99 knowledge, whereas students who identified less than two However, a lower percentage of students felt comfortable were classified as having ‘poor’ knowledge in defining SND. treating those with visual/hearing impairments (45.9%), complex medical conditions (39.5%), intellectual disabilities Statistical analysis consisted of Chi-square regression (31.7%), infectious diseases (21.2%), and psychological or analysis (P <0.01). Ethics was obtained through the University behavioural issues (19.8%) (Figure 2). of Melbourne Human Research Ethics Committee and the Medical Ethics Committee, Dental Faculty, University of The majority of students felt that undergraduate dental Malaya. The study was funded by the Melbourne Dental students should receive didactic teaching (96.9%) and clinical School Postgraduate Research Grant. training (89.6%) in SND. Overall, 61.2% of the respondents expressed interest in postgraduate training in SND, with Results a significantly higher response rate reported by female students {X2= 6.257; P <0.01}. Comparison of dental curriculum in relation to SND Discussion All 6 Malaysian public dental schools and 8 of 9 Australian dental schools responded to the survey. 75% of Australian The rising number of people living with SHCN globally together dental schools offered a module in SND, in contrast to with increasing demands in oral health care reflects the need only 10% of Malaysian dental schools. Teaching of SND in for the dental profession to be better prepared in terms of Australian and Malaysian dental schools was predominately patient management.14 In many countries throughout the incorporated into Paediatric Dentistry (75% vs. 83.3%), world, general dentists have been primarily involved in caring Oral Medicine/Oral Pathology (75% vs. 66.7%) and Oral for these individuals by providing preventative care and dental Surgery (25% vs. 66.7%) curricula. Both countries reported treatment.15-17 However, dentists have expressed discomfort that having lack of faculty expertise was the main barrier and reluctance in managing those with SHCN due to inadequate to providing teaching in SND for undergraduate students training and experience in the field.10, 18, 19 Training particularly (Australia, 71.4% versus Malaysia, 83.3%). at undergraduate level has been shown to be inadequate in clinician preparation around this field.6, 20 Clinical training in SND was offered in all Australian dental schools compared to 67% of those in Malaysia. Such training Competency in oral health management of patients with in Australia and Malaysia was predominately provided in SHCN begins through acquisition of sound knowledge, clinical dental school clinics (87.5% vs. 50% respectively), and proficiency and positive attitudes fostered through the residential aged care facilities (62.5% vs. 50%) and equally learning and practice of SND. The concept of SND or Special in hospital-based settings (75% for both). In terms of facilities Care Dentistry as used in American and European countries, available for the provision of teaching in SND, all Australian promotes the integration of the different individual and dental schools offered nitrous oxide sedation, compared to environmental aspects that may impinge on the oral health, only 50% of Malaysian counterparts. However, more dental preventative behaviour as well as dental treatment planning, schools in Malaysia were equipped with general anaesthesia delivery and outcome of people with an intellectual disability, facilities (66.7% vs. 37.5%), intravenous sedation (66.7% vs. medical, physical or psychiatric conditions (Royal Australasian 12.5%), and mobile dental services (33.3% vs. 25%). College of Dental Surgeons, 2010).13 Despite the differences in terminology, the importance of developing competency Investigation of dental students’ knowledge, attitude and comfort in managing patients with SHCN has been recognised and level when treating patients with SHCN together with their perception highlighted as an important element for accreditation of of SND education dental curricula in many countries worldwide, including Australia. 21-23 The majority of dental students (84.4%) was aware of SND as a specialty, and reported receiving this information from The present study reported that the level of undergraduate academic staff members (75.1%). About a half of the students education in SND in Malaysian dental schools was lower (50.6%) perceived that their training in managing patients than its Australian counterparts. Having inadequate clinical with SHCN at undergraduate level was inadequate. expertise is a critical limiting factor in developing countries such as Malaysia to implement a comparable amount of A majority of students (68.8% to 88.6%) claimed that they teaching of this newly recognised specialty. Lack of training in were able to define SND regardless of which university they SND provided in Malaysian dental schools is reflected by the attended {X2 = 6.017, P = 0.31}. A majority of students from poor level of knowledge and understanding of this specialty University A demonstrated adequate ability to define SND, amongst its students. Students also felt uncomfortable showing significant association with students from other treating patients with SHCN due to lack of clinical exposure, universities who demonstrated poor knowledge {X2= 45.186, supporting previous studies which demonstrated association P <0.01} (Figure 1). between attitudes, comfort level and educational experience. 10, 18, 19 However, it was encouraging to note that the percentage 77.5% of dental students had been exposed to clinical of Malaysian students who felt comfortable providing care experience treating elderly patients. A lower percentage of to patients with physical, intellectual and visual/hearing students reported to have gained clinical experience treating impairments were more than twice as high compared to those with complex medical problems (38.1%), psychological those who were exposed to clinical experience treating these or behavioural issues (23.2%), infectious diseases (18.3%), patients, indicating a positive attitude amongst students physical disabilities (16.6%), intellectual disabilities (12.5%), towards caring for people with disabilities. Students also and visual/hearing impairments (4.8%) (Figure 2). expressed interest in acquiring knowledge around SND at undergraduate and postgraduate levels, reflecting a positive The majority (82.8%) of the students felt comfortable treating attitude amongst students towards SND education. elderly patients, whilst half of those surveyed (50.7%) felt comfortable treating patients with physical disabilities.
100 To produce graduates with competency in SND, it is Direct correspondence and requests for reprints to Assoc. incumbent on dental institutions to provide opportunities for Prof. Mina Borromeo, Melbourne Dental School, 720 students to gain experience in managing patients with SHCN. Swanston Street, Carlton, VIC 3053, Australia; +61393411489 Introduction of SND into the undergraduate curriculum is phone; +61393411599 fax; [email protected] imperative in preparing students to providing care for this patient cohort. A guideline for curriculum development References in Special Care Dentistry has been established by the International Association for Disability and Oral Health (iADH) 1. American Academy of Pediatric Dentistry. Definition of special health as an approach towards establishing a global standards and care needs. Pediatric Dentistry 2012;34:16. requirements for undergraduate education in SND.24 As the guideline was produced for global reference, it is suggested 2. Barbotte E, Guillemin F, Chau N. Prevalence of impairments, disabilities, that an educational task force is to be set up in each country handicaps and quality of life in the general population: a review of to identify the local requirements that will constitute the recent literature. Bull World Health Organ 2001;79:1047-55. curriculum content. 3. Stiefel DJ. Dental care considerations for disabled adults. Spec Care To overcome the barrier of having inadequate clinical sites Dentist 2002;22:26S-39S. and access to patients with SHCN, dental institutions should establish collaborations with external organizations that 4. Casamassimo P, Seale NS, Ruehs K. General dentists’ perceptions of may offer effective teaching and learning environments. educational and treatment issues affecting access to care for children Liaising with health institutions, special education schools with special health care needs. J Dent Educ 2004;68:23-8. and disability support groups or welfare organizations may provide for opportunities for inter-professional education, 5. McQuistan MR, Kuthy RA, Heller KE, Qian F, Riniker KJ. Dentists’ learning and practice as well as research collaboration. Comfort in Treating Underserved Populations After Participating in Collaboration with government and private agencies may Community-Based Clinical Experiences as a Student. J Dent Educ also provide opportunities for funding opportunity to assist 2008;72:422-30. in the development of infrastructure or oral health promotion activities. 6. Dao LP, Zwetchkenbaum S, Inglehart MR. General dentists and special needs patients: does dental education matter? J Dent Educ Collaboration between dental institutions should also be 2005;69:1107-15. enhanced to promote sharing of expertise and facilities that may support for the conduct of teaching and research activities 7. Krause M, Vainio L, Zwetchkenbaum S, Inglehart MR. Dental education in this field. To further ameliorate students’ educational about patients with special needs: A survey of U.S. and Canadian dental experience, exposure in a variable setting may prepare the schools. J Dent Educ 2010;74:1179-89. students with challenges of working in a different clinical environment. This could be achieved through participation in 8. Dellavia C, Allievi C, Ottolina P, Sforza C. Special care dentistry for community service learning and voluntary activities, as well people with intellectual disability in dental education: An Italian as having access to facilities such as general anaesthesia, experience. Eur J Dent Educ 2009;13:218-22. domiciliary dental care and mobile dental service. 9. Smitley MG, Waldman HB, Perlman SP, Ocanto RA. Latin American and Dental institutions should also focus on human capital Caribbean dental schools: teaching about special needs. Rev Panam development by providing assistance to individuals with an Salud Publica 2009;25:322-7. interest in SND for further training.25 Continuous production of experts and trained professionals in SND is an important 10. Holder M, Waldman HB, Hood H. Preparing health professionals to aspect to ensure sustainability and development of the provide care to individuals with disabilities. Int J Oral Sci 2009;1:66-71. specialty through promotion of teaching and learning, conduct of research, as well as planning and provision of oral 11. Schwenk DM. Survey of special patient care programs at U.S. and health care service for individuals with SHCN. Canadian dental schools. J Dent Educ 2007;71:1153-59. Conclusion 12. Yahaya N. The perception of Special Needs Dentistry amongst the general dentists in Victoria, Australia [thesis]. Melbourne: University of Dental institutions should endeavour to provide available Melbourne; 2010. opportunities for their students to acquire educational experience in managing patients with SHCN. Multi-sector 13. Ettinger RL, Chalmers J, Frenkel H. Dentistry for persons with special collaboration with external agencies, sharing of expertise needs: how should it be recognized? J Dent Educ 2004;68:803-6. and facilities between institutions and human capital development should be enhanced to promote teaching, 14. World Health Organization. World report on disability. Geneva: World learning and practice of this field of dentistry. Training of Health Organization, 2011. SND should be introduced as early in the undergraduate years, with early clinical exposure in variable clinical settings, 15. Freeman R, Adams EK, Gelbier S. The provision of primary dental care aimed at developing the first concrete building blocks to for patients with special needs. Prim Dent Care 1997;4:31-4. dentists’ lifelong learning in assisting patients to achieve non- compromised oral health. 16. Smith G. Provision of dental care for special care patients: the view of Irish dentists in the Republic of Ireland. J Ir Dent Assoc 2010;56:80-4. The study was funded by the Melbourne Dental School Postgraduate Research Grant. 17. Loeppky WP, Sigal MJ. Patients with special health care needs in general and paediatric dental practices in Ontario. J Can Dent Assoc 2007;72:915. 18. Sullivan AL, Morgan C, Bailey J. Dental professionals’ knowledge about treatment of patients with spinal cord injury. Spec Care Dentist 2009;29:117-22. 19. Hopcraft MS, Morgan MV, Satur JG, Wright FAC. Dental service provision in Victorian residential aged care facilities. Aust Dent J 2008;53:239-45. 20. Weil TN, Inglehart MR. Dental education and dentists’ attitudes and behavior concerning patients with autism. J Dent Educ 2010;74:1294- 307. 21. Commission on Dental Accreditation. Accreditation Standards for Dental Education Programs. Educational Program. Chicago, Illinois: American Dental Association; 2010. 22. The Commission on Dental Accreditation of Canada. Accreditation requirements for Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DMD) programs. Ottawa: Commission on Dental Accreditation of Canada, 2010. 23. Australian Dental Council/ Dental Council of New Zealand. ADC/ DCNZ Accreditation Standards: Education Programs for Dentists. East Melbourne: Australian Dental Council; 2010. 24. Dougall A, Pani SC, Thompson S, Faulks D, Romer M, Nunn J. Developing an undergraduate curriculum in Special Care Dentistry - by consensus. Eur J Dent Educ 2013;17:46-56. 25. Ettinger RL. Where will the next generation of special needs dentists come from? Spec Care Dentist 2006;26:5-6.
101 Fig 1. Students’ actual ability to define SND across the six Malaysian public dental schools. Fig 2. Percentage of students exposed to clinical experience in treating the different groups of patients with special health care needs versus the percentage of students who felt comfortable to provide care following graduation (ELD=elderly, CMP=complex medical condition, PSY=psychological/behavioural issues, INF=infectious disease, PD=physical disability, ID=intellectual disability, VHI=visual/hearing impairment).
ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 102-106 HOW eHEALTH STRATEGIES MAY ENHANCE DENTAL RESEARCH Raymond Lam, BDSc(Hons)(WA) BEng(Hons) FRACDS Dr Raymond Lam is a Researcher and General Dentist at the International Research Collaborative- Oral Health and Equity at The University of Western Australia ABSTRACT Although evidence based dentistry has been the accepted protocol in guiding clinical decisions, there are challenges with establishing an adequate research base. This is no more obvious in modern dentistry where the gap between established research and new products and procedures is widening. Whilst traditional research methods have served the profession well, it may be an opportune time to take advantages of computer technology to enhance research. With this in mind, this paper introduces novel strategies in eHealth with a focus on item codes in electronic data collation and dental informatics. By considering the recent Chronic Disease Dental Scheme and the Australian Schedule of Services and Glossary, this paper will illustrate how e-health strategies may provide a cost effective solution to enhancing research that is applicable to the individual clinician and the entire profession. Introduction repair7,8. However, it was noted that ‘the trials selected for review were not ideal and there is a need for more clinically One disadvantage of the remarkable achievements in based evidence to assist in the decision making process to be dentistry is that treatment options have never been more more confident in our clinical outcomes”6(p276). Whilst there varied or confusing. For example, there are hundreds of is promise in the concept of EBD, there are still problems with implant systems, eight generations of bonding systems and establishing its research base at the clinical level. an expanding range of materials and procedures in operative dentistry. This can present many challenges to the dentist At the population level, there are ongoing problems with in choosing the right product or procedure for their specific obtaining research data. Whilst traditional epidemiological patient. Fortunately the literature has provided clues for studies have made significant advances in public health, they dentists in their clinical practice. This has seen the emerging require significant investment in time and resources. They concept of Evidenced Based Dentistry (EBD) where clinical are also susceptible to low response rates, exclusion bias and decisions are guided by best available evidence. Although errors with statistical inferences. Many of these studies such the principles embodied by EDB have been endorsed by as cross sectional studies capture data at only one instance professional associations worldwide, there are still problems in time and do not reflect changing health patterns. These with establishing an adequate research base1, 2. concerns were noted by the National Advisory Council on Dental Health who noted that “[dental public health] does At the clinical level, a large component of the literature has not receive sufficient emphasis and resourcing and there focused on key parameters to guide the clinician. Important is limited ability to positively influence policy development. markers such as success rates, restorability and prognosis There is a need for sustained data collection activity as there have long been a defining factor in selecting an appropriate are gaps in population level data”9(p63). As such, there is also procedure or treatment option. However, it is well known a need to strengthen population level research. that dental procedures are technique sensitive and results can vary significantly between clinicians3, 4. In addition, Over the past decade, electronic technology has created many published results may have been produced in different opportunities in the field of health. This has been noticed by environments from the private practice environment which the World Health Organization who has defined e-health to be may be difficult to standardise in research. Factors such as inclusive of “the use of information technologies for health time, academic setting, experience and qualification of the related benefits including its role in supporting scientific clinician, materials available and patient cooperation are information for professionals”10(p1). The aim of this paper is to all unique factors relating to the quality of a procedure. introduce and demonstrate some novel methods in e-health The applicability and relevance of reported results to each to address the aforementioned problems with establishing clinician is therefore questionable. Furthermore, dentistry is an evidence base. This will involve a discussion of electronic undergoing a paradigm shift with treatment options becoming data collation methods used in the Chronic Disease Dental more conservative in a concept known as “minimally invasive Scheme (CDDS) and dental informatics using item codes in dentistry”5. However, one disadvantage of emerging concepts Australian Schedule of Dental Services and Glossary11. The is that it evidence base has yet to be established with clinical scope of this discussion is primarily conceptual and focuses certainty. One such example is the ultraconservative stepwise on key questions often asked when considering e-health as a technique described by Burrow6. Under this principle, many potential tool in research. It is endeavoured that this will act proponents recommend leaving deep carious lesions in-situ as a stepping stone to a more substantial and clinical study to to avoid exposing the pulp and enabling affected dentine to confirm its benefit in mainstream dentistry. It must be noted
103 that much of this discussion is different to the literature in this How can ehealth benefit clinical based emerging field, which has so far focused mainly on patient research? centred electronic records. Dental informatics refers to the application of computer and How can ehealth benefit population level information science to improve dental practice, education research? and management14. As item codes represent a description of services that would otherwise be represented in words, they The CDDS represented the first major dental initiative to attract are amenable to dental informatics. It is also fortunate that benefits in the universal health insurance scheme, Medicare. the Australian Schedule of Dental Services and Glossary is In the administration of this scheme, the treating dentist encompassing and encyclopaedic in its description of each forwarded item codes to a single government department item code. This provides an opportunity to obtain important responsible for processing all claims. In this manner, there is an research and policy relevant information from the database assurance from two independent sources, private practice and of codes which has been demonstrated at the population the government department, that item codes were submitted level. and processed. As indicated in Table 1, the Department of Human Services provides a database of item codes that have Whilst the focus on item codes is maintained, this section been rendered under this scheme12. This is a continuous, real proposes on expanding these existing codes to enhance time and automated system and has resulted in over 22 million clinical based research. In its current form, item codes do item codes during 2007/12. These item codes were solely used not give circumstantial information or clinical outcomes but for processing claims but have indirectly yielded a complete rather mechanically describes a procedure rendered. Stated database that is useful for research without statistical differently, existing codes are retrospective and based on inferences and at no additional cost. It must be noted that treatment provided but give no information circumstances this database consists only of processed numeric codes and or health conditions. For example, the code 531 describes therefore patient confidentiality is preserved. placing a one surface adhesive restoration in a posterior tooth. As the code stands, there is no information on the pre- With complete data retrieval, many opportunities arise existing state of the oral cavity such as caries risk, depth of in population level research13. As item codes provide a the restoration, reason for restoration (recurrent, new, and description of services, there is the potential to assess prophylactic) and the time since the tooth was last treated. utilisation patterns and the types of services. With a greater It must be noted that this is not a flaw in the existing codes certainty that data is complete, there is confidence that because they were not designed for this purpose. However, utilisation patterns of this scheme is a reflection of access there is benefit incorporating suffixes after these codes to and availability of services for a particular geographic provide circumstantial evidence. location rather than based on poor sampling or exclusion bias. For example, it is standard procedure for a dentist to With this in mind, it has been proposed that existing software perform a comprehensive examination (item code 011) as part incorporate these suffixes when a particular code is selected. of their treatment when they see a patient for the first time. Once the code is selected on the computer, a checkbox of Correlating this item code by state and postcode enables relevant options is displayed. For example, the item code assessment of where services are being rendered which for a posterior restoration would then be recorded as in turn can be compared with water fluoridation patterns, 531-00X-00Y-00Z. With the objective of obtaining clinically workforce distribution, chronic health conditions and relevant information, only codes that achieve this purpose socio-economic status. This cost effective and continuous are considered rather than attempting to modify all codes in method of data collation is also sensitive to changing health the schedule. A selection of examples is shown in Figures 2 patterns over time as indicated by the types of item codes and 3 to illustrate this principle12. processed. Assessment of these codes can also provide a means to assess where money is being spent on what types Whilst this approach to using item codes is different, it is of services to monitor expenditure. Figure 1 shows a small not new. Many studies have considered dental coding from sample of relevant information that can be obtained from a diagnostic point of view13. The Oral Status and Intervention this dataset13. Index adopted by the World Health Organization proposed a classification index for oral health. This schedule attempted Although this discussion was confined to the CDDS which to provide a single digit integer from 0-9 to describe oral is no longer operational, there is the opportunity for this health status15. Similarly another classification known as method of data collation to become mainstream. The use of the Systematized Nomenclature of Dental Clinical Terms item codes is increasingly been used by other government (SNODENT) was proposed15. However, its practicality has dental policies and also from private health insurers. Other been limited and it has been speculated that dentists may policies such the Department of Veterans Affairs program, be reluctant to learn a new classification system. Schelyer the Teen Dental Scheme and the recent Child Benefits concluded that “the road to clinical practice supported scheme is an indication that codes are an effective means by informatics will be nothing short of arduous. Putting of processing claims which can indirectly benefit research13. these concepts into practice requires significant time and With this potential, there is a need to ensure that policies investment”9(p612). Furthermore, it has been highlighted continue to follow this manner of administration. that dentistry lacks an acceptable vocabulary to classify and identify oral disease16. This is unsurprising as most oral diseases relate to some form of caries or periodontal disease unlike Medicine where there is a wider classification of systemic diseases. This has been speculated to be the reason
104 why SNODENT was not as successful as the medical version16. Conclusion As this proposal uses an existing system in the Australian schedule as well as existing practices in administering This paper described a novel approach to how e-health treatment rendered, it is hoped that its utilisation would be strategies may enhance research. Whilst not a substitution to more favourable. traditional research methods, the use of e-health strategies in the area of dental informatics with a clinical focus is a cost By modifying existing item codes to provide circumstantial effective and convenient adjunct to enhancing evidenced evidence, there are many opportunities to enhance research. based dentistry. Similarly, the use of item codes as part of Firstly, the clinician will develop a personal database of their administration has been shown to be efficient in obtaining treatment which can be used for professional development. data that is complete, continuous, real time and cumulative This will enable the clinician to compare their results with without some of the deficiencies in conventional research those in the literature. Secondly, assessment in treatment gathering. Together, it is hoped that these e-health strategies planning is possible where there is still ambiguity in material may overcome some of the problems with establishing a selection or clinical procedure. Areas such as multiple research base. This has been demonstrated in principle by versus single visit endodontics, the use of a cortico-steriod data obtained from the Chronic Disease Dental Scheme and mixture as stand alone or with calcium hydroxide dressing, the existing Australian Schedule of Services and Glossary. leaving affected dentine in-situ (ultraconservative step wise technique), composite layering, use of glass ionomer cements Acknowledgements or using various liners are a small sample where there is variation in opinion or that evidence is not conclusive. This The author would like to acknowledge Marc Tennant, is possible because selected item codes may be expanded Estie Kruger and John McGeachie from the International to capture this information such as including a reference Research Collaborative-Oral Health and Equity, University of to time. For example, if a tooth required extracted and its Western Australia, for their support in preparing the original previous item code related to a restoration that was placed manuscript. within a particular timeframe, this will provide clues to success rate and longevity. Other indices such as decayed The author would also like to thank the Journal of Primary missing filled teeth (DMFT) may also be captured with this Health and Journal of Evidenced Based Dental Practice for method which can be correlated with location. With a focus the permission to reproduce the figures and tables by the on clinical outcomes, there is also the possibility of linking same author in this manuscript. detailed item codes to existing health data such as morbidity and admission rates to hospitals and therefore providing a Disclosure greater link between medicine and dentistry13. The author declares no financial support or relationships that Whilst expanding item codes may provide additional may pose a conflict of interest. information, it does not reduce the degree of subjectivity. Indicators such as caries risk, depth and severity of a cavity, References the need for restoration or restorability of a tooth remain subjective. Despite this, the variability will be consistent 1. Evidence-Based Medicine Working Group. Evidence-based medicine. for each clinician if they apply the same principles to their A new approach to teaching the practice of medicine. JAMA practice; which can be captured from a cumulative history 1992;268:2420-5 of their codes. Again, this enables comparison with their colleagues and published results. With the establishment 2. ADA Policy Statement on Evidence-based Dentistry. Available at: of clinical guidelines, it is envisioned that there will be less http://www.ada.org/1754.aspx (Accessed 20 March 2013) inconsistency in the selection of item codes. One such guideline is the caries management system described by 3. Lucarotti P, Holder R, Burke F. Outcome of direct restorations placed Evans17. Under this system, there are quantitative measures within the general dental services in England and Wales (Part 3): to define caries risk and the depth and severity of caries. For variation by dentist factors. Journal of Dentistry. 2005. Vol: 33, Issue: example, carious lesions have been measured according to 10, pp 827-835 the amount of radiographic penetration into tooth structure such as the outer enamel or inner two thirds of dentine. 4. Henry P, Liddelow G. Immediate loading of dental implants. Aust Dent It must be noted that the aim of item codes is to obtain J. 2008; 53:(1 Suppl): S69–S81 clinical information and outcomes rather than to eliminate subjectivity which is not practically possible. Treatment 5. Tyas M, Anusavice K, Frencken J, Mount G. Minimal intervention planning is always based on the specific needs of the patient dentistry: a review. FDI Commission Project 1-97. Int Dent J and the experiences of the individual clinician. 2000;50(1):1-12. The use of e-health and dental informatics can be expanded 6. Burrow M. Complete or ultraconservative removal of decayed tissue in further to benefit dental research at the global level. With the unfilled teeth. Cochrane Review. Aust Dent J. 2009; 54: 274–276 doi: development of a unified coding system and the use computer 10.1111/j.1834-7819.2009.01133.x software, every dentist would not only yield a personal database of their treatment but also contribute to research 7. Handelman SL, Washburn F, Wopperer P. Two-year report of sealant at the national and international level. This is a cost effective effect on bacteria in dental caries. J Am Dent Assoc .1976;93:967–970. way of enabling every dentist without restriction by distance or border to contribute to research without considerable 8. Thompson V, Craig RG, Curro FA, Green S, Ship JA. Treatment of deep change to their administrative duties. carious lesions by complete excavation or partial removal: a critical review. J Am Dent Assoc 2008;139:705–712. 9. National Advisory Council on Dental Health. Report of the National Advisory Council on Dental Health. Commonwealth Parliament of Australia. Canberra ACT.2012 10. World Health Organization. Building foundations for e-health. World Health Organization: Geneva, Switzerland. 2006 11. Australian Dental Association. The Australian schedule of dental services and glossary.’ 10th edn. Australian Dental Association: Sydney. 2013 12. Lam R, Kruger E, Tennant M. How a modified approach to dental coding can benefit personal and professional development with improved clinical outcomes. Journal Evidenced Based Dental Practice. Forthcoming 2014. doi:10.1016/j.jebdp.2013.12.002. Table 1,Real-time database of CDDS item codes by nature of treatment. 13. Lam R, Kruger E, Tennant M. A critical discussion of the benefits of e-health in population-level dental research. Australian Journal of
105 Primary Health 19(4) 303-307 http://dx.doi.org/10.1071/PY13020. 14. Schleyer T, Spallek H. Dental informatics. A cornerstone of dental practice. J Am Dent Assoc. 2001 May;132(5):605-13. 15. International Organization for Standardization. International Organization for Standardization Technical Report 13668-1998: Digital coding of oral health and care. Available At: https://www.iso.org/obp/ ui/#iso:std:iso:tr:13668:ed-1:v1:en (Accessed 12 September 2013). 16. White JM, Kalenderian E, Stark PC, Ramoni RL, Vaderhobli R, Walji MF. Evaluating a dental diagnostic terminology in an electronic health record. J Dent Educ. 2011 May;75(5):605-15. 17. Evans R, Pakdaman A, Dennison P, Howe E. The Caries Management System: an evidence-based preventive strategy for dental practitioners. Application for adults. Aust Dent J. 2008 Mar;53(1):83- 92. doi: 10.1111/j.1834-7819.2007.00004.x. Table 1. Fig 1. Sample results from electronic data collation
106 “This entry depicts an adhesive restoration that was placed on an non restored virgin tooth due to caries that had reached the DEJ “ Fig 2. Sample restoration template “This entry depicts the extraction of a tooth that developed endodontic and peri-radicular complications as a result of unsuccessful treatment over the last 6-12 months with the patient opting for extraction for financial reasons” Fig 3. Sample extraction template
ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 107-112 DISTRACTION OSTEOGENESIS – A PANACEA FOR INFANT MICROGNATHIA WITH UPPER AIRWAY OBSTRUCTION? Dr Ashim N. Adhikari, BDSc, FRACDS Dr Patrishia Bordbar, MBBS (Hons), BDSc, PGDip Surgical Anatomy, MDSc (OMS), FRACDS (OMS Associate Professor Andrew A. C. Heggie, MBBS, BDSc, MDSc, LDS, FRACDS, FFDRCS, FACOMS, FRACDS(OMS), FICD, FADI, FPFA Dr Jocelyn M. Shand, MBBS, MDSc, BDS, FDSRCS(Eng), FRACDS(OMS) Ashim graduated with a Bachelor of Dental Science in 2009 from the University of Western Australia, becoming a Fellow of The College in the General Stream in 2013. He is currently in his final year of the Doctor of Medicine course at The University of Melbourne, where he is undertaking a research project on mandibular distraction in infants at The Royal Children’s Hospital in Melbourne. Prior to commencing his medical training, Ashim worked as the Dental and Maxillofacial Resident at the Monash Medical Centre in Clayton, Victoria, cementing his passion for surgery. He has a particular interest in paediatric maxillofacial surgery. ABSTRACT Mandibular distraction osteogenesis (MDO) has been described as an effective method of treating upper airway obstruction (UAO) in micrognathic infants with a low morbidity and few short-term complications. This technique has almost eliminated the need for tracheostomy in non-syndromic patients at The Royal Children’s Hospital (RCH) in Melbourne. However, there are few studies describing the longer-term effects on feeding, growth and the developing mandible. This study describes the experience at the RCH in managing infants with micrognathia over the past twelve years, with particular emphasis on airway, feeding and growth. By international standards, this study comprises one of the larger cohorts of children under five years who have had MDO (n=73). This retrospective review shows that the procedure is effective in alleviating the need for airway assistance and supplemental feeding without adversely affecting the growth of these children. This study makes a significant contribution to the evidence base underpinning MDO as the preferred surgical intervention for infants with micrognathia and UAO. Introduction most of the literature describes short-term follow-up in small cohorts13 and there are few studies describing the long-term Micrognathia has been described as a feature in hundreds effects of MDO on the developing mandible. of syndromes1 and can occur with glossoptosis, resulting in upper airway obstruction (UAO). A major group is commonly The aim of this study was to analyse a series of micrognathic referred to as Robin Sequence (RS)2, which occurs in roughly infants with UAO that have had MDO at the Royal Children’s 1 in 6000 live births in Victoria3. Affected infants with severe Hospital of Melbourne (RCH) and to conduct a retrospective airway obstruction may suffer hypoxia, respiratory failure, review of outcomes over the first post-operative year, cardiovascular complications and feeding difficulties that specifically assessing their airway, feeding, growth, hospital may be fatal. Hence, the primary goal of treatment is to stay and short-term complications. establish airway patency and stability. Materials and Methods Prone positioning is the preferred treatment in less severe cases, but there is currently no evidence-based consensus All patients who underwent MDO under the age of five years regarding the optimal management regime for patients with between January 2000 and December 2012 at the RCH were moderate to severe upper airway obstruction4. Management identified by a hand-search of the Oral and Maxillofacial options have included nasopharyngeal intubation, Surgery Unit’s operation log. Ethics approval was granted by prolonged endotracheal intubation, tongue-lip adhesion and the Human Research Ethics Committee (Ref No: 33253B) of tracheostomy5. However, non-surgical management may the RCH. have suboptimal outcomes6, tongue-lip adhesion is rarely a definitive procedure7 and tracheostomy, which is associated A comprehensive review of the medical records was with significant morbidity8, is a heavy burden on families9. completed to document demographic, operative and peri- operative data as well as a growth assessment over the Recently, mandibular distraction osteogenesis (MDO) has first year post-operatively. Information collected included been described as an effective method of treating UAO due age, diagnosis, medical co-morbidities, airway status and to micrognathia in infants with low morbidity and few short- feeding, post-operative airway status and feeding, time to term complications10-12. However, as an emerging technique, decannulation (if a tracheostomy was present), laryngoscopy
108 at intubation, weight over the post-operative year, time spent region to minimise scarring and to facilitate wound care intubated, time until discharge and short-term complications. at this site with regular betadine ointment and the use of antimicrobial hydrocellular foam dressings (Allevyn/Allevyn The sample was subdivided into syndromic and non-syndromic AG, Smith & Nephew, Sydney, NSW, Australia) in 2010. cohorts as designated by clinical geneticists and a descriptive analysis of the data was performed. For laryngoscopy and Results weight, complete case analysis was performed, where patients with incomplete data were excluded from the analysis. Seventy-three children under the age of five years underwent MDO at the RCH between 2000 and 2012 and forty-two The laryngoscopy view was graded with the Cormack and were syndromic (Table 1). The oldest non-syndromic child Lehane scoring system14, which is a clinical measure of to undergo distraction was thirty-two months, while in the glottis visibility and was recorded in the anaesthetic chart syndromic cohort the oldest child was thirty-nine months. Only at time of intubation. These data were compared with one child treated had developed a secondary micrognathia the Wilcoxon Signed-Ranks test and reported using the due to temporomandibular joint ankylosis, possibly due to normal distribution approximation with a p-value of <0.001 an early post-natal streptococcal infection. All other infants considered statistically significant. had congenital micrognathia. There were two deaths in the cohort: one with Toriello-Carey syndrome who died prior to Growth data was analysed by calculating Z-scores of weight for distractor removal due to aspiration and respiratory arrest corrected ages from the World Health Organisation’s published and the other patient, with Treacher Collins Syndrome, died anthropometric data15 at birth, time of distractor insertion and two years post-distraction following a failed tracheostomy removal, and six and twelve months post-operatively. Z-scores tube change. Both deaths occurred at home. of birth-weight for pre-term infants were calculated from the Fenton growth charts16. A significant deviation from projected Airway growth was considered where a child dropped two or more centile lines17 (a drop in Z-score of ≥1.34). The mean of these Prior to surgery, forty-eight patients (69%) had airway Z-scores was then calculated at each time point for the two support with a nasopharyngeal tube and thirteen (18%) cohorts to indicate their average growth. were managed by non-invasive airway therapies such as prone-positioning and continuous positive airway pressure, Surgical procedure whilst nine (13%) were tracheostomy-dependant, all of whom were syndromic (Figure 4). On discharge, none of the A standard surgical technique was used, with a submandibular children without tracheostomies required any further airway access incision to expose the lateral cortex and inferior assistance, and of those who were tracheostomy-dependant, border of the posterior body and angle of the mandible. 56% were successfully decannulated within the year following The distraction device (Zurich Paediatric Ramus Distractor, the procedure, the majority of whom were decannulated KLS Martin, Tuttlingen, Germany) was then positioned for within three months of distractor removal. the intended antero-posterior distraction vector followed by a cutaneous “stab” incision to pass the activation arm to Laryngoscopies performed at distractor placement and exit posteriorly about 1cm below the earlobe. A curvilinear subsequent removal showed a significant improvement (p < monocortical osteotomy was then performed to extend 0.001) in glottis visibility in both cohorts (Figure 5). With 18% from the lower border just anterior to the angle of the of the data missing, complete data was available for analysis mandible and carried superiorly to the retromolar region as in 75% of patients in the non-syndromic cohort and 67% of posteriorly as possible to avoid molar tooth buds (Figure 1). patients in the syndromic cohort, as laryngoscopy was not Superiorly and inferiorly, the lingual osteotomies of 4-6mm routinely performed on those patients with a tracheostomy. were completed with straight osteotomes. Mobilisation of the mandibular segments was undertaken carefully, prior to Feeding securing the device with 1.5mm mini-screws (Figure 2). The same procedure was repeated on the contralateral side. The Most patients required supplemental feeding prior to MDO, wounds were closed in layers with resorbable sutures and with fifty-six (77%) having a nasogastric tube (NGT) and six antiseptic dressings applied. The patients remained intubated (8%) having a percutaneous gastrostomy tube (PEG). All and were returned to the Neonatal Intensive Care Unit (NICU) of the patients requiring PEG-feeding were syndromic. The where they remained sedated. remaining children were managed with special care nursing bottles such as the Haberman and fed orally (Figure 6). Most The devices were activated at a rate of 1.5mm per day (66%) resumed an oral diet within one month post-MDO (activated 0.5mm three times daily) to a maximum length of including 89% of non-syndromic children. At one year after 15mm over ten days following a latency period of one day. The distractor removal, fifty-six patients (77%) were feeding increase in mandibular length is clinically evident in Figure 3, orally but a majority of those that required PEG-feeding were showing a patient immediately before MDO and fourteen days still PEG-dependant. later, following completion of distraction. Growth The distractors were then left in-situ for an average of seven weeks, for bony consolidation, after which they were removed The average growth of the patients followed within one via the same access approach. Titanium appliances were used centile line of their birth-predicted trajectories (Figure 7), in seventy patients and three were resorbable. with the greatest “dip” noted close to the time of distraction. At birth, 5% of the non-syndromic cohort had a Z-score for Over the study period, the exit site for the activation arm was weight of <-2, whilst 10% of the syndromic cohort had a low changed from the labio-mental region to the infra-auricular birth-weight.
109 At one-year post-MDO, 95% of the non-syndromic cohort feeding disorders are common23, while others report improved were growing within two centile lines of their weight at feeding post-MDO24. The feeding outcomes for this cohort distractor removal and the same was noted for 90% of the were overwhelmingly positive, with 77% of the children syndromic cohort. With 10% of the data missing, complete changing to an all-oral diet within one year and thriving. Only data was available for analysis in 71% of patients. one non-syndromic child continued supplemental feeding (NGT) at one year, but changed to an all-oral diet four months Postoperative Complications following this. All other children that required prolonged supplemental feeding (22%) were syndromic. Patients were extubated in the Intensive Care Unit after a mean of five days and discharged home, on average, fifteen A failure to thrive was noted in 29% of patients prior to days following their first surgery. Two children had prolonged distraction but growth improved following distraction and lengths of stay that resulted from infection. One patient had only 7% had not caught-up or maintained growth at one year a respiratory infection with syncytial virus and the other a post-MDO. pseudomonas infection around the distractor activation arms. Erythema of the skin surrounding the activation arm due to Other growth metrics, such as length and head circumference a foreign body, low-grade infection was reported in thirty to further contextualise growth of the cohort, would have patients (41%). Most cases were amenable to antibiotic therapy been desirable but were not available. However, it has been and only four patients (5%) required early distractor removal noted that on a population level, weight alone will predict due to infection at six weeks without any adverse outcomes. growth failure at similar rate to other anthropometric data25. Transient weakness of the marginal mandibular branch of The growth experience of infants post-MDO has not been well the facial nerve was recorded in eight patients (11%) and was reported in the literature. In a smaller sample size (10 patients), noted to resolve over the year post-operatively. Spring and Mount23 showed a 70% rate of growth decline in the year following MDO, but all patients were syndromic. Device failure occurred in three children (4%). One patient This is consistent with the findings in this study, where the underwent re-attachment of an activation arm and two other syndromic cohort had the poorest growth outcomes. devices failed later in the distraction period, with lifting of the foot-plates in the resorbable devices, which occurred A recent review article by Master et al26 listed the most after resolution of airway obstruction and no intervention common complications associated with MDO. Complications, was required. apart from relapse, which arguably should not be included as the initial mandibular lengthening in MDO is stable27 Discussion with subsequent mandibular retrognathia likely caused by a lack of innate mandibular growth21, 27, included tooth Traditionally, the long-term management of UAO in injuries, hypertrophic scarring, nerve injury and infection. micrognathic infants that did not respond to non-surgical Postoperative transient weakness of the marginal mandibular therapy was a tracheostomy18. MDO is a relatively new branch of the facial nerve and infection have already been technique that offers a definitive resolution of UAO11. The noted in our cohort and other longer term complications are complication rate is low with a reduced inpatient stay and the focus of the next phase of this study, a clinical review, thus a decreased burden on families19. which is currently being undertaken. There was a significant improvement in airway outcomes Conclusion in this cohort with sixty-four (87%) being successfully discharged without airway assistance following MDO. For This study reports on the outcomes of a large cohort of children the non-syndromic children this was the case in 100% of this undergoing MDO under the age of five years, at a single group. Of those with pre-existing tracheostomies, 56% were centre. Eighty-seven percent of patients were successfully successfully decannulated within one year. These findings are discharged without supplemental airway measures and a supported by the literature, showing that MDO is a successful further 56% of patients who were tracheostomy-dependant technique for managing airway obstruction with the potential were successfully decannulated within one year. There was to eliminate the need for tracheostomy10-12, 20. A recent a 77% rate of return to oral feeding over the first year post- review by Lam et al21 of 123 patients with a similar proportion MDO and there appeared to be no adverse effect on growth. of syndromic diagnoses, albeit in an older cohort and predominantly with external distraction devices, described The surgical technique was standardised across the cohort a success rate of 76%, where success was defined as either with little variation and was performed, in each case, by one avoidance of a tracheostomy or decannulation in those with of two surgeons. It has proved to be safe, with a low rate of a tracheostomy. serious complications. However, longer-term outcomes such as dental injury, scar cosmesis and nerve injury, such as The improvement in glottis visibility confirmed a previous inferior alveolar nerve paraesthesia, need to be assessed. study at the RCH that demonstrated a decrease in the incidence of difficult intubation following MDO, although it Distraction osteogenesis proved to be a very predictable may not be as effective in individuals with Treacher Collins and highly effective technique in managing micrognathia syndrome22. Polysomnography or overnight pulse oximetry with UAO. However, it was not a panacea in all infants as provided more functional measures of airway patency, but syndromic infants may require additional procedures to relieve this data proved difficult to interpret due to multiple variables their UAO. It is done at the request of respiratory physicians associated with retrospective studies and missing data. and neonatologists, but this group are more likely to have tracheostomies. Decannulation is facilitated by MDO12, 21 and The literature regarding the impact of MDO on feeding is more while initially successful, second distraction procedures have equivocal, with some studies showing that post-operative
110 been necessary in some syndromic children as their anatomy 5. Evans AK, Rahbar R, Rogers GF, Mulliken JB, Volk MS. Robin sequence: and medical co-morbidities make the relief of UAO more a retrospective review of 115 patients. Int J Pediatr Otorhinolaryngol. demanding and parents are warned that further treatment 2006;70:973-80. for airway management may be required. The technique undoubtedly has a role in the management of both groups and 6. Abel F, Bajaj Y, Wyatt M, Wallis C. The successful use of the has become the treatment of choice at the RCH for severe UAO. nasopharyngeal airway in Pierre Robin sequence: an 11-year experience. Arch Dis Child. 2012;97:331-4. 7. Denny AD, Amm CA, Schaefer RB. Outcomes of tongue-lip adhesion Address for correspondence for neonatal respiratory distress caused by Pierre Robin sequence. J Craniofac Surg. 2004;15:819-23. Dr Ashim N. Adhikari BDSc, FRACDS 8. Pereira KD, MacGregor AR, Mitchell RB. Complications of neonatal Research Associate tracheostomy: a 5-year review. Otolaryngol Head Neck Surg. c/o Professor Nicky Kilpatrick 2004;131:810-3. Murdoch Children’s Institute for Research Royal Children’s Hospital 9. Hopkins C, Whetstone S, Foster T, Blaney S, Morrison G. The impact 50 Flemington Road, Parkville 3052 of paediatric tracheostomy on both patient and parent. Int J Pediatr Otorhinolaryngol. 2009;73:15-20. Dr Patrishia Bordbar MBBS (Hons), BDSc, PGDip Surgical Anatomy, MDSc (OMS), 10. Denny AD, Talisman R, Hanson PR, Recinos RF. Mandibular distraction FRACDS (OMS) osteogenesis in very young patients to correct airway obstruction. Oral & Maxillofacial Surgeon Plast Reconstr Surg. 2001;108:302-11. Royal Children’s Hospital 50 Flemington Road, Parkville 3052 11. Denny A, Kalantarian B. Mandibular distraction in neonates: a strategy to avoid tracheostomy. Plast Reconstr Surg. 2002;109:896-904; Associate Professor Andrew A. C. Heggie discussion 5-6. MBBS, BDSc, MDSc, LDS, FRACDS, FFDRCS, FACOMS, FRACDS(OMS), FICD, FADI, FPFA 12. Genecov DG, Barcelo CR, Steinberg D, Trone T, Sperry E. Clinical Associate Professor, University of Melbourne experience with the application of distraction osteogenesis for airway Oral & Cranio-Maxillofacial Surgeon obstruction. J Craniofac Surg. 2009;20 Suppl 2(8 SUPPL. 2):1817-21. Royal Children’s Hospital 50 Flemington Road, Parkville 3052 13. Paes EC, Mink van der Molen AB, Muradin MS, Speleman L, Sloot F, Kon M, et al. A systematic review on the outcome of mandibular distraction Dr Jocelyn M. Shand osteogenesis in infants suffering Robin sequence. Clin Oral Investig. MBBS, MDSc, BDS, FDSRCS(Eng), FRACDS(OMS) 2013;17:1807-20. Oral & Maxillofacial Surgeon Royal Children’s Hospital 14. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. 50 Flemington Road, Parkville 3052 Anaesthesia. 1984;39:1105-11. Professor Nicky Kilpatrick 15. de Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siekmann J. BDS PhD FDS RCPS FRACDS (Paeds) Development of a WHO growth reference for school-aged children and Senior Research Fellow adolescents. Bull World Health Organ. 2007;85:660-7. Murdoch Children’s Research Institute Director of Cleft Services 16. Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Royal Children’s Hospital Fenton growth chart for preterm infants. BMC Pediatr. 2013;13:59. 50 Flemington Road, Parkville 3052 17. Wright CM. Identification and management of failure to thrive: a References community perspective. Arch Dis Child. 2000;82:5-9. 1. Online Mendelian Inheritance in Man, OMIM® Baltimore, MD: McKusick- 18. Collins B, Powitzky R, Robledo C, Rose C, Glade R. Airway management Nathans Institute of Genetic Medicine, Johns Hopkins University; [cited in pierre robin sequence: patterns of practice. Cleft Palate Craniofac J. 2014 27th of May]. Available from: http://omim.org/. 2014;51:283-9. 2. Paletta CEMD, Dehghan K, Hutchinson RL, Klaw BA. P R. A fall of the 19. Paes EC, Fouche JJ, Muradin MS, Speleman L, Kon M, Breugem CC. base of the tongue considered as a new cause of nasopharyngeal Tracheostomy versus mandibular distraction osteogenesis in infants respiratory impairment: Pierre Robin sequence, a translation - 1923. with Robin sequence: a comparative cost analysis. Br J Oral Maxillofac Plast Reconstr Surg. 1994;93:1301-3. Surg. 2014;52:223-9. 3. Riley M, Halliday J. Birth Defects in Victoria 2005-2006. Melbourne: 20. Ow AT, Cheung LK. Meta-analysis of mandibular distraction Victorian Government Department of Human Services, Unit VPDC; osteogenesis: clinical applications and functional outcomes. Plast 2008. Reconstr Surg. 2008;121:54e-69e. 4. Evans KN, Sie KC, Hopper RA, Glass RP, Hing AV, Cunningham ML. 21. Lam DJ, Tabangin ME, Shikary TA, Uribe-Rivera A, Meinzen-Derr JK, Robin sequence: from diagnosis to development of an effective de Alarcon A, et al. Outcomes of mandibular distraction osteogenesis management plan. Pediatrics. 2011;127:936-48. in the treatment of severe micrognathia. JAMA Otolaryngol Head Neck Surg. 2014;140:338-45. 22. Frawley G, Espenell A, Howe P, Shand J, Heggie A. Anesthetic implications of infants with mandibular hypoplasia treated with mandibular distraction osteogenesis. Paediatr Anaesth. 2013;23:342-8. 23. Spring MA, Mount DL. Pediatric feeding disorder and growth decline following mandibular distraction osteogenesis. Plast Reconstr Surg. 2006;118:476-82. 24. Hong P, Brake MK, Cavanagh JP, Bezuhly M, Magit AE. Feeding and mandibular distraction osteogenesis in children with Pierre Robin sequence: a case series of functional outcomes. Int J Pediatr Otorhinolaryngol. 2012;76:414-8. 25. Raynor P, Rudolf MC. Anthropometric indices of failure to thrive. Arch Dis Child. 2000;82:364-5. 26. Master DL, Hanson PR, Gosain AK. Complications of mandibular distraction osteogenesis. J Craniofac Surg. 2010;21:1565-70. 27. Gursoy S, Hukki J, Hurmerinta K. Five year follow-up of mandibular distraction osteogenesis on the dentofacial structures of syndromic children. Orthod Craniofac Res. 2008;11:57-64.
111 Demographics of patients that had MDO Non-syndromic Non-syndromic Patients 31 42 - 10 Treacher Age at MDO (months) Collins <3 - 6 Stickler < 12 - 4 Goldenhar - 22 Other 2.0 (1.7 – 4.2)* 3.3 (2.1 – 7.4)* 6.2 (8.8)† 7.9 (10.5)† 22 18 Fig 2. Intra-operative photograph showing device secured to the mandible with mini-screws and the activation arm exiting 3 17 posteriorly < 60 6 7 Table 1. Data presented as counts, median (interquartile range)* or mean (standard deviation)† Fig 3. Photograph of a child immediately prior to MDO (left) and fourteen days post-operatively, following the completion of distraction (right) Fig 1. Diagram showing curvilinear osteotomy and device placement Fig 4. Supplemental airway management requirements pre- and post-MDO
112 Fig 5. Cormack and Lehane laryngoscopy grades at intubation for distractor placement and removal Bar chart showing the changes in glottis visibility in both cohorts pre- and post-MDO. Graded using the Cormack and Lehane system14 with the grades being: I – full view of the glottis; II – only posterior glottis or arytenoid cartilages visible; III – only the epiglottis is visible; IV – neither glottis nor epiglottis visible Fig 6. Supplemental feeding requirements pre- and post-MDO Fig 7. Growth trajectory of the cohort over the year post-MDO The Z-scores for weight have been converted into centiles commonly seen on growth charts used to assess paediatric growth and development in a clinical setting. The centile lines listed correspond with Z-scores: 1.9, 1.3, 0.7, 0, -0.7, -1.3 and -1.9
ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 113-115 DENTOFACIAL DEFORMITIES AND ORTHOGNATHIC SURGERY IN HONG KONG AND GLASGOW Crystal T.Y. Lee, BDS (Hons) Lim K. Cheung, BDS, PhD, FFD RCS (Irel), FDS RCPS (Glasg), FRACDS, FRACDS (OMS), FHKAM (Dental Surgery), FCDSHK (OMS), FDS RCSEd, FFGDP (UK) Balvinder S. Khambay, BDS, PhD (Birm), FDSRCS (Eng), MOrthRCSEd, FDS(Ortho)RCS (Eng) Ashraf F. Ayoub, BDS, MDS, FDSRCPS, FDSRCS, PhD Philip Benington, BDS, PhD, FDSRCS, MSc, MOrth Crystal Lee is a junior dental officer at Philip Dental Hospital, Lim Cheung is Honorary Clinical Professor of Oral and Maxillofacial Surgery at the University of Hong Kong, Balvinder Khambray is Clinical Associate Professor in Orthodontics at the University of Hong Kong, Ashraf Ayoub is a Professor of Oral and Maxillofacial Surgery at the University of Glasgow and Philip Bennington is a Consultant in Orthodontics at the University of Glasgow. ABSTRACT Objectives: To compare the cross-ethnic difference in dentofacial deformity profile and the associated surgical management in Chinese and Caucasian patients who required orthognathic surgery in Hong Kong and Glasgow, respectively. Material and Methods: This is a retrospective study of consecutive hospital patients’ records from the Prince Philip Dental Hospital in Hong Kong and the Glasgow Dental Hospital and School in Glasgow from 2003 – 2012. Data pertaining to patient demographics, diagnosis, surgical treatment received and complications were recorded. Results: 581 and 217 cases were retrieved in Hong Kong and Glasgow, respectively. Both centres shared a similar patient demographic profile. Class III skeletal pattern was the most prevalent for both centres. A significantly higher prevalence for bimaxillary dentoalveolar hyperplasia, total vertical maxillary excess and mandibular asymmetry was seen in Hong Kong, while a higher prevalence for bimaxillary retrusion and zygomatic hypoplasia was found in Glasgow. To address these, segmental Le Fort I osteotomies, vertical subsigmoid osteotomies, and lower anterior subapical osteotomies were preferred in Hong Kong, while non-segmentalized Le Fort I osteotomies and sagittal split osteotomies were more preferred in Glasgow. Further facial aesthetics surgeries were performed, with septo-rhinoplasty common in Hong Kong and zygomatic augmentation common in Glasgow. Both centres shared a similar complication profile. Conclusion: Significant differences in deformity profile exist between Hong Kong and Glasgow. Differing surgical techniques were employed by the surgeons in the two centres for correction of the deformities in addressing the dentofacial deformities of the individual ethnic group. Introduction study was completed during the elective period of CL at her 4th and 5th years of the Bachelor of Dental Surgery course. Dentofacial deformities can be defined as “deviation from The findings of the study were presented by CL at the Young normal facial proportions and dental relationships that are Lecturer Award Competition at the 22nd Convocation of the severe enough to be handicapping”.1 Surgical correction of Royal Australasian College of Dental Surgeons in 2014. CL dentofacial deformity is an important scope of service and was invited to submit the presentation for publication at the teaching of oral and maxillofacial surgery. The aetiology Annals of the Royal Australasian College of Dental Surgeons. of dentofacial deformity can be congenital, acquired, or The findings of the research project have been prepared for developmental, of which the last cause is the most common. publications at International Journals and two manuscripts Large variations in clinical presentation exist and it can affect were submitted.2, 3 A summary of the oral presentation at the any age and any part of the oral and maxillofacial complex. Convocation is presented below for information to the fellows It is commonly agreed that the norm of faces varies among and members of the Royal Australasian College of Dental the different ethnic background. However, there has been no Surgeons. comparison of ethnic profile and treatment methods between the Chinese and Scottish. Hence, a research project study was SUMMARY OF FINDINGS conceptualized as the first undergraduate research project of the Faculty of Dentistry, University of Hong Kong for the first This was a retrospective study of consecutive patient author (CL), when she was in her fourth year undergraduate records from the Prince Philip Dental Hospital in Hong Kong, program. The aim of the study was to compare the cross- representing the Chinese group, and compared with the ethnic differences in facial profile and management methods patient records from the Glasgow Dental Hospital and School of dentofacial deformities of Chinese and Scottish faces. The in Glasgow, representing the Scottish group. Patients were
114 included if they presented with malocclusion and dentofacial Glasgow. On the contrary, in cases of mandibular setback deformity, whose case have been presented at the joint in Glasgow, sagittal split osteotomy was preferred, being orthognathic assessment clinic and have subsequently performed alone or together with other common mandibular underwent orthognathic surgery between 2003 and 2012. procedures in half of the cases, when compared to about Patients with cleft lip and/or palate, those with acquired 20% of cases in Hong Kong. defects, and those who denied or did not complete treatment were excluded. A total of 581 and 217 cases were retrieved There were also significantly more cases of lower anterior from Hong Kong and Glasgow, respectively. subapical osteotomy or mandibulplasty performed in Hong Kong than in Glasgow. On the contrary, more cases of Class III skeletal pattern was the most prevalent in both the independent genioplasty were performed in Glasgow when Chinese and Scots, accounting for two thirds of cases in Hong compared to Hong Kong. Kong and in Glasgow (Fig. 1). The class III skeletal profile was contributed by a combination of maxillary hypoplasia Some patients were found requiring additional facial with mandibular hyperplasia, showing that the problems aesthetics surgery to achieve a balanced facial profile. The commonly occur in both jaws, as opposed to affecting one jaw most common procedure performed in Hong Kong was septo- alone. This result is similar to the findings of many published rhinoplasty, possibly related to a larger number of facial studies,4 – 9 suggesting that a class III profile with a reverse asymmetry cases, where in addition to the deviated chin overjet is perceived to be more problematic by patients and and mandible, these patients may also present with deviated hence a feel for need of treatment. This could be related to noses. For patients with multiple level of facial asymmetry, the the difficulty in incising foods and speech distortion, which diagnosis of facial scoliosis is labeled. In Glasgow, zygomatic are particularly associated with a reverse overjet. augmentation with iliac crest bone graft was more common in order to manage a high prevalence of zygomatic hypoplasia. In comparing the dentofacial deformity profile of the two ethnic groups, there were a higher percentage of bimaxillary Similar percentage of patients in Hong Kong and Glasgow dentoalveolar hyperplasia, vertical maxillary excess, and experienced no major complications. However, there were mandibular asymmetry in the Chinese, as opposed to a more cases with post-surgical infection and dehisced wound significantly higher prevalence of bimaxillary dentoalveolar in Hong Kong, while in Glasgow, there were more cases with retrusion and zygomatic hypoplasia in the Scots. This reflects dental decalcification after treatment. the inter-ethnic difference of the accepted norm, particularly with the perception of zygomatic hypoplasia, which is more In conclusion, there are distinct ethnic differences in prevalent in the Scots. This is not to say that such a profile dentofacial deformity profile between Chinese in Hong Kong does not exist in the Chinese, but it is more acceptable to and Scots in Glasgow. Such a difference may have reflected have a flatter zygoma as the norm amongst the Chinese. the differences in the accepted norm of the individual ethnic Therefore, zygomatic hypoplasia, unless severe, is not population. A variety of surgical techniques have been considered problematic in the Chinese population, and hence utilized to address the deformities of the individual ethnic not diagnosed. The high prevalence of zygomatic hypoplasia group. As surgeons and clinicians, it is crucial that treatment in the Scots reflected the preference for more prominent planning be tailored to each individual patient, including his zygomas. ethnic background in order to achieve a natural appearance. Although orthognathic surgeries seldom lead to major For management, orthognathic surgery remains the standard complications, but like all other surgeries, orthognathic treatment method in both centres, with Hong Kong having surgeries can still lead to long term, though intermediate to a higher prevalence of simultaneous 2-jaw surgeries when small complications, many of them can be controlled with compared to Glasgow. For maxillary procedures, Le Fort good management. It is part of modern medicine that any I osteotomy was the commonest procedure performed in clinical procedure as well as risks and complications need both centres, with Hong Kong having a higher preference to be explained clearly to patients as an integral part of the for segmentalized Le Fort I osteotomy than Glasgow, where surgical consent process. the professors and consultants preferred non-segmentalized Le Fort I osteotomy. Segmentalization allows more freedom ACKNOWLEDGEMENTS of surgical movements, and is valuable in the correction of dentoalveolar protrusion, which is highly prevalent in Hong The authors would like to acknowledge the Overseas Research Kong. Dentoalveolar protrusion is commonly presented Internship Award 2012 funding support from the University of with beak-shaped lips, acute naso-labial angle and a B point Hong Kong to enable the Undergraduate Research Fellowship which lies anterior to the pogonion. Segmentalization will Programme to take place. allow the dentoalveolus to be up-righted and rotated into the proper position independently of the maxilla. In Glasgow, the REFERENCES maxilla was kept mostly as one piece, which allowed it to be repositioned as one unit without changes in the arch integrity. 1. Proffit WR, White RP, Sarver DM. Contemporary Treatment of Dentofacial Deformity. Missouri: Mosby, 2003:2. For mandibular procedures, significant differences were found in the choice of procedure performed between Hong 2. Lee CTY, Cheung LK, Khambay BS, Ashraf AF, Benington P. Profile of Kong and Glasgow. In cases of mandibular setback, vertical dentofacial deformities and multidisciplinary management in Hong subsigmoid osteotomy, alone or in combination with another Kong and Glasgow: A retrospective study. Plos One (submitted). mandibular procedures, such as genioplasty, step or anterior subapical (Hofer) osteotomy, accounted for over 50% of the 3. Lee CTY, Cheung LK, Khambay BS, Ashraf AF, Benington P. Comparison cases in Hong Kong, as opposed to about less than 10% in of surgical management and complications in patients with dentofacial deformities in Hong Kong and Glasgow. Int J Oral Maxilofac Surg (submitted). 4. Boeck EM, Lunardi N, Pinto A. Occurrence of skeletal malocclusions in Brazilian patients with dentofacial deformities. Braz Dent J 2001;22:340-5.
115 5. Ong M. Spectrum of dentofacial deformities: A retrospective survey. Ann Acad Med Singapore 2004;33:239-42. 6. Chew MT. Spectrum and management of dentofacial deformities in a multiethnic Asian population. Angle Orthod 2006;76:806-9. 7. Martos Diaz P, Garcia RG, Gias LN. Time used for orthodontic surgical treatment of dentofacial deformities in white patients. J Oral Maxillofac Surg 2010;68:88-92. 8. Samman N, Tong ACK, Cheung LK. Analysis of 300 dentofacial deformities in Hong Kong. Int J Adult Orthodon Orthognath Surg 1992;7:181-5. 9. Al-Deaiji A. Characteristics of dentofacial deformities in a Saudi population. Saudi Dent J 2001;13:101-5. Address for correspondence Prof. Lim K. Cheung CLK Center of CMF and Dental Implants 1205 Tower 2 Lippo Centre 89 Queensway, Admiralty Hong Kong SAR, China Tel: (852) 2866 6525 Fax: (852) 2866 6524 Fig 1. Skeletal patterns seen in Hong Kong and Glasgow
ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 116 THE ORAL HEALTH OF CAMBODIAN PRESCHOOL AGED CHILDREN Bach K, Manton DJ, (Melbourne Dental School, University of Melbourne, Australia) Katie is in her final year of the Paediatric Dentistry specialty program at Melbourne University. Her postgraduate training is being supported by a fellowship from Health Workforce New Zealand. Katie has always had an interest in oral health promotion in developing countries and has spent extensive time in Cambodia, working at the Angkor Children’s Hospital and assisting with the Seal Cambodia research. Background Cambodia has the highest mortality rate for under five year-olds in the South–East Asian region, with many children being affected by infections and malnutrition. While there is extensive literature on general child health outcomes there is limited epidemiological data regarding the oral health status of pre-school aged children in Cambodia. The aim of this study was to determine the prevalence and severity and oral consequences of Early Childhood Caries (ECC) in a population of pre-schoolers in Siem Reap Province, Cambodia. Methods Standardized oral examinations were conducted in a convenience sample of 356 children aged six months to six years of age. These children attended preschools run by a Non-Governmental Organization (Caring for Cambodia). A new index, The Caries Assessment Spectrum and Treatment Index, was used to record caries and any associated oral infections in these Children Results The prevalence of ECC was found to be: 31.9% at one year of age, 69.4% at two years increasing to 100% at five and six years of age. The mean dmft was 2.53 at two years, increasing to a mean dmft of 12.81 at six years. The majority of the carious lesions were untreated, five children had restorations placed and 21 children had teeth extracted due to caries. Overall 39.2% of children reported a history of dental pain and 90% of six-year-old children reported a history of dental pain. Conclusions ECC and experience of dental pain was found to be highly prevalent in this population of Cambodian pre-school aged children. Further research exploring risk factors, appropriate education programs and preventive and restorative strategies, is required to reduce the burden of disease in these children. Address for correspondence [email protected]
ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 117 AN INVESTIGATION INTO PERFORMANCE OF THREE TYPES OF IMPLANTS IN A NOVEL OVINE MANDIBLE CANINE MODEL C. Barker, C. Vaquette*, S. Ivanovski† Dr Christopher Barker is a Dental Associate within a general practice in Queensland, Australia and a Dental Locum in a satellite practice based in regional Queensland *Research Fellow, Queensland University of Technology †Professor and Chair in Periodontology, Discipline Lead: Periodontology and Implantology, Griffith University ABSTRACT The release of new implants commercially often does not correlate with the amount of evidence to support the suggested advantages in terms of osseointegration in specific sites of either reduced quantity or quality of bone. This is very significant in implantology as osseointegration dictates not only the success of the surgery but also the longevity of the implant and subsequent restoration. Where previously the majority of literature has focused on implants made from pure commercial grade titanium, (cp Ti) new alloys have been developed to enhance material characteristics. A recent example is the release of Titanium –Zirconium alloys (Ti Zr alloy), primarily to enhance material characteristics. The differences between previous cp Ti implants utilizing established surface treatments such as sand-blasted, large-grit and acid-etched (SLA, (Institut Straumann, Basel, Switzerland)) and the further modified hydrophilic SLA surface treatment (SLActive, (Institut Straumann, Basel, Switzerland)) vs new Ti ZR alloys (consisting of 83–87% titanium, 13–17% zirconium) using the modified SLA surface treatment (Roxolid, (Institut Straumann, Basel, Switzerland)) has yet to be quantified in the environment of poor quality bone. This investigation aims to provide insight into the affects of changing the core material on osseointegration performance in poor quality bone, which will allow clinicians to make an informed choice of specific implants for specific sites. The animal model chosen for the research also adds to the significance of the outcomes. Currently there is no gold standard for animal models of poor quality bone in implant dentistry research and this investigation also reviews an animal model to address this. Address for correspondence [email protected]
ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 118 Orofacial Disease – Genes, Genetics and Geriatrics Richard M. Logan BDS MDS PhD FFOP(RCPA) FICD FPFA Dr Logan is Head of Oral Diagnostic Sciences and Head of the Discipline of Oral Pathology Dental School, The University of Adelaide and Consultant Oral Pathologist at Clinpath Laboratories, Adelaide. ABSTRACT With an ageing population, dentists will have to manage and treat increased numbers of patients with systemic conditions associated with advanced age such as hypertension, cardiovascular disease, diabetes and cancer. Furthermore some specific oral conditions are more likely to manifest in older patients and it is obviously important that dentists are able to recognise these pathologies. But what about “genetics” – what role does this play in the oral health of older patients? Does this play a role in the risk of developing oral manifestations of systemic disease or complications association with their medical treatment? Are there genetic factors that influence the development of oral pathology later in life? In the years since the human genome was first mapped, advances have been made in the understanding of genetic influences on disease and risk of disease. Increasingly we are heading towards an era of personalised medicine. What does this mean for dentistry and our patients? This presentation will explore orofacial pathologies encountered in older patients and discuss the role of genetics in understanding their development and potential management. Address for correspondence Dental School, Faculty of Health Sciences The University of Adelaide, SA 5005, Australia [email protected]
ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 119 ENDODONTIC ADVANCES Dr Geoffrey Young, BDS(Hons)(Syd), DClinDent(Melb), FRACDS(Endo) Dr Young is in private practice and is the current President of the Australian Society of Endodontology (NSW Branch) having served on the Executive Committee for over 5 years. He also teaches Endodontics part-time at the University of Sydney. ABSTRACT Industry publications contain advertisements and testimonials about new techniques and advances in endodontics. Claims such as “virtually unbreakable”, and “this proven technology provides superior leakage protection” are some examples. How can we tell the difference between marketing and clinical reality? When should we make the leap to a new, possibly unproven technology? This lecture evaluates the published research relating to technologic advances in endodontic instrumentation, irrigation, medicaments, and obturation techniques and materials. Address for correspondence [email protected] ENDODONTIC OUTCOMES Dr John McNamara BDSc(Qld) MDS(Adel) FICD FADI FPFA MRACDS(Endo) Dr McNamara has been awarded Fellowships of the International College of Dentists, the Academy of Dentistry International, and The Pierre Fauchard Academy. Dr McNamara is currently Chairman of the Australian Advisory Panel for Dental Protection Ltd, a mutual indemnity company that provides indemnity cover for dentists worldwide. ABSTRACT Endodontic treatment forms a significant proportion of modern general dental practice, and indeed is consistently responsible for 20% of all dental indemnity claims, worldwide and in Australia. There has been an extraordinary focus on technological change in endodontics over the last two decades, and this continues, largely sales driven. It has unfortunately detracted from perhaps the most critical factors which determine outcome of endodontic treatment and prognosis for tooth retention. An important and often overlooked aspect of endodontic procedures is complete assessment of the patient and tooth to make an informed diagnosis and facilitate more satisfying and successful outcomes. This presentation is designed to illustrate the importance of a thorough preoperative assessment of the patient, their dentition and tooth in question, together with sound risk management practices, including records and warnings in endodontics, which should result in a more favourable outcome for the patient, and so a less stressful time for the treating practitioner. There are particular times in the practitioner’s career when one is more at risk in particular areas of practice, including endodontics, particular patient conditions which are potentially more problematic to manage, and some conditions which are readily over- treated without adequate information or understanding of prognosis, and alternatives. Some specific examples of appropriate occasions to ask for second opinions and when to consider referral, or no treatment at all, and more appropriate alternatives will be presented. One factor which will become clear is that knowledge is key to informed decision making, and hopefully the addition of some further information to participants’ knowledge base will assist in planning their patients’ care. It is designed to challenge participants to critically look at their own scope of treatment, and provide a basis for more satisfying practice of endodontics. Address for correspondence [email protected]
ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 120 MINIMALLY INVASIVE CERAMICS – REALLY? David Mark Roessler, BDS MDSc FRACDS FADI FPFA FICD MRACDS(Pros) Adjunct Professor Roessler has maintained a private practice as a Dental Board registered Specialist Prosthodontist for over 25 years. He is an Adjunct Associate Professor at the University of Sydney. He has authored countless publications and is Clinical Editor for Australasian Dental Practice magazine. ABSTRACT The lecture presented an overview of the current state of dental ceramics, bonded ceramics in par-ticular. The advantages and reasons for success and failure of ceramic restorations were outlined. Methods to increase ceramic longevity were summarised. The current high success rate of ceramic restorations was highlighted with reference to the literature as well as illustration with clinical cases. Although we can already use ceramic restorations with con-servative tooth preparations, there are a number of factors which will allow even less tooth removal: MATERIALS THAT CAN BE THIN AND PREFERABLY BIOMETRIC There are already materials which can be reduced to thicknesses of 0.3 mm. The resin/polymer infiltrat-ed ceramic networks appear to show the most promise. Materials that are biomimetic will cause less stress on restoration, cement and tooth. DIGITAL IMPRESSIONS, INSTANT CAD / CAM, 3D PRINTING As material thicknesses are reduced, it will become more difficult to stabilise teeth between prepara-tion and restoration. Digital impressioning combined with immediate construction and provision of the definitive restoration will become increasingly important. EFFECTIVE BONDING The etchable ceramics, including the hybrid ceramic materials depend on bonding for their longevity. Bonding also reduces the need for classical resistance and retention form making it possible to do less tooth preparation. UNDERSTANDING OCCLUSAL FACTORS Reduce stresses on the restored complex will result in greater longevity of restoration and tooth. This can be accomplished by understanding that angle of load and depth of cavity are the most important factors. MODIFIED THINKING ABOUT TOOTH PREPARATION Traditionally, indirect restorations have been categorised as crowns, veneers, inlays and onlays. Cur-rent materials combined with bonding have already blurred these distinctions. The lecture demon-strated a number of novel ways to restore teeth, including conglomerate ceramic restorations (more than one per tooth); partial onlays; creneers and compact crowns. Address for correspondence Adjunct Associate Professor, University of Sydney Prosthodontist, Level 2, 70 Pitt St Sydney 2000 [email protected]
ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 121 MULTIPLE MISSING TEETH: WORKING TOGETHER AS A TEAM Dr Lochana Ramalingam, BDS, Grad Dip Clin Dent, MDSc, FRACDS(GDP), FRACDS(Paed) Dr Lochana Ramalingam is Clinical Director at the Royal Children’s Hospital Melbourne, a part-time clinical demonstrator at the University of Melbourne in addition to being in private practice. ABSTRACT The management of patients with multiple congenitally missing teeth is very challenging. Patients with missing teeth could have 1-6 missing teeth (hypodontia) or 6 or more missing teeth (oligodontia) or no teeth (anodontia). The prevalence of hypodontia is about 2.3 to 9.6% in the permanent dentition and the prevalence of oligodontia is about 0.08 to 0.16%. If teeth are missing in the deciduous dentition, there is a high chance that permanent teeth will be missing as well. Missing teeth is also common in certain medical conditions including Down Syndrome, Ectodermal Dysplasia syndromes and clefting syndromes. It is therefore important to diagnose whether oligodontia is associated with a syndrome. Non-syndromic oligodontia is commonly inherited as an autosomal dominant trait with incomplete penetrance and variable expressivity. Peg shaped lateral incisors could be considered a modified manifestation so careful dental assessment of all family members is required. Mutations in the MSX1 and PAX9 genes have been linked to non-syndromic oligodontia. However, this test is not currently available routinely. Genetic counselling is necessary to rule out syndromic oligodontia and to discuss issues related to inheritance. Missing teeth can be associated with dental anomalies such as delayed tooth formation and eruption, reduction in tooth size and form, ectopic eruption of teeth especially permanent canines, infraocclusion of deciduous molars, short roots and taurodontism. Early diagnosis and timely referral of patients with oligodontia is important. Key clinical signs to the possibility of missing teeth include delayed eruption of teeth, overretained deciduous teeth, thin and underdeveloped alveolar ridges, the presence of diastemas and a strong family history. Diagnosis can be confirmed by appropriate radiographs. The principles of dental management of patients with multiple missing teeth should also take the following into consideration: psycho-social factors, financial factors, medical factors and access to specialist care. The chief complaint of the patient should be addressed as best as possible. Interdisciplinary care is ideal if available or multidisciplinary care can be obtained. Quality of life studies have found that there is evidence to show that oligodontia has an impact on function and emotional wellbeing. There is a significant association between these scores and the number of missing teeth. There have been limited qualitative studies done in this area and preliminary studies have demonstrated that there is a need for better communication between dental practitioners and patients and that “normality” (aesthetics and function primarily) is the most influential factor when patients seek current or future dental treatment. Qualitative studies have also found that patients would prefer to be more involved in the decision-making process for their dental treatment needs. Timely diagnosis, referral and management of patients with multiple missing teeth is important. Treatment of patients with multiple missing teeth is complex and is best done in conjunction with a team of dental and medical specialists. Good communication between patients and their clinicians and assessing the patient’s expectations of treatment and outcomes are the key to successful management of this group of patients. Address for correspondence Royal Children’s Hospital, Melbourne [email protected]
ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 122 NATIONAL ORAL HEALTH PLAN 2014 - 2023 Andrew McAuliffe, BAppSci(Physio), GDSocSci (Health), AFAAQHC Mr McAuliffe is the Chair of the National Oral Health Plan 2014-2023 and Executive Director, Policy - Australian Healthcare and Hospitals Association. ABSTRACT Healthy Mouths, Healthy Lives, Australia’s National Oral Health Plan 2004-2013 was released in 2004. It was endorsed by all Health Ministers at the Federal, State and Territory level and served to focus the community and government on the important issue of oral health. The first National Oral Health Plan (NOHP) identified seven key Action Areas: • Promoting oral health across the population • Children and adolescents • Older people • Low income and social disadvantage • People with special needs • Aboriginal and Torres Strait Islander Peoples • Workforce A further action area: Rural and Remote Residents was added following a mid-term review. The plan contained a range of indicators and progress against measures has been particularly apparent in the areas of water fluoridation expansion and workforce growth. A further significant change that has occurred over the past ten years has been the increased policy engagement and investment in oral health programs by the Australian Government. This has included a range of direct service provision programs including the Chronic Disease Dental Scheme, Teen Dental and most recently the Children’s Dental Benefit Scheme. New National Partnership Agreements have also seen increased funding to states and territories for public dental programs. Workforce strategies have included Health Workforce Australia support for student clinical placements, relocation incentives for private practitioners and the Voluntary Graduate Year programs from dentists and oral health therapists. This activity, together with a range of Government established committees, and Senate and House of Representative Inquiries has been in stark contrast to earlier periods when the Australian Government was actively distancing itself from oral health issues. With the first plan reaching the end of its ten-year lifespan in 2013, the Standing Council on Health through the Australian Health Ministers’ Advisory Council tasked the National Oral Health Plan Monitoring Group to develop a new national plan for the period of 2014-2023. As indicated above the development of the new plan is occurring in a very different political and economic environment. The new plan is being been developed in the context of significantly great involvement of the Federal Government in service provision, workforce and infrastructure programs. However as all investment is under scrutiny due to the fiscal pressures on all governments, it is critical that the new NOHP provides an evidence-based and value-for-money approach to the strategic direction for oral health over the next decade. While the principles and objective of the first NOHP remain relevant there is a need to increase the focus on particular groups to reduce the inequities in oral health outcomes that persist in the community. The intended structure of the new NOHP will include Foundation Activities and Priority Population groups. The logic behind this approach is that activities in the Foundation areas will address the needs of the majority of Australia but those in the Priority Population Groups will require additional targeted actions to overcome the disproportionate level of disease and the access challenges they experience. Further information on the NOHP is available at www.oralhealthplan.com.au Address for correspondence [email protected]
ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 123 PERSONALISED GENETIC MEDICINE: IMPACT ON CLINICAL MEDICINE Professor Ravi Savarirayan MB, BS (Adel.); FRACP, MD (Melb.); ARCPA (Hon) Ravi Savarirayan is a clinical geneticist, and Head of Clinical Genetics Services at Victorian Clinical Genetics Services. His special area of expertise is in the inherited disorders of the skeleton that cause short stature, arthritis and osteoporosis in both children and adults. ABSTRACT Quantum advances have occurred in the field of human genetics in the six decades since Watson and Crick expressed their “wish to suggest a structure for the salt of deoxyribose nucleic acid (D.N.A.) 1”. These culminated with the human genome project which has opened up myriad possibilities, including that of personalised genetic medicine, the ability to deliver medical advice, management, and therapy tailored to an individual’s genetic constitution. The advances in genetic diagnostic capabilities have been rapid, to the point where the genome can be now sequenced for several thousand dollars. This ability to confirm a suspected genetic diagnosis at the molecular level is having a profound impact on clinical medicine for single gene and complex (multigenic) disorders alike. It has allowed the ability to offer: accurate recurrence risk estimations to families; prenatal (including preimplantation) diagnostic options; cascade testing of family members, including those who are asymptomatic; further insights into the basis/heterogeneity of the disease; and, crucially, identification of targets for specific treatments. The linchpin underlying treatment of infectious disease for decades, it is only now that we possess the tools to extrapolate this concept to the combat of genetic disease. Accordingly, effective adjunctive and ameliorative treatment for genetic conditions based on their underlying cause is now a reality. The use of mTOR (mammalian target of rapamycin) inhibitors to treat the tumours of tuberous sclerosis complex2, angiotensin receptor blockade to treat aortic wall fragility in Marfan syndrome3, anti-VEGF (vascular endothelial growth factor) therapy to treat age-related macular degeneration4, and human recombinant alkaline phosphatase to treat hypophosphatasia5, exemplify how targeted, pathogenesis-based treatments are revolutionizing management of genetic conditions, giving patients and families new options and outcomes. If we are to move swiftly to an era of individualized genetic medicine, it is vital that effective, quick, and robust pathways are established leading from the diagnosis of a genetic condition to the identification of biologically plausible intervention points. Advances in understanding our genome have also enabled identification of changes in genes (called polymorphisms) that, while they might not be sufficient to cause disease alone, can cause disease when added to other genetic changes and/or environmental inputs. These so-called “susceptibility” genes have been identified for numerous complex genetic disorders ranging from diabetes and lumbar disc disease, to infectious diseases and mental health conditions. This ability, to identify a specific high-risk group of people prone to a certain disease, has allowed tailored advice and medical management to be delivered to this group, aimed at decreasing the severity or delaying the onset of these conditions. It has facilitated the development of specific pharmacologic therapies tailored for these groups based on their genetic profiles. The identification of these high-risk genetic profiles (alleles) has opened up the possibility for screening of whole populations, with the aim of early intervention and therapy where appropriate, sometimes before the onset of clinical symptoms. Occasionally, the media in their eternal search for a “story”, and scientists in their desire to emphasize the importance of their work, have conspired to overstate the case and hence we read headlines such as “divorce gene found” which grossly distort the state of actual knowledge into the complex interplay between our genetic profiles and our environments. Having said this, never before has the promise of genetic medicine been more enticing. It offers to individualize the treatment of genetic disorders, select the right medication and dosage for the right patient, allow accurate prediction of disease severity and outcomes, and screen populations for susceptibility to common disease. The last 60 years has taught us the musical notes that make up the symphony of life. The challenge for future research will be to know how to play the music. REFERENCES Address for correspondence 1. Watson JD, Crick F. Molecular structure of nucleic acids: A structure for Victorian Clinical Genetics Services, Murdoch Childrens deoxyribose nucleic acid. Nature 1953;171:737-38. Research Institute University of Melbourne, Parkville, Victoria, Australia. 2. Krueger DA, Care MM, Holland K, Agricola K et al., Everolimus for subependymal giant-cell astrocytomas in tuberous sclerosis. N Engl J [email protected] Med 2010;363:1801-11. 3. Brooke BS, Habashi JP, Judge DP, Patel N et al., Angiotensin II blockade and aortic-root dilatation in Marfan syndrome. N Engl J Med 2008;358:2787-95. 4. Xu D, Kaiser PK. Intravitreal aflibercept for neovascular age-related macular degeneration. Immunotherapy 2013;5:121-30. 5. Whyte MP, Greenberg CR, Salman NJ, Bober MB et al., Enzyme- replacement therapy in life-threatening hypophosphatasia. N Engl J Med 2012;366:904-13.
ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 124 THE ORAL MICROBIONE IN HEALTH AND DISEASE Professor Lakshman Samaranayake, DSc (Hon), FRCPath (UK), DDS (Glas), FDSRCS (Edin, Hon), FRACDS Professor Lakshman Samaranayake is the Head of the School of Dentistry, and Professor of Oral Microbiomics and Infection at the University of Queensland. Prior to this he served at the University of Peradeniya, Sri Lanka, University of Glasgow, Scotland, University of Alberta, Canada and University of Hong Kong, China. He was the Dean of Dentistry at University of Hong Kong for a decade, from 2004. ABSTRACT Every human being has a personalized set of foreign inhabitants – microbes – essential to maintaining health, yet also capable of eliciting disease. These microbes exist in microhabitats of the various anatomical locations of the human body in the form of a microbiome. There are various microhabitats throughout the body that constitute the overall microbiome. Each of this microhabitat maintains a unique ecosystem. The mouth, skin, and gut, for instance each contains its exclusive microbiome and there is more and more data accumulating that one of these – the oral microbiome, a term given to the totality of bacteria; viruses and fungi in the oral cavity, may play a definitive role not only in maintaining the oral health of the person but also contributing to various systemic disease conditions. The organisms in these microhabitats do not exist as suspended particles (i.e. the planktonic phase) but as surface attached communities known as biofilms. Our understanding of biofilm formation and development has relied on observations made using various microscopic techniques such as scanning electron microscopy, fluorescence microscopy, and confocal scanning laser microscopy. A biofilm typically develops over four sequential steps: first, the adhesion of a microorganism to a surface, second, discrete colony formation, and organization of cells; third, secretion of extracellular polysaccharide; maturation into a three-dimensional structure; and lastly, dissemination of progeny biofilm cells. Microorganisms in biofilms and their by products in each of the habitats spread to different body sites through various mechanisms. For instance it is known that biofilm organisms that originate in the oral cavity can be cultured from blood, and in amniotic fluid in some situations indicating that they have the ability to cross the feto-placental barrier. The situation is further aggravated in periodontal disease and recent work has shown mechanisms by which pathogens derived from a periodontal inflammatory response make their way to even tumours in the gut or pancreas. Additionally the pathogens may enter the blood stream, alter proper immune responses, or produce excessive and deregulated amounts of inflammatory mediators, and in turn, may contribute to disease at different body sites. These include atherosclerotic vascular diseases, kidney diseases, pulmonary diseases, adverse pregnancy outcomes, and diabetes. Moreover, there is also a viral oral flora that constitutes this microbiome that may cause oral cancers in susceptible individuals. This presentation will outline ‘the good, the bad and the ugly’ residents within the oral microbiome, and how there interplay affects the total health. Featured also will be the aspects of this message that should be disseminated to the wider medical community and the public. REFERENCES Address for correspondence 1. Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE Defining the normal Head, School of Dentistry, and Professor of Oral bacterial flora of the oral cavity. J Clin Microbiol 2005;43:12. Microbiomics and Infection University of Queensland, Brisbane, Australia 2. Avila M, Ojcius DM, Yilmaz O The oral microbiota:living with a permanent guest. DNA Cell Biol 2009;28:7. 3. Bahekar AA, Singh S, Saha S, Molnar J, Arora R The prevalence and incidence of coronary heart disease is significantly increased in periodontitis:a meta-analysis. Am Heart J 2007;154:830–837. 4. Dewhirst FE, Chen T, Izard J et al. The human oral microbiome. J Bacteriol 2010;192:5002–5017. 5. Flemmig TF, Beikler T Control of oral biofilms. Periodontol 2000 2011;55:9–15. 6. Garcia RI, Henshaw MM, Krall EA Relationship between periodontal disease and systemic health. Periodontol 2000 2001;25:21–36. 7. Jenkinson HF, Lamont RJ Oral microbial communities in sickness and in health. Trends Microbiol 2005;3:589–595. 8. Parahitiyawa NB, Scully C, Leung WK, Jin LJ, Samaranayake LP Exploring the oral bacterial flora:current status and future directions Oral Dis 2010;16:10-14 9. Zaura E, Keijser BJ, Huse SM, Crielaard W Defining the healthy “core microbiome” of oral microbial communities. BMC Microbiol 2009; 259:12.
ANN ROY AUSTRALAS COLL DENT SURG 2014; 22: 125 ANNALS OF THE ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS VOLUME 22 - APRIL 2014 SCIENTIFIC PROGRAMME – PAPERS AND ABSTRACTS CONTRIBUTORS’ INDEX Adhikari A..................................................................................107 Kerr B...........................................................................................86 Andreasen FM.............................................................................74 Lam R..........................................................................................102 Ahmad MS...................................................................................98 Lee C............................................................................................113 Bach K.........................................................................................116 Logan RM....................................................................................118 Badstone MD...............................................................................96 McAuliffe A.................................................................................122 Barker C.......................................................................................117 McNamara J................................................................................119 Bischof W.....................................................................................33 Ramalingam L.............................................................................121 Broadbent JM.............................................................................88 Roessler DM...............................................................................120 Brown LF......................................................................................27 Samaranayake L........................................................................124 Harley K................................................................................45, 64 Savarirayan R............................................................................123 Heggie AAC.................................................................................48 Tagami J................................................................................39, 56 Hyam DM......................................................................................91 Walsh LJ......................................................................................60 Fricker J.......................................................................................77 Ye Q...............................................................................................71 Fryer FS.......................................................................................67 Young G.......................................................................................119 Johnson NW................................................................................82
Royal Australasian College of Dental Surgeons Level 13/37 York Street, Sydney NSW 2000 P +61 2 9262 6044 F +61 2 9262 1974 E [email protected] www.racds.org
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