ournal Guest Editorial Visit our websites: and The Australian New Zealand

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1 &Jof The Australian New Zealand ournal DENTAL AND ORAL HEALTH THERAPY ISSN: VOLUME 2 : ISSUE Guest Editorial Helen Tane PhD candidate, MPH, DPH, PG.Cert.Tert.T(Otago), RDT. Senior Lecturer Oral Health Charles Sturt University The College of Oral Health Academics Meeting in Fiji, October 2013 The College of Oral Health Academics (COHA) is a collective of academics, researchers and clinical educators who teach the professions of oral health therapy, dental therapy and dental hygiene throughout Australia, Fiji, and Micronesia & New Zealand. Members meet each year to share and foster the development of the body of knowledge and skills within these professions and this year they met October in Suva, Fiji, where the warm Fijian hospitality was very evident at all times. The venue provided the opportunity to visit the School of Dentistry in Suva, and meet the Fijian dental team who teach into the degree courses. Dr Leenu Maimanuku provided an informative presentation about the challenges of meeting community needs with curriculum design for a BOH graduate to meet the needs of the Pacific Islands. on the Gold Coast 2008, Auckland NZ in 2009 and CSU in Wagga Wagga in 2010 where the concept to formalise the college from the group of academic delegates was born. Academics from the School of Fiji joined this collaborative group during these meetings, and following that, meetings were then held in Otago in 2011 and in Canberra in 2012 in conjunction with the ADOHTA International conference. Throughout this time, COHA has enjoyed generous and ongoing support from Colgate. The Otago COHA meeting was also attended by a representative from the University of Washington s Alaskan Dental Therapist Aide Program, who had assisted with sending students from Alaska to New Zealand for their educational preparation. This group of Alaskan students subsequently returned to Alaska and started as the first practising dental therapists in an American state in The beginnings of COHA occurred when Dr Hanny Calache (with the BOH team) initiated and hosted the inaugural meeting at the University of Melbourne in 2002, with the generous support of Colgate. The objective of the meeting was to develop national dialogue on oral health therapy education issues and the inaugural meeting was attended by two delegates from each of the dental therapy, dental hygiene and oral health therapy educational programs in Australia and New Zealand (April 2002, ADTA Journal). Presentations were made by each school and program about course content and features unique to each program. Presentations were also made by the NSW Dental Hygienists Association who were working at the time to establish a dental hygiene program in NSW and from Dr Rosemary Cane from Tasmania about the progress in developing skills in dental therapists for the treatment of adults in that state (Satur, in Tsang 2012). Delegates from the courses listed above attended subsequent annual meetings in Sydney 2005, Griffith University The dedication to educating the professions of oral health therapy, dental therapy and dental hygiene is profoundly evident at the COHA meetings. Members of our professions can be assured that this collaboration fosters a platform where advanced concepts to examine, discuss and research curriculum development and assessment, clinical skills evaluation, graduate data, examples of best practice, educational innovation and developments in oral health therapy education. It is critical that members of our professions determine the standards and content for their educational preparation and qualifications, and the academics active in research can invest their advanced skills into curriculum development and the graduate outcomes for their professions. In more recent time, the need to have COHA representation on various discipline and governing bodies has been identified. It is critical to ensure the collective knowledgebase and expertise, particularly in educational standards in the oral health therapy professions is embodied, considered and The College of Oral Health Academics (COHA) Visit our websites: and on page 3

2 The Australian and New Zealand Journal of Dental and Oral Health Therapy (1) 2014 CONTENTS 4 Treatment Options Associated with Molar Incisor Hypomineralisation (MIH): A Review of the Literature, by Brie Zienkiewicz & Julie Satur 11 The Healthy Tribe: An Oral Health Project with Aboriginal School Children, by Cassandra M. Fletcher & Wendy Bowles 17 The Role of the Oral Health Therapist in the Management of Oral Complications due to Cancer Treatment, by Hayley Downey, John O Grady, Michael J McCullough & Julie Satur 21 Evaluation of Fissure Sealant Retention and Secondary Caries in Permanent Second Molars: A Clinical Audit, by Ali S, Croucher N & Boyce-Bacon K 24 19th International Symposium on Dental Hygiene, Cape Town South Africa, by Melanie Hayes 25 ADOHTA WA 2013 Conference, by Hellene Platell 26 Thankyou to our Peer Reviewers 27 Websites of Interest & Noticeboard 28 Colgate Corner, by Dr Sue Cartwright Advertising Rates and Deadlines The Australian and New Zealand Journal of Dental and Oral Health Therapy Inserts (2000 x A4 page supplied by advertiser) $2000 Advertising per ad single issue Full page $1000 Half page $750 Quarter page $400 Notice Board entry (2-3 lines) $100 The ANZJDOHT is published twice per year Deadlines are 30 April and 30 September each year Subscription Information Institutional subscription per year $100 AUD Advertising & Subscription Enquiries to Tania Fisher: fishert@unimelb.edu.au THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF DENTAL AND ORAL HEALTH THERAPY ANZJDOHT ISSN: EDITOR Dr Julie Satur Assoc Professor Oral Health Melbourne Dental School The University of Melbourne 720 Swanston Street, Melbourne VIC 3000, Australia juliegs@unimelb.edu.au ADOHTAJ EDITORIAL COMMITTEE Julie Satur, Barbara Dewson, Rebecca Ahmadi, Amanda Blyton-Patterson, Mark Gussy, Jennifer Miller, Carol Nevin, Agnes Smith, Erekle Siashavilli, Leonie Short, Helen Tane, Carol Tran, Janet Wallace ADMINISTRATIVE SUPPORT Tania Fisher fishert@unimelb.edu.au Guidelines for submitting authors can be found on the ADOHTA Website at: and on the NZDOHTA website at: CONTACTS NEW ZEALAND DOHTA contact@nzoral.org.nz PO Box 9893, Marion Square, Wellington 6141 Ph AUSTRALIA DOHTA adohta@adohta.net.au PO Box 337, Modbury North SA 5092 Phone AUSTRALIAN CAPITAL TERRITORY PO Box 1114, Woden ACT 2606 WESTERN AUSTRALIA PO Box 111, Como WA 6952 dthawa@dthawa.com.au QUEENSLAND PO Box 405, Nundah QLD 4012 secretary@dohtaq.com.au NEW SOUTH WALES PO Box 48 Westmead NSW 2145 info@nswdohta.com.au SOUTH AUSTRALIA / NORTHERN TERRITORY PO Box 547, Torrensville SA 5031 enquiries@sadta.com.au VICTORIA PO Box 154, Parkville VIC 3052 info@vdohta.org.au TASMANIA 1175 Elderslie Road, Broadmeadow TAS 7030 adohta-tas@adohta.net.au FIND US ON FACEBOOK 2

3 proudly supported by Presidents Message Julie Barker President ADOHTA ADOHTA and the NZDOHTA would like to thank the many people involved in the production, editing and peer review of this journal and acknowledge the contribution of Colgate who generously support its printing and distribution. The objectives of the journal are to: 1. provide a vehicle for communication between dental and oral health therapists in Australia and New Zealand 2. develop dental and oral health therapists access to self directed professional development 3. provide a vehicle for the reporting of new learning and research in the field of dental and oral health therapy 4. develop a capacity to contribute to the body of knowledge around the discipline of dental and oral therapy, for dental therapists, oral health therapists, dental hygienists and the wider health care field We are proud to present this edition of the ANZ JDOHT and we hope you enjoy reading it. Julie Barker, President ADOHTA & Gillian Tahi, Chairperson NZDOHTA Gillian Tahi Chairperson NZDOHTA continued from page 1... contributed to in education, policy, accreditation and workforce development discussions at state and federal levels. The College represents a collective academy for the oral health therapy disciplines and enables application of this expertise for the benefit of the professions and the community. The collaboration and development of the college has had many positive outcomes for both the individuals involved and for the OHT professions. In 2010, members of the college developed and published a monograph describing the development and current frameworks and processes for Oral Health Therapy Education in Australia and New Zealand (Tsang et al 2010). In 2013, the world s very first graduate year program for the oral health therapy profession was instigated by the Australian Commonwealth Department of Health and Aging. The curriculum development team for this program has included six academics, many of whom were also executive members for COHA at the time, and a range of other members as authors of the learning modules and peer reviewers adding expertise and integrity to the program outcomes. For members attending the COHA meetings, the opportunity to discuss their work with colleagues, share innovation in teaching and research and benchmark their practice is invaluable; it is a true community of practice. In keeping with the terms of reference which were developed by COHA members in 2011, membership of COHA is limited to those people actively teaching into BOH or similar programs. The 2013 AGM held a re-election of office bearers with the following people elected by the membership; Chair of the College: Jennifer Miller (Adelaide Uni) Secretary; Andrea Maguire (Uni of QLD) Treasurer: Ron Knevel (La Trobe Bendigo) General Executive Members: Mark Gussy (La Trobe Bendigo), Julie Satur (University of Melbourne), Rebecca Ahmadi (Otago), Sophie Karanicolous (Adelaide University), Raeanne Allan (Curtin University) For an update on COHA, more information can be found on the website which is currently undergoing development. The Colgate dinner at the 2013 meeting was again a highlight, and the wonderful Fijian dancing and singing was just as enjoyable as the delicious island food. The 2014 meeting will be held at La Trobe University in Bendigo, and following that in Melbourne in The over arching principles of collaboration, critical development of pedagogy in teaching and learning and collegiality in the oral health therapy professions, will continue to be built on at the 2014 COHA meeting and beyond. References Tsang A(Ed) (2012) Collaborative Monograph: Oral Health Therapy in Australia and New Zealand, Knowledge Books, Sydney 3

4 The Australian and New Zealand Journal of Dental and Oral Health Therapy (1) 2014 Treatment Options Associated with Molar Incisor Hypomineralisation (MIH): A Review of the Literature Brie Zienkiewicz 1 & Julie Satur 2 1. BOH final year Student, Melbourne Dental School, The University of Melbourne 2. Associate Professor Oral Health Melbourne Dental School, The University of Melbourne Abstract Teeth affected by MIH display softer, fragile and porous enamel, which can result in aesthetic concerns as well as making these teeth highly susceptible to bacterial invasion, caries, hypersensitivity and post-eruptive breakdown. An increased health burden exists from this condition, with children affected by MIH experiencing nearly ten times more dental treatment than their peers before the age of ten years. Treatment of hypomineralised molars is complicated due to hypersensitivity, difficulties in anaesthetising the affected tooth, complex cavity preparation and determination of an appropriate margin, poor bond strength to the affected enamel, management of the child s behaviour and choosing the right material or procedure for the individual. Dental therapists and oral health therapists may be the first to diagnose MIH and long-term outcomes depend on careful and considered diagnosis and treatment planning, and possibly timely referral. Molar-Incisor Hypomineralisation (MIH) is defined as a developmental defect of enamel of systemic origin that affects one or more of the first permanent molars (FPM) and is often, but not always associated with affected permanent incisors (Weerheijm, 2003; Lygidakis et al, 2008). Teeth affected by MIH often display softer, fragile and porous enamel, making them highly susceptible to bacterial invasion and caries, hypersensitivity and post-eruptive breakdown (PEB) (Fitzpatrick & O Connell, 2007; Crombie et al, 2009). Microstructural analysis of MIH defects revealed that the areas of hypomineralised enamel demonstrate inferior mechanical properties compared to normal developed enamel, including increased porosity and protein content, decreased hardness and abnormal ultrastructure (Crombie et. al, 2011; Xie, et. al, 2008). When compared with normal enamel, MIH defects have also been shown to exhibit low residual amelogenin content (proteins found in developing tooth enamel) and have significantly greater amounts of other proteins found in serum and oral fluids present, most importantly albumin (Mangum et. al, 2010, Farah et al, 2010). MIH lesions have an average of 10% to 60% higher carbonate levels than that of normal enamel (3-4% carbonate) (Crombie et al, 2011.). It has also been noted that increased carbon levels (a likely combination of carbonated apatite and organic content) may, to some extent, substitute for the normally occurring phosphate ions which contributes to the lower mineral content; creating a less stable, more soluble apatite than the normal hydroxyapatite or fluoroapatite in enamel (Kumar, 2011; Crombie, et., al ). This composition, combined with the loosely packed apatite crystals typical of MIH, and less dense prisms with wider inter-rod spaces, help to explain why, in appearance, these teeth often present as soft cheese like lesions that breakdown easily under masticatory forces (Kumar, 2011; Fitzpatrick & O Connell, 2007). In order to treat MIH defects appropriately, it is imperative that the condition is diagnosed correctly. Identifying the severity of the condition also helps to determine the type of treatment recommended. It has been suggested that MIH represents a spectrum; ranging from mild or moderate to severe (Chawla et al., 2008). Studies have demonstrated that severe cases of MIH typically involve both the molars and incisors; whereas milder cases typically only involve the molars and can therefore be referred to as Molar Hypomineralisation (MH) (Chawla et al, 2008). Table 1 (opposite) illustrates the clinical spectrum of MIH and the challenges in defining severity. It is also important to understand the effects of post-eruptive breakdown (PEB). Occurring shortly after the tooth has erupted, PEB is the breakdown of affected porous enamel as a result of masticatory occlusal forces and acidic oral environments (Weerhejim 2003; Fitzpatrick & O Connell, 2007). Post-enamel breakdown can lead to severe destruction of the crown, exposing the underlying sub-surface enamel and/or dentine and has been linked to severe hypersensitivity and rapid progression of dental caries (William, et. al., 2006; Fitzpatrick & O Connell, 2007; Crombie, 2009). It has been suggested that the colour of MIH defects can indicate the severity of the lesion, with yellow to brown lesions being associated with lower hardness values, higher porosity and less mineral density of the affected enamel compared to that of normal enamel values. A study by Jalevik and Noren (2000) concluded that hypomineralised molars with yellow defects were softer and more porous, when compared to white opacities, often extending through the entire enamel layer and were more likely to be associated with PEB. White opacities were more likely to be localised to the inner layer of enamel and less often associated with PEB. It is however suggested by Crombie et al. (2013) that categorisation of severity according to clinical appearance has only been supported to a limited extent and requires further validation. Many researchers and clinicians recognise the increased health burden from this condition, with reports stating that children affected by MIH will experience nearly ten times more dental treatment than their peers before the age of ten (Jalevik & Klingberg, 2002). Treatments needed for teeth affected by MIH are often a frustrating ordeal for both the patient and clinician. Those affected by MIH are generally condemned to a lifetime of regular dental appointments, repairs and costly procedures. 4

5 proudly supported by Table 1: Clinical spectrum of MIH: (Modified after Chawla, Messer & Silva, 2008; Lygidakis, 2010) MILD MODERATE SEVERE The first molar is affected (one, two, three or all four molars, with little or no involvement of the incisors). White or creamy demarcated opacities with no enamel breakdown. If PEB exists, it is generally limited to one or two surfaces without cuspal involvement. Yellow or brown demarcated opacities are found on the occlusal and incisal thirds of the affected teeth without posteruptive enamel breakdown. Molars and Incisors are typically affected. PEB is associated with crater like lesions, caries and crown destruction, resulting in exposed dentine and possibly pulpal involvement. Hypersensitivity is typically absent. Sensitivity is commonly reported. Patients commonly report dentinal hypersensitivity which is typically associated with PEB. Decay is normally not associated with the affected enamel- some authors suggest more caries resistance (Farrah et al 2010) Aesthetic concerns are generally reported by the patient or their parent. Atypical restorations may already be present. Aesthetic concerns are generally reported by the patient or their parent. Atypical restoration may already be present. Aesthetic concerns are generally reported by the patient or their parent. The child and their parents are required to attend more frequent dental visits, increasing the risk of dental fear and anxiety which could lead to future behavioural issues and lack of compliance, ultimately resulting in a downward spiral and destruction of the dentition. The cost of treatment is also generally much greater due to the increased frequency of appointments and the possible need for specialist care in severe cases of MIH (Crombie, 2011; Leppaniemi et al, 2001). Difficulties associated with treating children with hypomineralised molars Treatment of hypomineralised molars is commonly complicated due to the management of younger patients, hypersensitivity, and difficulties in anaesthetising the affected tooth, as well as complex cavity preparation, and difficulties with etching and bonding of the affected enamel (Fagrell et, al, 2008). Behaviour management Children who have MIH will generally experience a multitude of dental appointments involving lengthy and complex treatment (Lygidakis, 2010). Unfortunately, sometimes treatment is carried out without adequate anaesthesia or without anaesthesia at all, causing sensitivity and pain, escalating an already stressful situation (Leppaniemi A, et al 2001). Due to difficulties in adequately anaesthetising an inflamed pulp, as well as apprehension in young children, nitrous oxide may be required to help alleviate dental anxiety and in some cases a general anaesthetic may be necessary to carry out appropriate treatment (Lygidakis, 2010). Hypersensitivity Varying levels of sensitivity can act as a barrier to oral health for those who are affected by MIH. Hypersensitivity is a common problem and is generally more prevalent in severe cases (Crombie, 2011). Severe cases of hypersensitivity have been shown to prevent the individual from carrying out appropriate oral hygiene practices, resulting in diffuse plaque deposits leading to an increased risk of caries and periodontal disease (Fagrell et al. 2008; Rodd, et. al., 2007). Hypersensitivity can also impede appropriate preparation of the tooth tissues leading to discomfort for the patient and inability for the clinician to prepare the tooth appropriately. A contributing factor to hypersensitivity is due to PEB, breaking away the fragile outer surface of enamel under occulsal forces and exposing the underlying dentine. Hypersensitivity is also likely to be exacerbated in young patients as a result of the immature and thus large dentine tubules. A study conducted by Rodd, et. al, (2007) showed that increased vascularity due to pulpal inflammation or dentinal stimulation has been shown to cause increased tissue fluid pressure resulting in rapid outward flow of dentinal fluid which stimulates mechanoreceptors causing sensitivity (Rodd, et. al, 2007). The authors of the study recommended early intervention to reduce pulpal inflammation, including application of preventive products such as fluoride or bonding agents with the aim to occlude the dentinal tubules to prevent fluid movement and bacterial invasion (Rodd, et. al, 2007). Fagrell and colleagues also hypothesised that hypersensitivity associated with moderate to severe cases of MIH was a result of the highly porous enamel. It is thought that the highly porous enamel constitutes a mode of transport for bacteria through the enamel rods and allows for bacterial invasion of the dentine tubules, leading to pulpitis and resulting in sensitivity, pain and discomfort (Fagrell et, al, 2008). The authors concluded that although the sample size was small, the results clearly demonstrated that bacterial penetration through hypomineralised enamel is possible. The authors suggest that teeth affected by MIH which are exposed to the oral cavity over time may be associated with chronic pulpitis and further studies should be carried out (Fagrell et, al, 2008). There is little evidence to support the use of commercially available remineralising crèmes such as Tooth Mousse or sensitive toothpastes on MIH lesions, however anecdotally they are shown to reduce sensitivity and may make a considerable difference in some cases (Faye, 2003)....continued on page 6 5

6 The Australian and New Zealand Journal of Dental and Oral Health Therapy (1) 2014 Difficulties with local anaesthesia Anecdotally, MIH-affected teeth have been recognised as extremely difficult to anaesthetise. This is most likely to be due to the porous nature of the affected enamel, possibly resulting in inflammation which is the most common cause of inadequate or failed local anaesthesia (Fagrell et, al, 2008). This is a problem that has the potential to lead to future behavioural issues (Lygidakis, et al., 2010). Cavity preparation determining the margins Determining the cavity margins of hypomineralised teeth is difficult and there is considerable debate on how much affected enamel to remove. A conservative approach is to only remove the very porous enamel; however this can increase the risk of marginal breakdown and ultimately failure of the restoration. Tooth structure is ultimately sacrificed by removing all the defective enamel; however this can reduce the risk of margin failure and thus increase the longevity of the restoration. (William, et al., 2006). It has been recommended that all defective enamel is removed (until resistance is met with a stainless steel bur) when using an adhesive restoration such as composite resin (Kumar, 2011). Inadequate etching and poor bond strengths A reduced mineral content as well as the disorganisation of the enamel rods is likely to contribute to the variations in etching patterns of hypomineralised enamel. The high number of proteins found within affected enamel is also likely to contribute to the failure of adequate etching results which compromises the bond strength between the hypomineralised enamel and resin-based materials (Kumar, 2011). It has been suggested that further research into the use of protein degradants (such as sodium hypochlorite) may help to improve bonding of resin-based materials to hypomineralised enamel, ultimately improving bond strengths (Kumar, 2011). Evaluation of further evidence in this area will be an important contributor to future treatment planning. Minimal intervention dentistry preventive therapies Treatment options for MIH vary considerably, depending on the individual case and severity of the condition. Preventive strategies include discussions with both the parent and the child regarding the severity of their condition and treatment options. Parents and children should be advised that these teeth are much more susceptible to plaque accumulation, wear, dental decay and enamel breakdown (Lygidakis, 2010). Decreasing caries risk by adhering to a diet low in cariogenecity and effective oral hygiene practices should be strongly recommended and encouraged at regular recall appointments (Leppaniemi et al, 2001; Australian Research Centre for Population Oral Health, 2006). Other topical fluoride applications may be recommended, including topical fluoride varnishes (22,600ppm F) and mouthwashes ( mg/L F or ppm); however there is limited evidence regarding their efficacy in hypomineralised teeth. Fluoride varnishes have been suggested for decreasing sensitivity and to help promote the maturation of the immature surface layer of the affected newly erupted First Permanent Molars (FPMs) which is proposed to improve the micromechanical and bonding properties of the affected enamel in preparation for sealing or restoring with resin materials (Fayle, 2003; Kumar, 2011). There is no current evidence in the literature to evaluate the efficacy of many fluoridated products on MIH-affected teeth, however anecdotally high fluoride concentrations have been reported to help reduce sensitivity, enhance remineralisation and prevent dental decay on teeth with apparently unaffected enamel (Lygidakis, 2010; Leppaniemi et al, 2001). Casein phosphopeptide-amorphous calcium phosphate (CPP- ACP) has been shown to be very effective for the remineralisation of incipient lesions and white spot lesions/ demineralisation (Crombie, et al., 2011). With continued use, CPP-ACP provides a bio-available supersaturated solution of calcium and phosphate ions which have been anecdotally acknowledged to reduce sensitivity (Reynolds, 2005). Reynolds (1997) demonstrated that the casein phosphopeptide (CPP) component stabilises the calcium and phosphate components, preventing precipitation of these ions and thus allowing for penetration into the body of the lesion. Although there is little literature to support the efficacy of the use of CPP-ACP on hypomineralised teeth, studies have demonstrated an increase in mineral content and a decrease in porosity of demineralised enamel following CPP-ACP application and therefore there is potential for positive results in the use with hypominerlaised teeth. Preventive treatments also include fissure sealants and possibly resin infiltration techniques which are used to prevent bacterial penetration of the porous enamel and help protect the susceptible fissures, limiting the risk of dental caries and PEB (Fayle, 2003; Kumar, 2011) Management of hypomineralised molars Fissure sealants Fissure sealants (resin-based) and fissure protection (glass ionomer cement-based) are generally adequate for mild cases of MIH, where the tooth is asymptomatic and the enamel remains intact. Research does however show that conventional fissure sealants on MIH-affected teeth, using an etchant and resin sealant material, exhibit lower retention rates and require regular monitoring and maintenance compared to fissure sealants placed on unaffected enamel (Fayle, 2003). It is recommended that an adhesive system be used prior to sealing the fissures to improve retention. A study conducted by Lygidakis et al., (2009) shows that 5th generation adhesive systems (using primer and then bond) demonstrate a higher success rate and greater retention (70.2%) than conventional fissure seals using etchant and resin fissure sealant material (25.5% ) in MIH affected teeth (Lygidakis et al., 2009; Lydgydias et al., 2010). A glass ionomer cement (GIC) fissure protection may be more practical if the tooth is partially erupted (which hinders acceptable moisture control), or if hypersensitivity impedes adequate etching and washing/drying of the tooth tissues (Fayle, 2003). 6

7 proudly supported by Resin infiltration There is emerging evidence to show that resin infiltration may help improve hardness, caries resistance and prevent mechanical breakdown of demineralised enamel and therefore may be appropriate in the treatment of hypomineralised teeth as well (Malik, et. al., 2012). Resin infiltration is a technique that has been used because of its ability to penetrate porous subsurface enamel to seal incipient carious lesions and porosities. An aggressive etchant (15% hydrochloric acid gel) is required to break through the harder outer surface layer and is more stable than 37% phosphoric acid etch, allowing for greater surface erosion and deeper penetration into the enamel matrix. Ethanol (100%) is then used to completely dry the tooth tissue in preparation for the low viscosity infiltrant material which is injected into the microporosities of the incipient lesion (Malik, et. al., 2012). Recent studies conducted by Crombie et al., (2013) and Kumar, (2011), conclude that resin infiltrant materials were also successful in penetrating MIH-affected lesions and improved the hardness values, however the results were irregular and the protocol currently remains unpredictable. A study which analysed resin infiltration on mild to moderate hypomineralised enamel lesions was conducted by Kumar (2011). Of the twenty one treated teeth, 50 percent showed signs of infiltration. It was noted that the infiltrant material penetrated towards the dentino-enamel junction (DEJ), in the direction of the enamel rods, however the results of the study demonstrate that penetration was not uniform in MIH-affected teeth (Kumar, 2011). The variable nature of the enamel matrix in hypomineralised teeth may be one explanation for the poor penetration. It was noted that preparation of the tooth prior to infiltration was a key factor in success (Kumar, 2011). The study used 15% hydrochloric acid gel for 120 seconds, rinsed for 30 seconds, dried with oilfree compressed air and desiccated with 100% ethanol for 30 seconds prior to infiltrating with Icon resin. It was concluded that the use of resin infiltration in MIH-affected teeth may help to improve the micromechanical properties which may help prevent caries, PEB and marginal breakdown of restorations, leading to increased longevity of the tooth (Kumar, 2011). Restorative management The choice of restorative materials should be determined by the extent and quality of the defect, sensitivity and age of the patient (Fayle, 2003). Resin composite is the material of choice for moderate defects without cuspal involvement. In moderate to severe defects, especially if cuspal involvement is present and extensive PEB has occurred, the treatment of choice is a full crown coverage restoration such as stainless steel crowns, cast adhesive coping or full coronal coverage ceramic crowns. If the pulp of the affected tooth is involved or the tooth is severely broken down, extraction may be best the treatment option (Fayle, 2003; Lygidakis, 2010; Gowans & Williams 2003; Zagdwon et el. 2003). Endodontic treatment may be an option if retention of the affected FPM is necessary; however there is a high level of cooperation, time, effort and financial cost involved to achieve this result (Daly & Waldron, 2009). It is important for the parent and child to understand that these procedures will be lengthy and expensive (Daly & Waldron, 2009). Amalgam Amalgam is not recommended as a restorative material for MIHaffected teeth. The material is non-adhesive, resulting in increased risk of marginal leakage and excessive tissue loss due to the need for an extended cavity design to achieve a mechanical lock, leaving the tooth vulnerable and at risk of further destruction (Fayle, 2003; Kumar, 2011; Kilpatrick N 2007; Leppaniemi, et. al., 2001; Lygidakis, 2010). Glass Ionomer Cements (GIC) GIC restorations adhere cohesively; act as an insulator and release fluoride to protect surrounding tissues. GICs have recently been acknowledged as a sound material to act as a base in large cavities to protect the pulp and replace dentine, in what is known as the sandwich technique (Lydgydias, 2010). It is however important to remember that GIC, resin-modified GIC and polyacid-modified composite resin (PMCR) materials have poor wear, fracture resistance and acid-resistance properties and should not be used in stress-bearing regions of the FPM. GIC material can also be placed as an intermediate restoration until definitive treatment can take place (Fayle, 2003; Daly & Waldron, 2009). Resin materials Resin composite materials can be used to provide a definitive restoration when one or two surfaces of a tooth are affected, without cuspal involvement. Resin composite materials are adhesive, preventing microleakage and exhibit good wearresistant properties. The remaining pits and fissures should be sealed with a flowable resin material as an additional preventive measure and to protect the margins of the restoration (Daly & Waldron, 2009). Rubber dam should be used when restoring with resin composite materials as this not only isolates the tooth creating appropriate moisture control, but also isolates the rest of the mouth and protects other affected teeth from inadvertent sensitivity from cold air and water. (Fayle, 2003). A study conducted by Lygidakis et al. (2003) demonstrated a 100% retention rate of posterior composite resin restorations in MIH-affected FPMs at the end of a four-year study, with acceptable marginal adaptation and none needing replacement. The study included only teeth having more than two (of the total five) surfaces affected and all treated teeth had at least two sound surfaces. The study excluded defective teeth with total disruption of the crown. Some 31 of the teeth had never been restored before, whereas the remaining 21 had previous failed amalgam restorations. Of the 38 participants reporting sensitivity prior to restoration, only 14 had sensitivity one week post restoration and after 12 months only three still reported sensitivity (Lygidakis et al. 2003). It has been suggested that further research into the use of protein degradants (such as sodium hypochlorite) may help to improve bonding of resin materials to hypomineralised enamel, ultimately improving bond strengths (Kumar, 2011). Stainless Steel Crowns (SSC) or Cast Adhesive Coping (CAC) A study conducted by Zagdwon et el., (2003) revealed high success rates of both Stainless Steel Crowns (SSC) and Cast Adhesive Coping (CAC) restorations in MIH affected teeth and for amelogenesis imperfecta and enamel hypoplasia, albeit in a small sample. Out of a total of 42 restorations placed (19 SSC and 23 CAC) only three restorations failed and required replacing...continued on page 8 7

8 The Australian and New Zealand Journal of Dental and Oral Health Therapy (1) 2014 over the twenty four month observation period. One SSC failed at six months which was due to incorrect sizing of the preformed crown. The other two failed CAC restorations occurred at two and nineteen months respectively and no known cause was noted for their failure. Both SSC and CAC restorations were shown to be effective in preventing sensitivity and restoring the tooth to function in MIH-affected teeth and those with amelogenesis imperfecta and hypoplastic lesions. The authors concluded that there was no clinical significance in the longevity or success rates; however both types of restoration had positive and negative aspects and the choice of restoration should be indicated by the long-term needs of the individual (Zagdwon et al., 2003). Placing a SCC takes less time (only one visit is necessary), is more cost effective, is less technique sensitive and does not require precise impressions and the expensive laboratory work of a CAC restoration (Weerheijm, 2004; Faye, 2003). However the SSC requires slightly more tooth tissue to be removed (risking pulpal irritation in the immature tooth) and limiting future restorative options. Faye, (2003) suggests using orthodontic separating elastics to open the contact between the FPM and second premolar to reduce the required amount of tooth structure removed during the preparation of a SSC. The margins of the SSC extend subgingivally in order to cover the entire crown to reduce sensitivity and decrease the possibility of recurrent caries; however this also increases the risk of irritation to the periodontal tissues (Zagdwon, et al., 2003). The conservative preparation of the CAC restoration does not protect the entire tooth structure and thus caries is more likely and sensitivity may still occur; however the supragingival margins allow for healthier periodontal tissues and the minimal preparation also allows for a broader choice of future restorative needs (Zagdwon, et al., 2003). Preformed SSCs have been shown to prevent further breakdown, sensitivity and protect the previously exposed and susceptible enamel from acid attacks and dental decay (Lygidakis, 2010). Treatment of young teeth with fabricated full cast crowns should be avoided until later years due to the destructive preparation required and close proximity of the immature large pulp chamber. It is however advised that the SSC be replaced with a custom-made cast crown once gingival maturation is complete (Lygidakis, 2010). Koch and García-Godoy (2000) suggested that full-coverage gold or ceramic crowns are an acceptable restorative choice for the young FPM. The authors explained that these materials do not contain nickel or chromium, unlike SSC, which some people may be allergic to. The study analysed the success rate of 41 FPMs, all with developmental defects, over a five-year period. The results showed that all crowned teeth were asymptomatic, vital and non-carious at the beginning of the study and at the end of the five-year review program. Patients and parents preferred the tooth coloured crowns over the gold crowns, however this was for aesthetic reasons only. The authors did however explain some limitations in the use of cast crowns to restore FPM in young patients, including difficulty in the placement of the cast crown due to the shorter crown height of the young dentition; preparation of the tissues due to large pulps and previous loss of enamel (Koch & García-Godoy, 2000). This study was not MIH-specific and did not clarify if any other developmental defects were present in the rest of the dentition; however the criteria included defects such as localized opacities, localized enamel hypoplasia and generalized hypomineralized amelogenesis imperfecta. Although MIH is a separate and significantly different condition to hypoplasia and amelogenesis imperfecta, treatment of these conditions are often similar and therefore this study may offer credible evidence in the treatment of MIH in FPM s (Koch & García-Godoy, 2000). Extraction Although the FPM is generally not the first choice for extraction, in some cases of severe breakdown, extensive caries, irreversible pulpitis and peri-radicular infections, extraction may need to be considered (Jälevik & Klingberg, 2002; Jälevik, & Möller, 2007). There are many things to take into consideration before extracting a FPM. These include the child s age and stage of dental development, orthodontic considerations such as crowding, spacing or malocclusion, presence of other dental anomalies, the severity of MIH; pulpal involvement, presence of third molar germ(s), restorability of the tooth/teeth and expected long-term treatment costs (Gowans and Williams 2003; Lygidakis, 2010). If extraction is the option of choice, this should be done at an optimal time and collaboration with an orthodontist should be considered (Lygidakis, 2010). The optimal time to extract is generally at the age of 8-9, or when calcification of the bifurcation of the second permanent molar (particularly in the mandible) is present on an OPG, however this needs to be considered in the context of the individual s needs (Lygidakis, 2010). Treatment of affected incisors: Incisor defects associated with MIH are generally milder than that seen in the FPMs, with aesthetic concerns contributing the main reason for treatment (Weerheijm, 2004). The incisors rarely exhibit PEB, which is likely due to the lack of occlusal forces, unlike the FPM. A systematic review conducted by Lygidakis in 2010, concluded that the current literature lacked evidencebased results for the treatment and management of the affected permanent incisor. Treatment options to help alleviate aesthetic concerns depend upon the severity and colour of the defect. Research has demonstrated the regression of white spot lesions with the use of CPP-ACP (Kim et al., 2011). Other suggested treatment options for the incisor include; resin infiltration, bleaching, micro-abrasion, direct composite veneers or porcelain veneers (Daly & Waldron, 2009; Lygadis, 2010; Kim et al., 2011; Lygadis, 2010 ). Resin infiltration A study conducted by Kim et. al., (2011) looked at the use of resin infiltration to mask white spot lesions of the maxillary incisors. Twenty teeth exhibiting developmental dental defects such as hypomineralised opacities were prepared using 15% hydrochloric acid, 100% ethanol and Icon resin infiltration. The study revealed that discolouration of five teeth were completely masked; whereas discolouration of seven teeth were partially masked and eight were unchanged. The authors explained that the light refraction differs in areas with defects making their appearance different to that of initial caries and developmental defects (such as hypomineralisation) when compared to that of normal enamel. The use of a resin infiltrant aims to penetrate and 8

9 proudly supported by fill the microporosities to construct an internal diffusion barrier rather than on the surface of the lesion. The authors suggest that due to the irregularities of the enamel matrix and poor infiltrant penetration in MIH affected teeth, the masking effect of resin infiltration varied considerably compared to normal enamel. It is advised that the long-term stability of colour change be reviewed and that continued clinical studies be carried out to assess the efficacy of this procedure (Kim et al., 2011). Microabrasion Microabrasion is a suggested treatment to improve aesthetics of the incisors by removing the surface layer defect and exposing the normal underlying enamel (Daly & Waldron, 2009). The procedure involves; an 18% hydrochloric acid to be rubbed on the surface of the affected teeth for 5-10 minutes with intermittent washing; then after thoroughly drying the teeth, applying a 0.2 % sodium fluoride to enhance the remineralisation of tooth tissue (Lygidakis, 2010; Wong & Winter, 2002). A study conducted by Wong & Winter (2002) revealed that diffuse opacities (such as those seen in MIH) generally extend into the full thickness of enamel and thus removing the surface layer provides little improvement. It was concluded that microabrasion is a good treatment option for shallow defects, possibly caused by fluorosis or demineralisation; however if the opacities extend deep into the tooth tissues, microabrasion would not be the treatment of choice to improve aesthetics (Wong & Winter, 2002). Bleaching Bleaching has been shown to reduce yellow/ brown defects, however is unlikely to improve the underlying white opacity (Daly & Waldron, 2009). This may be due to the full thickness and more porous enamel associated with yellow/ brown defects, compared with the non-uniform thickness and less porous creamy, white defects (Jalevik & Noren, 2000). Both bleaching and microabrasion techniques have been questioned by Lygidakis, (2010) due to the immature nature of the tooth tissue, resulting in sensitivity, mucosal irritation and enamel surface alterations. It should also be noted that studies which looked at these procedures were mainly carried out with diffuse fluorotic opacities or white spot lesions post-orthodontic treatment. The interpretation of the results should therefore be assessed with caution as MIH defects have morphological differences and distinctly different characteristics from the specimens studied (Lygidakis, 2010). Direct Composite Veneers and Porcelain Veneers Direct composite veneers have been shown to be a successful and conservative approach for masking yellow and white opacities. Minimal tooth preparation is required, limiting pulpal irritation or exposure and preserving the immature tooth structure allows for future treatment. Porcelain veneers may be a more definitive option in later years when dental development and gingival maturation is complete (Daly & Waldron, 2009; Lygidakis, 2010). Discussion Evidence to support treatment planning for MIH is patchy, often not specific to the condition and hampered by inconsistent study methods. Most of the studies examined included small sample sizes which may bias the findings and limit generalizability; however they are valuable in informing the thinking of clinicians in the area when planning treatment for MIH. With the continuing development of new materials and technologies it is clear that further research and clinical trials need to be conducted regularly to test and review these products, materials and techniques. Many studies reviewed the success rate over a short period of time (between one and five years). Further longitudinal studies will give strength to these studies and are recommended for future researchers. Treatment of MIH can be costly for the parent, patient, clinician and the community. With increased and long-term consequences associated with treatment choices, a strong commitment to lengthy discussions and informed consent is required by all parties involved. Collaboration with other dental professionals including paediatric dentists, orthodontists, endodontists and prosthodontists may sometimes be required to establish the appropriate treatment plan for the individual. Conclusion Children affected by MIH are generally condemned to a lifetime of dental treatment due to the fragility and poor quality of the porous defects associated with MIH. Increased treatment needs have been shown to result in behavioural management problems caused by dental fear and anxiety. It is our role as dental and oral health therapists to reassure and educate patients and their families about this condition; providing them with realistic treatment options and referral pathways if necessary. Early diagnosis, regular reviews and the use of preventive products soon after eruption seem to help maintain tooth tissue and prevent PEB. A careful management plan by dental and oral health therapists, including a preventive and minimal intervention approach is therefore important to achieve favourable long-term outcomes for these children. References Australian Research Centre for Population Oral Health, Dental School, The University of Adelaide, South Australia 2006, The use of fluorides in Australia: guidelines, Australian Dental Journal, vol. 51, no. 2, pp Chawla, N, Messer, LB & Silva, M 2008, Clinical Studies on Molar-Incisor-Hypomineralisation Part 2: Development of a Severity Index, European Archives of Paediatric Dentistry, vol. 9, no. 4, p Chandra, S, Chandra, S & Chandra, G. 2007, Textbook of operative dentistry, Jaypee brothers medical publishers, New Delhi. Crombie, 2011, An investigation into developmentally hypomineralised enamel in first permanent molar teeth, D. R. Thesis, Melbourne Dental School, The University of Melbourne, Melbourne. 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10 The Australian and New Zealand Journal of Dental and Oral Health Therapy (1) 2014 Daly, D & Waldron, JM, 2009, Molar incisor hypomineralisation: clinical management of the young patient, Journal of the Irish Dental Association, vol. 55, no. 2, pp Fagrell, TG, Lingstrom, P, Olsson, S, Steiniger, F & Noren, JG 2008, Bacterial invasion of dentinal tubules beneath apparently intact but hypomineralized enamel in molar teeth with molar incisor hypomineralization, International Journal of Paediatric Dentistry, vol. 18, no. 5, pp Fearne J, Anderson P, Davis GR 2004, 3D X-ray microscopic study of the extent of variations in enamel density in first permanent molars with idiopathic enamel hypomineralisation, British Dental Journal vol. 196, no. 10, pp Farah, R. A., Monk BC, Swain MV, Drummond BK (2010). Protein content of molarincisor hypomineralisation enamel. 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R. Thesis, Melbourne Dental School, The University of Melbourne, Melbourne. Lygidakis, NA 2010, Treatment modalities in children with teeth affected by molar-incisor enamel hypomineralisation (MIH): A systematic review, European Archives of Paediatric Dentistry, vol. 11, no. 2, pp Lygidakis, S, Wong, F, Jälevik, B, Vierrou A-M,, Alaluusua, S & Espelid, I 2010, Best clinical practice guidelines for clinicians dealing with children presenting with Molar-Incisor- Hypomineralisation (MIH), European Archives of Paediatric Dentistry, vol. 11, no. 2, pp Lygidakis NA, Chaliasou A, Siounas G 2003, Evaluation of composite restorations in hypomineralised permanent molars: a four-year clinical trial, European Journal of Paediatric Dentistry, vol. 4, no. 3, pp Lygidakis NA, Dimou G, Stamataki E 2009, Retention of fissure sealants using two different methods of application in children with hypomineralised molars (MIH): A 4 year clinical study, European Archives of Paediatric Dentistry, vol. 10, no. 4, pp Mangum, JE, Crombie, FA, Kilpatrick, N, Manton, DJ & Hubbard, MJ 2010, Surface Integrity Governs the Proteome of Hypomineralized Enamel, Journal of Dental Research, vol. 89, no. 10, pp Meechan, JG 1999, How to overcome failed local anaesthesia, British Dental Journal, vol. 186, no. 1, pp Oliver K, Messer LB, Manton DJ, Kan K, NG F, Olsen CB, Sheahan J, Silva M, Chawla N 2013, Distribution and severity of molar hypomineralisation: trial of a new severity index. 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11 proudly supported by The Healthy Tribe: An Oral Health Project with Aboriginal School Children Cassandra M. Fletcher 1 and Wendy Bowles 2 1. Final year Bachelor Social Work, Charles Sturt University 2. Associate Professor, School of Human and Social Science, Charles Sturt University Abstract This paper discusses an oral health program which aimed to raise awareness of Aboriginal primary school students about oral and general health and to encourage them to engage with oral and general health workers. Using participatory action research cycles, five sessions led by health service providers were conducted with the primary school children using culturally appropriate strategies such as yarning. Cultural appropriateness was determined through consultation with the Aboriginal Education Officer who had strong links with Community Elders. The paper discusses the methodology of the reflective cycles of implementing session plans, observing student response, gaining student feedback, reflecting on outcomes in consultation with stakeholders and planning changes to the following session. This approach became essential in developing a culturally appropriate perspective. It also offered the flexibility to work successfully with an open group wherein participants changed each session. There are no clinical results reported in the paper as it was not a scientific inquiry. Rather outcomes from the project are discussed as offering evidence that this approach is effective in engaging Aboriginal children and their community in promoting oral and general health information. Outcomes include a series of oral health stories created by the children and expressed as artwork, then collated into a book of community stories which has been distributed state-wide. The paper concludes with recommendations for strategies for developing culturally appropriate health promotion programs. It is hoped that this paper contributes to closing the gap between Aboriginal and mainstream oral and general health inequalities by providing information for future research and development of skills in working with Aboriginal children and communities. Introduction The Healthy Tribe project piloted an oral health program of five sessions for 25 Aboriginal children aged years in a primary school located on the Mid North Coast of New South Wales. The aim was to raise awareness amongst Aboriginal primary school students about oral and general health and to encourage them to engage with oral and general health workers using culturally appropriate strategies. The project was funded by the Centre for Oral Health Strategy Demonstration Projects Grants Scheme This paper describes the evolution of the oral health promotion project. Local oral health professionals were aware that Aboriginal children and families were reluctant to engage with local oral health services and yet, due to low socio-economic status, were likely to have poor oral health. It was hoped that a culturally appropriate approach would encourage higher levels of engagement with healthy behaviour messages, and also with service providers and ultimately oral health services. The paper discusses the structure and content of the program and how participatory action research principles guided the evolution of the group as it strove to achieve its aim of engaging the children in learning about positive oral health behaviours. Initially, the project facilitators intended to include the clinical element of DMFT scoring. However, the steering committee advised that this technique was not culturally appropriate in this context so other more qualitative evaluation methods had to be adopted. This paper begins by reviewing links between poor oral health and high levels of social disadvantage that exist in Aboriginal communities. This is followed by discussion of the project s methods including the details of the program and how it changed in response to feedback with the steering committee. Outcomes of the project are then discussed including issues with evaluation. The paper concludes with recommendations for further research and strategies for developing culturally appropriate oral health promotion programs with Aboriginal communities. Context of oral health disadvantage in Aboriginal communities The concept of disadvantage is complex; for example the Socioeconomic Index for Areas (SEIFA) released by the Australian Bureau of Statistics (ABS 2006) comments: there are no perfect measures of disadvantage and socio-economic disadvantage is difficult to capture because it has many dimensions and because these dimensions are hard to measure. Notwithstanding difficulties in defining the disadvantage as a measurable concept, it is acknowledged that the people in the Aboriginal community of Forster endure the social, financial and health inequalities experienced by most Aboriginal people in Australia associated with low socioeconomic status and marginalization (Taylor, Wilkinson & Cheers 2009). The Lower Mid North Coast cluster is country to the traditional owners of the Biripi and Worimi peoples. According to 2006 Census statistics, the Aboriginal community in the regional township of Forster on the Mid North Coast of NSW has a population of 710 people ( ABS 2006 Census, Forster Local Aboriginal Land Council [FLALC] 2010) with the overall population of Forster being 35,777. The SEIFA measurement of disadvantage is 932.3, which indicates a high level of disadvantage in this location. Perhaps an explanation for this...continued on page 12 11

12 The Australian and New Zealand Journal of Dental and Oral Health Therapy (1) 2014 SEIFA indicator could be the presence of the Aboriginal Mission located in the Centre of Forster (Community Profile, Great Lakes Council 2011). This Mission is home to approximately ten out of the 25 Aboriginal students who participated in this project, (Forster Public School 2010) Hunter New England Oral Health provides services to 15 Aboriginal Nations across eight clusters (Didja Know Editing group, 2009). The need for oral health promotion with this community is supported by previous research findings of higher rates of dental decay in Aboriginal children residing in rural areas. Martin-Iverson, Phatouras & Tennant (1999) found that deciduous decay is significantly higher for Aboriginal children than for non-aboriginal children, particularly those residing in rural locations. Ten years later the Steering Committee for the Review of Government Service Provision (SCRGSP 2009) produced a paper for overcoming Indigenous disadvantage. A key indicator identified in the paper is the increased presence of untreated decayed deciduous teeth in Aboriginal children. Aboriginal people experience cultural barriers in accessing health services which could be one factor contributing to increased ill health for Aboriginal populations (Australian Institute of Health and Welfare [AIHW] 2012). Additionally, lower wages and lack of employment potentially lead to poverty which exacerbates the abovementioned factors and creates further disadvantage (Australian Institute of Health and Welfare [AIHW] 2012). The result is a cycle of ill health throughout generations which leads to sustained inequalities. Further, Bazen, Paul and Tennant (2007), point out the link between oral disease and general health and acknowledge the socioeconomic factors impacting on Aboriginal Australian s health. Through their research and development of the oral health curriculum in Western Australia the authors recommend bringing together a sociological view of health with the medical model. Their framework of learning assists oral health professionals to provide treatment to Aboriginal peoples from a culturally appropriate perspective. Slade et al. (2011) conducted extensive research and a dental intervention program with 666 children from 30 remote Aboriginal communities over a 2 year period. These authors conclude that despite an intervention consisting of fluoride varnish application, fluoridated drinking water and community oral health promotion, and notwithstanding that intervention resulted in a significant reduction in caries, the fact remains that even in intervention communities, 89% of children developed caries during the 2 year period (p.42). Certainly this program provided oral health benefits such as treatment and education to community and Primary Health Care workers in the prevention of disease. The program substantiates the community consultation process necessary for culturally appropriate oral health programs. However it is interesting to note the importance of traditional health care approaches as pointed out by Slade et al. (2011, p. 42): During the consultation process, we learned there is potential for interventions that build on strengths within communities, such as traditional medicine and bush tucker. Because we had limited resources to actively support communities in those traditions, we instead encouraged Aboriginal Health Workers to include the tooth story in their promotion of traditional health practices. One consequence was that the remaining components of the intervention had a noticeably European approach to caries control: fluoride varnish, water consumption and daily tooth cleaning with toothpaste. Given that caries levels remained high, even in intervention communities, we believe additional dental health benefits could be obtained by investing more resources in promoting traditional health practices. In a later study, Jamieson et al. (2013) reinforce the message that community consultation is imperative to oral health programs, and correlate dental disease with disadvantage. In their research with 15 Aboriginal communities in the Northern Territory, the authors conclude that dental disease goes beyond the individual s responsibility and may be viewed from a community development perspective. For example, factors such as social disadvantage may affect individual s self-esteem, diet and access to services. The research highlights the importance of identifying specific factors within a socially disadvantaged community. With community consultation, oral health issues can be identified from the community s perspective and programs may develop relevant objectives which draw together social determinants of health across the micro and mezo levels of the community. Australia s National Oral Health Plan stipulates the need for research that increases understanding of Indigenous oral health issues at a community level. Whilst this study goes some way towards this, it is clear that further information is required on the mechanisms by which area-level characteristics influence oral health outcomes. The findings have relevance for other marginalized populations throughout the world, as dental disease at a global level is recognized as being undisputedly related to social disadvantage. Greater insight into whether it is social disadvantage at an individual - or area-level (or both) would be beneficial to both policy makers and researchers involved in interventions to reduce oral health inequalities in Australia and elsewhere (Jamieson et al. 2013, p.80). Both the evidence from the literature and practice experience of local oral health professionals indicated that while it was very likely that Aboriginal children suffered poor oral health, traditional Western models of oral health promotion and service provision were not engaging Aboriginal people in the Forster area. It was time to try a different approach, one that was culturally appropriate if possible. In this instance one of the researchers had a dental background and was also a social work student undertaking a field education placement. The Healthy Tribe project was created with the intention of taking action in closing the gap between Aboriginal and non-aboriginal oral health inequalities (FaHCSIA, 2013). Goals and objectives The objectives of the project are as follows: Primary Goal To raise Aboriginal primary school students awareness about oral and general health and to encourage them to engage with oral and general health workers. Objectives 1. To pilot a culturally appropriate oral health promotion program for primary school Aboriginal students. 2. To work with key stakeholders in identifying culturally appropriate strategies to introduce oral health messages. 12

13 proudly supported by As little was known about how to conduct a health promotion group within a culturally appropriate framework, the researchers had to learn by consultation and trial and error. Therefore, a participatory action research framework (Alston & Bowles 2012, Wadsworth 2011) incorporating cycles of action and reflection involving the health promotion group leaders and a steering group of key stakeholders (Aboriginal and non-aboriginal) was an appropriate methodology and is described below. Project design yarning and participatory action research The Healthy Tribe project employed a participatory action research design and also a traditional method of knowledge transmission in Aboriginal communities yarning. Yarning or story telling was used during several of the group sessions. Participants were encouraged to develop yarns or narratives in relation to their oral and general health knowledge, behaviours and attitudes which in turn were used in structuring culturally appropriate education about oral health. Narratives occurred through yarning with students and their Aboriginal Education Officer along with implementing evaluative tools to record information. This qualitative approach to gathering and transmitting information increased communication between participants and facilitators which in turn stimulated participants learning and provided pathways to engaging with health services. At the start of the project a steering committee was established to guide the project as it developed. The steering group consisted of key Aboriginal and non-aboriginal stakeholders (see Acknowledgements for membership details). Adopting a participatory action research approach, the project followed a series of cycles with plans changing according to feedback received. Wadsworth (2011, p. 60) describes this as a framework of four phases which flow from one to the other in a series of cycles. The phases are: plan change, act, observe, reflect then implement the plan change phase in response to the reflection etc. Cycles can begin at any point in the process: In this case, each phase consisted of a cycle of implementing session plans, observing student response, gaining student feedback, reflecting on outcomes in consultation with the steering committee and planning changes to the next session. This framework became essential in working from a culturally appropriate perspective, also offering the flexibility to work with ad hoc numbers of students and new participants each session. The way in which the cycles helped to develop the program is outlined in more detail below. Before the project began the Aboriginal Education Officer gained parental consent for student participation. The Aboriginal Education Officer reported half the student group resided at the local Mission. This meant that it would be likely that these students experience poverty and disadvantage, backgrounds which strongly indicate the need for a culturally appropriate project. Therefore, in identifying the need for oral health promotion for Aboriginal children it was necessary to consult with existing professional networks in the local community. Drawing together professional knowledge from Hunter New England District Health Services such as Child and Adolescent Mental Health Worker, Community Dietician, School Link Coordinator and Oral Health Promotion Coordinator, along with the Primary School s Aboriginal Education Officer and Vice Principal, a model for the project emerged. The group evolved into the steering committee. Ongoing consultation about cultural appropriateness was made possible through ongoing support from the Aboriginal Education Officer, school staff and community Elders. Consultation with the steering committee also influenced the decision to structure the project in one hour sessions each week for five weeks. In total 25 students participated during the life of the program. However participation varied considerably with each session on average 8 12 students attended per session. This made evaluation and measurement of behaviour change difficult if not impossible at an individual level. The NSW messages for a Healthy Mouth were the key messages which the project aimed to promote and underpinned evaluations in all sessions. Evaluation questions were based on the five key messages; Eat Well, Clean Well, Drink Well, Play Well, Stay Well (Centre for Oral Health Strategy, 2007) Evaluation of the project consisted of questionnaires that were planned to be administered five times throughout the project in sessions one, two and five. Questions evolved as session feedback was gained from students and consisted of open, closed, scaling questions and were pictorial to address potential low literacy levels (New South Wales Department of Community Services, 2009). Program Session 1 The first session involved building rapport through the use of a yarning circle. Using a ball of wool and holding a thread, each facilitator introduced themselves, including their service and role in the group. The wool was then passed to each student who described personal food choices, frequency of brushing and favourite sporting activities. Finally, a web of wool within the yarning circle connected each person. Another objective for the first session was a pre evaluation to determine baseline knowledge of oral and general health behaviours. This included pictorial questions regarding healthy food choices and brushing habits. It was found that students had pre-existing knowledge about healthy food choices and brushing behaviours. At the end of the session, participants were provided with mental health education and resources from the Child Adolescent Mental Health team. Twelve students participated in this session. Results from the pre evaluation indicated students could answer the questions correctly. However, observation of students behaviour outside the group led facilitators to believe that students were attempting to please facilitators rather than report actual behaviour. Reflection on this indicated a different evaluation was needed. In order to adequately evaluate student knowledge and behaviours in regard to their oral health, a quantitative approach was considered to capture evidence of their claimed knowledge. Consultation occurred with the program s steering committee who advised traditional quantitative methods of gathering evidence through DMFT Scoring was not culturally appropriate in this context as the technique is invasive. Alternatively a non-invasive evaluation was created which recorded observable evidence: the flat and puffy gums questionnaire....continued on page 14 13

14 The Australian and New Zealand Journal of Dental and Oral Health Therapy (1) 2014 Session 2 The second session involved the Community Dietician presenting participants with a history of food available to their ancestors in the local area. The dietician prepared similar foods eaten by their ancestors and proportioned a sample of these foods to each student with an explanation of health benefits. For example, macadamia nuts and blueberries were gathered by women of the tribe for breakfast. From here, the dietician explained the next meal of the day as a cook-up and men would hunt for meat to provide for the family whilst women prepared damper from the bark of the Worimi tree. Finally, the dietician explained that Aboriginal people s traditional diets had changed to western diets and demonstrated the ingredients of cola. In particular, she highlighted the amount of sugar and vinegar in such products. From this oral health professionals explained how consumption of these products result in acid attack and decay in teeth. Eight students participated in this session. The evaluation began with students being shown a photo of an Aboriginal child s mouth with puffy gums and a mouth with flat gums. They were then asked to identify if their own gums were flat or puffy by smiling at themselves in a mirror and record their observation, then record brushing behaviours. The session moved on to toothbrush and flossing education and with demonstrated techniques using the Charlie Choppers mouth model. Student questions were answered regarding flat and puffy gums and students were given oral health resources (tote bags containing toothbrush, paste, floss and brochure). Data from this evaluation revealed differences in perception between the students and professionals in that students identification of their gums did not correlate with oral health professionals observations. Upon reflection, perhaps the western standard of aesthetically healthy gums differs to Aboriginal children s experiences in their own community. Given the oral health disadvantages outlined in this paper, it may be the case that Aboriginal children observe puffy gums as the norm in their community. Session 3 In co facilitation with CAMHS (Child and Adolescent Mental Health) workers, the third session was devoted to identifying student s personal strengths and story development (yarning). CAMHS workers introduced an activity based on building student s self-esteem. For example, students were asked to view coloured cards with words relating to personal strengths. Then participants formed groups of two and were asked to choose a card relating to the strength of each partner. Finally, discussion of each person s strength developed. CAMHS workers correlated these strengths with building life skills and healthy attitudes and behaviours. After this, class discussion regarding information learned from previous sessions and new found personal strengths began. From this, participants chose a favourite character; wombat, Kangaroo, etc. and imagined this character was ill. Students then yarned ideas as to how he/she could improve their character s health. In order to facilitate student participation, students were asked how they would like their stories presented. Ideas were brainstormed through yarning and the student group decided they wanted to paint an individual story. As this was a brainstorming session there was no evaluation. However, facilitators noted participants were motivated to create storytelling through artwork in the next session. Session 4 The fourth session involved creating artwork developed from student s stories. To begin the session oral health staff demonstrated the NSW five healthy messages from existing resources. The correlation of these with student s character stories resulted in creativity of artwork. Each participant presented their artwork and told the related story of how their character became well after being ill. Narratives included a snake that flossed his teeth to keep decay from eating them and a turtle that swam to the other side of a river to find healthy food. Finally, the Aboriginal Education Officer led the group in deciding how they wanted their artwork displayed. The group decided their artwork should be part of an art show which was a school event in the coming weeks. Evaluation of this session was in the form of each student presenting their story. Students were asked for their feedback in regard to their celebration session. Information was gathered and stakeholders took action in organising the event. Session 5 The final session involved a celebration which included student s choices of favourite healthy foods from session 2, music (students decided they wanted their Aboriginal Education Officer to play the didgeridoo) and a smoking ceremony. The Aboriginal Education Officer took this opportunity to teach students Welcome to Country in the community s language of Gathang. Finally, student s named the project and yarning led to The Healthy Tribe. Final evaluation was taken in this session and 14 students attended. Evaluation involved a questionnaire with seven open questions about the overall program. Project outcomes Artwork As an outcome, a local artist was commissioned to present the student s artwork into a narrative to represent the yarning. The artist took each piece and glued it to a tile. Each tile was embedded between two pieces of wood. The piece depicted a mouth of teeth made of tiles with the wood edge forming a lip across the tiles to depict a mouth. As observers walked around the piece, they were able to follow a story of character s health. Tiles included NSW messages for a Healthy Mouth and others included student s quotes from open questions. Photos 1 and 2 (right) show the final art piece displayed at the school s artwork show. Book of community stories The students stories and artwork were then collated to create a single storybook. This was a joint effort between Hunter New England Area Health Services Jye Simon, Aboriginal Education Officer from the school and Community Elders with Hunter New England Oral Health Services printing the book. The Healthy Tribe has now been distributed throughout the community and spread to further communities for the purpose of oral and general health promotion. Educators such as health staff, teachers and community members in New South Wales use the book as a learning tool for Aboriginal and non-aboriginal students. The book was officially launched as part of NAIDOC week celebration at Tobwabba Aboriginal Medical Services in July It has been distributed to each student involved in the project, the school s library and is now available to order through NSW Health. 14

15 proudly supported by Examples of how the book (Picture 3) has been utilised in classrooms throughout the Forster and Taree communities which include Aboriginal children from Worimi and Biripi Nations local area include: one teacher reported he was referring to the book for literacy skills with his year four class; another teacher reported she was using the book to teach healthy behaviours with year two students. The book has also been displayed as part of an art exhibition in a metropolitan teaching hospital in the Newcastle area in NSW. Picture 1 Discussion of, evaluation, project outcomes and recommendations for future health promotion programs with Aboriginal children An issue that emerged during the project was that data from the evaluation questionnaires that were administered in sessions one two and five did not provide useful information to evaluate the project. Two factors contributed to this. First, as noted, although the answers indicated that the students already understood the correct oral health behaviours, observations of student behaviour outside the group showed that their behaviour was not congruent with their answers. Another factor was that as group membership kept changing, the responses did not track behaviour change in group members over time. Instead the evaluation data reported cross-sectional results about the attitudes of participants in each session. On reflection after the conclusion of the group, it was realised that while the structure of each session was discussed with the steering group as the project progressed, planning for the evaluation was not included in the discussions until it was apparent that it was not effective. More appropriate and effective evaluation strategies might have emerged if the steering group had been consulted in the planning stages about evaluation. Picture 2 Picture 3 Instead of using results from the evaluation questionnaires, we suggest that the production of the book The Healthy Tribe, and its adoption in various health promotion activities throughout the region is evidence that the program has been successful in meeting its aim to raise Aboriginal primary school students awareness about oral and general health. While this is modest evidence of small scale success, we believe it is an important step towards engaging Aboriginal communities in oral health promotion and ultimately to improving oral health outcomes Follow up research is needed to determine if behaviour change has occurred, if rates of accessing oral health services have increased, or if oral health has improved with the raised awareness. The following recommendations for future health promotion groups with school aged Aboriginal children were developed in consultation with the steering committee and health workers involved in the Healthy Tribes project: Pre-program planning, should include, community consultation with Elders, potential program participants, and any other stakeholders, to ensure everyone has an equal voice in the project. This increases community ownership of the project and identifies existing community strengths from which to build all stages of the project including evaluation. It is essential to respect the Aboriginal culture prior to working in communities, therefore, it is recommended that cross cultural training be undertaken by non-aboriginal health workers prior to working with Aboriginal communities. This will assist in generating rapport, trust and respect. To overcome disruption of sessions, CAMHS workers recommend a whole day program rather than several weekly sessions. For example, one hour long session each for oral health, mental health and dietician, finishing the day with production of artwork. CAMHS workers believe this structure consolidates learning and complements efficient service delivery across health disciplines....continued on page 16 15

16 The Australian and New Zealand Journal of Dental and Oral Health Therapy (1) 2014 Conclusion The Healthy Tribe project confirmed that the collaboration created by a participatory research action approach, is a suitable method of developing culturally appropriate oral health promotion strategies for Aboriginal primary school students. The reflective cycles involved in participatory action research encourage key stakeholders to be involved in all stages of the process through the steering committee. In addition regular consultation offers non-aboriginal professionals opportunities for flexibility while they learn on the job about culturally appropriate strategies and also enables them to respond to unanticipated issues such as changing group membership. It is important however to extend this consultative approach to all parts of the project including planning evaluation strategies something that was not done in this case until later in the process. While change in oral health behaviours could not be measured in this project, the production and dissemination of the artwork and book of community stories which continues to evolve and expand beyond the community indicates that the group was successful in meeting its objective of raising awareness about positive oral health behaviours in a way that the community could incorporate on its own terms. Finally the project promotes skill development for oral health professionals in working with culturally appropriate oral health programs. It is concluded that a whole of community approach to project planning, implementation, evaluation and recording of outcomes throughout the duration of the project is the key to producing an effective culturally appropriate oral health program. Acknowledgements The authors would like to acknowledge the Traditional custodians of the land on which this project took place, the land of the Worimi peoples, and pay our respects to Elders past, present and future. Tobwabba and Biripi Aboriginal Medical Services and the Project Steering Committee: Lanny Chor (Clinical Director Hunter New England Oral Health Services), Kerith Duncanson (Community Nutritionist), Lisa Fitzgerald (Oral Health Promotion Coordinator), Cassandra Fletcher (Hunter New England Oral Health Services), Leanne Martin (General Manager, HNE Oral Health), Laura Rigby (Youth Mental Health Project Officer, Child & Adolescent Mental Health Service), Jye Simon (Aboriginal Education Officer), Karen Sleishman (Coordinator Community Aged Care Oral Health Programs), Kylie Stevenson (School-link Coordinator, Child & Adolescent Mental Health Service) References Alston, M. and Bowles, W 2012, Research for Social Workers an introduction to methods, 3rd edn. Sydney: Allen and Unwin. Australian Bureau of Statistics 2006, Information Paper: An Introduction to Socio- Economic Indexes for Areas (SEIFA) 2006, cat no , ABS, Canberra abs.gov.au/ausstats/abs@.nsf/latestproducts/2039.0main%20features82006?opendocu ment&tabname=summary&prodno=2039.0&issue=2006&num=&view= Australian Institute of Health and Welfare, Australian Government 2012, viewed 27 May 2012http:// Bazen J, Paul, D & Tennant, M 2007, An Aboriginal and Torres Strait Islander Oral Health Curriculum Framework: Development Experiences in Western Australia, Australian Dental Journal, June 2007, Vol. 52, Issue 2, pp csu.edu.au/ehost/pdfviewer/pdfviewer?sid=14e7b f39-a9e2-b94b3fa441dc% 40sessionmgr12&vid=7&hid=21. Centre for Oral Health Strategy, NSW Oral Health Promotion Demonstration Project Grants Scheme 2010, Information package, part 1 (p.6). Centre for Oral Health Strategy 2007, NSW Messages for a Healthy Mouth www0.health.nsw.gov.au/pubs/2007/pdf/healthy_mouth.pdf. Didja Know Editing group 2009, Didja Know: Aboriginal Cultural Communication, Hunter New England Local Health District. FaHCSIA (2013), Closing the Gap: The Indigenous Reform Agenda gov.au/our-responsibilities/indigenous-australians/programs-services/closing-the-gap. Forster Local Aboriginal Land Council 2010, viewed 20 March forsterlalc.org.au/. Forster Public School 2010, Annual School Report, viewed 22 March forster-p.schools.nsw.edu.au/documents/ / / _19eb9 eeb2b886e0d012cec9fec544f67.pdf. Great Lakes Council, Community Profile Jamieson, L, Do L, Bailie, R, Sayers S & Turrell, G, 2013, Associations between area-level disadvantage and DMFT among a birth cohort of Indigenous Australians, Australian Dental Journal, vol 58, pp detail?sid=ca3eb488-5f57-44eb-aaa2-555d09566bf0%40sessionmgr14&vid=5&hid=24 Martin-Iverson, N, Phatouras, A & Tennant, M 1999, A brief review of Indigenous Australian health as it impacts on Oral health, Australian Dental Journal, Vol. 44, pp New South Wales Department of Community Services, 2009, working with Aboriginal People and Communities: A Practice Resource, Aboriginal Services branch in consultation with the Aboriginal Reference group, Ashfield, NSW. SCRGSP (Steering Committee for the Review of Government service Provision), 2009, Overcoming Indigenous disadvantage: Key Indicators 2009, p.7.51, Productivity Commission, Canberra. Slade G, Bailie R, Roberts-Thomson K, Leach AJ, Raye I, Endean C, Simmons B, Morris P. Effect of health promotion and fluoride varnish on dental caries among Australian Aboriginal children: results from a community-randomized controlled trial. Community Dent Oral Epidemiology 2011, vol. 39, pp John Wiley & Sons A S web.ebscohost.com.ezproxy.csu.edu.au/ehost/pdfviewer/pdfviewer?sid=ca3eb488-5f57-44eb-aaa2-555d09566bf0%40sessionmgr14&vid=6&hid=24. Taylor, J, Wilkinson, D & Cheers, B 2009, Working with Communities: In Health and human Services, Community: Aboriginal Australian Perspectives, Oxford University Press, Melbourne, Vic. Wadsworth, Y. 2011, Do It Yourself Social Research: the Best Selling practical guide to doing social research projects, 3rd edn, Allen & Unwin, Sydney. World Health Organization, Health Impact Assessment 2013, viewed 27 October 2013, 16

17 proudly supported by The Role of the Oral Health Therapist in the Management of Oral Complications due to Cancer Treatment Hayley Downey 1, John O Grady 2,3, Michael J McCullough 3, Julie Satur 3 1 Final Year Bachelor of Oral Health Student, The University of Melbourne 2 Associate Professor, Dental Oncology, The Peter MacCallum Cancer Center 3 Professional, Melbourne Dental School, The University of Melbourne Abstract In 2008, 3395 Australians were diagnosed with head and neck cancer. More than 90% of all head and neck cancers diagnosed are oral squamous cell carcinomas. The mortality rate associated with the disease is 30-40% despite treatment advances, with the five year survival rate as low as 15%.Late presentation plays a large role in the high mortality rate. The role of dental hygienists in early identification and referral for oral cancer is well established (Clovis 2000; Hollows, McAndrew & Perini 2000). Management of the disease is complex and may involve surgery, radiotherapy and chemotherapy. Treatment is associated with known acute and chronic adverse effects such as mucositis and osteoradionecrosis, respectively. Oral Hygiene and Oral Health Education play a crucial role in both patient comfort as well as short and long term prevention. Unfortunately, many patients do not receive oral assessment pre-treatment and remained uninformed. There is a need for Oral Health Therapists to provide patients with pre-treatment assessment to identify patient specific risk factors and establish good oral hygiene practices to minimise the severity and impact of potential side effects during treatment. Such a preventive role extends beyond the completion of treatment, intending to reduce the morbidity associated with the disease and improve quality of life. Introduction In Australia in 2008, there were 3394 new cases of head and neck cancer with 1084 of these being within the oral cavity (Australian Institute of Health and Welfare 2008). More Australians die from oral cancer than cervical cancer each year (Cancer Council Victoria 2010). In 2008, 675 Australians died from head and neck cancer with mortality rates among men almost three times that of women (ABS 2008). More than 90% of all head and neck cancers are oral squamous cell carcinomas (OSCC) which is the sixth most common form of malignant disease, and ranks eighth in incidence for all cancers in developed countries, and third in incidence in developing countries (Soames & Southam 2005). Despite treatment advances in the last few decades, the mortality rate has not changed significantly and remains at about 30-40%. The five year survival rate, following diagnosis of oral cancer, is as low as 15-50% (McCullough, Prasad & Farah 2010). Recent reductions in mortality rates of cancers such as lung, prostate, colorectal and breast are due to advanced screening methods and early detection (Draper 2010). No advanced screening methods have yet been established for early detection of head and neck cancer, with detection relying on the health professional or the patient themselves. An issue of particular significance for this disease are the problems of regular access to dental examinations for many at risk groups in Australia, in particular low income and older people (Harford, Ellershaw & Spencer 2011). The aetiology of OSCC is predominately related to tobacco and alcohol consumption but may also include other factors such as human papilloma virus (HPV), candida, syphilis, iron deficiency, radiation, immunosuppression, oncogenes and tumoursuppressor genes (Farah & McCullough, 2008). The most studied and well established risk factor in the development of oral cancer is the use of tobacco. In the developing world, tobacco and areca nut use account for the majority of potentially malignant lesions with tobacco use alone accounting for the majority of lesions in the developed world (McCullough, Prasad & Farah, 2010). Alcohol consumption is an associated risk for oral cancer and may be related to the increasing incidence, especially in younger people, over the last few decades (Soames & Southam, 2005). There are a number of determinants of oral health which may act as barriers to improving oral health. When considering oral cancer, the most important determinants include socioeconomic status, health and social policy, access to care, social and family norms in relation to oral health knowledge, attitudes, beliefs, skills and behaviours, age, sex and genetics (Department of Health, 2011). The risk of oral cancer has been associated with low socioeconomic status (SES) and related to lifestyle risk factors. The interaction between risk factors, such as smoking, alcohol, diet and HPV exposure, and low SES may explain SES gradients found in oral cancer. Smoking and alcohol-consumption have been identified as coping mechanisms for the stress associated with low SES and may not only be a cause in itself but also a cause of a cause (Conway, Petticrew, Marlborough, Berthiller, Hashibe & Macpherson, 2008). Management of head and neck cancer often involves a multidisciplinary approach, with combinations of surgery, radiotherapy and chemotherapy, and often all three. Oral complications caused by cancer treatment can become so severe that an interruption of treatment is sometimes required to allow recovery of the oral cavity. Adequate management of these complications is desirable, to minimise the side effects that occur in the mouth, both during and following treatment (American Dental Hygienist s Association 2010). The role of dental hygienists in early identification and referral for oral cancer is well established and their capacity for recognition of abnormalities in the oral cavity, and education on oral cancer prevention, to decrease morbidity and mortality, has been documented...continued on page 18 17

18 The Australian and New Zealand Journal of Dental and Oral Health Therapy (1) 2014 (Nicotera Gnisci Bianco & Angelillo 2004). Similarly, there has been an increasing role for the oral health therapist in education, management and maintenance of oral hygiene for head and neck cancer patients (Chandu Stulner Bridgeman & Smith 2002). Oral cancer treatment The multidisciplinary team responsible for management of the head and neck cancer patient may include oral and maxillofacial surgeons, reconstructive surgeons, radiation oncologists, medical oncologists, dentists and oral medicine specialists, psychologists or an oncologist social worker (Chambers Day Lewin Lydlatt Murphy Peterson Pfister & Rosenthal, 2006). A multimodal approach is generally used to treat head and neck cancer and may include combinations of surgery, radiotherapy and chemotherapy. Surgery is a common treatment of head and neck cancers possibly including neck dissection to control regional nodal disease. Reconstructive surgery and prostheses may be used for rehabilitation (The Cancer Council New South Wales 2011). Radiotherapy is administered with the aim to reduce the size of the neoplasm or prevent metastasis (The Cancer Council New South Wales 2011). For the treatment of head and neck cancer, radiation beams target the tumour with the aim of reducing collateral damage, minimising salivary gland damage and reducing xerostomia (Oral Cancer Foundation 2011). Chemotherapy drugs (cytotoxic drugs) are used to reduce tumour size as well as decrease the recurrence of cancer after radiation and surgery. Palliative chemotherapy is also used in more advanced stages of the disease (Chambers et al 2006). There are many types of chemotherapy drugs and sometimes more than one type is used in combination therapy. Oral complications Oral complications of cancer therapy depend on the type of malignancy and its location, treatment used and host factors. Acute complications of cancer therapy include mucositis and oral infections such as Candida. Mucositis can be induced by either chemotherapy or radiotherapy. Pain associated with mucositis can be sufficiently intense to interfere with eating and a pause in therapy may be required to allow healing. Mucositis with ulcerations may also provide a portal for microbial entry and lead to local and systemic infection (Singh Scully & Joyston-Bechal 1996). Mucositis occurs in approximately 20-40% of adult patients receiving chemotherapy and approximately 50% of adults receiving radiotherapy and chemotherapy (Allen Logan & Gue 2010). Oral mucositis is more prevalent in children with approximately 65% being affected (Allen Logan & Gue 2010). Mucositis appears as mucosal erythema which may progress to ulceration before returning to a normal clinical appearance and occurs most frequently in areas of non-keratinised epithelium such as the buccal mucosa, ventral tongue and floor of the mouth. Oral mucositis lasts approximately three weeks, beginning three to five days after treatment commences and peaking after seven to fourteen days (Allen Logan & Gue 2010). Figure 1 Oral mucositis of the tongue Reproduced with the permission of Dr O Grady of Peter MacCallum Cancer Institiute Risk factors for oral mucositis include poor oral hygiene, dehydration, poor nutrition, alcohol and cigarette use, and being over sixty-five years of age (Allen Logan & Gue 2010). Management of oral mucositis may involve anaesthetic and antiinflammatory mouthwashes to reduce pain and inflammation and allow oral dietary intake. Chlorhexidine preparations may assist in oral hygiene management in patients unable to brush. Ongoing oral cavity assessment and care should be conducted (Oral and Dental Group 2012). Radiotherapy of the oral cavity may also lead to disturbance or loss of taste sensation and may contribute to poor nutrition. Taste sensation usually recovers within a few months after radiotherapy (Singh Scully & Joyston-Bechal 1996). Dry mouth and mucositis can also contribute to loss of taste (Oral Cancer Foundation 2010). Irradiation of the oral tissues may facilitate an increase in oral Candida and other fungal and yeast infections. These infections may cause discomfort and are increased in patients with dry mouth, a dental prosthesis and those who use alcohol and tobacco (Singh Scully & Joyston-Bechal 1996). Management of oral fungal infections includes improving oral hygiene, including denture hygiene where applicable. Figure 2 Candida infection resulting from radiation treatment Reproduced with the permission of Dr O Grady of Peter MacCallum Cancer Institiute Chronic complications of cancer therapy may include dry mouth which may involve qualitative and quantitative salivary reduction and is usually an adverse effect of therapeutics (Oral and Dental Group, 2012). Dry mouth as a result of cancer therapies can be associated with mucosal atrophy, burning sensations, difficulty in denture use, swallowing and speech, reduced or altered taste, and a predisposition to dental caries and Candida. Without the protective action of saliva the teeth may become thermally 18

19 proudly supported by sensitive and the mucosa sensitive to strong flavors in food and toothpastes (Singh Scully & Joyston-Bechal 1996). Management of dry mouth needs to be practical as many of the artificial saliva products prove to be of little benefit. Patients should be advised to ensure optimal hydration by drinking adequate amounts of fluids, in particular tap water. Eating chewy foods and chewing sugarless gum can stimulate saliva production. Limiting alcohol, tobacco and caffeine and use of bicarbonate mouthwashes instead of alcohol-containing mouthwash can also relieve dry mouth symptoms. Ensuring adequate oral hygiene and limiting sugar and acid intake will reduce severity of symptoms and decrease caries risk. Patients can also use fluoride and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) products to reduce demineralisation and promote remineralisation (Oral and Dental Group 2012). Children who are actively growing while being treated for malignant disease may incur problems in the long term development of both the hard and soft orofacial tissues. Orofacial asymmetry, trismus, failure of tooth development, delayed eruption of teeth and altered tooth and root form are all possible outcomes of cancer therapies. Surgical management of head and neck cancer can compromise oral function leading to difficulties with speech and chewing, dysphagia and direct communication between the oral and nasal antrum. The use of prosthetic devices, reconstructive surgery and a speech pathologist can help to restore oral function and speech. Trismus is the inability to open the mouth properly and can be a result of radiotherapy. When the muscles of mastication and temporomandibular joint are in the field of radiation, trismus can occur as a result of fibrotic changes. Trismus may lead to poor oral hygiene, impaired speech, and an inability to sustain adequate nutrition. Stretching exercises before and during treatment may be useful to minimise post treatment trismus. The most severe chronic complication of radiotherapy is osteoradionecrosis (ORN) and is a result of hypovascularisation of bone due to radiation changes. Hypovascularisation reduces the amount of oxygen and nutrients being carried to the bone and reduces the tissues capacity to sustain injury. ORN may be spontaneous or a result of trauma and occurs in 3-10% of patients (Oral and Dental Group 2012). A person s dental status should be established prior to radiotherapy and all unsalvageable teeth removed and periodontal health maximised. Patients requiring tooth removal in a previously irradiated field should be considered at risk of ORN depending on radiation dose and site. Conservative dental treatment such as root canal therapy, restorations and fluoride treatment should be considered if possible. Maxillary extractions are generally uncomplicated but if removal of the mandibular teeth is required the risk may be minimised with the use of hyperbaric oxygen and antibiotic prophylaxis. Specialist advice should be sought before extraction. Management of ORN is difficult, sometimes requiring treatment with hyperbaric oxygen and surgical resection of the necrotic bone (Oral and Dental Group 2012). Figure 3 ORN of the mandible Reproduced with the permission of Dr O Grady of Peter MacCallum Cancer Institute The role of the oral health therapist Oral health therapists are valued members of the dental team who provide primary oral health care, such as examination, treatment and prevention, for adults and children. Oral health therapists have a strong preventive focus and are strongly committed to fostering positive attitudes to oral health (ADOHTA 2012). The role of the oral health therapist is to address disparities in oral health by improving access to dental care. Tasks performed by oral health therapists include promoting oral health for the community by providing education and information on oral health, working with other health services and groups to improve oral health and bringing more complex dental problems to the attention of dentists, specialists or other health care providers and liaising with other health care providers to support oral health as part of general health (ADOHTA 2012). Oral health therapists predominately work in the public system which gives them access to high risk population groups for oral cancer, particularly those of low SES. There is a valuable role for oral health therapists in the education, management and maintenance of oral hygiene for oral cancer patients (Chandu et al 2002). Individuals undergoing treatment for all types of cancer need ongoing support from their oral health care providers, in addition to the oncology team, to minimise the side effects in the oral cavity that occur during and following their treatment (American Dental Hygienist s Association 2010). Oral health therapists can play a very important role in oral cancer education, risk factor management and continuing oral health maintenance. There is a strong need for oral health therapists to routinely carry out intra- and extra-oral assessments with all patients, referring those requiring specialist attention, and routinely providing risk factor education to prevent oral cancer. Development of the skills necessary for recognition of anomalies in the oral cavity would decrease morbidity and mortality rates associated with the disease (Nicotera Gnisci Bianco & Angelillo 2004). The oral health therapist plays an important and often overlooked role in the continuing care of the oral cancer patient by providing oral hygiene programs and care and support through all stages of cancer treatment (Joyce & Crean 2002). Being a pivotal part of the oral health team, the oral health therapist is well placed to provide oral health care and risk factor information, including alcohol and tobacco education, and cessation support. The time an oral health therapist spends examining the oral cavity gives them the opportunity to identify oral abnormalities early. Seeing a patient at the beginning, middle and end of treatment gives an oral health therapist the potential to play a role in early detection of potentially...continued on page 20 19

20 The Australian and New Zealand Journal of Dental and Oral Health Therapy (1) 2014 malignant lesions, and management of oral complications due to cancer therapies (Radhakrishnan McCullough & Satur 2008). Conclusion The side effects of cancer therapies that manifest in the oral cavity are debilitating and are related to the increased morbidity associated with the disease. Oral health therapists are in the best position to provide patients with a pre-treatment examination to identify potential problems and establish good oral hygiene practices to reduce severity of potential side effects. The importance of good oral hygiene, throughout a patient s cancer treatment, can be frequently overlooked by the patient and their medical team, with oral health education being delivered infrequently or not at all. Providing oral health education, establishing the importance of oral hygiene, and managing oral health and oral side effects will reduce the morbidity associated with the disease and support the patient s oral health as well as improving their quality of life. References Allan, G Logan, R & Gue, S 2010, Oral manifestations of cancer treatment in children: a review of the literature. Clinical Journal of Oncology Nursing. 14: (ABS) Australian Bureau of Statistics 2008, Causes of death, Australia, 2008: cancer (cited 12th September 2012); Available from abs@.nsf/products/60e6662b7045e704ca2576f600122fb2?opendocument The Australian Dental and Oral Health Therapists Association 2012, Oral Health Therapist (cited 11th October 2012); available from The Australian Institute of Health and Welfare 2012, Cancer Incidence 1982 to 2008 (cited 16th October 2012); available from The Cancer Council New South Wales 2011, Understanding Head and Neck Cancers, Cancer Council NSW, Woolloomooloo, NSW. Cancer Council Victoria 2010, Canstat: a digest of facts and figures on cancer, Cancer Epidemiology Center, Carlton, Victoria The Cancer Council Victoria 2012, Understanding Radiotherapy, Cancer Council Australia, Carlton, Victoria. Chambers, MS Day, TA Lewin, JS Lydlatt, WM Murphy, B Peterson, DE Pfister, DG & Rosenthal, DI 2006, A Team Approach to Treating Head and Neck Cancer, CancerCare Inc., New York. Chandu, A Stulner, C Bridgeman, AM & Smith ACH 2002, Maintenance of mouth hygiene in patients with oral cancer in the immediate post-operative period. Australian Dental Journal. 47 (2): Clovis J (2000) Professionalism in Dental Hygiene: an Investigation of Knowledge of Oral Cancer and Public Policy Thesis (Ph.D.)-Dalhousie University, Canada Draper, C 2010, Cancer prevention and treatment: the dental hygienists role. Access. 24 (9): Farah, CS & McCullough, MJ 2008, Oral Cancer Awareness for the General Practitioner: new approaches to patient care. Australian Dental Journal, 53: Harford J, Ellershaw A and Spencer AJ ( 2011) Trends in access to dental care among Australian Adults , AIHW Dental Statistics and Research Series No 55, AIHW DSRU Canberra Hollows, P McAndrew, PG & Perini, MG 2000, Oral Medicine: Delays in the referral and treatment of oral squamous cell carcinoma. British Dental Journal. 188: Joyce, C & Crean, St-J 2002, What does the dental hygienist have to offer the oncological maxillofacial surgeon. Dental Health. 41(5): 3-7. McCullough, MJ Prasad, G & Farah, CS 2010, Oral mucosal malignancy and potentially malignant lesions: an update on the epidemiology, risk factors, diagnosis and management. Australian Dental Journal. 55: Nicotera, G Gnisci, F Bianco, A & Angelillo, IF 2004, Dental hygienists and oral cancer prevention: knowledge, attitudes and behaviours in Italy. Oral Oncology. 40: Öhrn, Kerstin (2001) Oral health and experience of oral care among cancer patients during radio- or chemotherapy Doctoral Thesis, Uppsala University, Oral and Dental Expert Group Therapeutic Guidelines: oral and dental, Therapeutic Guidelines Limited, Melbourne, Victoria. Oral Cancer Foundation 2011, Radiation therapy (cited 7th May 2012); Available from Singh, N Scully, C & Joyston-Bechal, S 1996, Oral complications of cancer therapies: prevention and management. Clinical Oncology. 8: Soames, JV & Southam, JC 2005, Oral Pathology, Oxford University Press, Oxford, UK. Radhakrishnan, S McCullough, MJ & Satur, JG 2008, Early detection of oral cancer: the role of the oral health therapist. ADOHTA Journal. July 2008:

21 proudly supported by Evaluation of Fissure Sealant Retention and Secondary Caries in Permanent Second Molars: A Clinical Audit Ali S 1, Croucher N 2, Boyce-Bacon K 3 1. Oral Health Promotion Advisor, BDS, MPH. Northland District Health Board. Whangarei. 2.Clinical Director. Oral Health Services. BDS,MCCDRCPS,DMS,FICD. Northland District Health Board. 3.Clinical Manager. Oral Health Services. South Team. DT(NZR). Northland District Health Board. Abstract This paper describes a retrospective clinical audit, in which 200 dental records were reviewed to assess retention and secondary caries incidence for Glass Ionomer Cement (GIC) fissure sealants placed on fully erupted second permanent molars, in a sample of year old high school students from selected schools in Northland New Zealand. Even though at the end of this period only 32% of the study teeth had a fully-retained fissure sealant, no study teeth showed radiographic evidence of dentinal caries in pit and fissure surfaces. Whilst the retention pattern of GIC sealants in this study were not ideal, they may still play a part in preventing enamel and dentinal caries progression. Introduction Fissure sealants were introduced in the 1960s to prevent pits and fissures of occlusal tooth surfaces from developing dental caries. There are two main types of fissure sealants, resin-based sealants and glass ionomer cements. Later, compomers were released; a combination of composite resins and glass ionomer cements. Resin-based sealants are divided into generations according to their mechanism of polymerisation or their content. First generation sealants were activated with ultraviolet light. These are no longer available. Second and third generation sealants are autopolymersied and visible-light activated, whilst fourth generation sealants contain fluoride (Ahovuo-Saloranta et al., 2009). Fissure sealants inhibit or reduce the risk of dental caries by sealing the irregularities on the pits and fissures where bacteria can colonise and start the caries process (Kantovitz et al., 2013, Ahovuo-Saloranta et al., 2009). A systematic review by Yengopal and Mickenautsch (2010) demonstrated that fissure sealants reduce occlusal caries by 71% after a one-off fissure sealant application (Yengopal and Mickenautsch, 2010). In another study, there was 36% reduction in caries in first permanent molars after 15 years of observation (Jodkowsk, 2008). Northland is a rural area with a population of low-socio-economic status and comprises 7.7% of the total New Zealand Maori population, of which half the population is less than 23.5 years of age (Statistics New Zealand, 2011). In 2011, Northland region reported the highest mean dmft of 2.30 for Year 8 children while the national mean dmft was (Ministry of Health, 2011, Gowda and Croucher, 2011). Therefore fissure sealants have been routinely placed on all patients as part of Northland District Health Board s (NDHB s) School and Adolescent Dental Service. The aim of this research was to undertake a retrospective clinical audit to assess the percentage of second permanent molars in year old high school students in selected schools in Northland that had fully retained fissure sealants over a three year period. In addition, radiographic analysis was undertaken to identify the number of fissure sealed, second permanent molars that had dentinal caries occurrence. Methods This study was a retrospective clinical audit which used convenience sampling to review the records of 200 adolescents (15-17 years of age) who had fissure sealants placed in Dental records were retrieved and patient treatment was reviewed in 2011, three years after placement of GIC fissure sealants on permanent second molars. Students from six selected high schools in Northland, New Zealand, were chosen to participate in the audit within their regular dental recall visits. These schools were selected from a single clinic catchment where the study clinician placed GIC fissure sealants in 2009 and then reviewed them in 2011; no intra-examiner reliability test was undertaken. As GIC fissure sealants are part of normal delivery of care for NDHB S School and Adolescent Dental Services and this was an internal audit of practice no formal ethical approval was required from the New Zealand Ministry of Health Ethics committee for the study and its publication. The normal consent process for NDHB s School and Adolescent Dental Service was used for each participant. Inclusion criteria: The participants were all patients aged between 13 and 15 years from six selected schools in Northland. These participants were enrolled in the school for the three year duration and had GIC fissure sealants placed on fully erupted and caries-free second permanent molars at the beginning of this period (in 2009) following baseline bitewing radiographs. Exclusion criteria: Participants and teeth were excluded from the study, using clinical notes, for the following reasons. i) They did not have a pre-treatment bitewing radiograph taken, or did not consent to a bitewing radiograph being taken as part of the recall examination. ii) A fissure sealant material other than the one selected for the study had been used. iii) Fissure sealants had been placed according to the study criteria but had then been subsequently repaired or replaced....continued on page 22 21

22 The Australian and New Zealand Journal of Dental and Oral Health Therapy (1) 2014 iv) If there was doubt in the mind of the study clinician, as to whether a fissure sealant was performed with relatively good moisture control. v) If there was doubt in the mind of the study clinician, as to whether the occlusal fissure was decalcified or carious in any way prior to the GIC being placed. Fissure Sealant Application in 2009: When fissure sealants were placed in 2009, isolation was achieved with cotton rolls. For the upper arch, cotton rolls were placed in the buccal arch only and for the lower arch cotton rolls were placed both in the buccal and lingual sulcus. Manufacturer s instructions were strictly followed for manipulation of the GIC fissure sealant material. No acidetching was undertaken before placement of the fissure sealant. The finger pressure technique was primarily used to apply the material into the fissures; gloved finger dipped in cocoa butter and pressure applied to the material. Excess material was removed with a probe from around the tooth. Once the material was set, articulating paper was used to test the bite. Adjustments were made using a round polishing bur and cocoa butter was re-applied. Data Collection: Demographic characteristics such as age, gender and ethnicity were collected. All occlusal surfaces of second permanent teeth included in the study were visually examined by the study clinician using good light and compressed air. Findings were recorded as: full retention, where all fissures have intact fissure sealant material; partial retention, where greater than fifty percent of fissure sealant material was lost from the fissures, and; complete loss, where all fissure sealant material was lost. All patients included in the study had routine bitewing radiographs taken as part of their standard annual recall examination. Presence of occlusal dentinal radiolucency on the bitewing radiograph was noted as dentinal caries. Information was recorded on a standard paper chart. Data Analysis: Simple descriptive analysis was undertaken using Microsoft Excel Results Of the two hundred dental records that were examined, only forty-five participants met the inclusion criteria. Nearly twothirds of the participants were non-maori and majority were females; around three in five were 16 years old (Table 1). Table 1: Demographic characteristics of the participants (percentages in brackets) Number of participants (%) Ethnicity Maori 13 (29) Non-Maori 32 (71) Gender Male 16 (36) Female 29 (64) Age (years) 15 8 (18) (67) 17 7 (15) Total 45 (100) A total of 141 teeth were reviewed both clinically and radiographically. Table 2 shows that nearly one in five teeth had completely lost their fissure sealants. There was a pattern seen across the sample; 38% of those with fully retained fissure sealants were female compared to only 23% males. Among those who had completely lost their fissure sealants; nearly half were male and one quarter were female. When comparing with the baseline bitewing radiograph, over the three year period, no confirmed radiographic occlusal dentinal caries was detected in any the teeth examined. Discussion Thirty-two percent of the participants had fully retained fissure sealants and no confirmed radiographic dentinal caries was seen on any of the study teeth at the end of three years. One of the weaknesses of this audit was the small sample size which limited its generalisability however the study is useful in informing future study designs. Northland has a very transient population, therefore it becomes challenging to trace the same cohort of children. In this study only patients of the study clinician were selected to be part of the sample. A shortfall was the lack of intra-examiner reliability tests. This was not carried out as the study clinician has been in the practice for ten years and it was presumed that reliable and valid results were likely to be recorded. This was a representative sample reflecting the characteristics of the Northland population, being predominantly non- Maori with only 32% Maori (Northland District Health Board, 2012). Female participants were more numerous than male participants. However, the selected schools had higher proportion of females and this may account for the differences in findings between sexes. Higher failure rate of fissure sealants, especially among upper second molars could be attributed to poor operator vision as upper second molars are more distally located. As suggested by Beauchamp (2008), the use of self etching bond that does not have a separate etching step may provide less retention of fissure sealants. The retention factor of the fissure is instrumental for case selection in the absence of acid-etch technique. Adequate retention of fissure sealant requires the sealed tooth to have a maximum surface area with deep, irregular pits and fissures (Subramaniam et al., 2008, Grewal and Chopra, 2008). Ease of application of the material used for fissure sealant is another crucial factor. Flowable fissure sealant material with low elasticity improves retention, particularly in those teeth which are thought to be difficult to seal (S Beuna et al., 2012, Chaitra et al., 2010). Patient cooperation can affect the clinical technique especially if the second molars are selected. A high failure rate of GIC on a long-term basis has been demonstrated in other studies (Kühnisch et al., 2012, Ulusu et al., 2012). However, despite the high failure rate of fissure sealants, no dentinal caries was detected on the radiograph. This audit has supported the findings of Azarpazhooh and Main (2008), that GIC sealants have shown protective effects (0.22, 0.32 and 0.28 RR) after 3, 4 and 5 years of placement. It has been hypothesized that although the GIC sealants appear partially or totally lost clinically, the openings of the fissures remains sealed (Yengopal et al., 2009). The effectiveness of GIC is then attributed to the 22

23 proudly supported by Table 2: Retention pattern of fissure sealants (column percentages in brackets) Retention Pattern Full Retention Ethnicity Gender Age (years) Tooth Non- Maori Male Female Upper Lower Maori 17(38) 28(29) 13(23) 32(38) 8(35) 34(35) 3(15) 22(28) 23(37) Partial Retention 17(38) 44(46) 17(30) 35(41) 5(22) 44(45) 12(60) 35(45) 26(41) Complete Loss 11(24) 24(25) 26(47) 18(21) 10(43) 20(20) 5(25) 21(27) 14(22) Total 45(100) 96(100) 56(100) 85(100) 23(100) 98(100) 20(100) 78(100) 63(100) isolation of bacteria from nutrients in the substrate below early carious lesions that have been sealed, the release of fluoride into the dentin or a combination of both factors. Newer high viscosity GIC sealants that are applied with a gloved indexed finger coated with petroleum jelly, have been shown to achieve deeper fissure penetration of the material (Yengopal et al., 2009). The fluoride releasing properties of GIC fissure sealants make it ideal for use in high- risk patients (Mickenautsch and Yengopal, 2011). Conclusion The clinical audit suggests that fissure protection using GIC fissure sealants, using the finger pressure techniques, may be effective in halting caries initiation and progression. However, there is a need for further research to take into consideration clinical techniques and criteria for fissure sealing a tooth with GIC that would allow for improved retention rates. Acknowledgment The authors would like to thank management of Community Oral Health Services, Northland District Health Board, Whangarei, New Zealand for funding and permission to undertake the clinical audit and also facilitating data collection. We would also like to thank Sunitha Gowda (Public Health Strategist, Northland District Health Board) for her guidance in drafting this report and Rosemary Wilson (Dental Therapist, Northland District Health Board) for supporting us with data collection. References Ahovuo-Saloranta A, Hiiri A, Nordblad A, Makela M, & Worthington Hv. (2008). Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents (Review). The Cochrane Collaboration. Retrieved from: wiley.com/doi/ / cd pub3/pdf Azarpazhooh A. & Main P. (2008). Pit and fissure sealants in the prevention of dental caries in children and adolescents : A systematic review. Journal of the Canadian Dental Association. 74(2), Beauchamp J, Caufield P, Crall J, Donly K, Feigal R, Gooch B, Ismail A, Kohn W, Siegal M & Simonsen R. (2008). Evidence-based clinical recommendations for the use of pit-andfissure sealants. The Journal of the American Dental Association 139, Beun S, Bailly C, Devaux J. & Leloup G. (2012). Physical, mechanical and rheological characterization of resin-based pit and fissure sealants compared to flowable resin composites. Dental Materials, 28, Chaitra T, Reddy V, Devarasa G. & Ravishankar T. (2010). Flowable resin used as a sealant in molars using conventional, enameloplasty and fissurotomy techniques: An in vitro study. Journal of Indian Society of Pedodontics and Preventive Dentistry, 28, Gowda S. & Croucher N School-based toothbrushing program in a high-risk rural community in New Zealand- an evaluation. Whangarei, New Zealand Northland District Health Board. Grewal N & Chopra R. (2008). The effect of fissure morphology and eruption time on penetration and adaptation of pit and fissure sealants: An SEM study. Journal of Indian Society of Pedodontics and Preventive Dentistry 26, Jodkowska E. (2008). Efficacy of pit and fissure sealing: long-term clinical observations. Quintessence International, 39, Kantovitz K, Pascon F, Nociti Jrn F, Tabchoury C. & Puppin-Rontani R. (2013). Inhibition of enamel mineral loss by fissure sealant: An in situ study. Journal of Dentistry, 41, Kühnisch J, Mansmann U, Heinrich-Weltzien R. & Hickel R. (2012). Longevity of materials for pit and fissure sealing Results from a meta-analysis. Dental Materials, 28, Mickenautsch S. & Yengopal V Caries-preventive effect of glass ionomer and resinbased fissure sealants on permanent teeth: An update of systematic review evidence. BioMed Central, 4. Ministry Of Health. (2011). Age 5 and Year 8 Oral Health Data from School Dental Services. Wellington: Ministry of Health Northland District Health Board. (2012). People and Population. Retrieved from: Statistics New Zealand. (2011). Quick Stats About A Place. Retrieved from: stats.govt.nz/census/2006censushomepage/quickstats/aboutaplace.aspx Subramaniam P, Konde S & Mandanna K. (2008). Retention of a resin-based sealant and a glass ionomer used as a fissure sealant: a comparative clinical study. Journal of Indian Society of Pedodontics and Preventive Dentistry 26, Ulusu T, Odaba_ M, Tüzüner T, Baygin O, Sillelio_lu H, Deveci C, Gökdo_an, F. & Altunta_, A. (2012). The success rates of a glass ionomer cement and a resin-based fissure sealant placed by fifth-year undergraduate dental students. European Archives of Paediatric Dentistry, 13, Yengopal V, Mickenautsch S, Bezerra Ac & Leal Sc. (2009). Caries-preventive effect of glass ionomer and resin-based fissure sealants on permanent teeth: a meta analysis. Journal of Oral Science, 51, Yengopal, V. & Mickenautsch S. (2010). Resin-modified glass-ionomer cements versus resin-based materials as fissure sealants: a meta analysis of clinical trials. European Archives of Paediatric Dentistry, 11 (1),

24 The Australian and New Zealand Journal of Dental and Oral Health Therapy (1) th International Symposium on Dental Hygiene Cape Town South Africa Melanie Hayes BOH, BHSc(Hons),PhD Lecturer, School of Health Sciences Faculty of Health and Medicine, University of Newcastle SAVE THE DATE June, 2016 The next Symposium to be held in Basel, Switzerland Capetown, South Africa, was the venue for the 19th International Symposium on Dental Hygiene, which was held from the 14th-17th of August With the theme of Oral Health The vital link in achieving total health, it promised to look beyond calculus removal and cavity preps, and allow us to consider the bigger picture. The opening ceremony was truly welcoming, with each country represented by two delegates; DHAA President Hellen Checker and Founding President Sue Aldenhoven proudly waved the Australian flag. All delegates joined in an unforgettable Africa drumming experience, and this was followed by an impressive reception in the Trade Exhibition area. Professor Robin Seymour kicked off the symposium with the question How important is oral health as a risk factor for general health? which set the scene for the following days. It framed us all to consider the impact of preventive dental health in benefiting the systemic health and wellness of our patients. A range of interesting topics and engaging speakers followed over the next three days. The scientific evidence to support the role of motivational interviewing in the dental setting was noteworthy, particularly the cost-effectiveness and improvements in health outcomes. These findings help confirm the important, but often overlooked, role of dental hygienists in talking with their patients. The potential for probiotics to influence how we think about the balance of bacteria in the oral cavity gave us all food for thought (pardon the pun!). Furthermore, there were accepted abstracts for presentations from oral health researchers all around the world. I had the pleasure of hearing about how the fibres from orange bag netting can be used as a floss alternative in lower socioeconomic communities; how oral health promotion can reach other cultures through the use of radio; and, how a variety of medicinal plants have been demonstrated to be active against Candida Albicans isolates. By the end of the final day, what was clear to me is that our role as dental hygienists, therapists and oral health therapists is going to transform significantly in the coming years. As preventive health care providers, our duty of care will extend beyond the mouth, and we must be prepared and willing to take on this responsibility. It is essential that we continue to promote our role to the wider community, and that we are involved in developing the research that will influence our professions evolution. As we build our global community, the International Symposium will continue to bring hygienists, therapists and oral health therapists from all around the world together, to be inspired by the current research and inspire us to be better dental practitioners. Delegates at the International Symposium, August 2013 Papers presented at IFDH Cape Town by Australian and New Zealand OHT researchers Blanche Farmer, NZ; A case for integrating oral health promotion and general health initiatives a New Zealand perspective Melanie Hayes, AUS; The effect of loupes on neck pain and disability among dental hygienists Ron Knevel, AUS; Reasons for choosing dental hygiene as a professional career; a study involving Nepalese dental hygiene students Mary Mowbray, NZ; Dental hygienist s management of peri-implantitis; an issue we all struggle with. Julie Satur, Zohra Rashizada and Ra Chung, AUS; Oral health promotion using community radio for Horn of Africa refugees in Melbourne Lise Slack, AUS; The barnacles and the fluffy towel Margie Steffans, AUS; Community outreach begins at home Robyn Watson, AUS; Medical history; risk factors and periodontal disease 24

25 proudly supported by ADOHTA WA 2013 Conference Together Towards Tomorrow Hellene Platell, RDT, RDH, Curtin University Another successful event in June allowed our members to accrue 11.5 CPD Hours. The Conference was officially opened by the Honourable Helen Morton MLC, Minister for mental health, disability services and child protection at a Cocktail Party on the evening prior to the commencement of the Scientific Program. Two hundred delegates made up of local members, our graduating Bachelor of Science (Oral Health) degree students and visitors from Victoria, Queensland, Northern Territory and New South Wales attended the two day event. Many of our second year Curtin University students were invaluable; assisting at registration, at trade display tables and in scanning our delegates entering the lectures. Speakers included Professor Ian Meyers, Dr Lyndie Foster-Page, Professor Ivan Darby, Associate Professor Leonie Short and Mr Ron Knevel as well as local speakers Associate Professor Bernard Koong, Ms Margaret Hays, Dr Gosia Barley and Ms April Jones. Topics varied from clinical applications in restorative and periodontal areas, evolving research, diagnostic imaging and work resilience and self care advice. Trade Displays included our supportive dental companies as well as delegate information from Diabetes WA and Beyond Blue. Because our work brings us in touch with diabetes sufferers and those battling depression from other issues, we include any groups that can provide support and increase our knowledge of the many conditions associated with mental illness. We work in dental environments where isolation can increase depression and reduce the capacity to function. Self care advice was well received and provided some steps to take to decrease stress and alter lifestyle to allow a good balance. Conference evaluation feedback was very positive with many compliments on the program content, selection of speakers, central venue and exceptional running of the event. Our next Biennial Conference would normally be held in However, given that our ADOHTA International Conference is scheduled for 2015 in Melbourne, we encourage members to plan and register to go east at that time and enjoy the camaraderie of new colleagues and experience a truly wonderful event. Delegates at the ADOHTA Conference, June given that our ADOHTA International Conference is scheduled for 2015 in Melbourne, we encourage members to plan and register to go and enjoy the camaraderie of new colleagues and experience a truly wonderful event. 25

26 The Australian and New Zealand Journal of Dental and Oral Health Therapy (1) 2014 Thankyou to our Peer Reviewers The ADOHTA Journal Committee, on behalf of our readers, would like to thank the following people for their contribution as peer reviewers for the journal: Rebecca Ahmadi RDT, Lecturer in Oral Health, University of Otago Leigh Barry BOH, Senior OHT, Yeronga Dental Clinic, Metro South Oral Health, QLD Fiona Blinkhorn BDS, MDS, PhD, Associate Professor, Oral Health Newcastle University Amanda Blyton Patterson, Dental Therapist, Tuggeranong Health Centre, ACT Health Felicity Crombie BDSc (Hons), PhD, Lecturer, The University of Melbourne Dental School Hanny Calache, BDSc, DPH, Adjunct Professor La Trobe Univ Director Clinical Leadership & Research, DHSV Narissa Chalwa BDSc, DCD Specialist Paediatric Dentist, Royal Children s Hospital of Melbourne Stuart Dashper BSc, PhD, Principal Research Fellow, Oral Health CRC, University of Melbourne Dental School, Callum Durward BDSc, MDSc, Dean, Faculty of Dentistry, Cambodia International University Lyndie Foster Page BSC, BDS, MComDent, PhD, Lecturer,Faculty of Dentistry University of Otago Sue Gardner DT, BEd, BScD, Lecturer & PhD Candidate School of Dentistry University of Adelaide Mark Gussy OHT, PhD,Associate Professor LaTrobe University, School of Dentistry and Oral Health Ben Keith BDSc Senior Lecturer, School of Dentistry and Oral Health La Trobe University Clinton Kempster BOH,BScD (Hons) Lecturer,School of Dentistry, The University of Adelaide Nicky Kilpatrick BDS PhD FDS RCPS FRACDS (Paeds) Murdoch Research, Royal Children s Hospital Ron Knevel OHT, PhD Cand., Senior Lecturer, School of Dentistry and Oral Health La Trobe University Pam Leong OHT PhD, Murdoch Childrens Research Institute Royal Children s Hospital Melbourne Erin Mahoney BDS, MDSc (Paediatric Dentistry),PhD, FRACDS, of the NZDA Wellington Branch Andrea McGuire Lecturer BOH Program University of Queensland Jennifer Miller Senior Lecturer and BOH Coordinator School of Dentistry The University of Adelaide Susan Moffatt RDT, BA, DPH,PhD Candidate,,Lecturer,Oral Health School of Dentistry University of Otago Christine Morris RDT, MPH, Director Health Promotion, SA Dental Service Mike Morgan BDS, PhD Professor Population Oral Health, University of Melbourne Dental School, Janice Okine Oral Health Training Coordinator Queensland Health & DOHTAQ Katrina Plastow RDT, Lecturer Oral Health,The University of Adelaide Rhonda Roan OHT, School Oral Health Service Wide Bay Health Service District QLD Brenda Ryan Lecturer Oral Health, Melbourne Dental School, University of Melbourne Andrew Neil BDSc. MPH. Environmental Health Unit Department of Health Victoria Julie Satur RDT, MHSc, Phd Assoc. Prof Oral Health University of Melbourne Dental School Elizabeth Senior RDT, MPH, Health Promotion Coordinator, Eastern Access Community Health Leonie Short RDT,BA, PhD Candidate, Associate Professor, Head Oral Health Central Queensland University Carol Tran BOH, PhD candidate Lecturer Oral Health University of Queensland Helen Tane RDT, MPH, PhD Candidate,Head of Oral Health Science, School of Dentistry & Health Sci, Charles Sturt University Tammy Yap BDSc, DCD Oral Medicine Candidate, University of Melbourne Dental School Janet Wallace DT, BOH, PhD, Lecturer Oral Health, School of Health Sciences, Newcastle University 26

27 WEBSITES OF INTEREST NSW Community Services and Health ITAB e-learning Courses This site offers on line learning programs for those working in the sector. An example is the ORAL HEALTH IN AGED CARE course. This is an on-line a course to develop oral health care skills for those working in residential aged care settings. It allows people to gain the necessary skills and knowledge to assist aged care residents with oral health care so that they can support dentists and OHTs and dental hygienists; also useful for oral health practitioners working in aged care for the first time. Coursera Coursera is an education company that partners with the top universities and organizations in the world to offer courses online for anyone to take, for free. You can watch lectures taught by world-class professors, learn at your own pace, test your knowledge, and reinforce concepts through interactive exercises. Courses are offered in a wide range of subjects, including for example CAMBRA by John Featherstone, and many courses offer CPD credits. Viva Learning Dental CE vivalearning.com Viva Learning is a dental continuing education platform that delivers free CE content through the Internet. Webinars are prepared and presented by respected clinicians, speakers and dental educators. Viva Learning provides free online access to high quality, clinically relevant presentations (interactive and on-demand), with the goal of helping dental professionals improve the way they practice dentistry. Corporations, organizations and other entities that are interested in and dedicated to high quality support Viva Learning. Colgate Professional Website professionaleducation Where you can find webinars, articles and the latest oral health news at Colgate Oral Health Network and Dental Tribune Study. Events updates proudly can be supported found at by Noticeboard NoticeBoard February FEBRUARY TO 1 MARCH: ANZSPD- VIC RK Hall Lecture Series in Pediatric Dentistry, Sofitel Hotel Melbourne. Visit: com.au/ March MARCH: QLD Brookwater Dental Study Group presents a lecture on Kids will be kids: Sports, Injuries, Complications, Management, Special needs & Rehabilitation at the Metro Hotel Ipswich noon-5.30pm followed by drinks MARCH: NSW ADX14 Sydney Conference at the Sydney Exhibition Glebe Island, exhibition, conference and sales. Australian Dental Industry Association Free CPD and entry to the Exhibition. Register Online at April APRIL: IDEM Singapore 2014 There is a specific DH/DT Program and special member s rates are on offer along with group discounting. Visit: APRIL 2014: ADOHTA SA/NT CONFERENCE McLaren Vale more info to come! Keep an eye on the ADOHTA website June JUNE: Australian Health Promotion Association (AHPA) 21st National Conference will be held at the Sydney Exhibition and Convention Centre. For more information: JUNE: International Association of Dental Research (IADR) General session Cape Town South Africa. For more information go to the events pages at JUNE: NZ DOHTA Conference Auckland for more information: August 2014 ADOHTA VIC Conference Melbourne. September SEPTEMBER: Public Health Association Australia (PHAA**) Annual Conference Perth 2014: The future of public health: big challenges, big opportunities. Pan Pacific Hotel Perth. For more information visit: 26 September ADOHTA NSW Conference Cutting Edge Oral Health. Contact Sharyn for further details: sharynjames@hotmail.com or Phone: September September: VIC 4th ADOHTA International Conference Melbourne, including College of Oral Health Academics meeting. Hilton on the Park East Melbourne. For more information: The ANZJDOHT does not endorse any of these sites but offer them as information for our readers. Readers should make their own critique of the quality of the content. ** PHAA have an Oral Health Special Interest Group 27

28 Corner Dr Sue Cartwright BDS, Dip Clin Dent, M Ed Oral Health Therapists are at the forefront of the prevention of dental disease. Colgate is also focussed on this important area and would like to bring some education materials to your attention. You may be interested to read an article published in 2013 that summarises caries management pathways from around the world including CAMBRA, ICDAS and the Caries Management System developed by Assoc Professor Wendell Evans at Sydney University. This article is free to download and can be obtained from: Alternatively you may like to visit the Alliance for a Cavity-Free Future website: where you will find 10 webinars presented by international cariology experts discussing these management pathways. If you would like to learn more about caries as a disease continuum and how to prevent and reverse early lesions keep our next lecture series in mind. In April 2014 we will be featuring Prof Roger Ellwood from Manchester University and Assoc Prof Wendell Evans in Sydney, Melbourne and Auckland, talking about caries management and research relating to the new Maximum Cavity Protection plus Sugar Acid Neutraliser toothpaste from Colgate. We hope to see you at one of the lectures! Join children s... and help lifetime! a smiles last Order Your FREE Oral Health Education Kit Today! EACH KIT CONTAINS: Dr. Rabbit and the Tooth Defenders Animated DVD Brush Better Poster Parent Education Brochures (25 per kit)* Kids Challenge Brushing Charts (25 per kit)* Colouring Sheets (50 per kit)* Tooth Defender Stickers (2 x 3 versions)* *Refills and Maori versions available. To order: Free Call AUSTRALIA NEW ZEALAND Order today while supplies last. YOUR PARTNER IN ORAL HEALTH