, and development professional behaviour, ensuring practitioner health, teaching of resources. We place great emphasis on the translation of supervising and assessing, and undertaking research. The evidence into the everyday life of the child – through their Dental Council of New Zealand principles of ethical conduct home and family, their local community such as childcare, similarly states: provide good care, respect patient’s dignity kindergarten and school, and the wider society that supports and choices, cooperate with members of the dental team, and children and families to ensure the best possible outcomes uphold trust and professional integrity. This may seem like as children grow. Our more recent work is on how to frame a daunting list of responsibilities but in looking carefully at messages that evolve from the evidence to influence families, them and reading the background to them it would be difficult communities, bureaucracies and government to advocate for to say that any one of them is not important. the best possible outcomes. In my role as chair of the Specialist Education Accreditation This thinking is very relevant to ongoing research in Committee of the AMC I am responsible for reporting to the developmental dental defects. They have their origin in Directors of the AMC and subsequently to the Medical Board genetics, are influenced by the environment, and have of Australia on the accreditation of all the specialist medical significant long-term effects on the health of the individual colleges. This includes joint Australian Dental Council and and the population as a whole. Work in such an area requires Australian Medical Council accreditation of the Oral and collaboration between laboratory research, clinical research, Maxillofacial Surgery program of your College of Dental and public health arenas – preferably informed by community Surgeons. consultation. The AMC purpose is to ensure that standards of education, This raises issues of collaborative research translation into training and assessment of the medical profession promote practice, influencing change of service delivery and practice, and protect the health of the Australian community. I influencing public perception, and influencing public policy emphasise the importance of all these words -the promotion and advocacy regarding the importance of dental health and protection of the health of the Australian community throughout the life span. How to frame these messages is and of course the New Zealand community is a shared just as important in dental research as it is in early childhood responsibility of all health professions, and exemplified by the research. In attempting to influence public policy, advocacy medical and dental professions in their shared understanding for equitable access to health including dental health care, and care of individuals, and their shared understanding of and particularly for disadvantaged populations, is a grave and call for population health. responsibility for all of us. I have a strong belief in the value of setting standards for One example of shared responsibility is your College’s and education and training bodies and for continuing professional my own Royal Australasian College of Physicians’ publication development by their members and fellows. There are nine of a joint statement on Oral Health in Children and Young standards for specialist medical education providers. These People in September 2012. It is a very good example of range from the context of education and training, though joint collaboration by expert bodies with authority in the organisational purpose and program outcomes, curriculum community, in an attempt to influence policy and service content, teaching and learning methods, assessment, trainees development. This is one example of a proud history of perspective, educational resources through to continuing dentistry in the public domain. Others in the child health professional development. These standards are consistent domain include community water fluoridation and strong with those developed for medical school accreditation and advice regarding children’s dietary habits and tooth brushing. those recently developed for intern accreditation. The concept of a trajectory from genome to nursing home When a program is assessed there are recommendations is also very relevant in thinking about the lifelong learning made for each of these nine standards. Each is designated as trajectory for health professions. Entry to vocational met, substantially met or not met. Conditions are imposed on training, vocational training for professional entry and those standards substantially met or not met. Commendations specialty training, and continuing professional development are made for excellent progress and innovative ideas. occurs along an educational continuum which is increasingly Accreditation can be for an initial period of up to six years recognised in the standards applied to such education. followed by a further period of four years if a comprehensive The Australian Health Boards have recently published new written report shows progression on conditions and versions of Codes of Conduct which include a medical code recommendations. For example initial joint accreditation of called Good Medical Practice and a similar code for all other the Oral Maxillofacial Surgery program in 2006 recommended health professionals. These codes underpin the standards of accreditation for three years and subsequently to six years education and professional development programs. on satisfactory annual reports. A comprehensive report in 2012 has enabled full extension of accreditation to 10 years As a Director of the Australian Medical Council I am proud that is to the end of 2016. The responsibility of the Australian that the AMC developed a code of conduct first published in Medical and Dental Councils then to recommend to their 2009, which was taken up by the Medical Board of Australia respective Boards that this accredited program enables in 2010 and subsequently modified to be relevant to all other specialist recognition for medical and dental practitioners in health professions. It is worthwhile reflecting on the content Oral and Maxillofacial Surgery. of the codes, both when undertaking vocational training and

23 My understanding is that not all training programs within the Revalidation is seen as part of the transparency required College of Dental Surgeons are subject to such a rigorous from us as professionals to reassure the community that we set of accreditation standards. I would recommend that all serve. When I graduated over 40 years ago I didn’t reflect educational programs follow a set of equivalent standards, much on what the long-term future held, or really on what partly to anticipate a similar process, but mostly to ensure the community expected of me since I assumed that I was the best outcome for the dental health of Australians and a good learner and would be competent in the future. I New Zealanders. became a paediatrician in 1982. Now over 30 years later can the public trust me to deliver safe, evidence-based There has been a lot of discussion over the years about care using contemporary knowledge and skills and in an the value of continuing professional development - what environment of respectful partnership with my patients and it means, is it effective, how to measure it, and for some their families? I hope so, but can I demonstrate it, can I show whether it is needed at all, on the assumption that a self it to the community? Belonging to my college, knowing that regulated profession will automatically maintain competence. my college has reached and maintains standards in education Regarding the latter there are many unfortunate examples in and continuing professional development, and complying our countries and around the world where self-regulation has with those standards may be enough to reassure me that I failed at the individual level and it is our responsibility to ensure am up-to-date and fit to practice. I suspect that revalidation that self-regulation does not fail at the level of the profession will be required in the future for the community to continue to as a whole. There is gathering momentum in medicine for a invest their trust in me as a medical practitioner. process of revalidation. The New Zealand Medical Council requires both continuing professional development and I have always felt that being a member of the medical recertification. Revalidation is part of medical practice in profession has tremendous privileges as well as tremendous Canada and the United Kingdom. In the UK the General responsibilities, and I am sure it is the same for the dental Medical Council defines revalidation as being up-to-date profession. Going back to the citation for Robert Harris when and fit to practice, and includes a mix of recertification and he received his Membership of the Order of Australia those continuing professional development. The Australian Medical two characteristics, a desire to serve his profession, and a Board has commenced a conversation about revalidation determination as to strive for excellence in all his undertakings and I think it is likely that there will be a move towards it in remain a beacon for all of us. an approach similar to New Zealand and the UK. Watch this space for a flow on to other health professions – and it will be Thank you much better coming from the professions, than imposed from the outside.

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 24 TWENTY-SECOND convocation royal australasian college of dental surgeons gold coast, australia, april 2014 IN MEMORIAM ASSOCIATE PROFESSOR BRAHAM PEARLMAN RFD This beautiful grand ballroom and the venue for this As a Fellow of the College, he was a stalwart supporter. Convocation were recommended to Council by a very senior He served as Registrar in GDP for over 10 years and was dedicated fellow of the College after a site visit made by instrumental in setting up the Primary Examination in him. This Fellow is A/Professor Braham Pearlman RFD. Universiti Sans Malaysia. He also actively promoted the Unfortunately he cannot be with us this evening as he sadly Primary Examination in Hong Kong. passed away in February 2013. His involvement with and contribution to the College On behalf of the College, I would like to take this opportunity culminated in the role of President, being elected at the to honour A/Professor Braham Pearlman. Braham, after November 2012 Council meeting. Unfortunately, knowing that his dental undergraduate training in Australia, went to the his health was quickly deteriorating, he resigned at the same Eastman Dental Institute in England for postgraduate training meeting and sadly passed away in February 2013. in periodontics. He then furthered his specialist training at the University of Boston. Braham is survived by his beloved wife Deborah Pearlman and his children. Braham always had a wish to help advancing Braham served the dental profession throughout his life with dentistry in developing countries, in particular Fiji. In memory a selfless devotion to duty, standards and professionalism. of his significant contributions to the College and the For the country, he served as a dentist in the RAAF. For profession, the College has set up a scholarship in his name the community, he looked after his patients with their best for the Fijian Dental School for students to further dental interest at the highest professional standard. education in Australia. As an educator, he offered the most sincere encouragement Those of us who were fortunate to know Braham held him in to young dentists. He taught, shared his knowledge and high esteem. His spirit of devotion to the community, College experience, counselled, guided and led by example. In his and profession always live with us. many years of teaching at the Westmead Dental Hospital, he had numerous local and international students.

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 25 TWENTY-SECOND convocation royal australasian college of dental surgeons gold coast, australia, april 2014 YOUNG LECTURERS AWARD The Young Lecturer Award has established itself as an • Dr Katie Bach: The Oral Health of Cambodian Preschool important part of College Convocation. Once again it was a Aged Children well received part of the scientific program. The College is grateful to Colgate for their continued support of this award. • Dr Christopher Barker: A Blinded Randomized Gratitude is also extended to our panel of judges, Professor Controlled Trial of Three Types of Implants in an Aged Martin Tyas AM, Professor Ward Massey and Professor Ovine Poor Quality Bone Model. Lakshman Samaranayake. The winner was Dr Ashim Adhikari from the University of This year’s six candidates presented on topics from diverse Melbourne. He was awarded a certificate and a cheque from disciplines and provided the judges with the difficult task Ms Lenore Tuckerman from Colgate Oral Care, Sydney. The of deciding a winner. The candidates and the titles of their other 5 lecturers were awarded a Certificate of Achievement. presentations were: The five judges noted that all presentations, in both content • Dr Mas Ahmad: Developing an Oral Health Care Service and delivery, were of a high standard. for People with Special Needs in Malaysia, Adopting an Australian Model Convocation delegates were left in no doubt as to the value of the Young Lecturer Award in fostering young presenters • Dr Raymond Lam: How e-Health Strategies May Benefit and their research, which bodes well for the future of our Personal and Professional Development in Dentistry profession. • Dr Ashim Adhikari: Distraction Osteogenesis - A Panacea Dr Patrick Russo for infant micrognathia with Upper Airway Disease? Convener, Young Lecturer Award • Dr Crystal Lee: Profile and Surgical Management of Dentofacial Deformities in Hong Kong and Glasgow Young Lecturers (from left) Young Lecturers (from left) Dr Mas Ahmad, Dr Crystal Lee, Dr Francis Chau (President), Dr Crystal Lee, Dr Ashim Adhikari, Dr Mas Ahmad, Mrs Lenore Tuckerman (Colgate, Sydney), Dr Patrick Russo Dr Raymond Lam (YLA Convener), Dr Ashim Adhikari, Dr Raymond Lam

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 26 ANNALS OF THE ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS SCIENTIFIC PROGRAMME PAPERS AND ABSTRACTS FROM THE TWENTY-SECOND CONVOCATION OF THE ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS GOLD COAST, AUSTRALIA, 10-13 APRIL 2014 Readers are advised that since the Annals reports the Proceedings of Convocation, none of the scientific papers has been peer reviewed.

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 27-32 DETERMINING RISK FACTORS FOR PERIODONTAL DISEASES: A RISKY BUSINESS? Louise F. Brown MDSc, MPH, MRACDS(Perio), PhD, FADI, FICD, FPFA. Dr Brown is a specialist periodontist, working full time in her private periodontal and implant practice. She teaches and examines in the postgraduate periodontics program at Melbourne University. Dr Brown actively involved in the periodontal profession and is currently serving as President on the ANZAP Council. ABSTRACT Analytical epidemiology can be a powerful tool to determine risk factors for diseases, and potentially uncover causality of chronic diseases. However, it is governed by strict research methodology to ensure rigour of the results of studies. In the attempts to identify and quantify risk factors for periodontitis, many of the studies fall short of the scientific rigour, particularly with regard to the measurement and classification of individuals with and without disease, or progression of periodontal disease. The lack of consensus over how to measure and classify periodontitis cases has led to reporting of a pletora of “significant” associations, either identifying periodontitis as a risk factor for systemic diseases, or in identifying risk factors for the development of periodontitis. Many of these results are later not validated by replicate studies, or by studies using a different method of classifying a person with periodontitis. This paper looks as some of these methodological issues and the influence of classification on analytical epidemiological results. INTRODUCTION The classification of who has disease (a case), and whether the disease is getting worse over time, is fundamental to As a clinician, there is a constant need to translate the the science of analytical epidemiology. A problem with knowledge acquired through reading the literature and from Periodontics is that while research has focused on the attending conferences into answers to very fundamental measurement of putative genetic, microbiological and questions that patients pose, when they learn that they have immunological risk factors often down to a molecular level, periodontitis. and have hypothesized numerous causal pathways for such factors, researchers have tended to avoid the sticky issue of • Why have I got this disease? Why me? Why now? how to measure, define and classify the actual disease itself.2 In addition, the focus of the last 10 to 15 years of research has • How bad is my disease? been to establish periodontal diseases, or periodontitis, as a risk factor for systemic diseases, with little attention paid to • Why does it affect some teeth and not others? how a person is classified as having periodontal disease, or periodontitis, let alone how to define consistently if there is • Should I be concerned about my receding gums? worsening of the disease (incidence) and its relationship to the onset or worsening of systemic diseases. • Is it because I did not brush my teeth properly? It is timely to address the need to draw the focus back to • Are my family members at risk of getting the disease periodontal disease itself, because before risk factors for and how do we prevent them getting it? disease can be identified with any validity, we need to determine the accuracy of measuring and classifying the periodontal • Will I lose my teeth? disease entities. • What happens if I do nothing? MEASURING PERIODONTAL DISEASE • How effective is treatment? In an ideal world, a gold standard would be used to definitively characterise whether in an individual, a disease is present or • What are the side effects of treatment? absent. This same gold standard would be used by clinicians and analytical epidemiologists alike, so that the findings • Can I have dental implants to replace my teeth? of research into the cause of diseases would be readily translated into the clinical environment. Some diseases have • Will implants fail like my teeth have failed? such definitive diagnostic tests and biological markers can be used to grade severity of the disease or monitor the return • Does my general health affect periodontal disease? to a state of health. Examples of such diseases with gold standards include many bacterial infections where a known • Does having periodontal disease affect my general bacteria is the cause (tuberculosis, syphilis), and genetically health? defined diseases or syndromes, where a characteristic DNA sequence can be detected. The science of analytical epidemiology provides clinicians with a framework to start answering such questions. As with all scientific research, analytical epidemiology has strict protocols for research design to minimize the effects of errors in measurement of disease and the measurement of factors hypothesized to be associated with that disease.1 The overarching aim of analytical epidemiology is the pursuit of the causes of disease. The identification of risk factors is a vital step in the pathway for uncovering the causes of diseases.

28 Many of the chronic diseases affecting mankind do not have recession, bleeding on probing, suppuration on probing are a black and white single test for determining the presence made at up to 6 sites per tooth, other measurements such as or absence of disease. For example, the diagnosis of Type plaque and calculus deposits may be made on up to 4 sites per 2 diabetes relies on measuring blood glucose levels, and tooth, measurements such as furcation involvement affect a threshold is set above which a diagnosis is made. The only some teeth and some surfaces, and other parameters threshold is set by consensus of clinicians, and generally is such as mobility are measured per individual tooth. In a treatment driven threshold – in other words, the threshold order to facilitate the efficacious examination of subjects in is set at the level at which clinicians agree that treatment epidemiological research, there have been numerous indices should begin.3 based upon split mouth examinations, partial examination of some teeth (nominated “index” teeth), and examination of a The very nature of periodontal diseases poses a particularly limited number of sites per tooth. Each index introduces a challenging set of problems. Clinical measurement of the disease compromise, with the risk of misclassification of an individual’s is a crude exercise, using a metal probe marked in millimeters. disease status, or underestimation or overestimation of the Probing is affected by many variables that will be reflected in extent and severity of disease, inherent in the indices.4 the measurement error of the readings. Diameters and shape of probe tips vary greatly. Individual examiners can exert variable The structure of indices reflects the prevailing concepts of pressure on the probe, which will in turn affect the degree the nature and aetiology of disease at that time. This has the penetration of the probe tip through the base of the pocket. The tendency to introduce a confirmation bias so that the results degree of pressure may also be modified by patient feedback – of the studies using a particular index become self- fulfilling those patients with inflammation may experience pain and the prophecies. The demonstration by Marshall-Day and Shourie examiner may modify the probing pressure to accommodate in 1944 of a reciprocal relationship between gingivitis and this. Parallax errors can occur when reading the probe. There is periodontitis, with a high prevalence of gingivitis and low always the weighing up of keeping the probe parallel to the long prevalence of periodontitis being observed in younger age axis of the tooth and potentially missing the deeper interproximal groups and the reverse in older age groups, gave rise to the probing depth beneath a contact point versus slightly angling notion that gingivitis gives rise to periodontitis.5 Russell’s the probe to capture the deeper pocket. The background of Periodontal Index, widely used in the 1960’s and 1970s, the clinical examiner may determine this – periodontists will was a linear index that weighted more advanced stages approach measuring deep interproximal pockets differently of the disease more heavily.6 This created a neat linear from trained and calibrated epidemiologists. Factors such as correlation with age in cross-sectional studies which readily the presence of plaque, calculus and other debris, as well as and erroneously was interpreted to confirm the prevailing bleeding or discharge, can affect the ability to read the probe understanding that periodontitis was merely a reflection of accurately. Further, the very presence of inflammation at the age and plaque accumulation, crudely measured with oral base of the pocket introduces another source of error, in that hygiene scores. Disease progression was neatly modelled this will allow the probe to penetrate more deeply and give a with linear regression as being a continuum from gingivitis falsely increased reading. to severe periodontitis and the weightings given to the indices allowed for this to be simply demonstrated. The Measurement of recession and probing depth relies upon ‘domino’ effect of poor oral hygiene leading to eventual loss identification of the cementoenamel junction (CEJ) or of teeth was readily adopted as a public health message and the crest of the gingival margin. The gingival crest may be advertising jumped on the opportunity to use the message affected by inflammation, fibrotic tissue changes, partial to promote oral hygiene products. Up until 1980, it was still eruption of teeth and over-eruption of teeth and crowding. widely believed that ageing and plaque accumulation were The CEJ may be covered by gingival tissue or obliterated by a the major causes of periodontitis. When it was observed that restorative margin or decay or resorption. These factors are smokers experienced worse periodontitis, this was put down difficult enough to account for in a prevalence study, but can to the assumption that smokers simply paid less attention to contribute to significant measurement error in longitudinal oral hygiene. studies examining the incidence of periodontitis. THE NATURE OF DESTRUCTIVE PERIODONTAL Bone loss, as detected radiographically, reflects past DISEASES disease activity, rather than whether the disease is currently progressive. While radiographic evidence of progressive bone The concepts that grew out of these early epidemiological loss, such as when digital subtraction radiographic techniques prevalence studies were challenged by observations that are employed, may be closer to a gold standard to define the emerged when individual patients and teeth were studied difference between periodontitis and gingivitis, its usefulness longitudinally.7 The recognition of the episodic or cyclic nature in population based analytical epidemiological research is of destructive disease allowed for modelling of the variation limited by the ethics of exposing research subjects to ionizing among individuals and even among individual teeth or sites radiation and the practicalities of standardization of angles within the individual, with regard to the frequency and rate of exposure to allow for reproducibility and comparison of of progression of periodontitis. Progression of disease was sequential images. recognised as an infrequent event and it was demonstrated that diseased sites may ‘undergo cycles of exacerbation PERIDONTAL INDICES and spontaneous remission’, thus calling into question the concept of periodontal disease as a slow, continuously Periodontal diseases are site specific. Different indices progressive disease.8 The 1980s saw a reclassification of used in epidemiological studies over the years have periodontal diseases to reflect the fact that different forms tried to accommodate the fact that in a clinical scenario, measurements for parameters such as pocket depth,

29 of the disease appear to progress with different patterns. The Analytical epidemiological studies can be based upon focus of research in the 1980’s was often at the site level of cross sectional studies and case-control studies, in which analysis, in the quest to identify what factors were associated studies the “case” reflects a one-off measure of disease at with an active burst of attachment loss at that site. In order a particular time. This prevalence measure tries to separate to extend the site level observations to the individual level of the groups of subjects into categories of diseased (cases) and unit of analysis, the notion of extent and severity of disease non-diseased (controls). was developed. Clinical parameters such as bleeding on probing and suppuration, identification of specific bacteria, Examination of the different methods employed show a and the presence of specific antigens in gingival crevicular wide variation in thresholds used to discriminate between fluid led the way for the identification of risk factors for cases and controls. Borrell and Papapanou examined the disease activity at a particular site. At the epidemiological case definitions used in analytical epidemiological studies level, longitudinal studies of disease progression in untreated and found a plethora of case definitions, using an array of populations revealed wide individual variation in disease clinical signs and symptoms, poor discrimination of the use of susceptibility, and broke down the paradigm of the linear clinical attachment level (CAL) and probing depth (PD), with relationship between plaque accumulation and severity some studies erroneously using both measures, and wide of disease.9 The paradigm of high risk individuals and high variations in thresholds used to define a case, regardless of risk groups became the focus. Smokers and diabetics were the indicators used.11 They demonstrated that altering the recognised as being at high risk of periodontal destruction, case definition had a significant impact on the identification independent of their level of plaque control. of risk factors, and that the variation between studies made a direct comparison of odds ratio or relative risk for the same STUDY DESIGNS FOR IDENTIFYING risk factors almost impossible. RISK FACTORS In the last decade, there have been three case definitions The research into the identification of risk factors for of periodontitis devised by international bodies. These periodontitis reflected the increasing sophistication of differ significantly and do not resolve the fact that we computing and analytical modelling available over the years. need a consensus for a priori use of a case definition, in As the capacity for handling extremely large data sets became order to be able to validly compare the results of analytical available, and complex statistical modelling techniques were epidemiological studies. developed, more and more individual parameters could be thrown into the models. This also coincided with rapid Periodontitis (sensitive definition): Presence of proximal advances in molecular level analysis of biological parameters. attachment loss of Instead of the labour intense requirement to culture aerobic and anaerobic bacteria from plaque samples, DNA technology ≥3 mm in two or more nonadjacent teeth allowed for plaque samples and other body samples (blood, crevicular fluid, saliva) to be collected, stored appropriately Periodontitis (extensive definition): Presence of proximal and analysed by a sophisticated techniques to produce an attachment loss of ≥5 mm in ≥30% of teeth present immense number of variables with relative ease and speed. The epidemiologists and molecular biologists joined forces, Table 1. Tonetti and Caffey, (2005), on behalf of the with an ease not previously achievable, so that the laboratory European Workshop in Periodontology:12 based results previously restricted to small clinical, patient based studies, could be extended to large population-based No periodontitis: No evidence of mild, moderate or severe analytical epidemiological studies. The statistical methods periodontitis used to identify risk factors at an epidemiological level required the identification of categorical based classification Periodontitis Mild: at least two interproximal sites of disease rather than a continuous linear classification. with clinical attachment loss ≥3 mm and at least two And this is the point at which there has been an overriding interproximal sites with probing depths ≥4 mm (not on failure of periodontal research to reach a coherent approach the same tooth) OR one site with probing depth ≥5 mm between epidemiologists and clinicians. Periodontitis Moderate: at least two interproximal sites HOW ARE PERIODONTAL CASES DEFINED IN RISK with clinical attachment loss ≥4 mm (not on the same STUDIES? tooth) OR at least two interproximal sites with probing depths ≥5mm (not on the same tooth) The term “risk” is a loosely used term in general parlance. In analytical epidemiology, there are strict definitions of the Periodontitis Severe: at least two interproximal sites with concept of risk. A risk factor is defined as “characteristics of clinical attachment loss ≥6 mm (not on the same tooth) the person or environment that, when present, directly results AND at least one interproximal site with probing depth in an increased likelihood of a person getting a disease and ≥5mm when absent, directly result in a decreased likelihood”.10 Risk indicators are assessed from cross-sectional studies or case- Table 2. Page and Eke (2007), Eke et al. (2012) Centers for control studies, whereas risk factors are verified through Disease Control – American Academy of Periodontology longitudinal studies. However, these terms are often used criteria:7,13 interchangeably with little regard to their epidemiological definitions.

30 Periodontitis Aggressive: in subjects ≤25 years: at least two of the inflammatory burden of the disease. Other measures interproximal, non-adjacent sites in different teeth with such as “cumulative probing depth” which attempts to clinical attachment loss ≥4 mm and bleeding on probing capture the surface area of the inflamed pocket epithelium, have been developed by a some researchers in an attempt to Periodontitis Aggressive: In subjects 26-35 year: at least better suit these study aims.18 two interproximal, non-adjacent sites in different teeth with clinical attachment loss ≥6 mm and bleeding on WHAT ABOUT MISSING TEETH? probing Periodontitis is effectively eliminated by extraction of teeth. Periodontitis Aggressive: In subjects ≥36 year: not defined Without a tooth, there is no periodontium to be inflamed. But unless the population being studied has no access to dental Table 3. Demmer and Papapanou (2010) suggested care and teeth are lost spontaneously due to progressive amendment to the Centers for Disease Control – American loss of periodontal support, the fact that a tooth is missing Academy of Periodontology criteria:14 is difficult to interpret in analytical epidemiological studies. It brings into play many variables, such as multifactorial The definition of an incidence case – in other words, a person decision making in tooth extraction and the impact of the in whom there has been measurable progression over a healthy survivor effect. One of the unanswered dilemmas in longitudinal study time period from a state of health to a studies designed to correlate more advanced periodontitis state of disease (attachment loss) or an individual in whom with more advanced cardiovascular or other inflammatory the disease has worsened (additional loss of attachment) is diseases, is that while there is a strong correlation between even more difficult and variable to capture and to define. the two entities, the strongest correlation persists in the This is because as well as needing an a priori consensus on edentulous.19,20 In other words, extraction of all teeth and what constitutes a clinically significant deterioration in loss of elimination of the periodontium fails to reduce the correlation attachment, the measurements within the study must exceed with more severe forms of cardiovascular disease, at a cross- the measurement error inherent in the repeated sequential sectional level. This is a simplistic interpretation, given the periodontal probing depth and recession, in order to be multifactorial nature of cardiovascular diseases. But it valid. The degree of measurement error is usually done by highlights the complexity of trying to tease out the effects of analyzing the correlation the agreement of repeat probing treatment of periodontitis as a means of reducing the impact measurements within and between examiners on a subset of systemic inflammatory diseases. of the subjects. Using this method, the threshold for loss of clinical attachment at a site was 3mm or more.15 Longitudinal SO WHERE ARE WE AT WITH REGARDS TO RISK studies have varied in how they define a case using such FACTORS AND PERIODONTITIS? criteria. More recently, many studies have ignored the need to set a threshold and have reported very small differences In spite of the shortcomings and lack of uniformity in in attachment level or probing depths as being indicative of our methods of measuring and defining what constitutes true progression of disease. This has been most evident in the periodontitis, there have been significant changes in our studies designed to establish periodontitis as a risk factor for understanding of periodontal disease over the past 30 years. systemic diseases.16 The predominant changes have been the introduction of the concept of risk itself – the awareness that not everyone WHAT TO DO ABOUT RECESSION? is susceptible to the disease and that oral hygiene is not the determinant of who gets more severe diseases. As to In many longitudinal studies of untreated individuals, most identifying why an individual gets a disease, the understanding of the sites that exhibit ≥3 mm loss of attachment over of genetics and epigenetics combined with the role of tobacco a relatively short period of time did so predominantly by as risk factors has had a far more broad reaching impact than recession on buccal aspects of teeth rather than as a result of the efforts to find a particular strain of bacteria or biofilm increasing probing depths.17 There is lack of consensus about characteristics that lead to an increase in susceptibility. how to handle gingival recession. To use clinical attachment The emphasis on periodontitis as an inflammatory disease, level (CAL) as the outcome measure of clinical significance rather than an infectious disease, has come at a time where ignores the fact that recession can be the result of disease, medical research into the destructive aspects of local and but can also be the result of tissue biotype, trauma (either systemic inflammation has been the “in” topic. Recognizing accidental or from over-zealous tooth brushing), malposition periodontitis as one of the spectrum of genetically determined of teeth leading to a developmental dehiscence in the inflammatory diseases places it in context of these diseases. underlying alveolar bone. If we recognise that some forms However, to infer that the presence of periodontitis causes of recession are not reflective of an underlying inflammatory or increases the severity of these other diseases is more disease process, It is illogical to suppose that the risk factors equivocal. Findings linking periodontitis to impotency, obesity, for those subjects who meet the definition of a case on the cancer, dementia, cardiovascular diseases, stroke, respiratory basis of CAL made up of recession and only shallow pockets diseases, rheumatoid arthritis, diabetes, premature and low would be the same as the risk factors for cases whose CAL is birth weight babies may simply reflect that those individuals composed predominantly of deep pockets. who are susceptible to a host of inflammatory diseases are more likely to be also susceptible to periodontitis, rather than Similarly, in studies where periodontitis is being examined there being any causal link present. as a risk factor for systemic diseases, such as cardiovascular disease, CAL and recession may not capture a true measure

31 The Consensus Report of the Joint EFP/AAP Workshop on “It turns out – this is serious – that dental hygiene is Periodontitis and Systemic Diseases was published in 2013.21 actually very important for keeping your heart healthy. This working group concluded that it was not possible to infer It turns out that heart disease can be triggered when causal relationships between periodontitis, and among other you’ve got gum disease. So everybody floss. Am I right? diseases, COPD, chronic kidney disease, rheumatoid arthritis, You got to floss” (President Barak Obama, Nevada, April cognitive impairment and cancer. When the relationship 12 2010) between periodontitis and adverse pregnancy outcomes was examined, the Consensus group found only “modest Professional bodies have also been keen to jump on the band associations” and no causation, and the group identified the wagon, with the purported links to systemic diseases used perennial problem of classifying periodontal diseases as one to exaggerate the role of the dental profession in managing of the reasons for the observed variations in study results systemic diseases through periodontal treatment. In late across different populations.22 2012, the President of the Dental Hygienist Association of Australia describes the role of dental hygienists as: The working group examining periodontitis and atherosclerotic cardiovascular disease (ACVD) concluded that “excess risk Hygienists also have a significant role in the (of ACVD) could be due to unknown confounders” – common management of non- communicable disease, these genetically determined pathways underpinning various include periodontal disease, cardiovascular disease, complex inflammatory diseases.23 They suspected that it oral cancers, diabetes, respiratory disease in aged care could be these unknown confounders, and not periodontal facilities, diet and nutrition and smoking cessation. diseases, have an etiological role in ACVD. (Written communication from Hellen Checker, President Finally, the Consensus group report for diabetes and DHAA to Dr Louise Brown, President, Australian and periodontal diseases concluded that there is a positive robust New Zealand Academy of Periodontists, 24.08.2012) relationship between the two entities. Studies have shown that “periodontal treatment reduces plasma HbA1C (a measure of In 2012, the Australian Dental Association had to be advised glycaemic control) … by levels equivalent to adding a second by the Australian and New Zealand Academy of Periodontists drug to a pharmacological regime”.24 This strong statement as well as the conveners of the periodontal teaching programs affirmed that periodontal diseases and diabetes exhibit a in Australian Universities against publishing the following in bidirectional relationship. The group proposed development their draft “Dental Fact Sheet” linking “gum diseases with of no-nonsense dental/interface guidelines for physicians and other illnesses”. dentists caring for patients with diabetes, and for patients with diabetes. FINAL MESSAGE • Diabetes: Periodontal disease can contribute to diabetes. Professional treatment of periodontal The wide variety of case definitions used in analytical disease, combined with regular brushing and epidemiological studies hints of juggling data sets to create flossing, will reduce infection and can help prevent divisions of diseased and non-diseased subjects defined by diabetes. arbitrary post priori thresholds to produce the best statistical modelling of risk factors, rather than being made a priori • Strokes and heart disease: Current evidence suggests based on agreed clinically relevant criteria. This has led to periodontal disease is associated with inflammation publication of a plethora of studies espousing significant and of the arteries, which can in turn lead to strokes and clinically relevant associations between periodontitis and a heart disease wide range of systemic diseases. • Alzheimer’s disease: a recent study revealed that Dissemination of information is selectively and aggressively missing teeth and chronic inflammation can driven by researchers keen to publicize their results ahead significantly increase the risk of developing of competitors. Research funding is tight and media publicity Alzheimer’s disease. Systemic inflammation caused has emerged as a crucial step in attempts to secure on-going by periodontal disease can go on to damage brain funding. However, simplistic reporting of statistical correlations tissue, which can lead to Alzheimer’s disease and the results of one-off findings not yet corroborated by multiple studies comparing “apples with apples” can be • Pre-term birth: Researchers have found links between sensational and create persistent erroneous messages. This periodontal disease in pregnant women and affects not only the public’s perception, but the messages are premature birth, with researchers estimating 18 out readily taken up by the profession and by marketing. The long- of every 100 premature births may be triggered by standing impact of advertisements highlighting the “domino” periodontal disease. Babies born prematurely may effect of inevitable tooth loss as a consequence of poor oral risk a range of health conditions including problems hygiene still plays a large role in the public’s perception of why with eyesight and hearing. they may develop gum disease. The messages of the role of periodontal disease as a risk factor for cardiovascular disease For all the flurry of research into systemic diseases and found its way to the words of the President of the United States periodontitis, a person’s underlying genetic susceptibility, of America, who urged the public to floss their teeth to reduce smoking and diabetes emerge as being robust factors, but the risk of heart disease. these three factors were strongly identified 30 years ago.7

32 It is time to focus our efforts back to the disease itself, and 12. Tonetti MS, Caffey N. Advances in the progression of periodontitis and to answer some very fundamental questions about how proposal of definitions of a periodontitis case and disease progression for to measure, define and classify individuals with differing use in risk factor research. J Clin Periodontol 2005; 32 (Supp 6): 210-213. presentations of periodontal diseases and reach a consensus on this. Only then can analytical epidemiological research 13. Eke PI, Page RC, Wei L, Thorton-Evans G, Genco RJ. Update on case into the identification of risk factors proceed in a manner definitions for population-based surveillance of periodontitis. J Periodontol that will provide comparable and meaningful results across 2012; 83:1449-1454. studies. This will allow better translation of these results into the clinical scenario and into public health approaches for 14. Demmer RT, Papapanou PN. Epidemiologic patterns of chronic and targeting the prevention and treatment of periodontitis. aggressive periodontitis. Periodontol 2000 2010; 53:28-44. REFERENCES 15. Brown LF, Beck JD, Rozier RG. Incidence of attachment loss in community-dwelling older adults. J Periodontol 1994; 65:316-323. 1. Rothman KJ, Greenland S, Lash TL. Modern Epidemiology. 3rd ed. Oxford University Press, 2008. 16. Dietrich T, Sharma P, Walter C, Weston P, Beck J. The epidemiological evidence behind the association between periodontitis and incident 2. Baelum V, Lopez R. defining a periodontitis case. Analysis of a never- atherosclerotic cardiovascular diseases. J Clin Periodontol 2013; 40 treated adult population. J Clin Periodontol 2012; 39:10-19. (Supp 14): S70-S84. 3. Harris P, Mann L, Phillips P, Bolger-Harris H, Webster C. Diabetes 17. Murray Thomson W, Slade GD, Beck JD, Elter JR, Spencer AJ, Chalmers management in general practice. Guidelines for type 2 diabetes. 17th JM. Incidence of periodontal attachment loss over 5 years among older ed. 2011–2012. The Royal Australian College of General Practitioners and South Australians. J Clin Periodontol 2004; 31:119-125. Diabetes Australia. 18. Beck JD, Offenbacher S. Systemic effects of periodontitis – epidemiology 4. Page RC, Eke PI. Case definitions for use in population-based surveillance of periodontal diseases and cardiovascular disease. J Periodontol 2005; of periodontitis. J Periodontol 2007; (Supp): 1387–1399. 76 (Supp): 2089-2100. 5. Marshall-Day CD, Stephens RG, Quigley LF. Periodontal disease: 19. Dietrich T, Jimenez M, Krall-Kaye EA, Vokonas PS, Garcia RI. Age- prevalence and incidence. J Periodontol 1955; 26:185-203. dependent associations between chronic periodontitis/edentulism and risk of coronary heart disease. Circulation 2008; 117: 1668-1674. 6. Russell AL. A system of classification and scoring for prevalence surveys of periodontal disease. J Dent Res 1956; 35:350-2359. 20. Elter RJ, Offenbacher S, Toole JF, Beck JD. Relationship of periodontal disease and edentulism to stroke/TIA. JADA 2013; 144:1362-1371. 7. Page RC, Shroeder HE. Periodontitis in man and other animals. A comparative review. Basel: Karger 1982. 21. Linden GJ, Herzberg MC, working group 4 of the joint EFP/AAP workshop. J Clin Periodontol 2013; 40 (Suppl. 14): S20-S23. 8. Socransky SS, Haffajee AD, Goodson JM, Lindhe J, New concepts of destructive periodontal disease. J Clin Periodontol 1984; 11:21-32. 22. Sanz M, Kornman K, working group 3 of the joint EFP/AAP workshop. J Clin Periodontol 2013; 40 (Suppl.14): S164-S169. 9. Loe H, Anerud A, Boysen H, Smith M. The natural history of periodontal disease in man. The rate of periodontal destruction before 40 years of 23. Tonetti MS, Van Dyke TE, working group 1 of the joint EFP/AAP workshop. age. J Periodontol 1978; 49:607-620. J Clin Periodontol 2013; 40 (Suppl.14): S24-S29. 10. Beck JD. Methods of assessing risk for periodontitis and developing 24. Chapple ILC, Genco R, working group 2 of the joint EFP/AAP workshop. J multifactorial models. J Periodontol 1994; 65:468-478. Clin Periodontol 2013; 40 (Suppl.14): S106-S112. 11. Borrell LN, Papapanou PN. Analytical epidemiology of periodontitis. J Address for correspondence Clin Periodontol 2005; 32 (Supp 6): 132-158. Postgraduate student, School of Dentistry, University of Queensland [email protected]

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 33-38 IMPLANT SUCCESS, COMPLICATIONS AND FAILURE – INDIVIDUAL PATIENT RISK Associate Professor Werner Bischof. MDSc. FRACDS. MRACDS(Perio) Werner is a Periodontist in practice in Geelong and Ballarat, Victoria. He is the consultant Periodontist, Royal Children’s Hospital, Melbourne, and is Associate Professor in Periodontology, Department of Dentistry and Oral Health, Latrobe University. Werner is a Past-President and Fellow of the College, a Fellow of the Pierre Fauchard Academy and the International College of Dentists. ABSTRACT Dental implant supported prostheses provide a valuable solution for tooth replacement in dental reconstruction and rehabilitation. The high level of success and predictability of initial osseointegration and long term function of dental implants have been well documented. It is recognised that the factors contributing to this success are multi-factorial in nature, with documented local and systemic risk indicators that may contribute to complications. Of importance to the clinician and the patient is how relevant is the risk of complications or failure. This paper aims to explore the literature regarding the implant survival, success and complications and what may be the limitations in the discussion of outcomes and risks with the individual patient. INTRODUCTION design and loading. The performance of dental implants in clinical practice and in the literature described on the basis of The dental implant supported prostheses provides a valuable survival, failure, success and complications. solution for tooth/teeth replacement in dental reconstruction and rehabilitation. The high level of success and predictability IMPLANT SURVIVAL of initial implant osseointegration and long-term function have been well documented. It is generally considered that Implant survival can be simply described as whether this success is dependent upon the interrelationship of a the implant is present at the prescribed time of review/ number of variables.1 Complications and failure in dental assessment. Survival may be determined from the time implant treatment have also been described in the literature. of implant placement or from the time of restoration and Given the technically demanding and multi-disciplinary nature loading. The reporting of implant survival has been either of implant dentistry the patient must be given adequate in the form of life table statistics and cumulative survival information regarding the expected outcome of treatment. rates or the percentage of implant survival. Many of the A key question for both the clinician and the patient is how papers presenting implant performance are characterized as relevant is the risk of complications or failure. cohort studies or case series and may either be retrospective or prospective in design. Small and heterogeneous study The principle of evidence-based practice is that the clinician populations, convenience sampling and inconsistent follow- translates the available research to clinical decisions, taking up present limitations when interpreting or extrapolating into consideration the particular circumstances of the the results to clinical practice. There have been a number of individual patient. Treatment decisions are dynamic and multi- systematic reviews that allow for a more robust evaluation of dimensional and may be influenced by the clinician’s diagnostic the clinical performance of dental implants. The systematic and clinical skills, experience, knowledge and education. To this review aims to identify, assess, review and summarize studies process the patient will contribute their particular priorities, with sound methodology, using predetermined criteria related attitude and knowledge with the decision to accept treatment to the clinical question. The strength of the results presented influenced by their expectations and finances. in systematic reviews, and the application to clinical practice, is directly related to the quality of the individual studies and This paper aims to explore the findings in the literature the application of stringent inclusion criteria for the review. regarding the survival, success and complications associated with dental implants; the factors that may be attributed to Berglundh et al, in a systematic review of longitudinal complications or failure; and, the way in which this information prospective cohort studies (greater than 5 years), reported may contribute the discussion of outcomes and risks with the the incidence of complications with dental implants individual patient and treatment planning. categorized on the basis of treatment group.2 The survival rate of implants following 5 years of function was high for WHAT IS SUCCESS IN IMPLANT DENTISTRY all treatment categories; over-dentures, 74.7-100%; fixed complete dentures, 79.3 -100%; fixed partial dentures, 89.2- In the modern era of the root-form dental implant, 100%; single-tooth replacement, 85.7-100%; immediate Albrektsson et al. described six key requirements for osseo- placement/early loading 96.4-100%; and, augmentation integration.1 These relate to the biocompatible material procedure 84.6-100%. Although a number of the treatment and design of the implant (macroscopic and microscopic categories aggregated cases according to prosthetic type, surface characteristics); the bone health and quality; the the report of survival and complications was at implant-level surgical technique and healing phase; and the prosthetic

34 outcomes. Subject level or prosthesis outcomes were not in 1978, included patient–reported subjective criteria such reported. as adequate function; absence of discomfort; and, patient’s belief that esthetics and emotional and psychological attitude More recently systematic reviews have reported on the are improved.5 Some of the objective criteria included vertical survival rate of both implants and implant-supported bone loss of no greater than one-third after 5 years, and, prostheses. Jung et al. reviewed studies published between mobility of less that 1mm bucco-lingually, mesio-distally and 2006 and 2011 reporting on the survival and complications vertically.5 In 1986 Albrektsson et al. presented criteria for of single tooth implants.3 The survival of single tooth success that were more stringent and reflected the results implants at 5 years was 97.2% and at 10 years was 95.2%. obtained with the Brånemark endosseous titanium implant.6 The survival rate of the implant-supported single crown at (Table 1). 5 years was 96.3% and at 10 years was 89.4%. Pjetursson et al. conducted a similar review of studies between 2004 Given the variety of commercial implant systems available, and 2011 reporting the survival and complications of implant- with varying configurations, it must be remembered that the supported fixed dental prostheses.4 Again the survival rate criteria by Albrektsson et al. was based on the observation of implants supporting a fixed prosthesis was high at 5 years of the Brånemark external hex two-piece implant system. (95.6%) and 10 years (93.1%). However, the there was a Schwartz-Arad et al. suggest that marginal bone behavior may significant difference in the survival rate of fixed prosthesis be influenced by the implant neck and body configurations when comparing the 5 years and 10 years of function; 95.4% of the one- or two-piece implant system. Marginal bone and 80.1% respectively. remodeling may be influenced by the differing position of the implant/abutment micro-gap in cases of an internal conical It was recognized that the individual studies included in the connection or inward positioning (platform switching).7 systematic reviews were heterogeneous in nature.2,3,4 The Therefore, although many implants demonstrate marginal studies often lack detail regarding methodology, statistical bone level dynamics according to the criteria by Albrektsson power (relating to number of implants and/or number of et al, there is evidence to suggest that different marginal patients) and sources of bias. The subject group studied was bone resorption patterns may exist.7 often poorly described with regard to inclusion/exclusion criteria, systemic health or habits, and reasons for loss to Implant success may be assessed on the basis of cross- follow-up. There were often significant clinical variations such sectional or longitudinal criteria. van Steenberghe as implant system, surgical protocol and site considerations, advocated a criteria for success that included clinically abutment and prosthetic design and material, and practice relevant and objective features.8 Success is defined on setting; university or private practice. the basis of biocompatibility (absence of allergic, toxic, or gross infectious reactions), structural integrity (no signs of Criteria for implant success fracture or bending), functional stability (anchorage to a functional prosthesis no sign of mobility as tested by tested 1. That an individual, unattached implant is immobile hand instrument or electronic device) and radiographic when clinically tested stability (no sign of radiolucency). In circumstances where the prognosis of a successful implant is to be evaluated van 2. That a radiograph does not demonstrate any Steenberghe added the longitudinal criteria of; absence of evidence of peri-implant radioleucency ongoing marginal bone loss (assessed by annual/biannual intra-oral radiographs) and absence of ongoing attachment 3. The vertical bone loss is less than 0.2 mm annually loss (as measured with a periodontal probe). However, the following the implants first year in service prognosis, and therefore success, would be a concern if the observed changes (bone loss and/or attachment loss) when 4. The individual implant performance be extrapolated would compromise the anchoring function of characterized by an absence of persistent and/or the implant after 20 years.8 irreversible signs and symptoms such as pain, infections, neuropathies, parasthesis, or violation SUCCESS OF IMPLANT TREATMENT of the mandibular canal Although widely accepted, the criteria presented by both 5. That, in the context of the above, a successful Albrektsson et al. and van Steenberghe, both focus on the rate of 85% at the end of a five-year observation success at the implant level.6,8 Papaspyridakos et al. suggest period and 80% at the end of a ten-year period be that the evaluation of the success of implant treatment should a minimum criterion for success. be comprehensive and consider additional criteria such as the health status and appearance of the peri-implant soft Table 1. Criteria for implant success - Albrektsson, Zarb, tissues, prosthodontic parameters and patient satisfaction.9 Worthington and Eriksson6 Papaspyridakos et al(9) reviewed the success criteria used in 25 studies grouping them under four main headings. (Table IMPLANT SUCCESS 2) Assessment was considered at the level of the implant, the peri-implant soft tissue and the prosthesis, with the Having survived the prescribed review time, the success fourth group describing patient satisfaction. Papaspyridakos of dental implants may be considered as the absence of et al. noted that the parameters of patient satisfaction or complications. The clinical evaluation of dental implant prosthetic -level assessment were less frequently used.9 If success has been described with both subjective and objective we were to consider both the clinical outcome measures, as criteria. In the ‘pre-modern’ era, the criteria for implant success, presented at the NIH/Harvard Consensus Conference

35 well as measures of patient satisfaction, this would result in IMPLANT COMPLICATIONS a more complete assessment of the oral health outcomes of treatment. Lang and Zitzmann described Patient-reported The literature regarding implant performance, although outcome measures (PROMs) as subjective reports of patients’ qualified at times due to methodological issues, would perceptions of their oral health status and its impact on their indicate to both the patient and clinician a high survival rate. quality of life.10 They identified the significant value of such The survival of implants may vary according to the prosthesis qualitative research in implant dentistry, however, conceded category (74.7%-100%).2 Also, there may be different factors that there is a lack of standardization in methodology. influencing the survival of the implant-supported prosthesis (single or multiple teeth) that are not reflected in the Assessment of implant success assessment at the implant level.3,4 These results also indicate that there is a percentage of failure that occurs at the implant Category Criteria level. The recognition of implant failure or complications is an important considerations in the discussion with the patient Implant level Pain and the proposal of any treatment. In the context of informed Bone loss < 1.5mm 1st year consent there is a duty of care to provide the patient with Annual bone loss < 0.2 mm sufficient and accurate information that is relevant to the thereafter individual’s situation. Radiolucency Mobility Berglundh et al. described implant complications as either Infection Biological or Technical.2 Biological complications present in the peri-implant hard and/or soft tissues and have an Peri-implant soft tissue Probing depth > 3 mm impact on implant function. This includes implant failure, level Suppuration peri-implant bone loss and soft tissue complications such as Bleeding signs of inflammation, mucositis, bleeding, suppuration and Swelling soft tissue dehiscences. Technical complications referred to Plaque Index mechanical damage of the implant or implant components Width of keratinized mucosa and the prosthetic supra-structure. Esposito et al. described > 1.5 mm similar criteria, however, added Iatrogenic complications Recession (nerve damage and wrong alignment of the implants) and Inadequate patient adaptation (phonetic, aesthetic and/or Prosthetic level Minor complications (chair- psychological problems).11 side approach) As discussed earlier implant survival/loss is the most Major complications / frequently described criteria of implant performance. failures On the other hand biological complications (soft tissue complications, peri-implantitis and bone loss of greater than Aesthetics 2mm) have been reported in only 30–60% of the clinical studies.2,3,4 Jung et al. identified the reporting of biological Functional complications in 33% of studies of single tooth implants.3 The 5-year cumulative rate of peri-implant bone loss (> 2 Patient satisfaction Lack of discomfort/ mm) was 5.2% (95% CI; 3.1%–8.6%) and for soft tissue paresthesia complications (signs of inflammation, mucosal inflammation, Satisfactory appearance mucositis, bleeding, suppuration and soft tissue dehiscences) Ability to chew was 7.1% (95% CI; 4.4%–11.3%). Ten of the 32 studies Ability to taste (31%) reviewed by Pjetursson et al. described biological General satisfaction complications in implant-supported fixed prostheses.4 The 5-year cumulative rate for bone loss of greater than 2mm was Table 2. Assessment of implant success - criteria grouped 2.6% (95% CI; 2.0%–5.5%) and for soft tissue complications according to category as per Papaspyridakos et al.9 was 8.5% (95% CI; 5.5%–13.2%). Of the studies reporting on biological complications the mean incidence appears to be low, however there have been significant variations noted in the range of results recorded. Again due to methodological issues it is difficult in many cases to identify what might be the underlying factor or factors that are responsible for the variation in complication rates. The other important element when assessing and comparing the results in the literature is a need to have a consistent definition and diagnostic criteria for the clinical entity of interest. Of relevance in the category of biological complications is the definition of the peri-implant diseases, peri-implant mucositis and peri-implantitits. Both involve an inflammatory reaction involving the peri-implant tissues. Peri-implant mucositis is a reversible inflammatory reaction involving the mucosa surrounding a functioning implant.

36 Peri-implantitis, will in addition to the inflammatory reaction have been categorized as polished, turned, moderately rough in the mucosa, show irreversible loss of supporting bone of an (Sa between 1.0 and 2.0 mm) and rough surfaces. Some implant in function. studies have shown an increased prevalence of peri-implant mucositis and peri-implantitis associated with rough surface Tomasi and Derks in a review of the quality of reporting implants (such as ITI TPS implants). However, other studies and case definition of peri-implant diseases identified two have shown no increased risk of peri-implant disease when incidence studies and six prevalence studies reporting on comparing turned implants with moderately rough (etched peri-implant disease.12 The two incidence studies showed surface-modified) implants. It has been noted that due to a significant variation in the results (peri-implant disease the variability of study populations and the confounding incidence of 1% and 22.8%) and therefore provide little effect of systemic health, smoking, hygiene and maintenance meaningful extrapolation to the clinical setting. The results of there appears to be no significant impact of implant surface the prevalence studies for peri-implant mucositis range from characteristics on the initiation of peri-implant disease.14 36.3% to 64.6% and for peri-implantitis range from 12.4% to 47.1%. Tomasi and Derks comment that the prevalence studies There are a number of surgical protocols that may be lack consistency in methodology and limited consideration employed in implant placement. In circumstances of given to bias and limitations.12 All studies utilized convenience inadequate native bone there may be a requirement for sampling with a subject drop-out rate of up to 50%. There ridge augmentation either prior to or at the time of implant was also no consistency in the case definition of disease, placement. The requirement for ridge augmentation either peri-implant mucositis or peri-implantitis. increases the surgical complexity and therefore the risks of complications or failure. Chiapasco et al. summarized the In summary it would appear that the literature does identify literature related to augmentation procedures and indicated the incidence of biological complications associated with that the survival rates of implants ranged from 92% to 100% dental implants. However, the limitations in interpreting for Guided bone regeneration; 60% to 100% for onlay bone these results are firstly, it appears that complications were grafts; 91% to 97.3% for ridge splitting/expansion techniques; not consistently reported and secondly that when they were 90.4% to 100% for Distraction osteogenesis; and, 88.2% for recognized the diagnostic criteria varied. Therefore, clinician revascularized flaps.15 may have some difficulty in translating this qualified evidence to the clinical setting. The depth and angulation of the implant, as well as the proximity to teeth and other implants will directly impact on RISK INDICATORS FOR PERI-IMPLANT DISEASE the integrity of the overlying peri-implant soft tissue. Clinically this may be related to the thickness of the overlying mucosa, Even with the limitations of the literature, the experience of the width of the keratinized tissue and the integrity of the most clinicians is that, peri-implant disease, is a recognized inter-dental/inter-implant papillae. Evans and Chen identified biological complications in the provision of implant treatment. that the prevalence of mucosal recession on the facial aspect The accumulation of bacterial biofilm is considered as the in cases of immediate implant placement was related to the primary aetiological factor associated with the development gingival biotype.16 Recession of ≥1 mm was evident in 40.5% and progression of peri-implant disease.13 There may also be of sites; (45.8% for thin tissue biotype and 33.3% for thick a number of local and systemic factors that increase the risk biotype). In cases where the implant was positioned more of the initiation and/or progression of disease. It has been buccally the recession was greater for both thin and thick recognized that due to the lack of prospective longitudinal biotypes; 85.7% and 66.7% respectively. Anecdotal evidence studies in implant dentistry it is difficult to identify true risk would suggest that a band of keratinized tissue would be factors associated with peri-implant disease.13 However, favourable for peri-implant hygiene and maintenance. There the literature does identify a number of local and systemic have been few studies that have evaluated the impact of the factors that are associated with biological complications presence or absence of peri-implant keratinized mucosa. such as implant failure, peri-implant mucositis and/or peri- Those that have been published show no association between implantitis. the absence of keratinized mucosa and peri-implant disease.13 LOCAL FACTORS The implant position and/or the prosthetic design and connection may potentially increase the difficulty for the The local factors that may lead to biological complications patients’ plaque control and professional maintenance. The have their point of influence either at the post-surgical depth of the implant placement will result in a deeper peri- healing and/or the accumulation of plaque (encourage plaque implant sulcus. This pseudo-pocketing coupled with the design accumulation or hinder plaque removal). The local factors of the prosthesis and position in the arch may hinder access that may be associated with an increased risk of biological for effective of plaque control. The depth and angulation of complications include the implant surface characteristics, the implant may also compromise the seating and evaluation bone quality and quantity, and the implant orientation of the prosthesis, and in the case of cementation result in (position, depth, angulation and proximity to adjacent teeth/ residual cement material in the peri-implant sulcus. Where implants). Complications may also arise as a result of the there has been significant ridge remodeling the design of the thickness and characteristics of the overlying mucosa or prosthesis may need to compensate for soft tissue deficiency design features of the prosthesis. or incorporate ridge-lap features to achieve the required support for the soft tissue, aesthetics, occlusal function and It has been proposed that the implant surface characteristics phonetics. This ridge-lap design may hinder access for oral and roughness may encourage the accumulation of plaque hygiene, routine assessment and maintenance. and result in an increased risk of the initiation and progression of peri-implant disease. The implant surface characteristics

37 SYSTEMIC FACTORS Karoussis et al. presented data on a 10-year prospective cohort study describing the incidence of implant failure and In addition to the local factors there are a number of patient- peri-implant disease in patients with and without a history based risk indicators, which may contribute to the prevalence of periodontitis.20 The patients received ITI TPS hollow of biological complications. Patient-based factors may screw implants. The results indicated a significantly higher interfere with hard and/or soft tissue healing or increase the failure rate in the periodontitis group relative to the control susceptibility for the initiation of disease. A number of recent (non-periodontitis) group; 10% and 3.5% respectively. The reviews have highlighted the methodological issues that limit incidence of peri-implantitis (defined as >5mm periodontal the ability to establish a significant link between various probing depth; bleeding on probing and suppuration) was systemic conditions and implant complications.13, 17, 18, 19 Diz et also significantly higher in the periodontitis group (28.6%) al. suggest that although there may be a number of conditions relative to the control (5.8%). The results suggested that with that increase the risk of implant complications there appears a decrease in periodontal health correlates with a decrease to be few absolute contraindications to treatment. 19 These peri-implant health. However, in reviewing the research, risk indicators may be characterized as systemic conditions Heitz-Mayfield suggested that there may be some difficulty in or treatment, a history of periodontal disease and smoking. drawing significant conclusions from the literature due to the variability of study design, the definition of the periodontal When considering any surgical procedure there are a number case, diagnosis and reporting of peri-implant disease, the of systemic conditions which may be relevant with regard to level of supportive periodontal therapy and the impact of intra- or post-operative bleeding, post-operative infection confounding factors such as smoking.13 However, with this in or compromise initial wound healing. There is a need to mind the systematic reviews have described a significantly ensure adequate pre-operative preparation to reduce these greater incidence of peri-implantitis and increased peri- procedural risks. Some of the more common systemic implant marginal bone loss in individuals with periodontitis- conditions that have been studied to assess the contributory associated tooth loss.14 impact on peri-implant disease include, Diabetes, radiotherapy and bisphosphonate therapy. Cigarette smoking has been recognized as a contributing factor to the initiation and progression of periodontitis. The The review of the clinical literature suggests that there is no impact of smoking has been related to its negative effect on significant difference in the prevalence of implant failure or wound healing and on components of the host response. These complications in patients with diabetes.13, 17, 18, 19 Given the well same mechanisms may be of relevance in implant-associated documented evidence of compromised healing in those with complications. The implant failure rates in smokers has been poorly controlled diabetes, the inclusion criteria of implant described between 12 to 23% and as high as 33% in cases of studies may have required the blood glucose levels to be well onlay bone grafting.15,17 A number of studies and systematic controlled prior to surgery. reviews have identified the significant association between smoking with peri-implant mucositis, marginal bone loss and Bone turnover and repair are compromised with both peri-implantitis.13, 17, 18, 19 the effect of bisphosphonate therapy and radiotherapy. Bisphosphonates may be administered either orally or FINAL CONSIDERATIONS intravenously with the potential complication being the development of Osteonecrosis of the jaw (ONJ). The The literature indicates high and predictable survival rates presentation of ONJ has been described in cases where the of dental implants and the success of implant dentistry. It is bisphosphonate therapy was commenced either prior to or recognised that the factors contributing to success are multi- after implant placement. The estimated prevalence of ONJ factorial in nature, with documented local and systemic risk in implant patients taking oral bisphosphonates has been indicators that may contribute to complications. However, calculated to be less than 1%.19 Although there appears to be the literature can only report on what is observed, influenced no significant increased risk of implant failure in association by how it is recorded and in many cases qualified by the with oral bisphosphonates, one must consider the increased characteristics of the study population. One must concede difficulty in the management of the ONJ lesion.19 Intravenous that survival, success and complications have most frequently bisphosphonates pose a greater risk of implant complications been described at the implant level. and some authors have suggested that this should be considered as a contra-indication for implant therapy.19 Where possible the principles of evidence-based practice Significant implant failure rates have been attributed to the should be implemented. However, we may not be able to rely effect of radiotherapy. Liddelow and Klineberg17 noted the on the literature in circumstances of incomplete, inconsistent documented failure rate was as high as 28% in sites having or unclear results. The onus, therefore, is then on the clinician been exposed to radiation dose of 50Gy. The have also been to work from basic principles in the provision of care for the inconsistent findings regarding the impact of hypobaric individual patient. In the clinical setting the focus is providing oxygen therapy in reducing the incidence of implant failure.17 predictable patient-based outcomes such as comfort, function, aesthetics and stability. Implant dentistry could be Often the consequence of periodontal disease has been the considered an example of tertiary level treatment – following loss of teeth and in such cases implant therapy is considered emergency management, and disease control and dental/oral for rehabilitation and reconstruction. It has been suggested stabilization. Predictable outcomes are a product of thorough that the periodontally-susceptible patient may present with clinical evaluation, including risk assessment, and dialogue to host-related factors that could contribute to an increased establish the patients needs. risk of peri-implant disease. Also periodontal pathogens residing in sites of untreated or unstable periodontitis may contribute to the colonization of the peri-implant sulcus.

38 REFERENCES 12. Tomasi C, Derks J. Clinical research of peri-implant diseases – quality of reporting, case definitions and methods to study incidence, prevalence 1. Albrektsson T, Brånemark PI, Hansson HA, Lindström J. Osseointegrated and risk factors of peri-implant diseases. J Clin Periodontol 2012;39 titanium implants. Requirements for ensuring a long-lasting direct (Suppl 12):207–23. bone-to-implant anchorage in man. Acta Orthop Scand 1981;52:155-70. 13. Heitz-Mayfield LJA. Peri-implant diseases: diagnosis and risk indicators. 2. Berglundh T, Persson L, Klinge B. A systematic review of the incidence J Clin Periodontol 2008;35 (Suppl 8):292–304. of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. J Clin Periodontol 14. Renvert S, Polyzois I, Claffey N. How do implant surface characteristics 2002;29 (Suppl 3):197–212. influence peri-implant disease? J Clin Periodontol 2011;38 (Suppl 11):214–22. 3. Jung RE, Zembic A, Pjetursson B, Zwahlen M, Thoma D. Systematic 15. Chiapasco M, Zaniboni M, Boisco M. Augmentation procedures for the review of the survival rate and the incidence of biological, technical rehabilitation of deficient edentulous ridges with oral implants. Clin Oral and esthetic complications of single crowns on implants reported in Impl Res 2006;17 (Suppl 2);136–59 longitudinal studies of at least 5 years. Clin Oral Impl Res 2012;23 (Suppl 6):2–21. 16. Evans CD, Chen ST. Esthetic outcomes of immediate implant placements. Clin Oral Impl Res 2008;19:73–80. 4. Pjetursson B, Thoma D, Jung R, Zwahlen M, Zembic A. A systematic review of the survival and complication rates of implant supported fixed 17. Liddelow G, Klineberg I. Patient-related risk factors for implant therapy. dental prostheses (FDPs) after a mean observation period of at least 5 A critique of pertinent literature. Aust Dent J 2011;56:417–26 years. Clin Oral Impl Res 2012;23 (Suppl 6):22–38. 18. Bornstein MM, Cionca N, Mombelli A. Systemic Conditions and 5. Schnitman PA, Shulman LB. Dental Implants: Benefits and Risk, an NIH- Treatments as Risks for Implant Therapy. Int J Oral Maxillofac Implants Harvard consensus development conference. U.S. Dept. of Health and 2009;24:12–27 Human Services, 1979 pp.1-351. 19. Diz P, Scully C, Sanz M. Dental implants in the medically compromised 6. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The Long-Term patient. J Dent 2013;41:195-206 Efficacy of Currently Used Dental Implants: A Review and Proposed Criteria of Success. JOMI 1986;1:11–25. 20. Karoussis IK, Salvi GE, Heitz-Mayfield LJA, Brägger U, Hämmerle CH, Lang NP. Long-term implant prognosis inpatients with and without a 7. Schwartz-Arad D, Herzberg H, Levin L. Evaluation of Long-Term Implant history of chronic periodontitis: a 10-year prospective cohort study of Success. J Periodontol 2005;76:1623-8. the ITI Dental Implant System. Clin Oral Impl Res 2003;14:329–39. 8. van Steenberghe D. Outcomes and their measurement in clinical trials of Address for correspondence endosseous oral implants. Ann Periodontol. 1997;2:291-8 Academic Lead in Periodontology 9. Papaspyridakos P, Chen CJ, Singh M, Weber HP, Gallucci GO. Success Department of Dentistry and Oral Health Criteria in Implant Dentistry: A Systematic Review. J Dent Res La Trobe Rural Health School 2012;91:242-8 La Trobe University 10. Lang NP, Zitzmann NU. Clinical research in implant dentistry: evaluation [email protected] of implant supported restorations, aesthetic and patient-reported outcomes. J Clin Periodontol 2012;39 (Suppl 12):133–8. 11. Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factors contributing to failures of osseointegrated (I). Success criteria and epidemiology. Eur J Oral Sci 1998;106:527–51.

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 39-44 MINIMALLY INVASIVE AESTHETIC RESTORATION WITH INNOVATIVE ADHESIVE MATERIALS Professor Junji Tagami, D.D.S., Ph.D. Dr. Tagami is Dean of the Faculty of Dentistry and Dean of Graduate School at Tokyo Medical and Dental University. ABSTRACT Among the adhesive resin materials, the 2-step self etching adhesive is now recognized as the gold standard of adhesive. By the self etching adhesive, the so called “Super Dentin” is created at the dentin adjacent to bonding resin, which is more resistant to the acid and basic attack than normal dentin. Even with excellent adhesive materials, the shrinkage stress of the composite resin is still a concern in clinical situation. The purposes of this article is to provide the latest information on the adhesive resin materials and the clinical procedure to obtain perfect adaptation of filling material to cavity floor and walls. The minimally invasive approach in caries treatment which is effective to reduce the post operative sensitivity is also introduced. INTRODUCTION Kuraray. This material consisted of the total etching technique by phosphoric acid and the chemical cured bond containing Because of the developments of adhesive resin materials, the functional, adhesive monomer, named Phenyl-P. In Clearfil Minimal Intervention Dentistry, which is a minimally New Bond, new functional monomer, MDP, was utilized instead invasive operative approach for treatment of cavitated of Phenyl-P, which exhibited extremely increased dentin lesions or healing the non-cavitated lesion became bond strength. After application of the photo curing catalyst, possible.1 Understanding the bond mechanism is believed Clearfil Photo Bond, a dual cure type adhesive, the dentin bond to be important to manipulate the materials for deriving the strength increased drastically again. maximum performance of materials. In 1991, an adhesive primer was developed and combined The recent adhesive resin materials are classified into 2 with the etching and bonding procedures in Clearfil Liner categories. The one consisted of phosphoric acid etching to Bond. At the same time, the acid etchant was changed enamel and dentin, which was initially named as total etching from phosphoric acid to 10% citric acid containing 20% technique.2 This type of adhesives is now said as the etch and ferric chloride, 10-20 solution. Additionally, a low viscosity rinse type adhesives. Another type of adhesive consisted of resin named Protect Liner, which must have been the first self etching type adhesives. The self etching type materials flowable compojite resin, was applied after the light curing does not require the etching with phosphoric acid. The the bond, before composite resin application. The clinical enamel and dentin is etched by the application of the self tests in 1990s evaluated this boning material as the best. etching primer or self etching adhesive. The acidity of the self Probably the coating the bond layer with flowable resin etching primer and adhesive is provided by the adhesive resin provided durable bonding in clinical situation. monomers which contains phosphoric base or carboxylate base (Fig.1). The functional adhesive resin monomers were also described as the acidic resin monomer because they usually included At the moment, regarding to the dentin bonding, the adhesive the acidic bases such as phosphoric or carboxyl groups. These consisted of the self etching primer and the adhesive resin adhesive resin monomers were used as the ingredient of primer is recognized as the gold standard among the researchers.3 solution, which might have been the indication of development The enamel bonding is not so much complicated and the self of the self etching technique. In 1993, the first products with etching type of the adhesive is clearly shown to provide very the self etching primer, were launched as the products names stable and high bond strength to enamel without phosphoric of Clearfil Liner Bond 2, and ED primer for Panavia. acid etching.4  Then after the self etching technology, the materials became FACTORS FOR BONDING one bottle self etching primer and bond in the product of Clearfil SE Bond. Reviewing the history of development of adhesive resins, especially by Kuraray Medical Inc., is informative to understand NEW CONCEPT OF DENTIN BONDING the mechanism adhesion of recent dental adhesive materials. Particularly, dentin bonding has been improved step by step The dentin bonding has been explained to be obtained by with various technologies such as, surface treatment by acid, creation of the hybrid layer, in other words, micro-mechanical functional resin monomer, catalyst system, primer, self etching bonding. Creating the hybrid layer, the adhesive resin technology, application of a flowable resin, and so on (Fig. 2). monomers were considered to be necessary.5 However, the hybrid layer has been pointed out to be very susceptible to For the first product by Kuraray, Clearfil Bond F, was launched the gradation process, and this is considered to be the cause in 1978 by the collaboration between Prof. Takao Fusayama and of the problem in dentin bond durability.6

40 In general, all the adhesive resin monomers had been considered to be the cause of degradation of both bonding designed and synthesized with the expectation of chemical resin and hybrid layers. It was reported that compared reaction with hydroxy apatite (HAp). For many years, the with the self-etching systems, strong acidic treatment like chemical reaction had not been confirmed because of the phosphoric acid etching decreased bond strength significantly lack of appropriate technique for analysis. Fortunately the in evaluation of adhesion to dentin long-term durability.12 The recent studies revealed the real chemical bonding, which is weakest layer at the interface of dentin and etch and rinse the ionic bond different from the hydrogen bond, occurred type adhesive is thought to be the de-mineralized dentin between MDP and HAp in a very short period, and the salt without penetration of bonding resin, which is the naked was very stable in water.7,8 collagen layer damaged by phosphoric acid. The chemical bonding with HAp, which had been expected to The dentin bond durability was also improved by adhesive the adhesive resin monomers, is confirmed to be achieved in resins that can release fluoride ion. The recent material the cases of some monomers. The reaction is believed to occur consisted of self-etching primer and fluoride releasing bond, in the hybrid layer and/or at dentin under the hybrid layer. showed stable dentin bonding even after a long period storage in water (Fig. 5).13 Also, the material exhibited the thicker SUPER DENTIN Super Dentin creation than the materials without fluoride release (Fig. 6).14 Fig. 7 shows the difference of the super Through the studies of dentin bonding, a new dentin structure dentin formation between the bonding resin with (bottom) or that showed more resistant to the acid and base attacks than without (top) fluoride release. normal dentin. This acid-base resistant dentin is observed adjacent to the hybrid layer only when the self-etching type For further improvement of the dentin bond durability, adhesives are applied.9 We named this new dentin layer as the mechanical properties of the bond layer is believed to be “ Super Dentin”(Fig. 3).10 effective. The component of the bonding resin is one of the factor for the mechanical strength. In addition, the higher The mechanism of creating the Super Dentin is still unclear, conversion should be achieved by developing or modifying however, the penetration of the adhesive resin monomer to the catalyst system. A recent trial has shown the possibility the dentin under the demineralization front by self etching of the next generation of adhesive with extremely high effect must be necessary. Plausible chemical modification of mechanical property. dentin with the adhesive resin monomers is expected. PREVENTION OF GAP FORMATION AT CAVITY FLOOR The Super Dentin is believed to be very effective to prevent the recurrent caries at the dentin margin, as well as improvement In the clinical situation the gap is often propagated even of dentin bond durability. when the excellent adhesive is used. It is because of the contraction stress during the polymerization. The bulk filling DURABILITY OF DENTIN BONDING tends to create more gap than in the case of the incremental filling technique. A recent study revealed that the one step The investigation of small voids and defects at the dentine adhesive exhibited gap formation, however, a 2-step self adhesive interfaces can evaluate the quality of bonding etching material prevented the gap completely even with system used. Silver particles from a silver nitrate solution the bulk filling procedures in 2-mm deep cavity. The flowable that can infiltrate into dentin adhesive interface could clearly resin composite lining was very effective to prevent the gap indicate these subtle voids under the SEM observation. These even with the one step adhesives (Fig. 8).15   space is recognized as the nano-leakage space,11 which is observed at the bottom area of the hybrid dentin. In the MINIMALLY INVASIVE CAVITY PREPARTION case of a etch and rinse type adhesive, silver particles were observed at the bottom of the hybrid layer, which shows The long term clinical evaluation revealed excellent clinical bonding resin infiltration was insufficient in this area, even performance with adhesive resin composite restorations.16,17,18 though collagen fibrils were exposed by phosphoric-acid- The restoration was performed under the procedures etched demineralization. Water can also easily penetrate as established by Takao Fusayama.19 The dentin carious lesion well as silver nitrate in this area. Substances which damage was removed by using slow speed round burs under the guide collagen are also able to penetrate. In such circumstances, of caries staining dye solution. The point is that only the outer collagen and/or bonding resin degradation can occur easily, lesion is removed leaving the inner carious lesion, since the and failure of the adhesive interface is suspected to occur inner layer is not stained by the solution. The inner carious soon after bonding. dentin is softened slightly, however, bacterial invasion is limited in the outer lesion (Fig. 9).19 The remained inner layer The etch and rinse type of adhesives tends to show more of carious dentin consisted of dentinal tubules which are nano-leakage space than the self-etching type adhesive. occluded with the mineral crystals. The dentin permeability The results for this self-etching product, using this above is extremely reduced in the inner carious dentin, which is said method showed no silver particles at the adhesive interface. to be the caries affected dentin. Because of the presence This result showed the self-etch type adhesive was able to of the caries affected dentin at the bottom of cavity floor, achieve consecutive infiltration and polymerization of into the sensitivity of the tooth during the excavation of carious tooth substances.11 lesion is very low and the shot of anesthesia is not needed (Fig.s 10-12). Even in the case of deep cavities, the lining is Fig. 4 shows the schematic adhesive interface between not necessary since the cavity floor dentin is not permeable bonding resin and dentin treated with etch and rinse (Fig. 4 nor sensitive because of the mineral crystal deposition in the top) and self-etch type adhesive (Fig. 4 bottom) respectively. The defects in the bonding resin and/or hybrid layer were

41 dentinal tubules and reparative dentin formation. The post operative tooth sensitivity cannot be seen as far as the outer lesion is excavated and the inner lesion is preserved. CONCLUSIONS The minimally invasive restoration became possible because Fig 1. Adhesive resin monomers, of very reliable adhesive resin materials. The author prefers Phenyl-P: Methacrylic acid 2-(phenoxyphosphonyloxy)ethyl ester direct restorations because the direct bonding is still more MDP: 10-Methacryloyloxydecyl dihydrogen phosphate reliable than indirect bonding even with the latest materials. The selection of the adhesive material and the application of appropriate procedures to prevent troubles and to obtain maximum performance of the material are essential for the clinical success. REFERENCES MAC-10: 2-[10-(Methacryloyloxy)decyl]malonic acid 1. Tyas MJ, Anusavice KJ, Frenken J, Mount GJ, Mnimal Intervention 4META: 4-[2-(Methacryloyloxy)ethoxycarbonyl]phthalic dentistry -a review FDI Commission Project, Int Dent J 2000;50:1-12. anhydride 2. Fusayama T, Nakamura M, Kurosaki N et al. Non pressure adhesion of a MPa 2BSE 2BDC 1BDC new adhesive restorative resin. J Dent Res 1979;58:1364-1370. 18 10‐20  3. Scherrer SS, Cesar PF, Swain MV. Direct comparison of the bond 16 SAP strength results of the different test methods:a critical literature review. MDP Dent Mater 2010;26:e78-93 14 PL 4. Shimada Y, Tagami J. Effect of regional enamel and prism orientation on 12 Adhesive failure resin bonding. Opera Dent 2003;28:20-27. 10 PA 5. Nakabayashi N . The promotion of adhesion by the infiltration of 8 PA MDP monomers into tooth substrates. J Biomed Mater Res 1982;16:265-273. 6 PA MDP Cohesive failure  4 PP of dentin 6. Burrow MF, Tagami J, and Hosoda H. The long term durability of bond strengths to dentin. Bulletin of Tokyo Medical and Dental University, 2 1993;40:173–191. 0 NB PB LB LB2 LB2Σ MSEEGBA  7. Yoshida Y, Nagakane K, Fukuda R, et al.(2004). Comparative study on adhesive performance of functional monomers. J Dent Res 83:454-458 CBF 8. Yoshihara K, Yoshida Y, Nagaoka N et al., Nano-controlled molecular 1978      1984    1987      1991    1993     1998     1999      interaction at adhesive interfaces for hard tissue reconstruction, Acta Biomaterialia 2010;6:3573-3582 Fig 2. Accumulated results of adhesive resin, dentin bond strength of products by Kuraray Medical Inc. from CBF to 9. Tsuchiya S, Nikaido T, Sonoda H, et al.. Ultrastructure of the Dentin MEGA. (Results from researches of Cariology and Operative -Adhesive Interface after Acid-base Challenge. J Adhes Dent Dentistry, Tokyo Medical and Dental University: unit MPa) 2004;6:183-190. CBF: CLEARFIL BOND SYSTEM-F (total etching) 10. Nikaido T, Weerasinghe DD, Waidyasekera K, Inoue G, Foxton RM, Tagami J. Assessment of the nanostructure of acid-base resistant zone by the NB: CLEARFIL NEW BOND (change from Phenyl-P to MDP) application of all-in-one adhesive systems:Super dentin formation. Bio- med Mater Eng 2009;19(2):163-71. PB: CLEARFIL POHTO BOND (photo polymerization) 11. Yuan Y, Shimada Y, Ichinose S, Tagami J. Qualitative analysis of adhesive LB: CLEARFIL LINER BOND SYSTEM (introduction of primer) interface nanoleakage using FE-SEM/EDS. Dent Mater 2007;23;561-569. LB2: CLEARFIL LINER BOND 2 (self-etching primer) 12. Okuda M, Pereira PNR, Nakajima M, Tagami J, Pashley DH. Long term durability of resin dentin interface:Nanoleakage vs microtensile bond LB2V: CLEARFIL LINER BOND 2V strength. Opera Dent 2002;27(3):289-296. (self-etching primer and dual-cured bonding) 13. Nakajima M, Okuda M, Ogata M, Pereira PNR, Tagami J, Pashley DH. The SEB: CLAERFIL SE BOND durability of a fluoride-releasing resin adhesive system to dentin. Opera (one-step self-etching primer and bonding) Dent 2003;28:186-192. After LB2, failure of dentin occurred in adhesive tests, and 14. Shinohara MS, Yamauti M, Inoue G, et al.. Evaluation of antibacterial adhesive failure was not observed. and fluoride-releasing adhesive system on dentin-microtensile bond strength and acid-base challenge. Dent Mater J 2006;25:545-552 15. Yahagi C, Takagaki T, Sadr A, Ikeda M, Nikaido T, Tagami J. Effect of lining with a flowable composite on internal adaptation of direct composite restorations using all-in-one adhesive systems. Dent Mater J. 2012;31 :481-488. 16. Akimoto N, Takamizu M, Momoi Y. 10-year climical evaluation of a self- etching adhesive system. Oper Dent 2007;32:3-10 17. Burrow MF, Tyas MJ. Clinical evaluation of three adhesive systems for the restoration of non-carius cervical lesions. Oper Dent 2007;32:11-15 18. Peumans M, De Munck J Van Landuyt K et al.. Five year clinical effectiveness of Twostep self-etching adhesive. J Adhes Dent 2007;9:7-10 19. Fusayama T. A simple pain-free adhesive restorative system by minimal reduction and total etching. Tokyo, St.Louis, Ishiyaku Euro America Publishers, 1993:9.

Original tooth surface 42 Super dentin Fig 3. Scanning electron microscopic image of the interface between dentin and CLEARFIL SE BOND after the acid and base challenges14). Red arrow: defect created by the acid- base challenge, Yellow arrow: width of super dentin Hybrid layer Bonding resin B H DD D Fig 4. Schematic representation of dentin adhesive interface created by etch and rinse type adhesive(top) and Clearfil SE BH D Bond(bottom). B: Bonding layer H: Hybrid layer DD: Collagen layer, covered with neither resin nor hydroxyapatite. D: Dentin Fig 5. Dentin bond durability of the fluoride-containing 45 bonding resin is better than that of the bonding resin 40 without fluoride under the accelerated aging condition. 35 SEB: Clearfil SE Bond 30 25 1 day LBF: Clearfil Liner Bond F (fluoride releasing adhesive) 3 momths 20 6 momths 15 10 5 0 F (+) F (‐) SEB LBF Fig 6. Scanning electron microscopic image of the interface between dentin and CLEARFIL LINER BOND F after the acid and base challenges14). Red arrow: defect created by the acid-base challenge, Yellow arrow: width of super dentin

B H SD D 43 B H SD D Fig 7. Schematic representation of dentin adhesive interface created by Clearfil SE Bond(top) and Clearfil Liner Bond Plus(bottom). B: Bonding layer H: Hybrid layer SD: Super Dentin D: Dentin 100 No flowable Fig 8. Cavity adaptation rate(%) of adhesive resin materials 90 Flowable with and without lining of flowable composite. 80 70 SE: Clearfil SE Bond, BF :Bond Force, GP: G-Bond Plus, OP 60 :OptiBond All-in-one, 50 40 GBP OP BF 30 20 10 0 SE Knoop Hardness Number Caries affected Intact dentin Fig 9. Schematic illustration of the relationship of dentin dentin hardness, crystal deposition, bacterial invasion and sensitive odontblastic process19). Caries Pulp infected dentin EDJ Transparent dentin bacteria “Caries-arrested” Mineral deposits Odontblastic process Fig 10. Cavity preparation for treatment of deep proximmal caries.

44 Fig 11. After restoration. Fig 12. Dental radiograph. Address for correspondence Professor and Chair, Cariology and Operative Dentistry, Department of Restorative Sciences, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan [email protected]

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 45-47 HYPODONTIA – THE CHALLENGES OF RESTORATION IN THE YOUNG PATIENTS Kathryn Harley BDS MSC FDS RCSEng FDS RCSEd FDS RCPSG FFGDP(UK) Miss Harley is a Consultant in Paediatric Dentistry at the Edinburgh Dental Institute and Dean of the Faculty of Dental Surgery, The Royal College of Surgeons of England. ABSTRACT Severe Hypodontia is present when six or more permanent teeth (excluding third permanent molars) are absent. This presents a significant challenge for the Paediatric Dentist who will be required to restore function and aesthetics whilst the child is growing and the dentition developing. A range of treatment options may be considered including removable and fixed prostheses as well as direct restorations. Much of what can be achieved will depend on whether or not the child is able to comply with treatment. Microdont teeth, a lack of clinical crown height and restricted alveolar growth all contribute to the complexity of management in young patients. It is important to ensure that children can access appropriate care as much can be done to improve their dentitions. INTRODUCTION rubber dam and the ability to maintain good oral health. What makes this group a particular challenge for the dentist is not Hypodontia is defined as the developmental absence of one only the missing teeth but the shape and size of those teeth or more teeth, which can affect both the primary and the which are present. Microdont teeth, whether conical or not, permanent dentition. The prevalence of hypodontia in the together with a lack of clinical crown height place demands permanent dentition in Britain is 3.5-6.0%.1 The absence of six on both the operator and the adhesive materials he/she may or more teeth, excluding third permanent molars, is defined use to restore the dentition. as severe hypodontia and is much less common affecting 0.1- 0.2 % of the population.2 Whilst the aetiology of hypodontia Young children (with some primary or/and permanent teeth) is multifactorial, genetics undoubtedly plays a key role can be managed in the primary dentition with a combination particularly in cases of severe hypodontia where it is likely to of removable prostheses and composite resin restorations. occur as a feature of a syndrome such as Ectodermal Dysplasia Composite build-ups of primary incisors to provide a more (ED). This syndrome is said to be present when two or more normal shape and form can be rewarding for both the child abnormalities of ectodermal structures are present, already and parent provided patient compliance is achievable. more than 150 ED syndromes have been identified many of Partial dentures may also need the assistance of composite which involve the teeth e.g. Tooth and Nail Syndrome.3 additions to modify the shape of denture abutment teeth so that undercuts can be created facilitating placement of The majority of children with severe hypodontia will require appropriate clasps for denture retention. Restoration of the a wide range of dental treatment throughout their lives vertical dimension in children where there is/has been a hence early identification and referral for specialist advice lack of opposing teeth completely changes their facial shape is essential to ensure appropriate management. Following improving their appearance beyond recognition. the first referral to a specialist unit they are likely to see numerous clinicians often as part of a multidisciplinary team Anodontia or the complete absence of teeth represents a who will discuss the various treatment options available. major handicap for a child. However it is almost easier to treat than when a small number of often awkwardly shaped THE EARLY YEARS – BEFORE ORTHODONTIC teeth are present. For the child with no teeth, the provision INVOLEMENT of complete dentures at a time when the child can readily adapt to the presence of a “foreign body” in their mouth is Step one is the diagnosis. At this stage it is necessary to immensely gratifying. The earlier these are fabricated the establish which teeth are present in the mouth following a more success one can expect, the only limitation being patient clinical examination or radiograpically to determine the compliance. The initial appointment is probably the most presence of unerupted but developing teeth. The need for difficult when only crudely fitting stock trays are available the latter is paramount if the ridges are going to be covered to take impressions for casts from which special trays are with a baseplate as practitioners need to know which teeth fabricated. This is often the first time the child has had to sit will erupt. in the dental chair for a reasonable period of time and needs to keep their mouth open. If there is the opportunity and the How much treatment can be provided to improve aesthetics family can be provided with some trays to practice, Mum/ and function will depend on the wishes of the child (and to Dad can repeat putting empty trays into their child’s mouth some extent the parent) and their ability to co-operate with in preparation for the visit. Using special trays with addition the delivery of care. This is likely to involve long periods in a silicone to record accurate impressions of the edentulous dental chair, acceptance of local anaesthesia, placement of ridges at the second visit is infinitely easier than using

46 “runny” alginate and overextended trays at visit one. As with behave as ankylosed teeth becoming infra-occluded. In any technical procedure where laboratory work is required anodontia, alveolar height is unlikely to significantly alter the final result is dependent on the skill and expertise of the with growth thus placement of implants in the canine region technician. The number of visits from the first appointment has been recommended to aid denture retention.4 to completion excluding the initial consultation and any acclimatisation visit, is usually around six as follows: EARLY TEENS – JOINT WORKING WITH ORTHODONTIC COLLEAGUES • primary alginate impressions The options for restoration of the mouths of young patients • addition silicone secondary impressions using will depend on how many and which teeth are missing. custom trays Orthodontic management is necessary when movement of one or more teeth is required to facilitate satisfactory • try in of acrylic resin base plates with wax rims restoration whether removable, fixed or later implant plus retruded axis position jaw registration. supported prostheses are being considered. Realignment, redistribution of the spaces and alteration of the vertical • try in of wax set-up of teeth, further occlusal position of teeth will all be necessary prior to the provision of registration record if required definitive restorations. • final try in and fit of complete dentures Anterior Restorations • review and minor adjustment if necessary. Where teeth are present the most frequent requirement to improve aesthetics is alteration of tooth shape. Direct When the dentures are first issued the patient is advised composite resin additions for diminutive or conical teeth to to practice trying to bite on a straw such that it cannot be restore the size and shape of the clinical crowns of anterior removed from his/her mouth. The best way to gain their teeth to the dimensions of “normal” teeth are both effective comprehension as to what is required is to bite on a straw and conservative. There is no indication for the use of yourself and then ask the child to pull it from your mouth. The porcelain veneers or conventional crowns in the young child can see the action of you closing your teeth together patient. Occasionally extraction of a diminutive tooth may be and how this holds the straw in place. Closing teeth together considered to be the best option, particularly if it has a root and biting is a learned behaviour not a reflex which will which is similarly small. require repetition before it becomes spontaneous. Likewise the child is encouraged to keep the dentures in his/her mouth Whilst there remains a role for removable prostheses it is whilst eating although they may be readily abandoned in the more likely that smaller spaces will be restored with resin early days. The advice is for the child to wear the dentures all retained bridges. The success or failure of these will depend day taking them out at night before going to bed and storing on three key factors: them overnight either in water or water with a very small amount of washing up liquid which will require to be rinsed • surface area of the abutment teeth covered by the off in the morning. The dentures are cleaned with a medium metal framework toothbrush using either well diluted washing up liquid or non- abrasive toothpaste. • thickness and rigidity of the metal framework The change in facial appearance may be significant. Provision • control of the occlusion of adequate lip support, an increase in the vertical dimension and suddenly showing teeth when smiling has a tremendous Resin-retained bridges fabricated to replace missing anterior impact on the child’s confidence. Many parents state that a teeth can be highly successful restorations. A fixed-fixed dramatic improvement in speech can be heard immediately design (Figure 1) is recommended in the young patient and at last their child sounds coherent. where orthodontic treatment has been provided to reduce the possibility of relapse and space loss (Figure 2). This When it comes to partial dentures the instructions with regard design requires excellent framework design with maximal to cleaning, wear and storage are similar. coverage of the abutment teeth by the retainers. However a lack of clinical crown height may limit both coverage An often asked question is, “How will I know when the denture and also connector height. The latter being essential to no longer fits?” The answer is remarkably straightforward as it provide a prosthesis with sufficient rigidity. A surgical crown becomes uncomfortable to wear. For complete dentures in the lengthening procedure may be required to allow an adequate case of the maxillary base-plate the most frequent initial sign framework for the bridge to be provided. As no tooth of a problem is an ulcer on the hard palate in the post- dam preparation is necessary the technique is considered to be region. Growth of the facial skeleton in the AP direction results reversible. When/if the bridge eventually fails it is possible to in the post -dam moving from the soft palate onto the edge consider replacing it with another resin-retained bridge or an of the hard palate causing irritation to the mucosa. An ulcer implant as the abutment teeth will be sound. These bridges anywhere in the mouth sited at the periphery of one of the rely on effective adhesion between the luting cement and dentures is an indication that all is not well. Initially it will be due the etched enamel surface and the fit surface of the metal to overextension but once the denture has been successfully framework. The latter is obtained by sandblasting the nickel worn for a number of months it will be a sign that the base is chromium metal surface with 50micron aluminium oxide no longer seating properly which in a growing child is due to particles to create an oxide layer which bonds chemically to growth of the facial skeleton and alveolar development. the resin luting cement and mechanically to the roughened surface created. Whilst cantilever bridges offer advantages In the absence of teeth, alveolar growth is restricted. The placement of dental implants in children to retain prostheses is technically possible however as they osseointegrate they

47 with regard to longevity in the adult5 their use in the teenage In the maxilla these provide an acceptable restoration where patient is rarely indicated as most patients have received visibility of the metal framework is minimal. In the mandible orthodontic treatment. extension of the framework to include the occlusal surfaces of the abutment teeth results in greater visibility of metal which is a contraindication for some patients. In this instance it may be appropriate to consider early replacement with an implant before the resin-retained bridge has failed. It is not uncommon to need to wait several years following orthodontic treatment before an implant can be placed. This depends on the age of the patient at debond. If an implant is likely to be used to replace a missing tooth consideration must be given to the position and alignment of the roots of the abutment teeth. There are reports that after successful opening of the implant space roots re -approximate during retention and prevent implant placement. The placement of a resin bonded bridge will help reduce this occurrence.6 Fig 1. Palatal view of a fixed-fixed resin-retained bridge. REFERENCES 1. Brook AH. Dental anomalies of number, form and size: their prevalence in British schoolchildren. J Int Assoc Dent Child 1974;5:37-53 2. Hobkirk JA, Brook AH. The management of patients with severe Hypodontia. J Oral Rehabil 1980;7:289-298 3. Hodges SJ, Harley KE. Witkop tooth and nail syndrome: report of two cases in a family. Int J Paed. Dent. 9:207-211 4. Cronin RJ Jr., Oesterle LJ, Ranly DM. Mandibular implants and the growing patient. Int. J Oral Maxillofac Implants 1994;9:55-62 5. Djemal S, Setchell D, King P, Wickens J. Long term survival characteristics of 832 resin-retained bridges and splints provided in a post-graduate teaching hospital between 1975 and 1993. J Oral Rehabil 1999;26:302-330. 6. Olsen TM, Kokich VG, Postorthodontic root approximation after opening space for maxillary lateral incisor implants. Am J Orthod Dentofacial Orthop 2010;137:158 1-158.e8 Fig 2. Relapse following use of a cantilever resin-retained Address for correspondence bridge. Edinburgh Dental Institute Posterior Restorations 4th Floor, Lauriston Building Lauriston Place Again partial dentures (or orthodontic retainers) may be Edinburgh needed to provide post orthodontic retention until such EH3 9HA time as implant placement might be possible. Provided sufficient teeth are present resin retained bridges are again [email protected] the restoration of choice. As above critical to success is the surface area covered by the metal framework, the thickness and rigidity of the restoration and control of the occlusion.

ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 48-55 GENETIC ANOMALIES OF THE CRANIOFACIAL SKELETON Andrew A. C. Heggie, MBBS, BDSc, MDSc, LDS, FRACDS, FRACDS(OMS), FFDRCSI Professor Heggie is Head, Section of Oral & Maxillofacial Surgery, Department of Plastic & Maxillofacial Surgery and Associate Professor, Department Paediatrics, at the University of Melbourne, Royal Children’s Hospital of Melbourne ABSTRACT With the evolution of sophisticated genetic testing, many disorders that were previously deemed to be “idiopathic” or of “unknown aetiology” have been shown to have a genetic mutation or inheritance pattern that accounts for the phenotypical features. There is a growing transition from grouping disorders by their clinical features to that of a classification based on genetics. Cleft lip and palate remains the most common disorder managed in the paediatric setting followed by craniofacial microsomia, yet the cause of these anomalies remains unclear and is likely to be polygenic. The syndromic craniosynostoses, where premature fusion of calvarial and cranial base sutures results in retardation of mid-facial growth, are a particular challenge to the clinician. Micrognathia, with associated upper airway obstruction, such as can occur in Pierre Robin sequence, can be managed with newer techniques of mandibular lengthening that has largely eliminated the need for tracheostomy. There is also a vast array of craniofacial syndromes such as Gorlin syndrome and Beckwith Wiedemann Syndromes that have genetic markers in a proportion of affected individuals that may inform the diagnosis, help to more accurately predict the biological behaviour of the condition and may influence treatment decisions. The management of typical patients with specific conditions are presented to demonstrate the need for a protocol for treatment through growth until skeletal maturity. INTRODUCTION 1. CLEFT LIP AND PALATE In his classic book, “The Selfish Gene”, Richard Dawkins Clefting of the lip and palate is the commonest congenital introduced a “gene’s-eye” view of the biological world and anomaly of the oro-facial complex with an incidence thought emphasized that the prime purpose of genetic material is to to be between 1:600 - 1:2500 live births. There is an ethnic/ replicate itself as units of natural selection.1 It served as a geographical variation with the highest incidence in Asian reminder to biological scientists that genetic information has countries followed by Caucasian and Latin Americans and evolved to build bodies that are structured to assist in the is the least common in the African population. There is a reproduction of the species concerned and that modifications male-to-female ratio of 2:1 for cleft lip and palate whereas over time serve to enhance this process. in isolated cleft palate patients, this ratio is reversed. There is also an awareness that isolated cleft palate patients are Biological classification has relied on the features of particular more likely to be syndromic and probably represent a species yet phenotypes only reflect the genetically-directed different genetic pattern to those with a cleft lip and palate. instructions for growth and development that intense research However, the majority of patients with cleft lip and palate is progressively revealing. The embryology of the craniofacial are non-syndromic and this pattern of clefting is likely to region is of great complexity and heavily dependent on be caused by array of genetic factors. In the syndromic differentiation of the cell populations at the border of the group, there are known genetic factors that contribute to neural plate that can be separated into the craniofacial disorders e.g., Stickler’s syndrome. In Type 1 of this disorder placodes and cells of the neural crest. The latter migrates that is predominantly ocular, individuals affected have a to the periphery under the direction of a complex array of mutation in the COL2A1 gene.3 There are also environmental transcription factors that remain under investigation.2 teratogenetic syndromes that are thought to contribute to clefting disorders, eg. foetal alcohol syndromes, anti- For the undergraduate and postgraduate students of over convulsant medication. 25 years ago, the aetiology of the majority of disorders were referred to as “unknown” or “idiopathic”. This was certainly It is widely regarded that the optimum approach to multi- the case in regard to the syndromes of the head and neck. disciplinary care for affected patients is via a cleft team with With major advances in genetic research, mutations have an appropriate coordinator of care.4 Paediatric dentists and been identified that affect cell signalling pathways that are orthodontists are key team members together with plastic providing an understanding of the mechanisms that produce surgeons, maxillofacial surgeons and other specialists that anomalies. There is also a growing realization, that for many include speech therapists, otolaryngologists, specialist common disorders, polygenic and epigenetic factors are nurses and paediatricians. Should an ultrasound diagnosis likely to be involved. of a cleft lip and/or palate be made, the treatment pathway for the unborn infant commences antenatally with parent In this paper, some of the more common conditions of the counselling. Primary surgery is undertaken for lip closure in oral and craniofacial region will be presented together with the first few months followed by closure of the palate that is an outline of the management protocols in the Melbourne usually undertaken by 18 months. A functional palatal repair Craniofacial Unit, Royal Children’s Hospital of Melbourne.