Synopses December 2000, Issue 23

12 Pages·0.9 MB·English

by  ANZSPD

The Newsletter of the Australian
and New Zealand Society of
Paediatric Dentistry
SSyynnooppsseess
DECEMBER 2000, ISSUE 23
Approaching the Question of Microvascular Remodeling
*Gue S, *Cameron A, +Zoellner H
*Dept. of Paediatric Dentistry, Westmead Dental Clinical School, Westmead Hospital
+Dept. of Oral Pathology, Faculty of Dentistry, The University of Sydney, Westmead Hospital Dental Clinical School
Dr Sam Gue was the winner of the 2000 Colgate Oral Care Paediatric Dentistry Graduate Student Award. Address Correspondence to: Dr. Sam Gue, Paediatric Dentistry
Registrar Paediatric Dental Department Westmead Hospital and New Children’s Hospital Darcy Road, Westmead 2145 University of Sydney, Sydney, New South Wales
Microvascular Remodeling the change in color from granulation tissue This contrasts with necrosis, in which
as a Model for Pattern Formation which is pink with new vessels to white homeostasis is lost due to toxic or other
scar tissue containing very few blood noxious agents. In necrosis there is
The microcirculation serves to supply vessels. This process is mediated by apoptosis disruption of membranous structures,
nutrients to the tissues as well as to remove of the constituent endothelium while degeneration of mitochondria and
waste products and this principal role endothelial cell apoptosis has also been ribosomal detachment from rough
demands the formation of a complex shown to be responsible for microvascular endoplasmic reticulum. In addition to this,
branching structure by the constituent remodeling during pressure induced atrophy DNA fragmentation in necrosis is random
endothelial cells. Although numerous of the parotid and involution of the so DNA has a smeared appearance in gel
signals have been identified as important mammary gland. In addition to this, electrophoresis. Further, since necrosis is
for microvascular development including endothelial cell apoptosis has been found due to tissue damage it usually occurs in
Fibroblast Growth Factor, Vascular to contribute to delayed wound healing in large groups of cells while apoptosis is
Endothelial Growth Factor, Angiogenins diabetes, hypertensive vasculopathy and described as occurring in single cells. From
and Ephrins, significant problems remain scleroderma. From this, it appears that this, apoptosis appears to be tightly
to be solved in understanding microvascular endothelial cell apoptosis plays a central controlled at the level of individual cells
morphogenesis. In particular, it is unclear role in both physiological and pathological rather than in a tissue wide manner.
what mechanisms are responsible for microvascular remodeling and it is likely
organization of individual endothelial cells that this is also important during orthodontic Continued on Page 3...
into complex microvascular networks. The tooth movement and bone remodeling.
difficulty of this problem becomes apparent
when it is considered that microvascular Apoptosis: A Matter of Life and Death
ttttthhhhhiiiiisssss iiiiissssssssssuuuuueeeee
flow in each part of the microcirculation is
functionally dependent upon flow in all of Apoptosis is currently accepted as the
the remaining parts, while individual principal mechanism whereby excess cells
endothelial cells are only in contact with are removed from the body. Morphologically 1. Approaching the Question of
adjacent cells and so have no direct and ultrastructurally, apoptosis is Microvascular Remodelling.
opportunity to communicate with their recognized by cellular fragmentation
more distant but nonetheless functionally into apoptotic bodies often containing 2. President’s Report.
dependent fellows. One approach to dealing fragments of condensed nuclear material
with this problem is to study microvascular but with intact organellar structures.
4. Dental Project for Cambodia.
networks undergoing remodeling. endothelial cell apoptosis appear to be
ultrastructurally unique in that complex
Endothelial Apoptosis in canalicular structures form in apoptotic 5. Oral Manifestations of
Microvascular Remodeling particles. This has been proposed as a Oncology Treatmeant in
Paediatric Patients.
mechanism aiding the mechanical
During wound healing, highly vascular fragmentation of apoptotic endothelial cells
granulation tissue undergoes significant and thus minimizing the micro-embolic 10. Branch Reports.
microvascular remodeling and maturation potential of these cellular fragments.
to become mature scar tissue. The dramatic Internucleosomal cleavage of DNA into 12. Coming Events
extent to which excess vessels are removed 180 base pair fragments is a widely
during wound maturation is illustrated by accepted biochemical marker for apoptosis.
PRESIDENT’S REPORT
President’s Report
PROFESSIONAL RESPONSIBILITY AND PATIENT WELFARE
M
y earliest recollections of children’s discovered alternatives to amalgam including therapy may be utilised for disease prevention,
dentistry were occasional visits to composite resins, glass ionomer cements and subject to public acceptance. New techniques
a mobile government dental clinic stainless steel crowns. Most importantly, for cavity debridement and restoration
in a railway carriage at ten years of age. The there was a professional realisation that placement will evolve. Infants and pre-
clinic visited country Queensland on a the age for a child’s first dental visit should schooler attendance will increase due to the
regular annual run with the itinerant be much younger than five years. perceived importance of early identification
dentist. To my best knowledge, I had After a few years in public hospital and intervention. The presence of child
amalgam fillings done in my primary teeth practice and part time academics, it dawned friendly techniques will improve both
and I can recall two distinct smells; one I on me that there must be a better approach compliance and behaviour management
think was eugenol and the other may have to maintaining children’s oral heath than during the active treatment phase.
been formocresol. I can vividly remember restoring decayed teeth. The surgical approach Paediatric dentistry is an exciting and
being asked to mix the mercury with the to disease management has since been energetic field of dentistry but is not
silver filings in a small bowl for the dentist, outdated by the medical model of disease without its share of controversy. However,
following the struggle of slow speed cavity control and prevention. I am convinced that it is our professional responsibility to
preparation without a local anaesthetic. dentists that treat children have a distinct embrace those concepts and techniques
What was happening in the world of advantage over all other disciplines of that further our patient’s health and
dentistry for children in the 1960’s? The dentistry. Only we can reduce the impact welfare. ANZSPD will continue to promote
only available written documentation was of dental caries and it’s effect on oral and the practice and science of paediatric
the Journal of Dentistry for Children. At somatic development through early dentistry through its organisational activities.
the time, it was the only dedicated journal intervention and initiation of a comprehensive Even though the challenge to continue is
to children’s dentistry and a quick scan of preventive program in high-risk children. great, the creativity, energy and intellect of
the content of four issues suggests that Although dental decay in children will future members will allow the society to
the problems in the 1960’s continue to be never be eradicated, the treatment options progress and develop.
similar to those problems that children’s for disease management are extensive, Kerrod B Hallett
dentists face today. For example, the including effective antimicrobial and fluoride
journal issues included articles on general preparations. Most children in Australia
anaesthesia, a technique on vital pulpotomy and New Zealand drink fluoridated water an invitation
on young permanent teeth, dental and almost all paediatric toothpaste
treatment for children with congenital contains fluoride. Fissure sealants reduce TO ALL ANZSPD MEMBERS
heart disease, caries in hospitalised children, occlusal caries and there are hundreds of
the Howe technique for pit and fissure toothbrush designs to effectively remove
An invitation is extended to all members
caries, concern over the availability of dental dental plaque. More importantly, increasing
of the Australian and New Zealand Society of
services for children and more interestingly, numbers of parents, doctors and dentists
Paediatric Dentistry (ANZSPD), to participate
dental care from birth to two years of age. recognise the importance of early
in the development of “Oral Health Care Policies
After reviewing the journal, I considered examination and guidance of the
and Standards of Care Guidelines for Paediatric
what had changed over the last 35 years. developing primary dentition and its
Dentistry”, which is currently being produced
When I entered dental school in 1972, importance for general growth and
by the Australasian Academy of Paediatric
I realised I was not the only student that development. In addition to the Journal of
Dentistry (AAPD).
had a lot of cavities as a youngster. In fact Dentistry for Children, there are a number
A full day meeting will be held at Rydges
some of those fillings still remain and are of journals that publish contemporary
Southbank Hotel, Brisbane, Queensland (ADA
working just a well, despite the concerted issues in paediatric dentistry.
Congress Hotel) on Thursday 3 May 2000, just
attempts from my dental student How about the next 35 years?
prior to the 30th Australian Dental Congress.
colleagues to replace them. Restoration in Discussion on pulp treatment in the
Further details and copies of the proposed
1972 was limited to amalgam in the primary and permanent dentition will
protocols may be obtained by contacting Ms
posterior teeth and silicate cement in the continue, probably in the area of induced
Sarah Raphael, Secretary, AAPD
anterior teeth. Seldom were children osteogenic repair. With new medical
younger than five years of age treated therapies to treat childhood diseases that
Email: [email protected]
(except for emergency extractions) and the were once fatal, I expect there will be more
Address: 151 Woodland Street
benefit of fluoride was only just beginning complex issues in managing children with
Balgowlah NSW 2093
to emerge. When I finished my speciality special health care needs. The genes
Telephone: [phone].
training in 1991, dental decay in children responsible for tooth development will be
was certainly on the wane. Systemic and mapped and a host of diagnostic tests will
Peter J Gregory, President
topical fluorides had decreased the be available to identify children at highest
Australasian Academy of Paediatric Dentistry
prevalence of smooth surface caries and I risk for dental disease. Gene replacement
2 SYNOPSES DECEMBER 2000
APPROACHING THE QUESTION OF MICROVASCULAR REMODELING
...Continued from Page 1 recently revisited the question of the quantitate the extent of endothelial
possible effect of shear stress upon apoptosis by simply counting the number
endothelial cell apoptosis. of cells surviving experiments. These were
Co-ordination of Endothelial Apoptosis: are easy to separate from apoptotic cells
A Significant Problem A Simple Rocking Platform Model because endothelial cells detach early
to Stimulate Endothelium with Shear Stress during apoptosis and can be washed away,
If, however, apoptosis is regulated at while surviving cells are all adherent to the
the level of individual cells, additional Experiments stimulating cells with culture surface.
problems become apparent in regulating shear stress are quite difficult, primarily
apoptosis of endothelial cells during because highly specialized and complex Data Were the Opposite to What Was Expected
vascular remodeling. It is clear that if apparatus is required. This makes
endothelial cell apoptosis is not properly performing preliminary experiments Instead of finding that shear exposed
coordinated, the microvascular network problematic, as significant expenditure on cells were protected from apoptosis, what
will be disrupted resulting in either ischaemic new equipment can not always be justified we found was that fewer cells survived on
necrosis or bleeding. Since this does not without any evidence that the new line of the rocking platform than in static culture.
occur in-vivo, it is clear that there must be investigation might be fruitful. To get This was the absolute opposite of what was
mechanisms to co-ordinate endothelial cell around this rather practical problem, we expected, as we had argued that functional
apoptosis and maintain vascular perfusion established a very simple experimental signals should inhibit endothelial apoptosis
during micro-vascular remodeling. system, in which endothelial cells grown and shear stress was clearly a functional
Since the principal function of blood to confluence in tissue culture flasks were signal. Not only that, but while performing
vessels is to carry blood, it is possible that these experiments, other workers had
blood flow provides a mechanism linking published work with laminar flow
microvascular function to regulation of “Instead of finding that shear chambers showing reduced endothelial
endothelial cell apoptosis. Supporting this apoptosis in the presence of laminar shear
exposed cells were protected from
possibility is the observation that stress. At first, we rejected our data,
apoptosis, what we found was
microvessels carrying blood are maintained thinking that “something had gone
during microvascular remodeling in-vivo, that fewer cells survived on the wrong”. However, the more experiments
while those vessels which are poorly rocking platform than in static were repeated, the more clear it became that
perfused or have oscillatory flow undergo culture. This was the absolute endothelial cells in our rocking platform
degeneration. An important conclusion opposite of what was expected.” model die more quickly than parallel cells
from this is that the default status of sitting on the incubator shelf. This
endothelial cells appears to be apoptosis, difference was seen regardless of the culture
with endothelial cells only surviving if medium used, although the gap between
receiving survival signals from flowing simply rocked back and forth on a survival and death seemed most
blood. This model is illustrated in Fig. 1, laboratory rocker. In this way, the culture pronounced when cells were cultured in
where vessels having indifferent or medium overlying the cells was allowed to serum free conditions with albumin.
conflicting flow in the “initial vasculature”, wash forwards and backwards over the It became important to check that cells
are removed by endothelial apoptosis to cells, thus exposing the cells to shear stress. were actually apoptotic and not simply
produce an optimized “final vasculature”. By aligning tissue culture plates in parallel necrotic. To look at this, we examined the
with each other, as well as being careful to cells by transmission electron microscopy,
Chemical Plasma Factors and Laminar Shear load equivalent amounts of culture DNA gel electrophoresis and FACS analysis
Stress Inhibit Endothelial Apoptosis medium in each flask, it was possible to and have found that the cells are clearly
stimulate sets of three or more flasks as apoptotic. The only conclusion left for us
The two types of anti-apoptotic signal triplicates to facilitate statistical analysis. was that we were inducing endothelial
which might act upon endothelial cells in Cells in these “rocking flasks” could then apoptosis by culture on the rocking platform.
functional blood vessels are shear stress or be compared with parallel cultures treated
chemical plasma factors. Laminar shear in the same way in the same incubator, Does Oscillating Shear Stress Affect
stress has been shown to inhibit apoptosis but on a stable incubator shelf. We knew Endothelial Apoptosis Differently to Laminar
in isolated cultured endothelial cells and it from earlier work that endothelial cells Shear Stress?
is likely that this plays some role in-vivo. become more rapidly apoptotic in serum
However, since isolated endothelial cells free conditions while albumin inhibits this As mentioned above, other workers had
grow and survive in the absence of shear process. Also, we had shown that shown that laminar shear stress protects
stress, it seems that although shear may endothelial cells do not proliferate in flasks endothelium from apoptosis so that our
inhibit endothelial cell apoptosis, it is not a unless stimulated with specific growth task became one of trying to reconcile our
critical anti-apoptotic factor for these cells. factors prepared from bovine observations with those of these other
In contrast, serum deprivation causes rapid hypothalamus. Because of this, we workers. Comparing our work with that
endothelial cell apoptosis in the absence of performed these experiments with both reported in the literature, the most obvious
shear, suggesting that chemical plasma “rocking” and “static” cultures with three difference was that we had stimulated cells
factors are critical anti-apoptotic signals for types of culture medium: i) medium in with oscillating shear stress while our
endothelial cells. This laboratory has been which endothelium has very low levels of colleagues had stimulated their cells with
investigating this possibility and we have apoptosis (M199 with 20% serum); ii) continuous laminar shear stress. Also, we
found that serum contains potent anti- medium in which endothelum is slightly knew that increasing the rate of rocking in
apoptotic factors for endothelium, with at more apoptotic (M199 with 4% serum our platform rocker model increased the
least one of these factors being serum albumin); and iii) medium inducing high extent of apoptosis. From this, we concluded
albumin. Although most effort has been levels of endothelial apoptosis (M199 that oscillating shear stress induces apoptosis
directed towards understanding the way alone). Also, earlier work had shown that while laminar shear stress inhibits this.
in which serum albumin may mediate this because endothelium does not proliferate
anti-apoptotic activity, we have more in these conditions, it is possible to Continued on Page 4...
SYNOPSES DECEMBER 2000 3
APPROACHING THE QUESTION OF MICROVASCULAR REMODELING
...Continued from Page 3 such excessively tortuous vessels might Dental Project for Cambodia
help to optimize microvascular shape.
2001-2002
The Possible Biological Relevance If this is the case, it becomes interesting
of Oscillating Shear Stress to speculate as to the possible ways in
Since the 1980s, progress has been made in
which this mechanism might be inhibited
It is always difficult to meaningfully in conditions where vessels become re-establishing oral health services and training in
extrapolate observations with isolated increasingly tortuous, such as chronic Cambodia following two decades of war, political
cultured cells to the in-vivo situation. periodontitis. Perhaps inflammatory instability and hardship. The Faculty of Dentistry
Cultured endothelial cells grown as a cytokines inhibit this process? Before in Phnom Penh has received some help in recent
monolayer on a plastic plate are clearly a extending work to these sorts of questions, years from non-governmental organisations, and
very poor model for endothelial cells in however, it is more important to properly a few Cambodian dentists have had the chance to
actual micro-vessels. Nonetheless, it seems characterize the current observations with make short educational tours overseas to improve
fair to assume that cells carry at least some oscillating shear. their knowledge. Unfortunately only 4 Cambodian
of their in-vivo properties across into cell dentists have had the opportunity to study abroad.
culture, and that the behavior of cultured The Need for an Improved Experimental Model Of these one has since retired and 2 have gone to
endothelium usually reflects some aspect
live in the US. In order for Cambodia to continue
of the real biology we wish to study. Accepting As mentioned above, the rocking
to improve oral health services for its people,
the limitations of cell culture models, but platform model was used primarily as a
upgrading the knowledge and skills of staff at the
on the assumption that their behavior simple and inexpensive way of stimulating
Faculty of Dentistry must be a priority.
reflects some aspect of biology, it became endothelium with shear stress. Although
The idea for this project came about during
important to try and imagine some way in permitting experiments to be performed, it
the Cambodian Dental Association Conference in
which oscillating shear induced endothelial was not possible to directly compare the
January 2000, when a group of foreign dentists
apoptosis might be biologically important. response of these cells with others exposed
who attended the meeting formed a group called
In-vivo observations by other workers to true, uniform, unidirectional laminar
have infact revealed that in remodeling shear stress. Also, because the flow varies “Friends of the Cambodian Dental Association”.
apoptotic vessels, where flow is already in direction and velocity according to the Following discussion with the Cambodian dentists
impaired, the blood often oscillates back and angle of the rocking platform, it was not the group proposed to help upgrade the
forth. Further apoptosis in these vessels possible to properly quantitate the levels of knowledge and skills of the teachers at the Faculty
eventually results in removal of these shear used. Worse still, turbulence generated of Dentistry by running 2-year part-time diploma
microvascular limbs and it seems reasonable at the extremes of each cycle makes courses in each of the clinical disciplines. The
to suggest that the increased apoptosis in calculation of shear stress impossible. Since first of the courses to be run is a Diploma of
“rocking” cultures reflects a mechanism for we now have this interesting data, further Paediatric Dentistry and will begin in January 2001.
accelerating endothelial apoptosis in these expenditure on more complex and expensive The course for 4-5 Cambodian dentists has
sorts of degenerating blood vessels. Similar equipment seems justified. To this end, we been developed with Cambodia’s specific needs
events may occur in vessels where there are are currently assembling an apparatus
in mind, and will involve intermittent visits by up to
flow conflicts (Figure 1). Another possibility, which will allow us to study these
8 overseas volunteer paediatric dentists, mainly
is that the oscillatory shear stress generated phenomena more carefully. Despite
from Australia and NZ. Each visiting lecturer will
on the rocking platform mimics the numerous technical difficulties and setbacks,
teach part of the course as well as providing clinical
oscillations in flow or turbulence generated we hope to be able to initiate experiments
supervision. The period of each visit will be 1-2
when vessels become excessively tortuous. with this much more sophisticated model
weeks with about 2 months between visits during
In this way, apoptosis of endothelium in system in the near future.
which time students will continue to treat children
on their own, and carry out prescribed readings
and assignments. Those Cambodian dentists
Initital Vasculature Final Vasculature
invited to attend the course include teachers at
the Faculty of Dentistry and the Dental Nurses
training school, and one or two general dentists
Arterlole
who have a particular interest in or responsibility
for treating children. The local coordinator for the
course is Dr Poum Sen, Lecturer in Paediatric
Dentistry at the Faculty of Dentistry in Phnom Penh.
Capillary Remodelling by Along with the teaching, we intend to upgrade
the sparsely furnished paediatric clinic at the
Endothelial Apoptosis Faculty of Dentistry, by seeking donations of
supplies, instruments and equipment. If this first
course in paediatric dentistry is successful, it is
Steady Laminar Shear? intended that courses in other clinical disciplines
Venule will be introduced later.
Anyone interested in helping support this
Oscillating Shear?
project should contact:
Fig. 1. Illustration of the effect of blood flow in individual micro-vessels upon survival of vessel segments during microvascular remodeling. Callum Durward
Blood enters the microvasculature via arterioles, passes through capillaries and exits via venules. Blood flow is indicated by arrows and Paediatric Dentist
vessel segments where blood flow is poor are lost by endothelial apoptosis with the effect that microvascular structure is optimized. Poor
Greenlane Hospital
flow may result from flow conflicts or insufficient arterial supply relative to the dependent capillary bed. As discussed in the text of this
article, we have found that chemical plasma factors have a central role in signaling the presence of flowing blood in functional blood Private Bag 92-189
vessels, inhibiting apoptosis and so helping to control the structure of the microcirculation. Other workers have demonstrated a protective
Auckland New Zealand
effect of steady laminar shear stress while we find that that oscillating shear seems to stimulate endothelial apoptosis. This may
contribute to removal of vessel segments where there are flow conflicts as well as excessive tortuosity. E-mail: [email protected]
4 SYNOPSES DECEMBER 2000
ORAL MANIFESTATIONS OF ONCOLOGY TREATMENT
Oral Manifestations of Oncology Treatment in Paediatric Patients
Peter Readman, Paedodontic Registrar Princess Margaret Hospital
Supervisor: Robert Bower, Consultant Periodontist Princess Margaret Hospital
Inroduction A longitudinal study by Fayle and their apparent differing susceptibilities.
Curzon investigated the oral complications Nonkeratinised mucosa generally contains
Malignant disease ranks only second of 43 paediatric oncology patients aged two a loose connective lamina propria, which
to accidents as the most common cause of to 14 years receiving treatment for offers little support and facilitates mobility
death in children under 15 years of age.1 malignant disease.3 Forty (93 per cent) of the overlying epithelium. In contrast,
The most commonly diagnosed paediatric developed oral complications during the keratinised mucosa is firmly bound to
malignancies are leukaemias, followed by study period which emphasizes the need periosteum by a collagen rich lamina
tumours in the central nervous system, for dental involvement in paediatric propria. Fourth, regional susceptibility may
lymph nodes, bones, joints and cartilage, oncology patients. also be explained by the presence or absence
and those of endocrine origin.2 The nature and incidence of oral of keratin, which offers physical protection
Complications resulting from neoplasia, problems observed during treatment are to the epithelium. Fifth, neutropenia and
or secondary to cancer treatment, frequently illustrated in Table 1. local secondary infection may progress to
manifest in the oral cavity.3,4 Surgery, overt ulceration as a result of the patients
radiation and cytotoxic chemotherapy Mucositis and Ulceration impaired healing response.12
disturb the normal integrity of the mouth Mucositis, ulceration and erosion are
both anatomically, histologically and The oral mucosa is comprised of cells the most common oral complications of
physiologically. This paper will review the with a high mitotic index, making these cancer treatment.1,3,13,14 Initial symptoms
oral complications of both childhood tissues particularly vulnerable to the include a burning sensation, dryness of the
neoplasia and cancer therapy. direct effects of cytotoxic chemotherapy.1,10 mouth, tingling of the lips and pain.1
By inhibiting cell growth, cytotoxic Depending on the chemotherapeutic
Oral Complications of chemotherapy alters the integrity of the regimen used, erythematous mucositis
Systemic Cytotoxic Chemotherapy oropharyngeal mucosa, thus creating a develops in three to five days after the
portal of entry for the microbial flora found initiation of therapy and a localised or
Cancer chemotherapy protocols are within the oral cavity.1,10 In addition, a generalised ulcerative mucositis in seven
designed to obliterate malignant cells at the gross reduction in granulocyte numbers, to ten days.3,5,13 These painful ulcerative
primary lesion and elsewhere throughout as well as modifications to their functional lesions are noted primarily on
the body.6 In acute leukaemia, the drug capabilities (eg. reduction in migration, nonkeratinised tissues, such as the buccal
schedules are targeted primarily against phagocytosis, and antibacterial effect), and labial mucosa, the ventral and lateral
bone marrow, inducing a pancytopenia.6 leads to an increase in susceptibility to surfaces of the tongue and the floor of the
The drug-induced myeloimmunosuppression infection.1,10,11 mouth. Keratinised tissues such as the hard
correlates closely with vulnerability to Barrett proposed that five interrelated palate, attached gingivae and dorsal
infection. Cytotoxic chemotherapeutic factors contribute to the clinical breakdown surface of the tongue are rarely subject to
agents may therefore produce adverse side and ulceration of the oral mucosa following mucositis but may become painful.3,5,13
effects by direct toxicity at the cellular level cytotoxic chemotherapy.12 First, the Predicting which patients will suffer
or indirectly, characterised by drug-induced relatively rapid rate of cell turnover in the mucositis remains difficult as the capacity
pancytopenia.6 oral mucosa is important in explaining its to tolerate cytotoxic chemotherapy varies
About 40 to 50 per cent of all patients susceptibility. Second, degenerative greatly between individuals.12,15 In almost
receiving chemotherapy develop oral changes in the supportive submucosal all cases, patients involved have low
changes, however, these figures approach collagen may play a key role in the neutrophil counts (less than 0.5 x 109/L). 3
90 per cent in children.1,5,7-9 The increased development of ulceration following The ulcers usually last five to ten days with
mitotic index in children and associated cytotoxic chemotherapy. Third, the healing coinciding with an improvement
rapid epithelial turnover and maturation structural characteristics of the mucosa and in the neutrophil count.3
rates is thought to be responsible for their submucosa in areas of keratinised and Cytotoxic chemotherapeutic agents
greater susceptibility to cancer therapy.9 nonkeratinised mucosa may help explain associated with mucositis include
antimetabolites and in particular
methotrexate, cytarabine and 5-fluorouracil,
and antitumour antibiotics such as
ORAL PROBLEM NUMBER AFFECTED (N=43) daunorubicin, doxorubicin, bleomycin and
Mucosal Ulcers 28 (65%) hydroxyurea.5 If cytotoxic chemotherapy is
Lip Cracking 15 (35%) given in combination with total body
irradiation prior to bone marrow
Lymphadenopathy 15 (35%)
transplantation a rapid-onset mucositis
Mucositis/Erythema 13 (30%) may develop.1,5
Oral Bleeding 9 (21%) Treatment of mucositis is primarily
Severe Gingivitis 8 (19%) palliative aimed at minimising mucosal
trauma and improving patient comfort.13
Herpes Simplex 6 (14%)
During radiation and chemotherapy, the
Candidiasis 5 (12%) oral tissues should be kept moist by
Dry Mouth 2 (5%) frequent water rinses.5 If mucous is thick
Table 1. Incidence of oral problems observed during treatment3 Continued on Page 6...
SYNOPSES DECEMBER 2000 5
ORAL MANIFESTATIONS OF ONCOLOGY TREATMENT
...Continued from Page 5 myeloimmunosupressed patients.13,18 The Cepacaine, Difflam mouth gel, Oratect Gel
majority of oral bacterial infections in and systemic analgesics.5 There is no
it can be diluted by rinsing with a five per children involve secondary involvement of experimental evidence, however, to
cent solution of sodium bicarbonate.5 mucosal ulcerations due to therapy-related establish the efficiency of any one or
Rinsing the mouth after brushing with a neutropenia.13,18 A wide range of bacteria, combination of these agents in the
salt and soda (half a teaspoon salt and one including odontopathic, periodontopathic, management of pain.5
teaspoon baking soda in one pint of water) is and transient pathogens of the oral cavity Conventional tooth brushing during
recommended. 14 Saline solutions are thought may infect ulcerative lesions.13 myeloimmunosuppression may increase
to aid in formation of granulation tissue and Predisposing factors to infection include, the risk of bleeding and infection.13 A
promote healing, while sodium bicarbonate neutropenia, mucosal damage, periodontal modified mechanical approach is
dissolves mucin and loosens debris. 14 disease, dentoalveolar abscess, mobile recommended consisting of either irrigation
To prevent oral mucositis, patients deciduous teeth, cellular immune with a Water Pik or cleaning with a
undergoing cytotoxic chemotherapy dysfunction, haematologic immune disposable sponge, piece of gauze or cotton
usually receive some form of prophylactic dysfunction and iatrogenic procedures.5 swab with a topical antimicrobial agent.13
mouthwash. 6 The double blind, The clinical appearance of potentially Patients receiving long-term
randomised clinical trials of Ferretti et. al., severe local infections can be reduced or chemotherapy may experience subtle
and Rutkauskas et. al., support even absent during chemotherapy as a changes in their saliva from microbial shifts
prophylactic use of chlorhexidine in result of induced neutropenia.1,6,10,19 This to a decrease in the quality and quantity of
immunocompromised patients. 7,16 These particularly applies to gingival and saliva.5 Brown et. al., reported a higher
studies showed a significant reduction in periodontal inflammation. 20 concentration of Candida sp and
both incidence and severity of mucositis in Staphylococcus sp in immunodeficient
chlorhexidine treated patients. 7,16 patients. However, a lower recovery of S
Consequently, patients undergoing mutans and a lower caries experience in
“The incidence of oral infection
cytotoxic treatment may achieve better immunodeficient patients was noted.21
nutrition, fewer septic episodes, and shorter These findings indicate that other protective
is reduced when all definitive
hospital stays. mechanisms may compensate for
Benzydamine containing mouthwash immunoglobulin deficiency. 21
dental treatment is completed
(Difflam) is often used in the treatment of
mucositis.17 Benzydamine hydrochloride 2. Fungal Infections
before the commencement of
is a topical nonsteroidal anti-inflammatory
drug with analgesic, antipyretic, Fungal infections in patients
cytotoxic chemotherapy.”
antimicrobial and local anaesthetic activity. undergoing cytotoxic chemotherapy most
When applied topically as an oral rinse it commonly involve Candida albicans.13
offers the unique property of concentrating Other less common fungal infections in
in inflamed tissues. Benzydamine is used The incidence of oral infection is immunosuppressed patients involve
widely in the management of pharyngitis, reduced when all definitive dental Histoplasma capsulatum and Cryptococcus
radiation mucositis, aphthous stomatitis treatment is completed before the neoformans. Under normal conditions in
and post-operatively following dental commencement of cytotoxic the oral cavity, the growth of C. albicans is
surgery. This mouthwash is also available chemotherapy.1 Patients who receive inhibited by commensal microorganisms
with the addition of chlorhexidine (Difflam- cytotoxic chemotherapy should have a and by an intact immune system. Once
C) improving its antimicrobial properties. 17 thorough oral examination including both pathogenic, C. albicans may spread to the
Kamillosan is another mouth wash clinical and radiographic examination.13 If oesophagus or trachea via deglutition or
which has been recently reviewed in the therapy has already commenced, it is still droplet aspiration, or via haematogenous
dental literature. Research has been aimed recommended that patients be evaluated spread. The most serious infections involve
towards developing an irrigation solution as early as possible to establish a baseline major organ involvement or disseminated
that will prevent or reduce mucositis and examination which will assist in the candidiasis.13
promote epithelialization of desquamated monitoring and treatment of oral The incidence of candidiasis in
regions of the oral mucosa.18 Kamillosan complications.13 paediatric patients receiving chemotherapy
solution is prepared from the flower of the Optimal dental treatment should has been reported at 15 and 30 per cent.3,22
camomile plant. The main constituents include a prophylaxis, restoration of carious Candidiasis in children occurs most
are chamazulene, levomenol, polyins, and teeth, replacement of unsatisfactory frequently on the dorsum and lateral
flavinoids. These constituents are restorations, smoothing of fractured surfaces of the tongue, the commissures
antiinflammatory and spasmolytic, and enamel or rough restorations, extraction of the lips, and the buccal, gingival and
promote granulation and epithelialization of necrotic, infected or exfoliating teeth and palatal mucosa.1,6 Candida colonisation
through a favourable effect on the energy- elimination of prostheses.13 Good plaque appears as raised, creamy white, curd-like
dependant process of cell metabolism. Carl control before chemotherapy is essential to strands, beads, flecks and patches that
et. al., studied the prophylactic and reduce the morbidity associated with soft adhere to the underlying mucosa and leave
therapeutic use of Kamillosan oral rinse in tissue infection.1,13 painful shallow ulcers when removed.6
20 patients who received head and neck Oral hygiene procedures, both Patients receiving broad spectrum
irradiation and 78 patients who received mechanical debridement and mouth rinses, antibiotics or steroids, may have atrophic
systemic chemotherapy reporting a should be performed three times a day.5 If candidiasis which presents as a red often
reduction in both intensity, onset and tissue complications develop or deteriorate, painful tongue.1
duration of mucositis.18 the frequency of oral care should increase Clinical management of oral candidiasis
appropriately.5 A number of anaesthetics, in children is similar to that in adults and
1. Bacterial Infections analgesics and mucosal coating agents are consists of antifungal agents.1 Nystatin
available for the control of pain. They oral suspension or amphotericin B syrup
Bacterial infections are a significant include Benadril, Kaopectate, milk of or troches are often given after early
cause of morbidity and mortality in magnesia, Orabase, viscous xylocaine, diagnosis of oral candidiasis.6 These agents
6 SYNOPSES DECEMBER 2000
ORAL MANIFESTATIONS OF ONCOLOGY TREATMENT
can be cariogenic as a result of the high cumulative incidence of oral candidiasis in sero-positive patients to prevent and control
sugar content and must therefore be the control group. 16 Furthermore, two HSV infection.5
accompanied by excellent oral hygiene in deaths from Candida sepsis occurred in the
paediatric patients.1 control group during the early post- 4. Haemorrhage
Epstein et. al., assessed the potential transplant period.16
role of prophylactic mouthwashes in the Nystatin and chlorhexidine should not Cytotoxic chemotherapeutic agents
reduction of oral complications in patients be used simultaneously. Combining these may secondarily induce thrombocytopenia
receiving chemotherapy for leukaemia.23 agents results in the formation of a which is the usual cause of intraoral
This study, along with many other chlorhexidine-nystatin complex that haemorrhage.1,13,38 The haemorrhage may
publications, did not identify any appears to be ineffective against candida.34 occur anywhere in the mouth and may
prophylactic effects in Candida If the fungal infection becomes occur spontaneously or secondary to
colonisation, clinical oropharyngeal disseminated, fluconazole or ketoconazole trauma or inflammation.13 Oral petechiae
infection or fungaemia with the use of tablets may be effective.6 Intravenous occur most often in patients with a platelet
nystatin. Other studies of Candida amphotericin B however, is the preferred count below 50 x 109/L, while
prophylaxis using nystatin have often been drug for treating serious systemic spontaneous haemorrhage is associated
based on small patient series which have infections.6 with platelet counts of less than 20 x 109/
produced inconsistent results.23-26,27-31 L.3,13
Compliance with nystatin rinsing is 3. Viral Infections Prevention is the most effective
often limited by taste complaints, nausea technique used to avoid haemorrhage.13
and vomiting. Recent research has Herpes simplex virus (HSV) infection is Eliminating potential areas of trauma
therefore focussed on fluconazole in (sharp restorations, fractured teeth, mobile
Candida prophylaxis. Bodey et. al., studied deciduous teeth) and pre-existing intraoral
oropharyngeal candidiasis in 112 adults disease before chemotherapy minimises
“Radiation therapy involving
undergoing therapy for metastatic haemorrhage.13
malignancies.32 In this double-blind study The oral mucosa should be kept moist
only two per cent of patients receiving the head and neck region can with saline rinses, to avoid friction that
fluconazole developed oropharyngeal may initiate bleeding.13 Management
candidiasis compared to 28% for those requires removal of accumulated blood to
result in temporary or permanent
receiving placebo. Of the patients receiving identify the bleeding site and then pressure
placebo, those who also received antibiotic should be applied with moist gauze,
therapy or systemic adrenal corticosteroid destruction of salivary glands.” periodontal packing or a mucosal guard.
therapy suffered a higher incidence of Management of haemorrhage may require
oropharyngeal candidiasis at 30 per cent antihaemorrhagic agents such as topical
and 44 per cent respectively. Candidiasis thrombin, absorbable gelatin sponges,
was also evident in 54 per cent of placebo the most common viral infection associated oxidised cellulose, aminocaproic acid and
patients who were colonized by Candida sp with cancer treatment.1 The virus may occur microfibrillar collagen haemostat. If the
at the commencement of the study. as a primary infection, or more commonly bleeding episode is associated with an
Fluconazole provided effective prophylactic as reactivation of the latent virus during infection requiring surgical intervention or
cover for oropharyngeal candidiasis in this periods of immunosupression and intense if local measures are unsuccessful, platelet
study with few reported side effects.32 chemotherapy.1 transfusion may be required.1,13
Quirk et. al., retrospectively studied 196 Oral infections caused by HSV may be
patients who underwent bone marrow preceded by prodromal symptoms of pain, Oral Complications of Radiation
transplantation.33 Patients were divided burning, tingling or itching.6 They often Therapy in the Head and Neck
into two study groups; 1) those receiving begin as multiple vesicles at the vermillion
oral nystatin/amphotericin or 2) those borders, which rupture leaving painful The major early side effects of head and
receiving oral fluconazole. Fluconazole ulcers that subsequently become encrusted neck irradiation are mucositis, salivary
significantly reduce the incidence and with dried exudate.6 HSV infections gland changes, candidiasis and
severity of oropharyngeal candidiasis, often follow an atypical course in dysphagia.5,18 Among post-irradiation
showed good compliance and had minimal immunocompromised patients.35 Lesions problems are radiation-associated dental
side effects. Oropharyngeal candidiasis are often larger and require up to four caries, periodontal deterioration,
occurred in 54 percent of those patients in weeks or even longer for complete healing xerostomia, reduced maxillomandibular
the nystatin/amphotericin group and in without antiviral therapy.35 opening, decreased resiliency of perioral
only seven per cent of those patients Diagnostic tests include immuno- tissues and intrinsic bone changes.5,18,39
receiving fluconazole.33 fluorescence, Tzanck test, polymerase chain Abnormalities in the developing dentition
The prophylactic use 0.12 percent reaction, antibody titres, Western Blot include; enamel hypoplasia, diminutive
chlorhexidine mouthrinse was shown by analysis, and electron microscopy. teeth, delay or failure of tooth development
Ferretti et. al., to reduce the incidence of However, viral culturing offers the most and eruption and altered root formation.1
oral candidiasis in patients undergoing sensitive diagnostic test for the detection
intense chemoradiotherapy after bone of HSV infections. 35 Early Effects
marrow transplant.16 In a prospective, As a result of the increased susceptibility
randomised, double-blind study, patients to HSV infections, the high frequency of 1. Salivary Changes
were assigned mouthrinses containing atypical appearance and the prolonged
either 0.12 per cent chlorhexidine or a clinical course of HSV infections, some Radiation therapy involving the head
control mouthrinse identical in investigators recommend prophylactic and neck region can result in temporary or
composition but without chlorhexidine. antiviral agents for patients who are permanent destruction of salivary glands.1
There was an absence of clinically evident severely myeloimmunosuppressed.36,37 An initial decrease in free flowing saliva is
oral candidiasis in the chlorhexidine-treated Acyclovir is the preferred treatment both
group compared with 64.7 per cent prophylactically and therapeutically in Continued on Page 8...
SYNOPSES DECEMBER 2000 7
ORAL MANIFESTATIONS OF ONCOLOGY TREATMENT
Figure 1 Figure 2
Figure 3 Figure 4
Figure 5 Figure 6
...Continued from Page 7 2. Mucositis
followed by an accumulation of sticky Mucositis induced by irradiation is
mucous, because the acini of serous glands defined as the reactive inflammatory-like
are affected more than the acini of mucous process of the oropharyngeal mucous
glands.5 The pH of affected saliva may fall membrane following therapeutic irradiation
to below 5.5.5 The severity of salivary of patients who have head and neck
changes is related to the radiation dosage, cancer.40 It is important to record the extent
quantity of salivary tissue exposed and the of mucositis due to irradiation from both a
patient’s age.1,5 Altered salivary gland clinical and research standpoint. A
function predisposes such patients to pain, scoring system of mucositis enables
inflammation, dysphagia, xerostomia communication between clinicians with
and severe radiation-associated dental respect to generalised complaints such as
caries.1 pain and dysphagia, as well documenting
Managing xerostomia involves a the dose-response relation for that
combination of strategies including patient.40
Figure 7 synthetic salivary substitutes, stimulation The first signs of mucositis, a whitish
of remaining salivary tissue, maintenance appearing mucosa, occurs after exposure
of good oral hygiene and use of topical to 1, 000 rads (10 Gy).5,41 Eventually, the
fluoride.1 Patients with xerostomia whose mucosal surface becomes erythematous
salivary glands can respond to stimulation with deposits of fibrin on the surface. In the
may benefit from using simple dietary uncontrolled patient, islands of ulceration
measures such as eating carrots or celery may appear after 3, 000 rads (30 Gy).5,41
or chewing sugarless gums.13 Pilocarpine As treatment progresses, the entire mucosa
also appears to be effective in patients with may be involved and the patient loses taste
residual salivary gland function, however sensation. Local factors such as poor oral
patients with no functioning salivary hygiene, dentures and defective teeth
glands require saliva substitutes.13 frequently aggravate the condition.5,41,42
8 SYNOPSES DECEMBER 2000
ORAL MANIFESTATIONS OF ONCOLOGY TREATMENT
3. Other Early Effects The use of megavoltage radiation has reduced root length of multiple teeth
reduced the incidence of osteoradionecrosis secondary to chemotherapy. This patient
Other acute complications of from around 37 percent to below 20 percent.45 sustained a palatal luxation injury of tooth
radiotherapy include loss of taste, dysphagia, However, clinicians should perform 21 as shown in Figure 7.
trismus, loss of appetite, nausea, malaise extractions carefully on patients who have
and weight loss.5 Patients who have received radiotherapy.5 In susceptible 3. Other Late Effects
received oral or radical neck surgery may patients the correct extraction technique
also develop oedema of the buccal mucosa involves alveolectomy and primary closure The effect of radiotherapy predisposes
and floor of the mouth as a result of of the socket to eliminate the potential for the periodontium to disease since both
impaired venous and lymphatic drainage.5 sharp bony edges or spicules that may vascularity and the capacity of the
damage the overlying mucosa.5,46 This is supporting bone to remodel and repair is
Late Effects performed under the cover of broad also reduced.43 In addition, a reduction
spectrum antibiotics.5,46 in the salivary flow increases plaque
1. Radiation Caries and Dental Erosion Wound healing of heavily irradiated deposition. Teeth with advanced
bone following surgery can be enhanced periodontitis are also at risk of initiating
A distinct type of rampant caries often with the use of hyperbaric oxygen.39 osteoradionecrosis through the invasion of
occurs in patients receiving radiotherapy Hyperbaric oxygen treatment requires about microbes directly into the underlying bone.43
regardless of whether or not teeth are located four weeks and results in revascularization Candidiasis is also more common
within the collimation of the beam.41,43 of irradiated tissue.39 The major difficulties following radiotherapy which has resulted
A reduction in the salivary flow together of this treatment are time and expense. Soft in xerostomia. Altered salivary flow
with a shift in the oral microflora towards and salivary histatin levels may be
more cariogenic organisms increases the important predisposing factors. The
risk of caries.43 “Children are particularly increased susceptibility to candidiasis is
Radiation caries usually appears in the particularly evident in patients wearing
cervical areas of teeth, if uncontrolled, caries susceptible to both the acute and dentures.43
will circle the entire tooth with subsequent Trismus is another chronic complication
chronic oral manifestations of
crown fracture at the gingival margin.5,43 of radiotherapy. A reduction in blood flow
Caries is also observed on the incisal edges cancer treatment. Multidisciplinary to the muscles of mastication as a result of
of anterior teeth and the cusp tips of the progressive endarteritis results in scarring
treatment and coordination of care
posterior teeth, which are normally bathed and fibrosis of the affected muscles.43
in saliva and caries resistant.5,43 is therefore essential.” As treatment for paediatric cancers
A major side effect of cancer treatment improves, the increased survival of these
is nausea and vomiting. The reduced patients may result in an increase in the
salivary flow in patients who have received number of second primary malignancies.
head and neck irradiation renders the tooth tissue oxygen partial pressure (tension) can Van der Waal reports on a case of oral
surfaces particularly vulnerable to dental be raised to approximately 80 percent of squamous cell carcinoma following
erosion. Erosion of the palatal surfaces of normal after a total of twenty, one and a treatment of acute lymphoblastic
the upper anterior teeth are most frequently half hour treatments at 2.4 atmospheres leukaemia.48 It is tempting to speculate that
affected as shown in Figures 1 and 2. of 100 percent oxygen.39 the previous oncology treatment, either
Radiotherapy may also damage irradiation or cytotoxic chemotherapy, was
2. Bone Changes and developing tooth buds.5,43,44,47 If irradiated related to this second neoplasm rather than
Developmental Defects before calcification is complete, the tooth a random event.48
buds may be destroyed.44 Exposure later in In a retrospective study of 9720
The most serious complication of the developmental process may arrest children treated for acute lymphoblastic
radiotherapy is osteoradionecrosis.43 Bone growth and cause irregularities in enamel leukaemia, Neglia et. al., found a seven-
absorbs a larger amount of radiation and dentine.44 Consequently these patients fold excess of all cancers and a 22-fold
compared to an equal volume of soft tissue.5 may have missing teeth, enamel opacities, excess of central nervous system tumours
Radiation reduces the number of bone cells hypocalcifications, thin or shortened roots when compared to prevalence rates in the
as a result of endosteum atrophy and direct and developmental malocclusions.43,44 general population.49 Children who
cell death of osteoblasts and osteocytes.5,44 Interestingly, teeth often fully erupt even if underwent cranial irradiation before five
The bone becomes significantly acellular and the roots may fail to form.44 years of age had the greatest susceptibility
avascular, with marrow spaces undergoing Figures 3 and 4 illustrate the same to brain tumours.49
fibrosis and fatty degeneration.5,44 patient with hypoplasia of the second
These changes make the bone premolars and second molars. The OPG Conclusion
vulnerable to trauma and infection impairing shown in Figure 5 presents a patient who
its capacity to remodel and repair.43 The received irradiation for treatment of a Children are particularly susceptible
mandible’s high bone density and low nasopharyngeal carcinoma. Note failure to both the acute and chronic oral
vascularity makes it more vulnerable to of tooth development in the anterior manifestations of cancer treatment.
osteoradionecrosis than the maxilla. If maxilla and impaction of the upper left Multidisciplinary treatment and
growth centres are affected by irradiation, second molar. coordination of care is therefore essential
the development of the facial bones may give The reduction in root length may result to reduce both the incidence and morbidity
rise to facial asymmetry and malocclusion.43 in endodontic infections secondary to of these complications.The dentist involved
The most common dental factors minimal periodontal breakdown.43 in the patients care must recognize the oral
precipitating necrosis are pre- and post- Although it is not reported in the dental complications of cancer therapy which may
radiation extractions and pre-existing literature, such teeth may also be affect cells either directly or secondarily
periodontal disease.43 Dentures that cause predisposed to luxation injuries as a result through myeloimmunosuppression.
ulceration to the underlying mucosa and of the reduced periodontal attachment.
underlying bone are also contributing factors.43 Figure 6 is an OPG of a patient illustrating Please contact the Editor by email for references
SYNOPSES DECEMBER 2000 9
BRANCH REPORTS
New South Wales
and Research Centre, Royal North Shore have an annual general meeting, being
Hospital. Dr Walker addressed current addressed. As a result, the society is now
President: Eduardo A Alcaino trends in pain management in the an incorporated body (many thanks to
Secretary: Juliette Scott paediatric patient; she also discussed Mary Livingstone).
Treasurer: Anthony Burges hierarchy of pharmacological Submissions were also reviewed and
Committee Members: management, and also focussed in pain forwarded to NZDA on several issues
Joanna Seppelt, Suzanne Turek, management for the paediatric dental including competency and continuing
Richard Widmer, Angus patient. This was an excellent talk with education, along with a short submission
Cameron, Kareen Mekertichian much interest from the audience. on registration requirements for foreign
and Mary Moss graduates.
Tuesday 7th November 2000 Auckland members ran a successful one
There are approximately 50 active This event has been scheduled for the day course with Drs Callum Durwood,
members of the Society for 2000. During afternoon of Melbourne Cup Day. A short Heather Keall, Kahtan Hameed, and Nina
this year, the society held three meetings at general trivia Quiz and Luncheon has been Vassan. being speakers.
the usual venue, The Duxton Hotel at arranged for the afternoon. We will then Fluoridation has been an issue again
Milsons Point. Although 4 meetings are join Melbourne Cup festivities, including a in various centres. In New Plymouth the
planned for each year, the 12th Biennial live coverage of the Melbourne Cup race. District Council opted to review the matter
ANZSPD Conference in Adelaide (between The afternoon is meant to be a social, by having a public forum which lasted one
the 24th-26th February 2000) also filled our informal and pleasurable event for all day, rather than a referendum or a series of
calendar, with several of our members dentists and their staff. public meetings. This enabled interested
attending to this meeting. The three parties to make submissions without
meetings for the year 2000 were as follows: Eduardo A. Alcaino interjections, and in a controlled
Hon Secretary ANZSPD 2000 (NSW Branch) environment. Submissions were varied &
Tuesday 11th April 2000 came from a wide range of the community
This meeting discussed “Contemporary including the youth council, Public Health
New Zealand
diet & nutrition and its effects on dental officials. various health workers, the Pure
disease”. Our guest speaker was A/Professor Water association, and individuals wanting
Linda Tapsell, Acting Director- Smart Foods The New Zealand Branch of ANZSPD to control the poisons in their drinking
Centre, The University of Wollongong. A/ met in October at the NZDA biennial water and their right to choose. Several local
Prof. Tapsell spoke about current aspects of Conference. There we thanked some very Maori groups spoke strongly in favour of
dietary advise, the effects of high frequency long serving members being Mary retaining fluoride. Prior to the forum most
eating (snacking) in children and dental Livingstone as Secretary/Treasurer and Alan councillors had indicated they wished to
caries, erosive wear, and current protocols Issac as committee member and previous remove fluoride, but the decision was
for pre-school children. president. The President is now Jo Pedlow strongly in favour of continued
Of interest also was the 5th Congress of from Christchurch, President Elect is Callum fluoridation. Only one councillor out of the
the European Academy of Paediatric Durwood (Auckland) & Secretary Mary twelve voted against continued fluoridation
Dentistry held from June 7-11 in Bergen, Anne Costelloe (Stratford, Taranaki). New Next year the society is planning to
Norway. This was attended by several Committee members are Nina Vassan have several visiting paediatric speakers
members of our state branch, with papers (Auckland) and Christine Holloway (Timaru). including the ANSPD President Dr Kerrod
being presented by A/Prof R. Widmer, Dr A. The conference enjoyed a good Hallet, but first we are all anticipating
Cameron, Dr E. Alcaino, and two of our paediatric program (organised by Dr family time over Christmas and a restful,
post-graduate students, Dr E. Mahoney Bernadette Drummond). Angus Cameron peaceful summer holiday which we hope
and Dr Katherine Ngu. This was a highly was a key speaker and was very well our Australian members will also enjoy.
successful meeting with approximately 350 received. Recent Otago Masters graduates
delegates attending. Allison Meldrum and Katie Ayers were also Mary Anne Costelloe
part of an interesting and well attended
Tuesday 1st August 2000 program along with Dorothy Boyd
Queensland
This meeting discussed “Pain The society executive has convened
management in the paediatric patient”. Our regularly by teleconference throughout the
guest speaker was Dr Suellen Walker, a staff last two years. Here the branch’s The year is coming to a close for the
specialist in the Department of Anaesthesia constitution has been reviewed and Qld Branch with our Annual Clinic Day and
and Pain Management and Clinical Lecturer updated with one notable requirement of AGM in November. Under the auspices of
in the University of Sydney Pain Management the NZ registrar of Societies, that we must our President, Dr. John Keys, the Branch
10 SYNOPSES DECEMBER 2000