CADMUS by Adbourne Publishing

CADMUS

THE JOURNAL OF AUSTRALIAN DEFENCE FORCE DENTISTRY

making a great first impression dr david sykes

Volume 31, 2012

vision keys for precise oral surgery dr stephen macmahon

polishing composite resins dr michael mandikos

CAD ADMUS

The Journal of Australian Defence Force Dentistry

ISSN: 1834-0601

CONTENTS 3 5 11

EDITOR’S MESSAGE OFFICIAL ADDRESSES ADF OPERATIONS

Royal Australian Navy Dental Branch: Fleet News; Pacific Partnership 2012 – RAN Perspective Royal Australian Army Dental Corps: Operational News; Exercise HAMEL 2012; Exercise SAUNDERS 2012 Royal Australian Air Force Dental Branch: Operational News; Pacific Partnership 2012 – RAAF Perspective; Exercise TENDON VALIANT 2012

RECOGNITION OF AWARDS AND SERVICE DIRECTORATE OF DEFENCE FORCE DENTISTRY ANNUAL REPORT TRAINING UPDATE

27 28 31

The ADF Dental School

FEATURE ARTICLES

Dental Risk Assessment and Management in the Australian Defence Force Forensic Dentistry in Investigation of Unrecovered War Casualties Examination and Maintenance of Patients with Dental Implants Usage and Retrieval of Posts in Endodontically Treated Teeth Vision Keys for Precise Oral Surgery The Accuracy of Cone Beam CT Radiography in Implant Dentistry

TECHNIQUE TIPS

8 Steps to Improve Mandibular Blocks C-shaped Canals and How to Identify Them 8 Steps to Diagnose Oro-Facial Pain Maintenance of Distal Sites on Lower Second Molars after Removal of Third Molars

Making a Great First Impression Polishing Composite Resins Obstructive Sleep Apnoea 10 Clinical Tips for Predictable Fixed Prosthodontic Treatment

Clinical Governance: What can you do? Dental Classification Quiz – Part 1 Dental Officer CL1-CL2 Case Studies: CL1–CL2 Case Study (RAN) CL1–CL2 Case Study (RAAF) Barodontalgia – A diagnosis and management (RAAF)

Dental Officers: 2EHS Dental Officers in Cambodia Section of Defence Forces Dental Services (SDFDS) Dental Classification Quiz – Part 2 Senior dental Assistants: Defence Recipe Competition 2012 Oral Health Promotion in Children Prevention for the future

RAADC CORPS AND HISTORICAL

Members on non-Corps postings 2012 Update from the RAADC Association Incorporated Timor, Java and Sumatra experiences of PTE Alexander (Lex) William Milne

UNIT NEWS Joint Units Regional Health Service – Southern New South Wales Regional Health Service – Northern New South Wales Regional Health service – Queensland Regional Health Service – Central and West Regional Health Service – Victoria and Tasmania

The statements or opinions that are expressed in the Journal reflect the views of the authors and do not represent the official policy of the Defence Health Service unless this is so stated. Although all accepted advertising material is expected to conform to ethical and legal standards, such acceptance does not imply endorsement by the Journal or the Australian Defence Force Health Service. All literary matter in the Journal is covered by copyright, and must not be reproduced, stored in a retrieval system, or transmitted in any form by electronic or mechanical means, photocopying, or recording, without written permission.

CADMUS 2012

ARTICLES OF INTEREST

CADMUS is published annually by Adbourne Publishing for the Australian Defence Force Health Services Division. For any correspondence regarding the content of this journal, please contact Commander Tanya Burton, SO1 Dental Plans and Programs, Directorate of Defence Force Dentistry. Email: tanya.burton@ defence.gov.au

Published by: ADBOURNE PUBLISHING 18/69 Acacia Road, Ferntree Gully, Vic 3160 Phone: (03) 9758 1433 Fax: (03) 9758 1432 www.adbourne.com SOUTH AUSTRALIA Phone: 0488 390 039

PROFESSIONAL AND TECHNICAL ITEMS

Front Cover: RAN Main picture: HMAS Melbourne returning to Fleet Base East, Garden Island following a six month deployment to the Middle East Area of Operations. FMDT 2 onboard (see page 13); Inset – FMDT 1 attending to crew aboard HMAS Newcastle (see page 12).

CADMUS THE JOURNAL OF AUSTRALIAN DEFENCE FORCE DENTISTRY

Army main picture: Open Fire! An M1A1 Abrams tank provides fire support during Exercise Hamel; Inset - AACAP 19 dental team provide treatment at ‘One Arm Point’ (see page 20).

RAAF main picture: F/A-18 Classic Adbourne Publishing and the Directorate of Defence Force Hornet involved in Exercise Pitch Black Dentistry cannot ensure that advertisements appearing in 2012 and Exercise Kakadu (FMDT 2 this magazine comply with the Trades Practices Act and involved - see page 11); other consumer legislation. It is the responsibility of the Inset – Pacific Partnership 2012 Contingent supplier of advertising materials to ensure compliance with 2 perform a dental extraction during a all legal requirements. MEDCAP in Vietnam (see page 23).

making a great ﬁrst impression dr david sykes

vision keys for precise oral surgery dr stephen macmahon

polishing composite resins dr michael mandikos

Volume 31, 2012

CADMUS

The Journal of Australian Defence Force Dentistry Volume 31, 2012

Editorâ&#x20AC;&#x2122;s Message CADMUS is now in its 31st year of publication, offering a variety of articles to assist dental health professionals in providing the highest level of quality dental care. Whether you are a Defence member or civilian; deployed, posted overseas or in Australia; this edition will provide inspiration to all. In 2012, Defence implemented a significant transformation with the delivery of health care. This Journal recognises the transition of Garrison Health Care to Joint Health Command and includes modifications to align with the broader military health community. Unit News is no longer separated into single-Services and is now situated within the Regional Health Service structure; facilitating understanding of our responsibilities and Command.

CMDR Tanya Burton

This year, Defence dental personnel have contributed to multiple Operations and Exercises. Pacific Partnership, the annual US-Navy led humanitarian mission, has seen two contingents from the Australian Defence Force with involvement of tri-Service Dental personnel. In addition, RAN Dental Branch embarked Fleet Mobile Dental Teams onboard HMA Ships NEWCASTLE, CHOULES, BALLARAT and MELBOURNE; sailing to New Zealand, North Queensland, North East Asia and the Middle East. RAADC was well represented in EX HAMEL, EX GIANT VIPER, EX PREDATORS RUN and EX SAUNDERS. RAAF Dental personnel have supported EX TENDON VALIANT.

A selection of professional feature articles provide a broad range of topics based on best-practice guidelines; including restorative, forensic, periodontic, endodontic, oral surgery and prosthodontic procedures. Building on the foundations of the General Dental Practitioner, several renowned Specialists have offered technique tips to assist us with delivery of dental care within the clinic. The aim is to utilise these step by step guides to increase accuracy and efficiency within our practice. Additionally, we have some general articles of interest from Defence dentists and Senior Dental Assistants. May I offer my sincere thanks to the publishers, advertisers and all those who have given generously of their time and efforts in the production of this journal. I have been fortunate to work with an energetic and enthusiastic team of Sub-Editors. Without the support and dedication of all those involved, it would not be possible to produce such a constructive and well-considered edition. I believe their outstanding efforts and unwavering commitment have culminated in a professional journal of which Defence Dental Services can be proud.

LCDR Peter Case CADMUS 2012

MAJ Karen Such

FLTLT Amy Dempster

Joint Health Command

Message from Commander Joint Health, the Surgeon General Australian Defence Force Rear Admiral Robyn M. Walker, CSC, RAN, MBBS, MHA, FRACMA

I began my tenure as Commander Joint Health and Surgeon General ADF in December 2011 with a sense of honour and a commitment to the continued delivery of high quality health care to the men and women of the ADF.

services by 4 November 2012. I am confident MHS have the capacity and capability to meet the health care requirements of the ADF. There will be no change to the health care on deployments with ADF health professionals continuing to provide these services.

The Defence Health leadership team of Air Commodore Tracy Smart, Mr David Morton, Duncan Wallace, Brigadier John Crozier, Air Commodore Rowan Story and I are committed to a unified defence health team comprising uniformed (permanent and reserves), Australian Public Service and contracted personnel that work together with focused goals.

My other priorities are the implementation of our new electronic information system â&#x20AC;&#x201C;JeHDI, the continued implementation of the Dunt recommendations for mental health and the 2011 ADF Mental Health and Well Being Strategy, continued improvement of Rehabilitation Services through the Simpson Assist Program and the continued development of our strategic alliances. Others include the refreshing of our deployed health equipment under JP2060 phase 2B and 3 and the future development of the deployed health operating concept, the provision of improved access to healthcare for all ADF dependents through the ADF Family Health Trial and the continued reform of health care delivery and the adoption of workforce innovation in support of the Strategic Reform Program.

My vision for the Command is that we must all provide high quality, patient centric, health services on operations and in garrison by ensuring our clinical governance frameworks are robust, our responsibilities and accountabilities are understood by all, our health providers are appropriately qualified, well trained and that they maintain their skill sets required for deployment and in garrison. In addition, our health providers must have the appropriate facilities, equipment and health materiel required for them to do their job that is supported by policies and procedures that reflect best practice and are up to date. We must provide the full range of health services - preventative, treatment and rehabilitation for both physical and mental health conditions and provide these health services efficiently and without waste. The whole of the ADF is facing difficult fiscal constraints and I am committed to ensuring our corporate governance frameworks are robust and responsibilities and accountabilities are understood by all health providers. We must all identify, understand and manage risks that could negatively impact our reputation as a health care provider and as an employer and in particular, we must all promote and demand a culture of inclusiveness, fairness, respect and transparency in our interactions with stakeholders, colleagues, patients and their families. 2012 has been, and continues to be, a busy year for the Command. Of particular note was the awarding of the Health Services Contract to Medibank Health Solutions (MHS) on 28 June 2012. MHS will provide on-base health support, pathology, imaging and radiology, a 24 hour hotline and off base services with full transition of

CADMUS 2012

ADF dental personnel continue to provide a level of care that reflects your professional mastery in garrison and on deployment. There was Tri-Service Dental representation for Pacific Partnership 2012 Contingents One and Two. Fleet Mobile Dental Teams embarked onboard HMA Ships NEWCASTLE, CHOULES, BALLARAT and MELBOURNE; sailing to New Zealand, North Queensland, North East Asia and the Middle East. A RAAF Dental Team participated in Exercise Tendon Valiant 2012. Exercise Tendon Valiant is a Tentara Nasional Indonesia and US Army coordinated exercise from the Soepraoen Army Hospital in Malang. Army dental teams also participated in Exercise Giant Viper, Exercise Predators Run, Exercise Hamel and Exercise Saunders. The dental personnel who participated in these deployments provided professional and high quality dental support. I look forward to working with you all and challenge you to consider these priorities in all that you do. I will endeavour to get out of Canberra as much as possible to meet with you and to seek your thoughts and suggestions as to how we can continue to improve our delivery of high quality health care.

Joint Health Command

Message from the Director, Defence Force Dentistry Colonel Genevieve Constantine, BDSc, Grad Cert Clin Dent, MPH, MHM

Once again we have seen many of our Dental Officers and Dental Auxiliaries providing support to Operations and Exercises. We had TriService Dental representation for Pacific Partnership 2012 Contingents One and Two. The dental teams saw an average of 15-40 patients per day and extracted 2-3 teeth per patient. Fleet Mobile Dental Teams embarked onboard HMA Ships NEWCASTLE, CHOULES, BALLARAT and MELBOURNE; sailing to New Zealand, North Queensland, North East Asia and the Middle East. A RAAF Dental Team participated in Exercise Tendon Valiant 2012 (Ex TV). Ex TV is a Tentara Nasional Indonesia and US Army coordinated exercise from the Soepraoen Army Hospital in Malang. 400 dental patients were treated throughout the Exercise. Army dental teams participated in Exercise Giant Viper, Exercise Predators Run, Exercise Hamel and Exercise Saunders. These endeavours have proven to be rewarding, challenging and unforgettable for all those involved. I am grateful to CMDR Tanya Burton for the enthusiasm and commitment that she has demonstrated as editor, to ensure that this edition of CADMUS met its deadline. I also commend the sterling single-Service editorial efforts of LCDR Peter Case, MAJ Karen Such and FLTLT Amy Dempster. I wish to acknowledge all of the contributors to this journal; despite your extremely busy clinical schedules you have found the time to support the journal with your submissions. I also wish to acknowledge and thank the companies that support the journal though their advertising, and Neil Muir and the Adbourne Publishing team, for their commitment to once again ensure an excellent product. 2012 has been a turbulent year. I have been double hatted as the Director of Specialist Clinical Advice, which includes responsibilities for radiation safety, physiotherapy, mental health/psychology and rehabilitation in the garrison. I am also responsible for the delivery of Intensive Recovery Program (the Government’s clinical investment in the Simpson Assistance Program) which will culminate in the establishment of two pilots in Townsville and Holsworthy in February 2013. The activities associated with the recruitment of 12 clinical APS personnel and two APS health clerks, procurement of the necessary equipment for these staff and the minor refurbishment of two facilities has certainly kept the IRP project team and I gainfully employed. I wish to acknowledge the magnificent contributions made by my dental staff, CMDR Tanya Burton, WGCDR Janine Tillott, LCDR Kate Bailey and WO Penny Stone. Their contribution has kept the Directorate operating smoothly throughout the year. Policy review and development has occupied much of 2012. Thanks to the efforts of my staff we have seen eight dental policies either updated or developed thus far this year. Many are awaiting the final step in the approval process prior to publishing. This is an outstanding effort on their behalf. I also wish to acknowledge the tireless efforts of WGCDR Janine Tillott in editing the JHC Radiation Safety Management Program and

Radiation Management Plan and in assuming the responsibilities of the vacant JHC Radiation Safety Officer position. I would like to take this opportunity to recognise the continued advice and support offered by COL Janet Scott, GPCAPT Greg Mahoney, COL Rick Olive, COL Stephen Curry, COL Geoff Stacey, COL Gerry Thurnwald, LTCOL Chris Daly and Professor Martin Tyas. Your ongoing assistance in the provision of clinical case review and treatment planning, specialist advice and materiel advice has been invaluable. I was lucky enough to attend the Section of Defence Forces Dental Service (SDFDS), World Military Dental Congress 2012 which was held in Hong Kong over the period 26 – 29 Aug 12; and also the FDI World Dental Congress from 29 Aug – 1 Sep 12. The SDFDS provided an opportunity to exchange ideas with Directors of Dental Services from other Defence Forces and to learn from their developments, successes and failures. The congresses also provided an opportunity to be updated on the latest advances in the dental field. The opportunity to engage and exchange ideas with your counterparts from other militaries should not be taken lightly. There were few occasions during presentations that the forum did not nod in agreement with the issues that were causing us all concern. It highlighted that dental equipment in the ADF is extremely dated, particularly the continuing use of wet film radiography and further work is occurring around this aspect. The majority of the militaries represented were also feeling the pressure from reductions in funding and restructures. Lessons learned in relation to e-Health systems were extremely useful and there are now opportunities to learn from the UK in this space. DDFD and WO Stone have been heavily involved in the review of JeDHI and how this will function for dental. Some compromises have had to be made as the system can not currently meet all of our requests. There is still a lot of work to be done to develop dental SOPs for the use of JeHDI to ensure standardisation of how the system will be utilised. I wish to thank WO Stone for her dedication and perseverance over the course of this lengthy process. The review of the Dental Officer Specialist Officer Career Structure (DOSOCS) has continued throughout 2012. At this stage we are due to proceed to the Defence Force Remuneration Tribunal in November. I would like to express my thanks to the dental SMEs (CMDR Matt Blenkin, MAJ Geoff Harvey and SQNLDR Andrew Draper) who have provided vital input into the development of the court book. I hope that you enjoy this 31st anniversary edition of CADMUS which once again showcases your outstanding efforts in delivering dental services. My thanks to you all for your continued commitment to the provision of excellent dental care for our Servicemen and women and as always for representing your parent Services and the ADF with pride.

CADMUS 2012

Royal Australian Navy Dental Branch

Message from the Leadership, Navy Dental Branch Commander Matthew Blenkin, RAN, BDSc, Grad Dip MDS, MSc, FFOMP (RCPA) Warrant Officer Penny Stone, OAM, BCom, Dip. Pract. Man

This year marks the end of my first as Head of Navy Dental Branch. CMDR Brazier handed over the role in January this year, having undertaken it with aplomb and an unshakeable enthusiasm for the last six years. We are in a strong and stable position today because of the hard work and dedication of CMDR Brazier over this time. Our branch has flourished under his leadership and for that I am grateful. It has been a year of great change with the final transition of Garrison Health Services to Joint Health Command and the implementation of new contracting arrangements for the provision of health care. These are all changes for the better that will see an improved delivery of service to our patients and an enhanced capability for the ADF. The Joint e-Health Data and Information (JeHDI) system continues to be developed with significant input from a number of Officers and Sailors from within our branch. The success of this system is dependent on the work we put in to its development now and I am very pleased to see a concerted effort being applied from all quarters. Encouragingly, opportunities for full-time professional development of Dental Officers (DOs) continue. Next year we will have DOs undertaking post-graduate studies in periodontics, implantology, oral surgery and military health administration. Additionally a number of DOs will be undertaking their primary Fellowship exams this December – I wish you all much success! The hard work of our Officers and Sailors, both in garrison and at sea, has been tremendous. In the pages ahead you will read of many deployments by our Fleet Teams that have served the Navy well. Their performance has been outstanding and has reflected well on our Branch. It’s why we are here. Our deployable capability is our ‘raison d’être’. The delivery of routine and emergency dental services in the deployed maritime environment continues to have a significantly positive impact on the Navy’s dental health and overall capability. It is a role of which we can all be proud. It’s why most of us joined the Navy in the first place. To quote Kenneth Grahame “…there is nothing - absolutely nothing - half so much worth doing as simply messing about in boats.” To all of you, the Officers and Sailors of the RAN Dental Branch, you belong to a Branch with a fine sea going tradition that continues to serve our patients exceptionally well. It is a Branch that has succeeded because of the efforts of you and those that have gone before you. It is a Branch of which we can all be justifiably proud and for this, I thank you all.

CADMUS 2012

Interesting times have been experienced over the last 12 months and while I hesitate to say again, ‘It’s been a busy year’ … It’s been a busy year! I am constantly impressed with the level of commitment and professionalism dental personnel continue to exhibit when faced with additional workloads or challenging constraints. Navy dental personnel have continued to provide outstanding dental care to the Fleet by deploying Fleet Mobile Dental Teams (FMDT’s) on a number of FFG’s and FFH’s in addition to the amphibious capability, HMAS CHOULES. Dental Officers and Sailors have also participated in Pacific Partnership, where they worked in difficult conditions and treated challenging patients. Often, the FMDT’s have been deployed simultaneously, which highlights the efficiency of Fleet Dental and the key support the FMDT’s provides the Fleet. The JeHDI project is moving toward implementation following a pilot conducted at HMAS PENGUIN in July. The pilot demonstrated reception functions, charting, compilation of clinical notes, referral processes and other general JeHDI electronic applications. We worked through scenarios which replicated patients presenting for an initial examination, ADE, undergoing treatment and requiring a specialist referral. Some discrepancies were identified and suggestions were submitted to provide suitable solutions. RAN Dental Facilities are working hard to maintain high levels of Dental Individual Readiness, with figures rarely falling below 90%. Over the previous financial year, a total of 37,360 patients have been treated and 15,533 ADE’s conducted in RAN Dental Facilities. These numbers have increased 17% and 20% respectively since last financial year. The motivation and enthusiasm of dental personnel has enabled the achievement of these commendable results. As CADMUS goes to print, a proposal has been sent to DDFD outlining the implementation of a Dental Auxiliary Work Group (DAWG). The DAWG concept followed discussions between the three key Dental Warrant Officers (equiv) from each Service. It was identified that there is a need to introduce a work group to address issues in training, governance, practice management, staffing, capability, morale and leadership. The DAWG will be the principal platform and conduit to identify solutions to dental auxiliary issues, gain the appropriate advice and present to the relevant stakeholder in a formalised manner. Additionally, the DAWG will provide mentoring and leadership to the Senior NCO’s throughout JHC dental facilities and in the operational space. The DAWG will not replace existing chains of Command or organisational systems, rather, enhance and support the dental capability of auxiliaries, working in unison with stakeholders. Thank you for rising to the challenges and going the extra mile this year. Your highly professional manner is acknowledged and commended.

Royal Australian Army Dental Corps

Message from the Leadership, RAADC Colonel Genevieve Constantine, BDSc, Grad Cert Clin Dent, MPH, MHM, Head of Corps Warrant Officer Class One Kym Chiesa, CSM, Corps Regimental Sergeant Major

2012 realised the culmination of the CHS restructure with the hubbing of all deployable dental assets into 33 Dental Company, 2nd General Health Battalion. This has been a period of significant change for RAADC personnel. There have been periods of frustration for clinical personnel as they have struggled to find opportunities to consolidate clinical skills and maintain clinical currency (due to the limited surgeries available). I thank you for your continued enthusiasm and patience during this period of transition. I visited Enoggera in Mar 2012 and was very proud to address so many enthusiastic DOs. We have not had that many DOs in the Corps and in the same place for many years. 2013 will see some dental personnel posting into JHC positions that have been frozen for a number of years. Higher recruiting of DOs in the last two years has enabled growth and finally an opportunity to post DOs to JHC dental facilities. Senior CAPTs/junior MAJs will once again work under remote supervision and experience the challenges of managing their own dental facilities. I look forward to further growth and expansion in 2013 with more DOs joining the Corps. On Fri 29 Jun 2012 the RSM and I represented the Corps and laid a wreath at the Health Services Memorial at ALTC. CAPT Alisa Wickham represented the Corps very well as part of the catafalque party. This was a very moving service with the memorial address delivered by HOC RAAMC, BRIG Stephan Rudzki, AM. If you have the opportunity to visit the garden at ALTC and partake of the memorial wall and eternal urn on display, I urge you to do so. I wish to thank MAJ Jo Ikin for her efforts in organising the memorial service and to those RAAMC and RAANC personnel who were instrumental in achieving the memorial wall. I wish to acknowledge those personnel who have been involved in Exercise Giant Viper, Exercise Predators Run, Exercise Hamel, Exercise Saunders and Pacific Partnership; you have represented the Corps extremely well. I would also like to acknowledge the ongoing commitment of RAADC personnel to the provision of high quality dental care in the preparation of personnel for deployments and the maintenance of readiness standards. I also wish to express my gratitude to the Corps Committee for their efforts in 2012 and take this opportunity to welcome MAJ Jo Ikin as the SO2 Corps replacing CAPT Ange Dent. On behalf of the Corps I thank CAPT Dent for her dedication and devotion to the role and wish her well in her new position.

2012 has seen our Corps again challenged on many fronts. As the realisation that the CHS restructure is here to stay; many Corps members, and in particular those in the non commissioned ranks, have been seriously contemplating what direction they would like to take in the new look Army Health Services. I have spoken with many of you over the last 12 months and it is evident to me that the future of our Corps is in good hands. Whilst many of you elected to stay with the Corps and revert to ECN 029, there are some who have elected to either discharge, Corps transfer, or Service transfer to follow their desired career goals. To those that elected to move on, I thank you for your efforts and for the commitment you have provided to Dental Corps. We also have more than a few members interested in the regimental stream and they are currently fulfilling pre-requisite postings to place themselves in the best possible competitive position for selection in years to come. Whilst attending the Senior Dental Officer Advisory Group in March this year, the three Dental senior enlisted members from across RAN, Army and RAAF, discussed the fact that the current turbulent climate has placed a certain amount of uneasiness across Dental in all of the three Services. As a result we are working together to come up with the Terms of Reference so as to propose a Dental Auxiliary Working Group. Essentially if this proposal is to be accepted, it would become the platform by which Dental Auxiliaries from across all three services would voice their concerns and ideas in relation to Dental Auxiliary management across the ADF. This concept is currently in its infancy stage, but I will keep you posted as progressive stages are met. For fear of sounding repetitive in my praise this year, I would like to bring to your attention, the tenacious efforts of the members that make up your Corps Committee. All members of the committee inject many hours of their own time in ensuring that the best possible outcome is always achieved for all Officers and Soldiers of the Corps. Their commitment is relentless and this is indicative of the hard working nature that RAADC members are known and recognised for across the Army and indeed the ADF. As the HOC mentioned, next year we will be having a Corps Conference and a Regimental Dinner in Brisbane to celebrate our 70 years of service to the nation. I will be in Brisbane later this year to start the initial planning process and will call upon many of you to be involved in this very important celebration of our proud history.

The RAADC will celebrate its 70th birthday on 23 Apr 2013, a significant milestone for our small Corps. At this stage we are planning a Corps conference in Brisbane, a regimental dinner and culminating in a march on ANZAC day. I encourage you to attend this celebration and support your Corps (where funding permits and release can be accommodated).

I would like to take this opportunity to remind you all to be constantly considering nominations for the COL M.G.T. Kenny Award, as well as ensuring you apply for a Certificate of Recognition for those leaving the Corps. These two forms of recognition are very important to individuals who do receive them, as it formally documents the recognition of their service to the Corps.

I am extremely proud of the continued professionalism, dedication and initiative demonstrated by all members of the RAADC. In spite of the challenges and adversity you face at times you strive to maintain your enthusiasm and dedication. I wish you all the best for 2013.

Yet again this year, you have surpassed what could be fairly expected of members of a Corps who have encountered such adversity. Your devotion to duty drives me to keep pursuing issues on your behalf and I thank you for your efforts. Good luck and good soldiering.

CADMUS 2012

Royal Australian Air Force Dental Branch

Message from the Leadership, RAAF Dental Branch Squadron Leader Andrew Draper, BDSc Flight Sergeant Heather Fitzgibbon

2012 has been a great year for Air Force with dental teams sent to provide support on Humanitarian Assistance missions as part of EX PACIFIC PARTNERSHIP and EX TENDON VALIANT. The accounts of their experiences make for interesting reading. We will also have one of our personnel serving on EX PACIFIC ANGEL with the US Air Force, but too late for inclusion in this yearâ&#x20AC;&#x2122;s CADMUS. We are proud of their contribution and the relationships built with their professional peers from the other forces and non-government organisations. Many lessons have been learned on these missions that will improve our collective training and preparedness for operations. I encourage all of you to aspire to serving on similar exercises. 2012 has seen significant reform to Garrison Healthcare. In Air Force, the Chief of Air Force has sought to strengthen and restructure Health Services Wing capability through AFOD 201202 to ensure it meets its current and future requirements. These changes will be implemented over the 2012 and 2013 posting cycles and when fully implemented, will see Air Force operate a stronger, more resilient deployable health capability. The changes will also improve role clarity and focus for our deployable capabilities and see tighter integration of our specialist reserves into the operational capabilities we generate. For dental, all these reforms come at a slight cost, but also with notable benefits for our personnel and their operational utility. Dental is now clearly identified as important within R2/R2E and with this we are better able to plan the individual and collective training which is needed to deliver the capability now and into the future. The professionalism, knowledge and skill of our SDA and SDAP in sterilising has been recognised as being the groups best placed to support the CSSD within the R2E surgical capability and the training needed for this extended role is being investigated. The Dental Officer Specialist Officer Career Structure is under review and a proposal is expected to be presented to the DFRT for consideration during 2013. In addition, approval has been granted to conduct an Employment Profile (EP) review of the Dental Musterings and the Dental Officer groups, expected to commence in the first half of 2013. A few of you have indicated that you will be separating from permanent service in the near future. I personally wish to thank for your contribution to the Air Force during your career and hope that you consider reserve service in the future.

This year I have had the opportunity to work in the Operations cell at 1EHS, as well as provide continual input into the Dental mustering as the Dental Mustering Adviser. Working in the operational area has provided a true insight into the planning within the Squadron and the liaison with Health Services Wing. New posting opportunities arising from AFOD 2012-02 recognises the importance of the dental team to the overall health capability for Air Force and offers the potential to remain in location for a little longer whilst retaining promotion prospects and job variety. I acknowledge the contribution of SGT Sears and CPL Dehncke who both were selected to deploy to â&#x20AC;&#x153;any tradeâ&#x20AC;? airman positions within the Headquarters as part of Op Slipper. Their time away was extremely demanding and rewarding. I am sure that both members are pleased to be back with their families. They have been a credit to the ADF and certainly to the RAAF Dental Branch. We are very proud of their service. On a personal note, FLTLT Keys and I were selected for Ex Tendon Valiant in Malang, Indonesia. This was a week long multi-national Pacific Medical Readiness training exercise, co-hosted by Indonesia and the USA. FLTLT Keys provides his report later in this edition, which makes for an interesting read. Through the humanitarian assistance outreach activities, we made a real difference to a group of patients from an underserved community in austere conditions. The six Dentists and myself, as the Dental Assistant, found the challenges in this environment required us to develop solutions with limited community resources and high demand. This really highlighted the importance of the high quality training provided by the ADF Dental School, which allowed us the freedom to adapt to the different environment and procedures. A number of you have been selected for promotion and I wish to extend my congratulations to you as you take this important career step. For others among you, a posting may be due. I hope that you may enjoy your next posting and have a safe trip. Finally, I wish to thank WOFF Brennan for her continual support to the mustering and wish all readers the very best for the future.

Best wishes to you all and I hope that you have a rewarding and successful 2013. CADMUS 2012

Reports from Operations and Exercises Royal Australian Navy Dental Branch RAN Fleet News 2012 Lieutenant Commander Peter Case It has been a fairly hectic year at Fleet Dental (East); between two dentists, we have served 21 weeks at sea and manned HMAS SUCCESS full time, for the better part of six months. In the first seven months of the year, we averaged 90% dental fitness throughout the Fleet, with our dependency being slightly shy of 2000 personnel. Between deployments, there have been extensive bulk bookings, with the majority of East based ships being given the opportunity to make the most of dedicated shore based teams when a deployment is not justified. Over 750 appointments have been provided by our Fleet Mobile Dental Teams at sea this year; including 230 fillings, 520 ADE’s and 27 casual patients. The experience gained by our Dental Officers and Sailors alike, is second to none for both professional and personal development. Our personnel ensure that they fully integrated with the organic crews of HMA Ships by participating in a variety of ship based duties and activities, as well as the core dental function. This year, we have been part of Ships Medical Emergency Teams, sporting teams, assisting special sea duty men, café party and undertaken weapon re-qualifications to name but a few. The aim of the Dental Branch to stay visible within the fleet is certainly being achieved, with plans to ensure this not only continues, but that we become even more visible to all Ships for whom we provide dental support.

Fleet Dental Update Petty Officer Katrina Kornacki 2012 has been a busy year for Fleet Dental with deployments and op-relief staffing. The year started out quietly with PO Alicia Hills moving on from Navy life and PO Katrina Kornacki taking up the Fleet supervisor billet. We wish Alicia all the best with motherhood and life outside of the RAN. Fleet Mobile Dental Team One (FMDT1) comprised of LEUT Karina Cvejic and LS Lantry (who was kindly loaned to us by HMAS KUTTABUL Dental Department). They spent a month onboard HMAS NEWCASTLE providing dental support whilst sailing from Melbourne to New Zealand for ANZAC Day. They then took up positions on HMAS SUCCESS. LEUT Cvejic was loaned to support the ship while LCDR Gregg was on deployment. LS Lantry filled the LSDEN billet assigned to HMAS SUCCESS. Fleet Mobile Dental Team Two (FMDT2) consisted of LEUT Shannon Godfrey and AB Tevita Kama. The team (and LS Lantry who flew up to relieve AB Kama) had the honour of being the first dental team to serve in HMAS CHOULES. FMDT2 regained their shore legs with a myriad of bulk bookings. They then flew to meet HMAS MELBOURNE and returned with her from the MEAO. On return LEUT Godfrey was required in Darwin to meet HMAS DARWIN. LEUT Godfrey and AB Michael Hatzivalsamis provided dental support during Exercises Kakadu, Singaroo and Queensland Navy week. CADMUS 2012

AB Lanie Boer spent the majority of the year on HMAS SUCCESS. She ensured the department continued to run smoothly despite the absence of a LSDEN. She has been posted HMAS ALBATROSS, where she seems to be settling in nicely. Her organisational skills will be sorely missed. LCDR Case continues his role as the Fleet Dental Officer, overseeing the organisation and execution of all Fleet Dental Deployments. He still occupies surgery five, seeing the more complex endodontic cases and relieving members’ pain. Between meeting with Ships’ COs and numerous other responsibilities throughout the fleet, there is little time for anything else! Throughout the year, whilst not at sea, the Fleet Dental Teams have conducted bulk dental bookings for HMA Ships DARWIN, SYDNEY, TOBRUK, NEWCASTLE, PARRAMATTA and ANZAC. This has helped us achieve a constant overall Dental Individual Readiness of 90 percent or above for Fleet Base East.

HMAS Newcastle (18 Apr–18 May 12) Lieutenant Karina Cvejic and Leading Seaman Jessie Lantry This year, Fleet Dental Team One had a memorable ANZAC Day with the ship’s company of HMAS NEWCASTLE. A small contingent, including LEUT Cvejic and LSDEN Lantry, marched in the small town of Devonport in New Zealand’s picturesque North Island; whilst the rest of the ship’s company attended the main service in Auckland. We remembered the ANZACS with our compatriots in a solemn but emotional wreath laying ceremony. We embarked a week before ANZAC Day and set up our mobile dental equipment in Aft Battle on two deck; an area half the size of a dental surgery. During our month on board HMAS NEWCASTLE completed the Long Navigation Course that took us via the North Island of New Zealand. The crew was welcoming, but the Tasman Sea was not. Let’s just say that anything above sea state four was the limit for the dental team! During the Long Navigation Course there were many Officer of the Watch Manoeuvres which involved lots of shuddering, shaking and rolling. We learned a lot about “cavitation” and not the dental kind. It’s something about the air bubbles caused by the propellers and the angle of the blades… needless to say, it’s not conducive to effective dental work particularly as Aft Battle is located directly above the props! The feeling of weightlessness followed by extreme gravitational forces was experienced as NEWCASTLE charged through the seas at 28 knots. During our time on NEWCASTLE, we participated in port visits in Auckland, Wellington and the quaint town of Nelson. The stand out experience of our time ashore was the orange

LEUT Cvejic and LS Lantry attending to the crew aboard HMAS NEWCASTLE

Reports from Operations and Exercises Royal Australian Navy Dental Branch A welcome break from workups and the looming Unit Readiness Evaluation, port visits included a number of visits to Townsville, followed by a short visit to Cairns. This provided an opportunity to liaise with the HMAS CAIRNS dental team. After leaving North Queensland, we had a brief visit to Brisbane. When not participating in the Ship’s activities the dental team managed to achieve 143 ADEs; an extraction; 3 root canal extirpations; 99 restorations as well as our 5 sick parade presentations; a total of 223 appointments. hues of the vine leaves (magical in the autumn afternoon) of the wondrous Marlborough Wine Region. We also experienced the spectacular views of Queen Charlotte Sound, along with the lusciously green countryside of New Zealand. Despite the challenges of rough seas, we managed to provide 161 appointments, which resulted in the crew being 97% ready. We were able to complete 31 fillings, 52 hygiene appointments and 100 ADE’s. During the month period, we saw 10 casual patients, including two Sailors, who were boat transferred to NEWCASTLE for dental treatment from HMAS WARRAMUNGA. We both enjoyed our time on board NEWCASTLE and managed to make some new friends along the way. Our shoulders are a little saltier now.

HMAS CHOULES (20 Feb – 19 Apr 12) Lieutenant Shannon Godfrey, Leading Seaman Jessie Lantry, Able Seaman Tevita Kama Hiking up the mammoth gangway of HMAS CHOULES prior to deployment, we were met with familiar friendly faces from MR2E, which braced us for the months ahead working closely with the Army in Far North Queensland waters. Our luxurious new home featured double stairwells (move over, ladder bays and hatches!) and – wait for it – ensuites in each cabin. Double beds and single berth cabins were a treat for many kellicks and above. Far from our tight HMAS CHOULES set up on warships, our dental suite felt as though it could have doubled as a football field when we set up our equipment. The difficulty was trying to find lashing long enough to secure the deployable dental chair into position in the centre of the compartment.

HMAS BALLARAT (09 Apr–30 Jun 12) Lieutenant Sarah Benton and Able Seaman Michael Hatzivalsamis Fleet Mobile Dental Team Three (FMDT3), LEUT Benton and AB Hatzivalsamis, had a busy start to the year, with a three month deployment to North East Asia on HMAS BALLARAT. We joined the ship after the Easter long weekend, refreshed and ready to put in some hard work. The deployment took us to parts of Asia, not usually encountered in your typical ‘up top’ trip. After sailing from Fremantle, we had port visits in Singapore, Shanghai, Pusan, Kure, Okinawa, Guam, Brisbane and finally home to Sydney. As this was a very high profile deployment, port visits were very busy with official receptions; especially in China, where we were celebrating the 10th visit of an Australian warship and Australian-Chinese diplomatic relations. As well as the many official engagements ashore, the ship was also very busy at sea participating in a multitude of international WAREXs with foreign Navies, including Singapore, Malaysia, China, Korea, Japan and the USA. The aim for the dental team was to see everyone onboard who had their dental IR expiring in 2012. This was to ensure that BALLARAT remained dentally fit for the remainder of their busy year. We managed to achieve this, despite the surprisingly high caries rate onboard and equipment issues. Most defects were able to be rectified as quickly as they occurred. Highlights of the trip were the many swim ex’s, in the warm waters of the South China Sea and also watching jets take off from USS GEORGE WASHINGTON, only 100yards off our starboard beam. A big thank you to all our support staff ashore, not only during the deployment, but also in organising post deployment dental appointments for members on return to Australia.

Although a ship of gigantic proportions compared to our current fleet, the Ship’s Company was relatively small. Hours could be spent wandering the monstrous hallways without bumping into a soul. However, once the Army force was embarked and the Exercise began the Ship’s numbers dramatically increased, as did our workload. Our Digital Dental Imaging System, affectionately known as ‘Rex’, became defective; luckily it was time for ABDEN Kama to rotate and replacement equipment accompanied LSDEN Lantry. The dental suite on CHOULES was once again fully operational.

LEUT Benton and AB Hatzivalsamis attending to the crew aboard HMAS BALLARAT CADMUS 2012

Reports from Operations and Exercises Royal Australian Navy Dental Branch HMAS MELBOURNE (17 Jul–21 Aug 12) Lieutenant Shannon Godfrey and Able Seaman Tevita Kama LEUT Godfrey and ABDEN Kama were to be the first Dental Team to join an east based warship, returning from duty in the middleeast, since 2005. We were on a mission to improve the Ship’s dwindling Dental IR Status; taking anti-piracy measures through the Malacca Straights and IED threats in our stride.

OP SLIPPER deployment. Celebrity ABDEN Kama caught the eye of Channel Ten reporters, as he held baby Miracle on the wharf. Of the 183 appointments conducted; 130 ADEs, 1 root canal extirpation, 1 extraction and 77 restorations were provided.

HMAS SUCCESS Lieutenant Karina Cvejic

The days between departing Australia and crossing the gangway on 21 Jul 12 had been spent taking in the delightfully balmy 58°C weather at Al Minhad Air Base (AMAB). We took part in a short course preparing us for our movements in the MEAO and met other members who would be joining the ship. Once the pre-deployment requirements were completed, we hitched a ride on a C130 to Djibouti, where we were ushered via camel-packed cargo ships and rammed boom gates to meet MELBOURNE. In contrast to the mystery enshrouding our movements to join HMAS MELBOURNE, there was no secret about the quantity of cracked teeth awaiting us on board. Expertly nursed by the keen MELBOURNE medical team (who cursed pork crackling); 12 dental casualties had been waiting for five months for the dental team to embark. Soon the sound of a dental drill was once again floating through the passageways to Aft Battle. Dental treatment only ceased when the Ship’s Company was unavailable during shore visits, taskings and when sea state limited operation. These included pulling into Singapore for four days of sightseeing; a weekend alongside in Fremantle; de-ammunitioning in Eden; Commanding Officer’s Rounds (not to mention the preparation) and when an 8m swell with 32° roll prompted an early Pipe Down for MELBOURNE. These rough couple of days bore witness to Wardroom deck slide mayhem and sleeping bodies being flung from their racks. Our return to Fleet Base East was met by crowds of families and friends eager to see their loved ones returning from the 6½ month

Ahoy there from the Dental Team on board HMAS SUCCESS! After a long time working alongside while HMAS SUCCESS was in refit, in June 2012, LCDR Kelly Gregg left the ship for an adventure on Pacific Partnership, aboard hospital ship USNS MERCY. LCDR Gregg has since moved on from the Navy and with her husband Simon, opened up her own dental practice in Alstonville on the north coast of NSW. We wish the Greggs all the best in their future endeavours. SDA-P, LSDEN Greg Pashen, discharged from the Navy in April 2012 and ABDEN Lanie Boer filled the billet for a few months before she posted to HMAS ALBATROSS. The SUCCESS Dental team made up of LCDR Gregg, LSDEN Pashen and later ABDEN Boer, achieved high dental readiness for the Ship’s Company throughout the refit period. LEUT Karina Cvejic and LSDEN Jessie Lantry posted on board in July 2012. SUCCESS is currently in a weekly running routine, primarily in the East Australian Exercise Area, with some port visits away from the home port of Sydney. Most recently the crew enjoyed a visit to Brisbane. Up-coming port visits to Melbourne, Hobart and Adelaide for South Australia’s Navy Week are highly anticipated by the crew; ahead of the Unit Readiness Evaluation period. This is when Sea Training Group will embark and try to sink the ship with casualties, fires, floods and toxic hazards. There are long days ahead, but the Dental team are armed with Ships’ Medical Emergency Team (SMET) bags and red cross brassards and are looking forward to it! The Dental team hold numerous auxiliary duties while on board; including Helo/Flight deck operations, Public Relations, ceremonial duties and SMET duties. Fair winds and following seas.

CADMUS 2012

Reports from Operations and Exercises Royal Australian Navy Dental Branch Pacific Partnership 2012 from a RAN perspective: Contingent 1: 22 May–04 Jul 2012 LSDENSDA(P) Rachelle Johnson Pacific Partnership 2012 (PP12), currently in its seventh year, is the largest dedicated annual humanitarian and civil assistance mission in the Asia Pacific region. This year, Pacific Partnership enhanced relations with Indonesia (North Sulawesi), the Philippines (Samar) Vietnam (Vinh), Cambodia (Sihanoukville), 13 Partner Nations and 23 Foreign Non-Government Organisations (NGO). USNS MERCY served as the command platform. The first Australian contingent boarded MERCY in Guam on 22 May 2012. There were 4 ADF Dental representatives in contingent one of PP12. LCDR Kelly Gregg (HMAS SUCCESS) and FLTLT Georgina Seto (RAAF Williamtown) were the Dental Officers; SGT Rachel Dudgeon (RAAF Richmond) and LSDEN Rachelle Johnson (HMAS STIRLING) were the Dental Auxiliary Staff. Having personnel from different Services strengthened the team and allowed us to maximise our learning from this unique operational experience.

Ship Life USNS MERCY, which bears the Red Cross, is impressive and spacious. At 272 metres long it is over double the length of an Australian Guided Missile Frigate. Given the size of the ship, there are a significant number of lifestyle differences when compared to serving on HMA Ships. Instead of ladder bays, MERCY has a staggering number of flights of stairs. Junior Sailor’s messes can contain up to 100 personnel, Multicultural Dental Team compared to 60 in the largest mess in an Australian Warship. With today’s modern technology, access to the internet, emails and phones were creature comforts that we all enjoyed having on board. The US Navy has its own traditions. Wakey Wakey is not piped of a morning; personnel set their own alarms. Need to request permission to board and depart the ship from the gangway. The food selection was also a new experience particularly as Americans love their peanut butter and jelly sandwiches! The US Navy is very environmentally conscious and strict guidelines are adhered to with regards to the separation of garbage to allow for recycling. The permanent dental department onboard has the capability to provide 4 fully functional surgeries, a dental laboratory and CSSD. The Australian SDA-Ps had the opportunity to work alongside 3 foreign Registered Dental Hygienists to enhance their hygiene skills. The US Navy internally trains their own dental hygiene auxiliary staff known as Prophylactic Technicians. They undertake a training course that is four weeks in duration.

Delivery of Dental Services The first port visit was Indonesia where tasking comprised of five Medical Civic Actions Projects (MEDCAPs). Each MEDCAP contained approximately 40 personnel, providing medical, dental, pharmaceutical and optometry services to the local communities. MEDCAPs deployed to one of five locations throughout the Indonesian Islands for a period of five days. The islands visited were Talaud, Sangihe, Mando, Siau and Sulawesi. Operating concurrently were Veterinary Civil Actions Projects (VETCAPs), Surgical Civil Actions Projects (SURGCAPs) and Engineering Civil Actions Projects (ENGCAPs). In some instances humanitarian teams were operating in regions too remote to return to UNSN MERCY on a daily basis. These personnel were allocated overnight accommodation in hotels, schools and jungle camps. The second mission was based in the Philippines. USNS MERCY anchored approximately ten minutes off shore from the city of Calbayog, Samar Island. Each morning humanitarian personnel were ferried ashore, via hovercraft. At any one time, up to three concurrent MEDCAPs were operating ashore at various locations including Northern Samar, Western Samar, San Isidro, Calbayog and Catbalogan. Between the five MEDCAPs, 929 dental patients were seen in LCDR Gregg & SGT Dudgeon, Indonesia. Treatment provided treating a patient in the Philippines. consisted of 1470 teeth being extracted, 70 prophylactic hygiene therapies as well as the placement of 6 restorations. In the Philippines there were six MEDCAPs, who saw a total of 2685 dental patients. Treatment provided consisted of 5336 teeth being extracted. This is a significant amount of treatment rendered. The queue of patients was overwhelming, with many patients camping out overnight to secure their place in line. The conditions under which the health care teams worked were arduous. Temperatures hovered around 40°C and local translators were needed to communicate with patients. Despite this support, challenges were faced, as for many patients this was the first time they had seen a dentist. Although much of the time between missions was spent replenishing the mobile field dental suites, recreational activities were organised to boost morale. Some of the highlights included Zumba, Salsa Dancing, Bingo, Karaoke, Ice Cream Social and A Biggest Loser Competition.

Clinical Cases A wide variety of clinical cases were seen, with some challenging even the most experienced clinicians. Beetle nut contributed to the diverse cases that presented. Chewing beetle nut is a tradition in many Asian and South Pacific cultures. Not only does it stain teeth and cause mouth ulcers, it is also a known carcinogen. CADMUS 2012

Reports from Operations and Exercises Royal Australian Navy Dental Branch According to North Carolina Dental Officer, Stuart Whiddon, “The biggest thing overall that surprised me was the lack of people presenting with swollen faces. Considering the thousands of abscessed teeth we saw in each country, we rarely saw any worrisome cellulitis or acute abscesses. Their ability to wall off infections was impressive; lots of granulation tissue and chronic infection around these abscessed teeth and lots of fistulas. This also made a lot of teeth easier to extract due to bone loss secondary to infection. Periodontal disease was rampant, even in the Treating hygiene patients onboard adolescent population. This also made our job easier doing extractions due to the loss of bone support around these teeth. You would be hard pressed to ever see in the US or Australia the kind of heavy calculus deposits we saw on posterior teeth in those 10 year old children in both Indonesia and the Philippines”. My most interesting case was a retained primary root (tooth 65) protruding, apex first, 1.5 cm laterally from the maxilla in a 10 year old boy in the Philippines. It was encased in a dense pocket of fibrotic tissue of the upper right cheek. This child could no longer move his right upper lip as it was locked around this root. Simply removing this root restored normal lip function. I also examined a 20 year old male with severe halitosis. Upon questioning the patient, I discovered that he did not adopt any oral hygiene practices in his daily routine due to time constraints. Explaining the importance behind good oral hygiene, disease progression, nutrition and demonstrating correct use of oral hygiene aids educated the patient to make a change in his daily routine. When I reviewed him three weeks later, there was a noticeable improvement in the patient’s oral hygiene. Another goal of the dental professionals working in each MEDCAP was to educate children and waiting crowds. Having the additional skill set of SDA-P enabled me to feel confident and prepared to deliver oral hygiene education. Many patients had never been seen by a dentist or did not know how to use oral hygiene aids.

Conclusion Participating in PP12 was both professionally and personally rewarding; it truly was an amazing experience. I made some great new friends onboard and ashore. I observed dental cases I only ever imagined reading in a textbook and have returned to Australia with a greater respect for those who Pacific Partnership Closing Ceremony survive with so little.

Contingent 2: 05 Jul – 14 Aug 12 Lieutenant Commander Catherine Galloway RANR Pacific Partnership 2012 (PP12) is an annual exercise designed primarily ‘to practice in calm, to help in crises’ and aims to create an international core of experience to render assistance after a major natural disaster, such as the Boxing Day tsunami of 2004. For PP12, Australia was invited to send two contingents of personnel; including, doctors, dentists, dental assistants, nurses, pharmacists, medics and preventive health specialists. Four dentists and four dental assistants had the good fortune to be selected from Navy, Army and Air Force Permanent and Reserve personnel. Contingent two was made up of LCDR Cate Galloway RANR, FLTLT Kate Aitken, CPL Rhianna Farley, and LACW Natalie Summersgill. After joining the ship in Subic Bay we settled into our new ‘home away from home’ for the next six weeks. We wandered around the enormous vessel feeling a little lost, as most of the ship’s company was on shore leave or ‘liberty’. Officers were accommodated in a comfortable 8- berth cabin; whilst CPL Farley and LACW Summersgill were in overflow bunks in one of the wards. They were eventually promoted to ‘Berthing B’, which they shared with 120 other females, but at least they now had somewhere to stow their gear! We soon became used to the colour-coded stairwells; the 18 flights of stairs between the mess and the cabins; and a further 16 flights of stairs down to the dental surgery. This was quite enough daily exercise for me, though many of the Aussie contingent made a daily foray to the gym as well. The American contingent of dental staff was also tri-service commandeered from all over the US. Several of the US contingent were reservists and a few of them had worked together previously. The focus of the deployment was on the Medical Civic Actions Projects (MEDCAPS) and the huge task of logistics management was coordinated by the US core staff; ably assisted by ADF and Canadian junior NCOs. PP12 was a great opportunity to meet and work with dental staff from many nations. There was a lot of swapping of badges and ‘coins’ and our uniforms, with their ‘hearts and bunnies’ were a source of amusement. In addition to the US, we worked alongside military staff from New Zealand, Malaysia, Singapore, Canada, Japan, Philippines, Peru, Cambodia and Israel. However, the biggest contingent was made up of civilian volunteers from the US; several dentists, hygienists, a lab technician and many pre-dental undergraduates. It was interesting that those nations, who trained with British heritage, were familiar with the same terminology and instrumentation. The US pattern forceps took some getting used to, though, as they required quite a different approach. The MEDCAPs were generally conducted in schools and as there was no power or running water, we were able to provide limited treatment with hand instruments only. The conditions were quite challenging; most of the chairs were very low and not adjustable; lighting was in the form of head or hand held torches. The language barrier also presented significant problems, depending on the skills of the translator. The heat was also quite debilitating, particularly in Vietnam. In spite of these difficulties, we were able CADMUS 2012

Reports from Operations and Exercises Royal Australian Navy Dental Branch to provide a valuable and worthwhile service to rural communities; which was both professionally and personally rewarding. Clinically, the vast majority of patients presented with gross caries, even in children as young as four and five years old. Very heavy calculus deposits and advanced periodontal disease was also prevalent. The most interesting case I saw was actually not a dental patient at all; the ophthalmologist was keen to show me a young patient with Marcus Gunn Jaw Winking Syndrome, or Trigemino-oculomotor Synkinesis. With this condition, which is usually unilateral, the upper eyelid retracts then rapidly returns to its normal position on stimulation of the external pterygoid muscle. Therefore it is evident when the patient is chewing, swallowing, jaw thrusting or on wide opening. It is thought to be due to an aberrant connection between the motor branches of the trigeminal nerve and the oculomotor nerve. It can be treated surgically, but no treatment was undertaken in this case. The other interesting phenomenon we saw in Vietnam was the jet-black teeth of elderly women. This was part of a deliberate ritual that was performed when the women were in their teens. Over several days, the process involved repeated application of a solution made from resin; extracted from aphids then diluted with rice wine. Further treatment then involved a mixture of iron nail filings and charred coconut husk, which oxidised with the resin dye to create the shiny jet black coating. Clearly it

confers resistance to caries, as these patients still had most of their teeth intact, by stark comparison with their younger counterparts. A French survey LCDR Galloway with part of the in the 1930s indicates that International Dental Team 80% of the rural women in northern Vietnam had blackened teeth. However, the process has now fallen out of favour. It is now rare to see women younger than 60 with such teeth. PP12 offers diverse experiences, not only within the dental stream. Being aboard a ship was a new entity for many; fortunately, being such a large vessel it was very stable, so seasickness on passage was not a problem. From a culinary perspective, the food wasâ&#x20AC;Ś interesting. We were subjected to the dubious delights of Meals Ready to Eat (MRE) - the US military version of ration packs. We also introduced a few brave souls to the delights of vegemite and watched with envy as the Japanese contingent were supplied with very appetising hot Bento boxes for daily lunches from their ship. We worked hard; made good friends, both from overseas and amongst the ADF contingent; and ultimately left a very good impression of the ADF dental services. Pacific Partnership is a fantastic opportunity for dental personnel to take part in and it was particularly pleasing that the opportunity was also extended to ADF Reservists.

Reports from Operations and Exercises Royal Australian Army Dental Corps RAADC Operations and Exercises 2012 Corporal Rhianon Farley and Major Karen Such EX GIANT VIPER was a great chance for all the junior members to see the hospital set-up in a field environment and learn all about the weatherhavens. This exercise was all about equipment. It was a 100% stocktake for the Battalion. We took the opportunity to clean MAJ Karen Such, LTCOL Kittie the masses of equipment that Dugan & WO2 Tracey Feillafe on came from Darwin, Sydney, Ex Giant Viper Adelaide and Townsville; all to be amalgamated to the Brisbane equipment. We also found some time to see patients and clean up the gym equipment (the medicine balls have never looked so shiny!) EX PREDATORS RUN saw a dental team deploy to Camp Growl at SWBTA. The dental team consisted of MAJ Such, PTE Huckin and PTE Petersen. They were detached to and co-located with 8 CHC. Their primary role for the exercise was to provide pre-deployment checks for 1 CSSB and 1 CSR. EX HAMEL commenced mid year with the dental team consisting of CAPT van Heumen, CPL Lawler and PTE Maros-Lindner. We would like to thank COL Hayes for once again offering his services to the exercise this year. This meant CAPT van Heumen was able to come back home, where he was quickly thrown back into surgery. The RAADC HAMEL team joined forces with members from the Royal New Zealand Dental Corps and provided ANZAC dental support. RAADC also provided support to the Army Aboriginal Community Assistance Program over the period May – October 2012. AACAP was split into three dental team rotations. CAPT Ross, LCPL Havili and PTE McGrath were in the first rotation; MAJ Such, CPL Cowgill

MAJ Karen Such, PTE Bella Badenhorst & CPL Ryan Cowgill assisting in the field kitchen on AACAP

and PTE Badenhorst in the second rotation; and CAPT Van Heumen, CPL Kempster and PTE Ivey in the final rotation. All teams spend just over a month on the Dampier peninsula north of Broome in Western Australia and have enjoyed providing dental care to the local communities. In addition, LCPL Havili was invaluable as an interpreter to the Tongan detachment. CPL Farley was selected to take part in the annual Pacific Partnership Humanitarian Civic Assistance program. As part of this program, CPL Farley deployed for 2 months to the Philippines, Vietnam and Cambodia with the US Navy onboard the USN Mercy, to provide dental care to the local populations. Aside from the major exercises and deployments, RAADC has sent fly away teams to support Navy, Army and Air Force bases in northern regions of Australia, including Lavarack Barracks, HMAS Cairns, Robertson Barracks and RAAF Darwin.

Exercise HAMEL 2012 Captain Thomas van Heumen From June to July 2012, the 2nd General Health Battalion (2 GHB) was deployed to provide medical support during Exercise Hamel in the Shoalwater Bay training area at Williamson Airfield. For the majority of Exercise Hamel, dental support was provided by a team from the New Zealand Dental Force (NZDF). This team consisted of a dentist, a dental hygienist, a SGT dental supervisor and dental assistant. The team was supplemented by ARA dental assistants, CPL Brett Lawler and PTE Jareth Maros-Lindner. PTE Jareth Maros-Lindner assisting MAJ Lisa Caulton (NZDF)

Left: MAJ Karen Such & PTE Kelli Huckin treating patients on Ex Predator’s Run. Right: PTE Luke Petersen & MAJ Karen Such treating the 5RAR mascot “Sabre the Tiger” on Ex Predator’s Run.

Somewhere in there lies the dental section

CADMUS 2012

Reports from Operations and Exercises Royal Australian Army Dental Corps L-R PTE Hika Rata, CPL Kelly Roberts, PTE Matthew Loughnane, COL Murray Hayes, CPL Brett Lawler, MAJ Lisa Caulton, PTE Jareth Maros-Lindner, SSGT Ross Heald ---- OR - The ANZAC dental team

Prior to the exercise, a thorough training week was conducted at Camp Growl under the supervision of CAPT Thomas van Heumen. This ensured that the NZDF personnel could operate effectively using ADF deployable dental equipment and were aware of our administration requirements. With two weeks of the exercise remaining, the NZDF team departed the location and COL Murray Hayes was deployed as the dentist with the two ARA dental assistants. 2 GHB was deployed in a tactical scenario and, when combined with a particularly wet month, lead to a very strenuous exercise. Every member of the dental team, both ADF and NZDF, worked in an exceptionally professional manner. An impressive 185 individual sessions of treatment were achieved during the exercise. A highlight of the exercise was the interoperability with the NZDF, which we hope will be repeated in the future.

Exercise HAMEL 2012 – A reservist’s perspective Colonel Murray Hayes Exercise HAMEL 2012 was a multinational Exercise held in and around the Shoalwater Bay Training Area (SWBTA) near Rockhampton in Queensland. With many thousands of troops deployed in the field environment, 2GHB was tasked to provide both real time and exercise health support to the operation. 3HSB was tasked to augment this health support with specialist elements such as surgeons, anesthetists and of course, Dental Officers.

happy to help out. CPL Roberts was kept busy with regular dental hygiene appointments (in between other duties around the hospital). SSGT Heald was surprised to hear that we did not have a Dental Technician with us, or any gear for him to use. It was soon time for the Kiwis to return home, leaving just CPL Lawler, PTE Maros-Linder and myself to look after all things dental. It was around then that the rain came…and came…and COL Murray Hayes, CPL Brett “Man came! Pretty soon the place Mountain” Lawler and PTE Jareth “2 was flooded, including the Dads” Maros-Lindner; wet to the Corps long drops. The nearest portaloos were on the other side of a completely flooded creek. Wet feet became the norm. Vehicle movement around the range became a real problem and the steady flow of patients slowed down. We were beginning to think we may be stuck out there forever. Luckily for all, when it came time to start the pack up, the rain paused. The place remained a quagmire though. I very much enjoyed lacing up the boots again and working with such a professional health team. Under the superb leadership of LTCOL Williams, 2 GHB put on a great show and was well supported by its dental team throughout. Acknowledgement of Colonel Murray Hayes for his fine photography for both Ex HAMEL articles.

Being posted to 3HSB, I was fortunate to be asked to support the last two weeks of an activity that had already been well underway for some four weeks. I arrived in the field to find the hospital well established and operating smoothly. The dental section was in the capable hands of CPL Brett Lawler and PTE Jareth Maros-Lindner, who were hosting a dental section from the New Zealand Defence Force. The team was constituted of: MAJ Lisa Caulton, SSGT Ross Heald (Technician), CPL Kelly Roberts (Dental Hygienist) and PTE Matthew Loughnane (Dental Assistant). Having deployed to the field many times under canvas, the most immediate and pleasing change was the air-conditioned Weatherhaven structure in which the dental section was situated. With duck board solid flooring, it was almost as good as being back in a garrison. There was no shortage of dental treatment to be carried out. MAJ Caulton had been looking after a steady flow and I was CADMUS 2012

Top left: SSGT Ross Heald (NZDF) wondering where the lab kit is. Above left: COL Murray Hayes busy examining a patient. Above right: Without the weatherhaven and duck boards, we would have been paddling in 5cm deep

Reports from Operations and Exercises Royal Australian Army Dental Corps Exercise SAUNDERS 2012 (AACAP 19) – Dampier Peninsula WA Captain Brad Ross During the period May – Oct 2012, 33 Dental Company, 2nd General Health Battalion provided dental support to Army Aboriginal Assistance Program (AACAP) 19. We were located in various locations throughout the Dampier Peninsula, which is situated about three hours north of Broome. The overall deployment manning (at full capacity) consisted of approximately 160 – 180 ADF members with frequent fluctuations due to scheduled rotations, visiting staff, and attached Tongan / PNG / Norforce personnel at different times. The dominant Engineering element included a wide variety of specialist trades, most of which were a combination of ARA and Reserve members on CFTS from 17 Construction Squadron (6 ESR), currently based at Holsworthy Barracks, Sydney. The Training Team were a mixture of mostly skilled Reservists, conducting training courses in small-engines repair, fire-fighting, music production and driver instructing. The Health Team, under the direction of our Health Development Officer (HDO), provided a Resuscitation, Primary Health Care, Evacuation, Dental, Environmental Health, Diagnostics, Imaging and Physical Training capability whilst deployed in the field. The Dental Team was an essential component of the Health Team. Our role was not only to support our deployed ADF members, but also to assist in providing a significant health effect towards improving the oral health and well-being of local Indigenous Communities. This was in line with our federal government funding from the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA). 33 Dental Company provided three rotations of dental teams over the duration of AACAP 19, each consisting of a Dental Officer and two Dental Assistants. The first rotation was: CAPT Brad Ross (DO), LCPL Nancy Havili (SDA) and PTE Brett McGrath (DA). The second rotation was: MAJ Karen Such (DO), CPL Ryan Cowgill (SDA) and PTE Anna (‘Bella’) Badenhorst (DA). The third rotation was: CAPT Thomas Van Heumen (DO), CPL Dan Kempster (SDA) and PTE Jenna Ivey (DA). Together we formed efficient and productive teams providing dental treatment and Oral Health Education (OHE) for the local communities at Beagle Bay, Lombadina / Djarindjin, and Ardyaloon (‘One Arm Point’).

AACAP Dental team with CA & RSM-A

Oral Health Education (OHE) at Ardyaloon Public School

MAJ Such with kids on AACAP

CAPT Ross attempting to convince the local Indigenous children at Djarindjin to give up the cokes & toffee apples

CAPT Ross & PTE McGrath treating an Indigenous patient at Ardyaloon (‘One Arm Point’)

CPL Cowgill & PTE Badenhorst on AACAP

OHI on AACAP Dikcoda Sampi

CADMUS 2012

Reports from Operations and Exercises Royal Australian Army Dental Corps For those of us who travelled by road in the Advance Party and Main Body, it was a picturesque, if at times chilly and wet, road trip over 15 days. For others arriving in the Air Party it was a glorious six hour C-130 ride direct from RAAF Richmond into Broome. Our new home for the next six months was a field camp site, cleared from native bushland. It was amazing how quickly the Engineers from 17 Construction Squadron were able to build the camp and establish running water for showers, toilets and washing facilities. Not to mention our canvas tents for accommodation / work areas and a concrete slab with full kitchen facilities for providing a constant supply of fantastic meals. There was even a welfare tent with several computers / phones and of course the ‘Bear Cave’. This was an excellent meeting place, for rest & recreation activities after-hours (including a well-constructed nightly bonfire). After establishing ourselves at the main construction camp near Lombadina (later named ‘Camp Birt’ in honour of CPL Ashley Birt from 1 Topo Svy Sqn who was KIA on 29 Oct 2011 whilst deployed on operations in Afghanistan), we then began the dental reconnaissance / liaison phase in search of suitable venues to perform our dental treatment. After some initial disappointment with being denied access to sharing WA Health facilities in each of the community clinics, we went in search of independent venues. The local Councils and Indigenous elders were extremely keen for us to be there and offered us excellent hard-standing facilities to set-up our deployable equipment and utilise local infrastructure wherever possible. In Beagle Bay we occupied the ‘Sacred Heart’ Catholic School which gave us excellent access to treat children of all ages. In Lombadina / Djarindjin we occupied the local ‘Centrelink’ office. In Ardyaloon we occupied the Kullari Regional CDEP Inc (KRCI) building, owned by a local businessman who is in charge of providing training opportunities to local Indigenous communities. Each of the venues were comfortable and had their own merits. We also visited each of the three major schools to provide some much needed Oral Health Education (OHE), focussing mainly on toothbrushing and the importance of a healthy diet.

advertising our presence in the area. We regularly spoke with school principals, community store workers, council members and would post a copy of our weekly timetable on local noticeboards wherever possible. It didn’t take long for the ‘bush telegraph’ to spread the word of our presence in town. The patients were not only local Indigenous residents, but would also comprise of school teachers, health care workers and overseas workers / volunteers who were directly in support of local Indigenous communities. These people were often poorly paid (or volunteers) and in dire need of some dental assistance. The dental treatment provided a healthy mixture of Exodontia, Restorative, Oral Hygiene, and Emergency treatment (e.g. toothaches and broken teeth / restorations). The Dental Team was also prepared to assist the Resuscitation teams, if required during any MASCAS or medical emergencies involving our own ADF members. Sadly, this was the first year that the AACAP Dental Team could not provide an integral Prosthetic / Laboratory capability whilst deployed in the field (much to the dismay of several patients in need of new dentures). It’s hard to describe the natural beauty of the Dampier Peninsula area. Away from the sea, the land is mostly flat and covered in fine red dust. In contrast, the ocean areas are surrounded by vivid white beaches edged by the sea, which is an intense blue-green colour. The tidal surges would often be between 10-15 metres high. Many sections of the surrounding road system were unsealed, which posed some serious problems for inexperienced drivers in whitefleet vehicles. Whilst living / working inside canvas tents at ‘Camp Birt’, we faced some unusual challenges such as the strong winds that covered all our dental equipment in a fine red layer of dust. This dust also infiltrated into our clothes and stained the skin. Many items of clothing (especially shoes) were later discarded prior to coming home due to their total saturation in red dust. Most wildlife in the nearby waterways were lethal and there was no shortage of scorpions (and the occasional snake) roaming the camp. Wearing of open shoes or thongs was not considered a sensible mode of footwear.

Our workload then increased dramatically as we re-engaged with the local Indigenous communities and local Councils. The Health Team’s external task-list quickly evolved and included not only Dental Support but also: Physical Education & Sports training in the local schools, Men’s & Women’s Health Programs, Children Health Expos, First-Aid Training, Environmental Health mentoring, general Vet services including de-sexing and micro-chipping of animals, Psychology guidance for local Health Clinic workers, remediation assistance for the Aged Care Service. Quite a diverse mix but this was all aimed at achieving the same outcome of improving the overall health and wellbeing so that we could help ‘close the gap’ in healthcare and life expectancy of remote Indigenous Australians.

Besides ongoing dental work during the working day, afterhours life within ‘Camp Birt’ was made as comfortable as possible. The PTI program kept us fit. With such a diverse mixture of engineering tradesmen in-loc, it didn’t take long for the camp to evolve, via the creation of additional creature comforts. An awesome gymnasium was erected which proved very popular with many of the Sappers. The Beach Volleyball court was later constructed and was the focal point for the weekly Volleyball competition amongst the different Troops / Teams. The SSM / Camp Commandant also introduced a weekly ‘fun night’ inside the Mess tent including trivia nights and bingo. These consisted of gold-coin donations to Legacy. The final amount of money raised for charity is unknown but was expected to be an extremely generous donation!

A timetable was quickly established and the Dental Team rotated on a weekly cycle, out to each of the three main local communities ie. Beagle Bay, Lombadina / Djarindjin, and Ardyaloon (‘One Arm Point’). The Dental Team was proactive in continually

Overall, the AACAP 19 deployment was a fantastic experience and one that provided a genuine opportunity to provide a real health effect to patients of all ages within the local Indigenous communities throughout the Dampier Peninsula.

CADMUS 2012

Reports from Operations and Exercises Royal Australian Air Force Dental Branch RAAF Operations and Exercises 2012 Squadron Leader Andrew Draper The past year has been one of our busiest with multiple operational commitments. We have welcomed the safe return of SGT Kerry Sears from an operational tour on OP SLIPPER although not in a dental role, and have sent CPL Terri-Anne Dehncke who is expected to complete a deployment shortly, again not in a dental role. These deployments have demonstrated the broad skills, flexibility and respect our workforce holds within the larger Air Force and ADF. We are justifiably proud of their contribution to the Australian Defence Force in their duties. We have been fortunate to be able to exercise our collective training and preparedness with opportunities arising for our personnel to participate on EX PACIFIC PARTNERSHIP lead by the US Navy, and also on EX TENDON VALIANT lead by the US Army. Through these exercises, our personnel have been able to share knowledge and work alongside military personnel from all over the world and also with a number of non-government organisations, each with a distinct way of working. It is hoped that 2013 will present us with more opportunities for our skills to be utilised. Please read on in the following articles of how our people used their actions to demonstrate the core Air Force values of excellence, agility, dedication and teamwork.

Pacific Partnership 2012: A RAAF Perspective Contingent 1: 22 May – 04 Jul 12 Flight Lieutenant Georgina Seto Introduction Exercise Pacific Partnership is a humanitarian assistance mission, sponsored by Commander US Pacific Fleet. It aims to strengthen alliances between partner nations and host nations; and to enhance our capacity to respond to natural disasters. Our Australian contingent boarded the USNS The USNS Mercy MERCY in Guam on 22 May 12 and disembarked at Subic Bay on 4 Jul 12. For Contingent 1, our Australian dental team included LCDR Kelly Gregg, FLTLT Georgina Seto, SGT Rachel Dudgeon and LS Rachelle Johnson. As a RAAF member, life at sea was a new experience. It almost felt like learning a new language. Due to the size of the USNS Mercy, many of us were fortunate not to feel the effects of sea sickness. However, on a few occasions from Indonesia to the Philippines, the Sick Call (Sick parade) waiting room was full of slightly greenlooking faces.

Indonesia In Indonesia, five MEDCAPs (Medical Civil Actions Projects) were sent ashore to different islands. Our MEDCAP team spent five days in Siau, Indonesia, providing healthcare, preventive

and environmental medicine, engineering services, veterinary medicine and education. At each MEDCAP site, the patients were triaged at reception and given a coloured wristband denoting what type of medical treatment they were seeking – Medical, Dental, The Dental team set up Paediatric medicine, Optometry or Pharmacy. Next, a Nurse or Medic recorded their vitals and then they were escorted or directed towards the relevant department to wait for their treatment. Most of our time was spent extracting severely decayed or periodontally-involved teeth. Many of the children and adults had never been to a dentist before. We handed out thousands of toothbrushes and tubes of toothpaste, along with oral hygiene instructions (with the help of our fantastic translators).

A typical patient requiring multiple extractions due to extensive decay and periodontal involvement. (Photo taken by CMDR Allen, June 2012)

We tried to speak a few phrases of Indonesian to our patients. The extent of our vocabulary only went as far as “Hello, how are you”, “Have you got tooth pain?”, “Please open wide” and “Please bite down on the gauze”. In order to treat as many patients as possible, we often used one FLTLT Seto treating a patient chair for anaesthetising a patient with the help of a translator and a second chair for extracting the teeth. This system worked well and enabled us to manage a greater number of patients. Never before had I extracted so many teeth in one day. Many of the extracted teeth had periapical abscesses attached to them, which gave me a greater appreciation of the pain they had endured. Moreover, we learned many new techniques for extracting stubborn (and slippery!) root tips. Trying out different models of extraction forceps was educational as well. It was a great opportunity to share and learn new clinical techniques SGT Dudgeon managing the with other military and civilian pack up in Siau, Indonesia dentists from other countries. On our last day on the island of Siau, the local people were keen for us to stay a little longer, whilst their local government thanked us for our work throughout the week. During this Closing Ceremony, their hospitality was evident by the banquet. CADMUS 2012

Reports from Operations and Exercises Royal Australian Air Force Dental Branch Philippines

A child with an intraoral swelling due to an infected 51 retained root (Photo taken by CMDR Allen, June 2012)

FLTLT Seto with a local family in Siau, Indonesia

In the Philippines our MEDCAP teams went ashore during the day, with everyone returning to the ship at night. This meant our days were long and exhausting, but nevertheless, also rewarding. Each day involved waking up at 0400 or 0430h to board a band-aid boat or hovercraft which took us ashore. Then we travelled in vans to our site, which was usually a school or a sports hall. The van ride could take anywhere from 10 to 90 minutes. Once there, we were greeted by crowds of locals waiting for their medical and dental treatment. It was humbling to think that they had travelled great distances and waited in line for hours in order to receive treatment.

The Australian Dental Team on Contingent Two consisted of two Dental Assistants; CPL Farley and LACW Summersgill and two Dental Officers; LCDR Galloway and FLTLT Kate Aitken. We were greeted by the US Military with gusto, several of them telling us how much they loved our predecessors; so we knew that we had big shoes to fill. We had a diverse team with members from the US, New Zealand, Philippines, Peru, Malaysia and Canada. The transit time to Vietnam was spent conducting ship LACW Summersgill with a Peruvian drills and familiarising our- dentist selves with our workplaces. We were quick to learn the layout of the ship, memorising colours of floors and stairwells. This was to save us from the embarrassment of getting lost and making it on time to the all important musterings.

We worked alongside a team of Japanese and Philippine dentists and dental assistants. It was interesting to compare and contrast our extraction techniques and management of patients. It was a challenge to extract teeth all day in such humid conditions. After a couple of incidents of heat exhaustion amongst our team members, we became more diligent in taking water breaks at least hourly.

Assisting with surgical cases When we weren’t rostered to onshore missions, we stayed on the ship and treated local patients who were brought to us. Dental treatment on the ship involved not only extractions, but also restorations and scale and cleans. On several occasions we had the opportunity to observe the oral surgeons perform cleft lip and palate repairs. The comparison between these patients’ before and after photos was extraordinary.

Conclusion I am grateful that I had the opportunity to participate in Exercise Pacific Partnership 2012. It was a rewarding experience – both professionally and personally. The people I met and friends I made will be something I will never forget. Furthermore, the hospitality shown by the Indonesian and Philippine people was inspiring.

FLTLT Aitken and CPL Farley working in Vietnam

Vinh, Vietnam Similar to the Philippines, the MEDCAP teams went ashore each day and returned at night. Days were long, often departing at 0500h and sometimes returning at 2000h; with long transits on boats and buses to our sites. Most of the sites were at rural schools and we were welcomed by the local people and authorities. Vietnam provided an opportunity for learning different techniques and developing Oral Surgery skills.

Flight Lieutenant Katherine Aitken

The work achieved by all medical departments was impressive considering the 40oC+ temperatures and high humidity. A whole new meaning was brought to the word sweat; especially once we had placed on gloves, masks and glasses and faced a difficult extraction. Whilst the MEDCAPS were a little slower than the previous nations, we were informed that overall the mission was extremely successful; winning the hearts and minds of the local people and officials.

Introduction

Sianoukville, Cambodia

After a long journey we arrived in Subic Bay on the 5th July, having already become familiar with our fellow Contingent Two members. We were fortunate enough to have a couple of day’s liberty to get to know the ship and the people we would be working with.

Following Vietnam, we arrived in Cambodia with high spirits and ready to work hard. Three of the four MEDCAPS were overnight missions and one did day trips to a local community. I was fortunate enough to go out on a seven day mission to a village an hour south of Phnom Penh, being flown to and from the site by a

Contingent 2: 05 Jul – 14 Aug 12

CADMUS 2012

Reports from Operations and Exercises Royal Australian Air Force Dental Branch Blackhawk helicopter. Being the only Aussie on the team, I had a great time getting to know and work with the other nations. Our MEDCAP saw over 4000 patients in the five working days, with Dental treating over 500 patients and doing even more extractions. We even featured on the front FLTLT Aitken working in Cambodia page of the Phom Penh Post, headlined: ‘Sergeant Tooth Fairy’ with a photograph of FLTLT Aitken extracting a child’s tooth. The local people warmly welcomed the team and we were impressed with their high thresholds for pain and graciousness with which they received treatment.

clinical treatment phase, and interspersed with cultural engagement activities provided by the Indonesian Government. The Australian contingent consisted of WGCDR James Branley (RAAFSR; Infectious Diseases Physician), FLTLT Tim Keys (Dental Officer, 1EHS), FLTLT Lauren McHardy (Registered Nurse, 1EHS) and FSGT Heather Fitzgibbon (Dental Supervisor, 1EHS). Throughout the exercise, over 2000 medical consultations were provided by the teams, and some 400 dental patients were treated. It was extremely rewarding to be able as part of the exercise to provide dental care to the community. In terms of dental care, most treatments provided were extractions, but some limited basic restorative care and the occasional pulpotomy was provided. Clinically, there were many patients presenting

Summary Overall Ex Pacific Partnership is an excellent opportunity for different nations to unite and work as a team. Given this experience, I would feel much more comfortable joining forces in the event of a disaster, to react as an international team. The motto we shared and were reminded of is extremely apt “preparing in calm to respond in crisis.” Ex Pacific Partnership was the experience of a lifetime and one that I will certainly cherish forever.

Exercise TENDON VALIANT 2012 Flight Lieutenant Timothy Keys In 2012 RAAF Dental was fortunate to be able to send two members as part of the Australian contingent on Exercise Tendon Valiant 2012 (TV). EX TV is a Tentara Nasional Indonesia (TNI; the Indonesian Army) and US Army (18th Medcial Command and Pacific Surgeon’s Office) coordinated exercise from the Soepraoen Army Hospital in Malang, Indonesia, with treatment performed in regional hospital facilities. Representatives from the USA, Australia, Indonesia, Nepal, Cambodia, Thailand, Vietnam, Philippines, Malaysia, Timor Leste, and Tonga were in attendance. The primary objective of the exercise was to increase military interoperability and share knowledge between member nations as well as providing Medical and Dental care to disadvantaged Indonesians normally with limited access to healthcare at the invitation of the Indonesia Government. The exercise was 5 days long with a knowledge sharing component,

Photo Credit: Sgt. 1st Class Rodney Jackson, 18th Medical Command (Deployment Support) Public Affairs Delegates and distinguished visitors participate in the opening ceremony for the Southeast Asia Pacific Medical Readiness Training Exercise Tendon Valiant 2012, at the Soepraoen Army Hospital in Malang, Indonesia, June 18, 2012.

Photo Credit: Sgt. 1st Class Rodney Jackson, 18th Medical Command (Deployment Support) Public Affairs Malang, Indonesia “Delegates, Distinguished visitors, and VIP guests pose for a group photo after the opening ceremony for the Southeast Asia Pacific Medical Readiness Training Exercise Tendon Valiant 2012, at the Soepraoen Army Hospital in Malang, Indonesia, June 18, 2012. CADMUS 2012

Reports from Operations and Exercises Royal Australian Air Force Dental Branch with very large deposits of calculus, some deposits so large that it impacted their speech due to it causing deviation of their tongue. The differences from our usual clinical environment were immediately evident. Tuberculosis was endemic in some of the regions visited and this highlighted the importance of screening for potentially active cases and the importance of personal protection for the operators. There were significant challenges encountered in providing dental treatment under very basic, austere conditions. There was limited access to electricity and potable water at some locations, and our procedures needed to be adapted to suit the mission and the facilities available. We found our Indonesian hosts and the general population to be extremely welcoming and appreciative of our assistance. They provided us with gifts and local foods which allowed us to broaden our appreciation of international, traditional and customary foods. We found that music and Karaoke played an important role in bringing the participants together. Language was initially an impediment to communication. However our hosts provided multilingual medical students to act as translators and soon these barriers were removed, albeit with occasionally amusing results as the original meanings were lost or confused in translation.

Although this was a short exercise, we gained a better understanding of the challenges of providing HA treatment in austere conditions and of the types of dental disease likely to be encountered. We gained a better understanding of the capabilities of our clinical colleagues in Indonesia and the The Australian Contingent other member nations. I believe that we made a real difference to the quality of life of a small number of people in the community through our dental treatment. I believe the outcomes were invaluable, and allowed us to forge ties and trust between member nations and earn much good will. TV12 representatives from If the opportunity to participate various participating nations in this exercise is offered in the future, I strongly encourage people to nominate for this short but fantastic and rewarding experience.

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CADMUS 2012

Honours and Awards

Recognition of Awards and Service Colonel Genevieve Constantine BDSc, Grad Cert Clin Dent, MPH, MHM, Director of Defence Force Dentistry

It is important that we recognise the outstanding work of our personnel by nominating them for formal recognition of their performance over and above that expected in the conduct of their duties. We wish to publicly congratulate the following personnel for their recently received awards:

Awards Australia Day Medallion 2012 – CPODENH Craig Watkins LSDEN Amanda Cox CPL Daniel Kempster Commendations – LCDR Kelly Gregg PODEN Tracey Morris HMAS Stirling Sailor of the month February 2012 – AB Edward Todd RAN Dental Branch Outstanding Contribution Award (OCA) 2011 – CMDR Matthew Blenkin LSDEN Mark Smith

AUSTRALIA DAY MEDALLION 2012 Each year the Australian Government, through the Australia Day Council and the Department of Defence recognises outstanding achievement through the award of the Australia Day Medallion. In this way we recognise the contribution of individuals and teams for outstanding performance on special projects or in performance of their core duties. The Australia Day Medallions are reserved for the highest level of recognition and provide a unique way of inspiring and recognising staff when presented in the lead up to Australia Day. This year CPODENH Craig Watkins, LSDEN Amanda Cox (both of HMAS STIRLING) and CPL Daniel Kempster (33 Dental Coy, 2GHB) were the worthy recipients of these awards. Their efforts are to be commended.

COMMENDATIONS 2012 LCDR Kelly Gregg was recognised by US Navy leaders for outstanding duty while serving with Pacific Partnership. She received her award for efforts in treating a significant number of disadvantaged people during her five weeks in Indonesia’s North Sulawesi province and the island of Samar in the Philippines. She was commended for her tireless work ethic and calm demeanour. PODEN Tracey Morris was recognised for her exceptional professionalism at HMAS Cairns. She received her award for the outstanding service provided to HMAS Cairns personnel and respective Resident Units. CADMUS 2012

We also wish to congratulate the following ADF Dental School students of merit for exceptional achievement in their studies:

ADF Dental School Students of Merit 11/12 DDFD also wishes to congratulate the students of merit for ADF Dental School courses on exceptional achievement in their studies. Dental Assistant Course May – Jul 11 SGT Justine Hourihan (RAAF) Senior Dental Assistant Course Oct – Nov 11 PTE Morgaine Miscamble (ARA) Mar – Apr 12 PTE Brett McGrath (ARA) Senior Dental Assistant – Preventive Course May – Sep 11 LACW Teagen Walker (RAAF)

RECOGNITION OF SERVICE Dr Bill Fussell (CAPT, RANR) This year saw the retirement of Dr Bill Fussell from clinical practice at Stirling Health Centre. Bill’s association with the Navy has been long and distinguished. He served 22 years in the Permanent Naval Forces, retiring as a Captain and the last Director of Navy Dental Services in 1996. He has worked at Fleet Base West as a clinical dentist and occasionally SDO for the last 12½ years. Bill has been a great friend and mentor to many Dental Officers over the last three decades. Few people have given so much to the organisation over such an extended period. He has been a tremendous source of corporate knowledge and clinical advice for many years. His guidance and advice has always been sought after and much valued.

Dr Michael Stevens & Dr Grant Dawson The staff of Enoggera Dental Centre farewelled Dr Michael Stevens and Dr Grant Dawson after 7 years of dedicated service to the patients of Gallipoli Barracks. Both dentists have provided an excellent level of clinical skill and expertise to the Dental Centre. They have ensured continuity in the facility as military staff have posted in and out over the years. Both dentists are esteemed by all who have had the pleasure of working with them as well as the thousands of patients they have treated and managed over the years. They have provided excellent mentoring to the junior dentists who have worked at Enoggera. We wish both Michael and Grant the very best for the future and thank them for their dedication to the provision of dental services at Gallipoli Barracks.

State of the Union â&#x20AC;&#x201C; ADF Dentistry Directorate of Defence Force Dentistry

Focus for 2012: Policy Review and Clinical Governance Colonel Genevieve Constantine BDSc, Grad Cert Clin Dent, MPH, MHM, Director of Defence Force Dentistry

The mission of the Directorate of Defence Force Dentistry (DDFD) is to exercise technical control of the provision of dental services to the ADF. This is achieved through policy development, clinical decisions and the provision of advice to Commander Joint Health on issues of a dental nature, including dental capability and resourcing, oral health standards for the ADF and dental workforce requirements.

2012 In February 2012 Garrison Health Operations (GHO) Branch underwent a review. As a consequence of this review the Directorate was moved from the Strategic Health Coordination Branch to GHO. The Director of Defence Force Dentistry was double hatted as the Director of Specialist Clinical Advice with responsibility for the Intensive Recovery Program, Physiotherapy, Mental Health, Psychology and Rehabilitation service delivery in the garrison and radiation safety. The Directorate has been busy reviewing and updating dental policy with eight policies to date being cleared by the Defence Health Policy Steering Group. These will hopefully be cleared for dissemination in the not too distant future.

Radiation Safety Management Program & Radiation Management Plan Having assumed the responsibility for radiation safety the Directorate has been working hard to finalise the JHC Radiation Safety Management Program and Radiation Management Plan (RSMP & RMP). This document is close to endorsement and a draft has been disseminated to all units. Radiation safety is a legislative requirement and in order to achieve compliance for DRSA assurance inspections and ARPANSA inspections, units need to ensure that they are adhering to the JHC RSMP & RMP. This includes the deployed environment. The JHC RSMP & RMP, links to radiation legislation and inspection checklists are available at http://intranet.defence.gov.au/vcdf/sites/DSCA/ComWeb. asp?page=81865

the roles in all regions. Under the current constraints for APS positions the development of these positions may take some time.

JeHDI A number of personnel from the regions participated in the JeHDI pilot in July and as a result identified areas that need to be addressed prior to the implementation. DDFD and WO Stone are working closely with the project to ensure that the dental component of JeHDI will deliver a workable solution. This will involve the development of SOPs to ensure a standardised method of documenting clinical information where JeHDI offers more than one option.

Dental Auxiliary Working Group The three Single Service Dental Warrant Officers (and equivalent) have discussed introducing a Dental Auxiliary Work Group (DAWG) for Senior Non-Commissioned Officers to provide specialist advice and guidance to CJHLTH, DNH, DAH, DAFH and DDFD. The DAWG will facilitate resolution of key stakeholder issues; endorse project documentation, business cases and capability proposals. The DAWG will foster a mentoring and peer review program for junior dental auxiliaries while working with stakeholders and Command. The concept is currently with DDFD for endorsement.

SDFDS & FDI In August this year DDFD attended the Section of Defence Forces Dental Services, FDI and the FDI Annual World Dental Congress in Hong Kong. The scientific programs for each event were outstanding. There was an opportunity to be updated on some of the latest advances in dentistry and the SDFDS provided an ideal forum to exchange ideas with other Dental Directors. To those who have not attended a SDFDS before I recommend the next SDFDS which will be prior to the 2013 FDI World Dental Congress which will be held in Istanbul 28 â&#x20AC;&#x201C; 31Aug 2013.

Regional Dental Advisors As many of you would be aware it has been the intent of the DDFD for some time to establish Regional Dental Advisors (RDA) in the Regional Health Services (RHS). The RDAs will be responsible for the implementation of clinical governance and standards, including audit and peer review at the regional level. They will be the link between DDFD as the technical authority and the regions. We are currently developing the duty statement for this position and are trialling the functions of the RDA in RHS Central & West. Further implementation is going to require the establishment of APS positions as we do not have JHC positions/personnel to fulfil

CADMUS 2012

Training Update

The Australian Defence Force Dental School The Staff LCDR Kim Leong WO1 Wayne Butler CPO Robert Meldrum FSGT Carolyn Carruthers SGT Alaina Rodway PO Scott Norbury

Officer in Charge ADF Dental School 2IC ADF Dental School Operations Manager Dental Assistant Course Manager Senior Dental Assistant Course Manager Senior Dental Assistant - Preventive Course Manager

ADFDS 2013 Course Timetable Dental Assistant (DA) Course (103943) 13 May 2013 to 26 Jul 2013 Session 36 19 Aug 2013 to 01 Nov 2013 Session 37 Senior Dental Assistant (SDA) Course (200544) 18 Feb 2013 to 28 Mar 2013 Session 20 21 Oct 2013 to 29 Nov 2013 Session 21 Senior Dental Assistant – Preventive (SDA-P) Course (103940) 29 Apr 2013 to 20 Sep 2013 Session 17 Dental Officer Initial (DOIC) Course (113464) 23 Sep 2013 – 04 Oct 2013 Session 12

Once again, it has been a very busy and productive year for ADF Dental School. This year has seen personnel graduate from each of the three Dental Assistant Courses. The school completed three Dental Assistant Courses and two Senior Dental Assistant Courses. Due to a limited number of applicants, only a single Senior Dental Assistant-Preventive Course was run this year. If you require any information pertaining to any ADFDS courses, please contact the ADFDS or consult the ADFDS Website: http://intranet.defence.gov.au/navyweb/sites/ADF_Dental_ School/ComWeb.asp?page=148659

Dental Assistant Course (103943) Since the last CADMUS edition in 2011, only three Dental Assistant courses have been conducted at the ADFDS. Session 0031 consisted of five students: SGT Justine Hourihan, ACW Hannah Sunasky, PTE Filippa Cook, PTE Hannah Fraser and PTE Jareth Maros-Lindner. The student of merit was awarded to SGT Justine Hourihan, a well deserved recipient. Session 0033 had only two CADMUS 2012

students: GNR Matthew McKay and PTE Jasmine Howard. Session 0034 was cancelled as there were no candidate applications for this course. Session 0035 commenced on 20 Aug 12. At the time of writing this article, two Royal Australian Navy candidates are undertaking the course.

Senior Dental Assistant Course (200544) The ADFDS had 13 students graduate from the Senior Dental Assistants course this year. One student also completed the Qualified Entry Dental Assistant Course. Session 0017 was a class of six students; the student of merit was awarded to PTE Morgaine Miscamble. Session 0018 consisted of seven students; the student of merit was awarded to PTE Brett McGrath. Congratulations are extended to both students for their achievements. The curriculum of the Senior Dental Assistants course has experienced a significant review this year. Learning objectives in Simple Procurement have been replaced with the Defence Ionising Radiation Protection Officer X-ray (DIRPX) Course. Future SDA courses will involve students undertaking DIRPX assessments whilst on course. Successful candidates will then attain Certificate IV in Dental Assisting (Radiography) and will be DIRPX2 qualified on completion. As a result of Army’s career path restructuring, applications for recognition of prior learning were submitted by Senior Dental Assistant-Preventives and Dental Technicians that required gap training.

Senior Dental Assistant – Preventive Course (103940) The Senior Dental Assistant - Preventive course began on the last day of April with two very motivated Royal Australian Navy candidates. The students were extremely eager to begin the training program. Both trainees displayed a good aptitude during the theory phase and the practical elements. Throughout the course, both students received positive feedback from staff, other trainees and patients alike. This can be attributed to the candidates excellent academic results, combined with their ability to deliver high quality treatment and develop good rapport with their patients.

Dental Supervisor Course (200683) and Dental Manager Course (207288) The ADFDS currently has 15 members studying these courses; nine on the Dental Supervisor’s Course and six on the Dental Manager’s Course. Over the last twelve months, the Supervisors and Managers Course has again seen redevelopment and alteration. This is mainly due to unavailability of identified CAMPUS courses, contained within the package. The continual changes have been a source of frustration, for staff at the school trying to manage the training package and all candidates trying to complete it. The ADFDS are working with the RAN training developers from Training Support Faculty (TSF) to remedy these issues. We believe the outcome will provide a more robust, user-friendly training package. Personnel completing these curricula are requested to contact the Dental School if they are unable to locate any of the required CAMPUS courses to complete their training. While both courses are modified, temporary solutions have been identified for immediate training deficiencies. However, a complete training analysis is required before more permanent changes are implemented, scheduled to occur in 2014.

Dental Officer Initial Course (113464) The aim of the Dental Officer’s Initial Course (DOIC) is to introduce new entry Dental Officers to military dentistry, as well as Australian Defence Force Dental policy and logistics. Dental Officers are also briefed of their Service specific operational roles, as part of a deployed health care unit. The secondary objective of the course is to reinforce the career progression pathway from the initial entry Dental Officer Competency Level One to the Deployable Competency Level skill grade. This year, twelve Dental Officers came to HMAS CERBERUS to complete the course. The unusually large course size is due, primarily, to the significant number of new Dental Officers recruited into the ADF. The majority of these Officers were from Army. This year, for the first time, the Advanced Life Support (ALS) component was delivered by an accredited civilian agency. The external delivery of this component provided an interim solution, to ensure mandatory training objectives were achieved by the course. In the future, the portable Army School of Health’s ALS package will be utilised to fulfil this deployable requirement.

workbook for assessment by the ADF Dental School staff. Upon satisfactory completion of the workbook, access will be granted to an online examination portal via CAMPUS. The aim of this course is to provide training for Dental Officers and Dental Auxiliaries with a certificate IV in Dental Assisting (Radiography), to attain the DIRPX proficiency. There are future plans to remove the workbook component from the learning package, in the aim of creating a self-automated CAMPUS course.

The ADF Dental School Staff At the end of 2011, CAPT Paul Jacobsen posted to Gallipoli Barracks in Queensland after fulfilling the 2IC role at the ADF Dental School for five years. We welcomed the return of WO1 Wayne Butler to the Dental School to replace CAPT Jacobsen. First place: WO1 Butler, Second place SGT In spite of the busy Rodway and Third CAPT Jacobsen training tempo the ADF Dental School managed to squeeze in a Christmas Go-Karting function. The Army displayed their dominance over the other two Services, attaining all the places on the podium. At the end of 2012, the ADF Dental School will bid farewell to FSGT Carolyn Carruthers after a long stint of seven years. She will be posting to Newcastle to take up a recruiting position. The School will not be the same without her.

CEREMONIAL COMMITMENTS ADF Dental School was very well represented in ceremonial events. This year saw the three ADFDS Instructors; FSGT Carruthers, SGT Rodway and PO Norbury lead the ANZAC Day march. Each of the instructors represented their respective Service as participants in the catafalque party for the ANZAC Day Ceremony. The ceremony was held at the Shrine of Remembrance in Melbourne. This year FSGT Carruthers and SGT Rodway also represented the ADF as part of the flag party for the Women’s RSL Council of Victoria 2012.

Defence Ionising Radiation Protection Officer — X-ray Course (DIRPX) The DIRPX course is currently being delivered at the ADF Dental School as part of both the Senior Dental Assistants Course and Dental Officer Initial Course. On successful completion, the DIRPX PMKeyS proficiency number will be awarded to the ADF Senior Dental Assistant or Dental Officer. These personnel can then be appointed into the role of a DIRPX2 or a DIRPX1, respectively. Since the last issue of CADMUS, the DIRPX course has been fully developed and achieved audit point three. The DIRPX course is being converted into a CAMPUS Examination course. Candidates will have the opportunity to view the relevant educational material on the ADF Dental School website. There is still the requirement for each student to complete a printed

ANZAC Day: Flag party marching to the Shrine of Remembrance in Melbourne City (PO Norbury, SGT Rodway & FSGT Carruthers) CADMUS 2012

Feature Article

Dental Risk Assessment and Management in the Australian Defence Force Group Captain Greg Mahoney BDSc, PhD, MSc (Dent), GradDipClinDent, FADI, FPFA.

Group Captain Greg Mahoney joined the RAAF reserve in 1984 and has held a number of clinical and administrative positions. He is currently Clinical Director (Air Force Health Reserves) Specialist Health Services. In 1997 he completed his Graduate Diploma in Clinical Dentistry (USyd). In 2001, GPCAPT Mahoney completed his Masters of Science in Dentistry (USyd) where his thesis examined the association of workplace performance and toothache. In 2010 his PhD (UQ) found that a predictive model was possible in determining which patients were likely to have trouble in the period between dental examinations. 2011 saw GPCAPT Mahoney awarded fellowships with the Academy of Dentistry International and the Pierre Fauchard Academy.

Health risk assessment uses the known risk factors associated with a disease, injury or other health outcomes to determine which patients are most likely to develop that health outcome over a particular period of time(1). Typically, patients are classified as high, medium or low risk. Health risk management uses this assessment to identify the ‘at risk’ patient; alter patient treatment plans and, to provide targeted preventive programs. Risk assessment and management is the keystone to both private and public evidence based dentistry. An effective dental risk management model within the Australian Defence Force (ADF) would assist: 1. The military planner and dentist to predict future oral health needs and alter dental examination intervals based on risk. 2. The dentist in identifying the at risk patient using a prescriptive tool and not experience. 3. The patient in understanding what their risk status means and how that risk may be altered by their own actions. Figure 1 illustrates the processes within the risk management model from the identification of the risk; the development of the risk classification model, the implementation to preventive strategies and altered treatment which leads, in turn, to improved health outcomes for the patient and health system. This article will examine how the dental risk management study was developed for the ADF as well as a summary of its outcomes.

Identification of the risk The dental fitness classification system employed by the ADF (2, 3), which is similar to systems used by other Defence forces, places members in four broad categories. It was first introduced in the ADF in the late 1970s with the intention of providing commanders with a guide as to whether a member was dentally fit to be deployed. In the ADF, only those who are Dental Fitness Classification (DFC) 1 and 2 are deemed to be operationally deployable. It has been established that a higher dental fitness level will lead to fewer emergency presentations in a deployable situation (4). However, 79% of those presenting as dental emergencies are classified as dentally fit. So, if DFC is predictive, then how is it that so many of the dental emergencies were dentally fit at their previous Annual Dental Examination (ADE)(5)? Furthermore, in a prospective cohort study of ADF personnel, while dental unfitness was associated with an increased likelihood of the member having a dental emergency (Odds Ratio (OR)=1.85), DFC CADMUS 2012

was a poor predictor of having a dental emergency with a specificity =72.2% and a sensitivity=41.7% (6) In 1993, Chisick and King found that there was a problem with reviewing dental casualty rates. These studies used different definitions to classify a ‘dental casualty’ and six years later Mahoney and Coombs found that nothing had changed (4,7). Outcomes that were labelled dental casualties could be; Figure 1. Risk Management Model 1. Dental casualties (8) 2. Sick parade attendances (5) 3. Dental emergencies (9-11) 4. Dental emergencies or urgencies depending on whether they required immediate treatment or within the next 24-48hrs (12), or 5. Unscheduled Dental Attendance (13). This problem was recognized by a number of researchers in the field; consequently the US Navy sponsored a Dental Morbidity Workshop in July 2006 at the Great Lakes Navy Base, Illinois. At that workshop, a consensus was reached as to the definition of the outcomes that are of interest to the military: A dental emergency is a condition of oral disease, trauma or loss of function, or other concern that causes a patient to seek immediate dental treatment(14) An unscheduled dental visit is any visit to the dentist by a member that does not form part of their treatment plan from their routine dental examination (15). The outcome of importance, when considering the impact on a Defence force, is the unscheduled dental visit (UDV); a term first employed by Alexander, as it most accurately represents the dental casualty in the field or in garrison (13). UDV has been further refined to not include visits that are for trivial matters such as reviews, impressions or orthodontic consults.

Determining Risk Classification

Results

Rick Factor Selection From the literature 45 putative risk factors were identified as being potentially significant. These risk factors were in 3 broad categories of; 1. Demographics, 2. Lifestyle, and 3. Clinical

From the prospective cohort study of 875 deployable ADF members, it was hypothesized that there was an easily obtainable set of variables which could enhance the present DFC system’s prediction of a UDV. The aim of the study, therefore, was to conduct a prospective cohort study to determine whether a set of variables can more accurately predict an ADF member’s odds of becoming a UDV than the present DFC system.

The data were first analysed for associations between each putative risk factor and a binary variable indicating whether or not subjects had a UDV in the 12 months preceding enrolment into the study. In the main, risk factors were categorized into two or more mutually exclusive groups that represent meaningfully different levels of risk. Cut-points for collapsing the data were based on precedence from previous studies, scientific rationale (e.g. to create groups that contrast meaningfully on clinical grounds) or data distribution (e.g. to avoid producing a category comprising fewer than 15% of subjects).

The study found that there was indeed a set of variables which could be easily obtained which improved the predictability of the present DFC system. Ultimately there were two predictive models for two different cohorts that were established:

Modelling Variables for modelling were then selected, which yielded moderately significant associations with the outcome variable (UDV) or showed evidence of confounding or interaction. Moderately significant was defined as an odds ratio that exceeded 1.5 and for which 80% confidence intervals excluded the null value of 1.0. A confidence interval of 80% was chosen, as the more traditional level (95%) may not identify variables that are important, based on the findings of Bendel and Afifi and Mickey and Greenland in Hosmer and Lemeshow (16). To determine whether a risk factor should be included in the final model, these significant variables were analysed using multivariate logistic regression with only those with a p value <0.05 remaining.

Risk calculation The parameter estimates from the logistic regression model (including the intercept) were then used to create an Excel® spreadsheet for use in dental clinics. The spreadsheet contained the algorithm that calculated a patient’s probability of having a UDV, based on the reduced set of clinical findings and questionnaire responses found to optimize sensitivity and specificity. Cutpoints for predicted probability used to classify patients as low, medium or high risk were drawn from the prospective logistic regression model and the distribution of the probability of an ADF member becoming a UDV. This Excel spreadsheet was designed for chairside use and displayed risk classification immediately following entry of values of patient’s selected risk factors.

1. The Dentally Fit (at Baseline) Cohort, and 2. The Dentally Unfit (at Baseline) Cohort. Both models had improved sensitivity and specificity over the present DFC system. The largest improvement was in the sensitivity, with an increase from 41% to 82% in the case of the prospective dentally fit model. Furthermore, the Area Under the Receiver Operating Characteristic (AUROC) indicated that all the models were at least reasonably discriminative with AUROCs ranging from 0.74 to 0.83 (Table1). The dentally fit prospective cohort models had eight variables; DFC, Unsupported enamel on an endodontically treated tooth, Deep periodontal pocketing, Healthy diet, Prior dental visiting patterns, Years of service, an Oral Hygiene Score and an interaction term. In contrast, the dentally unfit model had 3 variables; DFC, Large fillings and Tooth brushing times per week. However, while the models are reasonable, the sensitivity and specificity of the models is such that there is some degree of uncertainty in the prediction as there are perhaps psychological and physiological dimensions to UDVs that we still do not comprehend or have not measured. Table 1. Summary of the Prospective Model Diagnostics Cohort

Model

GOF†

AUROC‡ Se*

Sp°

Dentally Fit Cohort

Final

0.18

0.83

82.61%

70.23%

Dentally Unfit Cohort

Final

0.17

0.74

62.86%

77.71%

†Goodness of Fit, ‡Area Under the Receiver Operating Characteristic, *Sensitivity, °Specificity.

The calculations for this tool appears Figure 2. The Dental Officer’s Worksheet for the Risk Calculation for the Dentally Fit Member on a separate spreadsheet to the Patient findings actual question and the responses 1 to the questions are linked to the DFC (DFC1=0, DFC2=1) calculation. Where there was a vari- No. of years served 3 able which was a summation of a 1 series of responses, as in the case In a usual day, how many pieces of fruit does the patient eat? of the Oral Hygiene Score, this In a usual day, how many glasses of plain milk does the patient drink? 1 calculation was completed first. The In a usual day, how many units of dairy products does the patient eat? 0 patient responses to the significant 1 variables were multiplied by the In a usual day, how many health bars does the patient eat? parameter estimates and totalled Are there root filled teeth with unsupported enamel (0=No, 1=Yes) 1 along with the intercept (log OR= How often per week does Patient use mouth rinse? 0 β0 + β1χ1 +β2β2+ ……+βpβp where p is the number of independent How often per week does Patient chew sugarless gum? 0 variables and β0 is the intercept)(16). How often per week does Patient brush their teeth? 14 This yielded the log estimation of Does the patient have perio pocketing >4mm (0=No, 1=Yes) 0 the odds of an event which is converted to a probability as the Prior To Joining the ADF did the patient only visit the dentist when in pain? 1 Pr = OR . The probability of an (0=No, 1=Yes) 1 + OR event was then compared to the cutPredicted 3-level risk High-risk offs for the level of risk.

CADMUS 2012

Finally, it was possible for these models to be used to determine a member’s risk of becoming a UDV from a simple chairside tool embedded in a Microsoft Excel® file. This tool could potentially assist the inexperienced dental officers of the ADF and the ADF (in general) in risk-managing their patients (Figures 2 &3) personnel.

Benefits While the study needs to be validated in an experimental study design, the intended benefits of a chairside prediction tool could lead to; 1, a higher percentage of deployable personnel through improvements in treatment planning and the identification of at risk personnel, 2. a lower long term cost of dental treatment via improved treatment focus, 3. fewer dental emergencies during deployments, and 4. a reduction in dental team resources used for ADE’s and deployed. In the shorter term, the addition of the risk assessment tool could assist in a re-evaluation of the need for ADEs. Clearly there are a large number of individuals in the ADF who are at low risk of having a UDV, yet regardless of this risk their dental examination interval is the same as a member who is at a higher risk. A

simplified DFC (Fit or Unfit) system along with the member’s risk of becoming a UDV could be used to alter a member’s interval between dental examinations. Dentally fit members with a low risk could have a longer period between dental examinations than those with a higher risk. 35% of the ADF population would no longer require an Annual Dental Examination, with an examination interval increased to 2 years. This would significantly reduce the amount of clinical time spent on dental examinations and free up dental time for other dental services. Any extra clinical time saved by altering the intervals between dental examinations, could be used to concentrate efforts to reduce UDVs in the high risk groups by, for example: 1. Reducing the risk of fractured teeth and fillings with the conservative use of cusp covered fillings and crowns, where appropriate. 2. Improving the oral hygiene of members, and 3. Identifying risk behaviours for periodontal disease.

Acknowledgements The author wishes to acknowledge the assistance of Joint Health Command and the Centre of Military and Veterans Health in the approval and the conduct of the study. Associated reference list is not shown due to space constraints. To request a copy please contact the editor.

Figure 3. The Dental Officer’s Worksheet for the Risk calculation for the Dentally Unfit Member Question What is the patient’s DFC (DFC3= 0, DFC4=1)? How many times per week does the patient brush their teeth? Does the patient have any large fillings involving cuspal/incisal replacement? (0=No 1=Yes) Predicted 3-Level Risk

CADMUS 2012

Patient Findings 1 14 1 High Risk

Feature Article

Forensic Dentistry in Investigation of Unrecovered War Casualties Captain Henry Wu BDSc, Grad Dip Forensic Odontology

Captain Henry Wu graduated from dental school at the University of Queensland in 2008 and completed a Graduate Diploma of Forensic Odontology at the University of Western Australia in 2010. He has been registered as a specialist Forensic Odontologist since 2011. CAPT Wu is an Army Reserve Dental Officer at Enoggera Health Centre, Enoggera, Queensland. In civilian life, he is also a Senior Dentist at Ipswich Community Dental Clinic and a Forensic Odontologist at Queensland Health Forensic and Scientific Services.

Thousands of Australian Defence Personnel remain unaccounted for from past overseas conflicts. There is a renewed interest and effort from within the ADF; and from the general public to recover and identify these Servicemen. Unrecovered War Casualties-Army (UWC-A) is responsible for the Armyâ&#x20AC;&#x2122;s official investigation and management of Australian Servicemen from all wars who are unaccounted for. The Unit is based in Canberra, operating from the Office of Chief of Army, and is a mix of both Australian Public Service and Defence personnel; including full time members and reservists from Army, Navy and Air Force. The team investigates all notifications of the discovery of human remains likely to be those of missing Servicemen, as well as information that may lead to the recovery of Australian Servicemen. Recent UWC-A investigations include notifications from Fromelles, Papua New Guinea, Vietnam, Malaysia, Korea and Indonesia. UWC-A has assisted the Government of Papua New Guinea in recovery of PNGDF personnel unaccounted for during the conflict in Bougainville. Investigations are initiated from notifications, which can be from several sources. A common source of notifications is from interviews with local people for whom the local history and landscape (and land ownership) can be transferred verbally through generations; so the role of the informant is more central to historical military recoveries than in contemporary investigations of disasters or missing persons. Unfortunately, with the passage of time, the rich oral history that can be garnered from local populations gradually diminishes and is eventually lost. The discovery of remains or a military wreck, which is believed to be Australian, will also trigger an investigation by UWC-A; as will research which presents new information supporting the possible location of a missing Australian Serviceman. Individuals or organisations can also make submissions relating to Australian Servicemen, which will be evaluated on strength of evidence to determine if a UWC-A Field Team will conduct an onsite investigation and possible excavation or recovery. Initial evaluation and research is performed by Case Investigators into the historical background, strength of information supplied, unit diaries of forces who may have fought in the location and perhaps war graves records. A UWC-A Field Team may travel to

UWCA Field Team during a welcoming ceremony in Bagou Village, Oro Province, Papua New Guinea. the site with the view to recovering any human remains for the purpose of forensic investigation. Testing is then conducted in order to determine the ancestry and hopefully the identity, of an individual. A typical UWC-A field team will include a mix of Case Investigators, Scenes of Crime Officers, Archaeologists, Forensic Anthropologists, Forensic Odontologist (a dentist with training in forensic science) and DNA scientists. The Case Investigators will conduct the historical research; provide the team with operational leadership and appropriate briefings for the task. The Case Investigators will also manage negotiations for accommodation, use of land and fees for local labour and conduct interviews. Scenes of Crimes Officers have recently been attached to UWC-A Field Teams to provide photographic and evidence collection support; particularly in view of establishing an auditable chain of evidence, proper recording and management of evidence collected. Archaeologists are responsible for conducting excavation of sites where human remains are believed to be and interpretation of artefact evidence found. Crucially, they can determine the extent of the grave cut. This can be quite challenging in view of adverse weather conditions, including localised flooding events and unexploded ordnance. The Forensic Anthropologists will also assist in excavation of the remains and generate a biological profile: an estimation of the ancestry, sex, age, height of the remains and any special features which may assist in identification. CADMUS 2012

Forensic Odontologists are responsible for recovering, evaluating and recording the dental remains for the possibility of future comparison with dental records of missing Defence personnel; as well as investigating the teeth and jaws for indications of ancestry. Forensic Odontologists also select and retain teeth suitable for DNA analysis. DNA scientists’ process and test bone and dental samples for ancestry analysis. They produce a DNA profile, with which to match donor samples from relatives of missing Defence personnel, to provide identification. The matching of donor samples from relatives has been very successful in the Fromelles project. For the last two years I have been fortunate enough to be attached to UWC-A Field teams, on tasks in Papua New Guinea as the team’s Forensic Odontologist. On my first trip in July 2011, we were tasked with investigating a report of human remains believed to be those of an Australian soldier, in the vicinity of Eora Creek on the Owen Stanley ranges. The site was named ‘The Lost Battlefield’ because the defensive positions and fighting pits of the area had remained relatively untouched since the battles of 1942 due to very uninviting terrain. The team was transported to the site by helicopter, then after a short trek we proceeded to set up our accommodation and examination facilities. After some days of work, we managed to excavate the remains, conduct initial field examinations and transport the remains back to Port Moresby for detailed examination. In Port Moresby and in Australia, we conducted further investigations and testing. We determined

that the remains were Japanese. Subsequently, plans are currently underway to forward these remains to the Japanese authorities. On my second trip to Papua New Guinea in May 2012 we focussed our attention on Oro province, where the battles of Buna, Gona and Sanananda occurred. We have examined dozens of sets of human remains in this area and I have examined many examples of very interesting dental remains; including extensive crown and bridge work, swaged stainless steel crowns, elaborate gold work and an extreme example of Linear Enamel Hypoplasia. Inevitably, due to the comparative number of unrecovered losses from either side, we will find many more Japanese remains than we find Australian remains. Nevertheless, we are very hopeful of recovering Australian Defence personnel and some of the early investigations from this trip are encouraging. Forensic Odontologists work as part of an investigative team from UWC-A to provide an official scientifically based response, to investigate potential human remains of unrecovered Australian personnel. Within this team, the role of the Odontologist is to record and chart the dentition for comparison with dental records; make an assessment of the ancestry of the remains from the dentition and jaws; and select dental samples for DNA analysis. In conjunction with the remainder of the team, Forensic Odontologists provide UWC-A with a strong mix of research and scientific skills to provide appropriate responses to a wide array of notifications. Acknowledgement to LCDR Russell Lain from UWC-A, for review and editing.

Forensic Anthropologists LT Donna MacGregor (RAAMC) and Dr Marc Oxenham (Australian National University), excavating human remains in vicinity of Bagou Village, Oro Province, Papua New Guinea.

Examples of Japanese WWII era dental work examined in Oro Province, Papua New Guinea. Note the swaged stainless steel crown on tooth 15 and the gold restoration on tooth 21.

Forensic Odontologist, CAPT Henry Wu (RAADC), recording and photographing dental specimens at Bagou Village, Oro Province, Papua New Guinea.

Very distinct Linear Enamel Hypoplasia (LEH) evident circumferentially on teeth 17, 15, 14, and 13. These linear grooves were visible in all quadrants.

CADMUS 2012

Feature Article

Examination and Maintenance of Patients with Dental Implants Major Geoff Harvey BDS (Adel), DCD (Perio) FRACDS (Perio)

Major Geoff Harvey BDS (Adel), DCD (Perio) FRACDS (Perio) is an ARA Periodontist who completed his specialist training at Adelaide University in 2011. MAJ Harvey is currently posted to 33 Dental Coy, 2 General Health Battalion.

All ADF dentists are aware of the importance of thorough clinical and radiographic examination of the teeth, restorations, prostheses and supporting soft and hard tissues, but should we be doing anything different when a patient with dental implants presents for an ADE? Although missing teeth may still be replaced by dentures or fixed dental prostheses, implants are becoming more and more common, providing many patients with reliable, long-lasting restorations. Whilst high survival and success rates have been consistently reported in long-term studies (Adell et al., 1981, Priest, 1999, Karoussis et al., 2003, Jemt et al., 2011), and even better results are being reported with modern implant surfaces (Buser et al., 2012), it has become clear that biologic and prosthetic complications can affect implants in the months and years following successful osseointegration. In the ADF, ‘implant teams’ of qualified specialists are responsible for placement and (in most cases) restoration of implants. However, with implant therapy becoming more common, Dental Officers (DOs) and Senior Dental Assistant – Preventive (SDAP) will encounter more patients with implants, and as such they will be required to examine and maintain implants in their dayto-day clinical work. This article will provide a short summary of the examination and maintenance of implants, diagnosis of complications and a guide for DOs on when to refer and what advice to give patients.

Soft and hard tissue interface Though an exhaustive description of these interfaces is beyond the scope of this article, it is important to understand the fundamental differences in soft and hard tissue attachment around teeth and implants. Whereas periodontal ligament fibres attach teeth (via cementum) to the alveolar process, implants interface directly with bone, and there are some important differences in the soft tissues around teeth/implants. Supracrestally, connective tissue fibre bundles attach perpendicularly to the root cementum, creating a strong connective tissue attachment to the tooth. In contrast, connective tissue does not attach directly to the implant surface, and fibre bundles tend to be arranged parallel to the implant surface. These relationships are illustrated in Figure 1 (Berglundh et al., 1991).

Figure 1. Soft and hard tissue interface (adapted from Berglundh et al., 1991).

Peri-implant diseases The 6th European Workshop on Periodontology (Zitzmann and Berglundh, 2008) defined the peri-implant disease entities as follows: Peri-implant mucositis: presence of inflammation in the mucosa at an implant with no signs of loss of supporting bone; Peri-implantitis: inflammation in the mucosa AND loss of supporting bone. These conditions are analogous, in many respects, to diseases of the periodontal tissues, i.e. gingivitis and periodontitis, and similarities have been reported in aetiology, pathogenesis, and risk factors for these diseases (Heitz-Mayfield and Lang, 2010). While there is consensus on the disease definitions, diagnostic criteria are more problematic, with numerous authors suggesting a minimum probing depths (PD) or bone loss measurement to be indicative of peri-implantitis. In the absence of accepted diagnostic criteria, the best we can do is interpret all clinical signs, paying particular attention to changes from baseline measurements and signs of inflammation, and taking into account the patient’s risk profile. CADMUS 2012

Risk factors/modifying factors A number of factors are known to increase the risk of peri-implant disease, including: Systemic – Poor oral hygiene – Smoking – History of periodontitis Iatrogenic – Excess restorative cement – Poor implant positioning – Incorrect seating of restoration – Errors in surgical technique (e.g. insufficient irrigation/ overheating bone)

Examination/Diagnosis DOs and Dental Hygienists/SDA-P have at their disposal a number of methods to examine implants, and detect peri-implant disease. While these are similar, in many respects, to the methods used to examine teeth, there are some subtle differences. It is important that baseline parameters are recorded at the time of placement of the definitive prosthesis, so that any changes can be readily observed at follow-up appointments (Lang et al., 2004, Lindhe and Meyle, 2008, Lang and Berglundh, 2011). In most cases, DOs/SDA-P won’t be examining implants during the integration phase – if so, it is generally best to leave them alone while they’re still under active care of the implant team (usually for 3-6 months following implant placement).

Visual inspection Simply looking at the implant restoration and the surrounding soft tissues may alert the clinician to pathology. The following should be examined: – Colour/contour of soft tissues (changes may include swelling, recession, or fistula/draining sinus) – Visible plaque – Damage to the restoration (e.g. porcelain fracture)

Probing All competent clinicians routinely use a periodontal probe as part of a routine dental examination. Just as it is impossible to properly examine and diagnose a patient’s periodontal condition without probing, judicious use of a periodontal probe is vital in early detection of peri-implant disease. Probing Depths Probing depths (PD) around implants have been shown to correspond well with histological measurements of attachment levels, and thus are the most reliable measure of clinical attachment (Lang et al., 1994, Schou et al., 2002). As mentioned previously, baseline measurements are taken at the time of restoration. Probing depths are measured from a fixed point (generally the restoration margin) at four or six sites around the implant, and measurements at ADE/maintenance appointments can be compared to those taken at baseline. Probing healthy peri-implant tissues should yield similar measurements to probing healthy periodontal tissues. In general, shallow PD <3mm are considered to be normal. It should be noted, however, that in some situations, implants may be intentionally placed ‘deeper’ (i.e. more apically) than usual; for instance, in the aesthetic zone, to improve emergence profile. In these cases, there may be slightly deeper PD at baseline. This illustrates the importance of taking an accurate baseline measurement, and monitoring PD over time. Indeed, while an CADMUS 2012

isolated PD reading on its own is not diagnostic, animal studies have shown that increasing PD over time is indicative of progressive attachment and bone loss (Lang et al., 1993, Lindhe et al., 1992). Furthermore, whilst PD >3mm at baseline is not necessarily a sign of pathology, it has been shown that PD >6mm is generally a sign of peri-implantitis and is associated with progressive bone loss (Fransson et al., 2008).

Bleeding/suppuration on probing Bleeding on probing (BOP) is indicative of inflammation in the tissues, and in conjunction with other findings, is a valuable sign in diagnosing peri-implant disease. Early research showed that BOP was observed at a majority of peri-implant mucositis and peri-implantitis sites (Lang et al., 1994), and more recent studies have shown that repeated BOP over a two year recall interval was predictive of disease progression (Luterbacher et al., 2000). Suppuration indicates the presence of infection and inflammation, and is often a sign of peri-implantitis (Roos-Jansaker et al., 2006). Thus, increases in PD over time, particularly in association with BOP/suppuration, should alert clinicians to possible disease progression. There seems to be some apprehension among clinicians as to whether or not probing will damage the implant or the soft tissues. Whilst there is some evidence that repeated probing during the integration phase is associated with alterations in the mucosal seal around the implant (Schwarz et al., 2010), it has been shown that once an implant has integrated, probing will not damage the mucosal seal (Etter et al., 2002). A recent study also showed that probing with a metal probe had no effect on abutment surfaces (Fakhravar et al., 2012). Thus, probing around implants is safe, and represents the most valuable diagnostic tool available for assessing peri-implant health and detecting peri-implant disease. It has been suggested that peri-implant probing depths and presence/absence of BOP should be recorded at least annually (Lindhe and Meyle, 2008). Given that ADF members are required to attend an ADE each year; this should be easily achievable for all implants in ADF patients. Patients with a higher risk profile may require more frequent monitoring.

Radiography Intraoral radiographs may be used to monitor crestal bone levels around implants over the long term. Following integration, baseline radiographic marginal bone levels (in relation to the implant shoulder) should be established with periapical radiographs, with care being taken to maintain consistent angulation of films to aid comparison over time. There is no accepted protocol dictating a requirement for regular follow-up radiographs, though as a general rule, many practitioners take a periapical film one year after implant placement. From this point onwards, it is generally recommended that radiographs only be taken when clinical signs suggest peri-implant disease (Salvi and Lang, 2004). Early pathologic or modelling changes in bone are often not visible on conventional radiographs. However, once established, peri-implantitis lesions often appear radiographically as ‘saucer-shaped’ radiolucencies around the implant in the crestal bone (as shown in Figure 2).

Mobility Mobility is generally a sign of complete loss of osseointegration, and represents implant failure. Removal of the implant is indicated in this situation. If the mobility is related to the restoration and not the implant fixture, it may be possible to repair/replace/ re-insert restoration. If either of these situations is encountered,

Figure 2. ‘Saucer-shaped’ pattern of bone loss ten months after implant placement. Figure 3. CIST protocol (adapted from Mombelli and Lang, 1998). it is generally best to refer back to the relevant specialist for further management.

Management of peri-implant disease While successful treatment of peri-implant diseases has been reported in numerous short-term studies (Roos-Jansaker et al., 2011, Serino and Turri, 2011, Heitz-Mayfield et al., 2012), treatment outcomes are often unpredictable (Charalampakis et al., 2011, Roccuzzo et al., 2011), and rate of disease recurrence is very high. Whilst many types of surgical and non-surgical treatment have been reported, there is currently no consensus on the most appropriate treatment methods (Esposito et al., 2012). In the absence of validated treatment guidelines, many clinicians use a protocol known as CIST – Cumulative Interceptive Supportive Therapy (Mombelli and Lang, 1998). Figure 3 summarises the protocol, and shows the suggested treatment for various clinical presentations. It should be noted that the ‘+ signs’ on the right of the figure indicate the cumulative nature of the protocol. For example, <3mm pocketing with plaque and BOP should be treated with treatment A (mechanical debridement, polishing, and thorough OHI), whereas 4-5mm pocketing would be treated with treatments A + B (i.e. not just B alone). Treatment B consists of chlorhexidine rinses (30 sec, twice a day for 3-4 weeks). If pocketing persists, or where clinical signs point to more advanced disease, referral to a periodontist is recommended. Whilst the DO/SDA-P usually will not be treating cases requiring more advanced treatment (i.e. treatments C and D), they have an important role in detecting clinical changes, instigating initial treatment, and referring where appropriate. Note that the probing depths used in this protocol are guidelines, and as stated previously, initial probing depths around implants may vary in a number of situations. As such, it is important for DOs to monitor changes in probing depths compared to baseline, and the presence of inflammation, when assessing peri-implant health, and prescribing treatment/referral.

Maintenance of implants An unfortunate misconception among many patients (and even a few dentists) is that once implants are placed, they can be forgotten about and will last for many years without further attention from the clinician and without any need to modify oral hygiene practices. Whilst some patients may get away with this approach, the reality is that implants require ongoing maintenance and proper home care. A recent study reported that inflammation in peri-implant soft tissues was predictive of future attachment loss, and that patients who did not undergo regular monitoring and preventive maintenance were at higher risk of disease progression (Costa et al., 2012).

Oral hygiene: Due to the structure of the peri-implant tissues and difference in shape of implant crowns compared to teeth, additional oral hygiene measures have been recommended for cleaning around implants. Indeed, toothbrushing and conventional flossing alone are often insufficient to effectively control plaque around implants. In addition to normal oral hygiene measures, all patients with implants must clean around the neck of the implants using a ‘wrap-around technique’, illustrated in Figure 4, in order to reduce accumulation of plaque below the soft tissue margin. Fray-resistant floss or tape should be used, such as the Teflon-coated varieties, to prevent separation of frayed strands of floss, which may become lodged in the soft tissues and actually contribute to inflammation. Maintenance: While the effectiveness of a patient’s oral hygiene practices will influence the accumulation of plaque around teeth and implants, professional plaque removal is often required in order to clean sites that patients are unable to adequately clean. For the DO and SDA-P conducting maintenance for a patient with implants, procedures shouldn’t differ greatly from standard hand scaling of teeth. In the absence of deep pockets, gentle debridement is usually sufficient to remove plaque without the need to use a lot of force. There has been plenty of controversy in the literature regarding the use of standard curettes on implants, with plastic, carbon fibre or titanium instruments often being suggested as safer alternatives. It is often stated that plastic instruments may have less effect on the implant surface than metal instruments, though most of the studies are 10-20 years old (Fox et al., 1990, Gantes and Nilveus, 1991, Rapley et al., 1990). A recent in vitro study found that both plastic and metal scalers caused alterations in the implant surface (Fakhravar et al., 2012). The effect of these alterations on the potential for reintegration is unknown, but it seems logical that plaque, excess cement and other debris should be removed, given the known role of these substances in the aetiology of tissue inflammation. Whatever instrument is used, care must be taken not to damage the surface of the implant or the crown. Gentle debridement to remove plaque/debris is very important in the maintenance of implants, and where appropriate force is used, will not adversely affect the implant or restoration. There is similar controversy over the use of ultrasonic instruments with metal tips, and care must be taken when using any ultrasonics to clean around implants. Maintenance programmes should be tailored for each implant patient. Similar to the maintenance protocols used for periodontitis patients, recall intervals for implant patients are influenced by the risk profile. This may not be as relevant in the ADF as it is CADMUS 2012

elsewhere, as case selection and the approval process tend to preclude higher risk patients from receiving implant treatment. Nevertheless, there are exceptions, and we also see patients who had implants placed prior to enlistment/appointment. Often, the specialists in the implant team will review the patient for the first 6-12 months, and they will generally give guidance to the DO on suggested maintenance programmes going forward. At the very least, our patients should be seen

annually, and this will allow observant DOs and SDA-P to monitor peri-implant health, maintain implants, reinforce oral hygiene instruction and provide initial intervention/referral where disease is detected. *Reference list not shown due to space constraints. To request a copy, or for general correspondence, please contact the author, MAJ Geoff Harvey: geoffrey.harvey@defence.gov.au

Figure 4 Images kindly donated by Dr Stephen Chen, Balwyn Periodontic Centre. Figure 4a: A length of floss (preferably Teflon floss/ tape) has been threaded through the mesial and distal contact points between the implant crown and the adjacent natural teeth. Figure 4b: Ends of the floss are crossed over on the labial aspect to encircle the implant crown. Fig 4c: By apically directing the ends of the floss, with a slight â&#x20AC;&#x2DC;sawingâ&#x20AC;&#x2122; action, the floss penetrates the sulcus of the peri-implant mucosa to effect submucosal debridement.

CADMUS 2012

Feature Article

Usage and Retrieval of Posts in Endodontically Treated Teeth Wing Commander Mark O’Sullivan BDSc (Hons) MDSc FRACDS MRACDS (Endo)

Wing Commander Mark O’Sullivan is a specialist endodontist, obtaining his Bachelor degree in Dentistry at the University of Queensland in 1998 and then completing his specialist training at the same university, obtaining his Masters degree in 2007. During this time WGCDR O’Sullivan also obtained Fellowship with the Royal Australasian College of Dental Surgeons in Restorative Dentistry as well as becoming a Member in the Endodontic division. He is a member of the Australian Society of Endodontics as well as a member of the Australian and New Zealand Academy of Endodontists. Following a 15 year career with the Royal Australian Air Force, WGCDR O’Sullivan is now a Reservist, with the majority of his time spent practicing in a referral based private practice in Newcastle, New South Wales.

In most situations, endodontic treatment is undertaken to address a bacterially mediated inflammatory process (the only exception being a restorative requirement for utilising the pulp/canal space for retention). Hence the treatment aims of this therapy is to remove the bacteria and provide conditions suitable for the periradicular tissues to return to or maintain a non-inflamed state. The establishment and maintenance of an effective coronal seal has been demonstrated in many scientific articles to be a key component in achieving this. As such, an effective coronal restoration is as important as effective endodontic management in order to achieve a successful long term outcome. Unfortunately in some cases, teeth that require endodontic therapy have lost a substantial amount of tooth structure and hence retention of the coronal restoration using only the residual coronal structure can be of concern. In these circumstances, options to increase the retention and resistance of the restoration to dislodgement exist through use of the pulp chamber and, when necessary, the root canal space. The placement of a post generally does nothing to increase the fracture resistance of teeth (in vitro reports of bonded posts increasing fracture resistance in immature teeth may be misleading in the clinical context due to microfracture of the initial resin dentine bond) and in most cases actually diminishes a tooth’s fracture resistance. In addition, the risks associated with post placement such as perforation (either apical or lateral) and excessive removal of dentine rendering the tooth weaker, behoves the clinician to avoid placement of a post when able. This is particularly relevant in cases when large parallel sided posts are placed resulting in loss of root dentine thickness. The loss of root dentine beyond that required to complete the root canal therapy is to be avoided, with minimal shaping of the canal permissible to allow use of an adequately sized post for resistance to post fracture. Briefly, in anterior teeth, if an indirect crown is intended to be placed, most will require use of a post due to the relatively small amount of dentine remaining following root canal therapy and crown preparation. The requirement to resist shearing and lateral forces is another factor in this decision. If a crown is not required

however, many anterior teeth can be more simply restored with a bonded core material and in doing so reduce the risk for a nonrecoverable restorative failure, which is increased once a post has been placed. In premolar teeth, being generally larger than anteriors, there becomes less of a requirement for the use of posts, particularly when crowns are placed. However, as they also are subject to a reasonable degree of lateral/shear loading and due to the shape of the pulp chambers, they frequently require the use of posts to retain the core when dentine walls are thin or have been lost. In molar teeth, the requirement for the use of posts should be significantly less. Most endodontically treated molar teeth have sufficient remaining dentine and/or depth within the pulp chamber to retain a sufficient bulk of core material to resist dislodgement. Molar teeth are also generally subjected to a greater axial loading pattern and are not required to resist significant shearing forces. It is thus commonly accepted that in most cases of sufficient pulp chamber depth, a molar tooth with at least one remaining dentine wall does not require the use of a post to retain the core. Generally speaking then, a decision to use a post within the root canal becomes a subjective decision depending on the case presentation. However, it goes without saying, that a post should only be used when there is insufficient remaining coronal tooth structure to support and retain the overlying restoration.

Post Systems There are a multitude of post systems available in the dental marketplace all espousing various benefits and suitability, thus posing a challenging choice when selecting an appropriate material. It is not within the scope of this article to cover all of these systems, but for brevity a short table of comparison is provided: (Table 1). In summary then, reviewing our aims of restoring the endodontically treated tooth, use of a directly placed post system is perhaps the preference as they are easy to use, achieve a coronal seal CADMUS 2012

In cases that have been restored with the use of posts, retrieval can pose difficulties. Factors such as size, position, material and remaining dentine are some of the assessment criteria that should be considered when determining a management approach when treating such cases. In the main, most restorations can be dismantled with minimal loss of underlying tooth structure if managed well and this is paramount as a further loss of structure in an already compromised tooth may render it further susceptible to crown/root fracture or indeed unrestorable. Table 2 lists some key features to appreciate when assessing suitability for retrieval of a post. Depending on this assessment some retrievals can be achieved using a normal restorative armamentarium whereas in some cases, to minimise further loss of tooth structure, specialised instruments and techniques must be employed. Generalising, posts that are assessed as being poorly adapted (ie parallel sided in a tapering canal) are easily retrievable once the overlying core is removed and a small amount of the coronal luting cement broken away. For the general dental practitioner, an approach that involves first removal of the overlying restoration/crown and then careful dissection of the core away from the post is the first step in this process. Once this has been achieved, use of an ultrasonic will break up and dislodge any thin remaining sections of core and most luting cements that will lie around the coronal third of the poorly fitting post. Once this circumferential material is dislodged, “activation” of a metal post using the ultrasonic instrument will likely further disturb the apical luting cements, eventually loosening the post for removal.

immediately, and with modern bonding systems achieve excellent resistance to displacement and fracture. In situations where there is a high shear stress (anteriors and some premolars depending on remaining dentine), use of a cast system may be preferable due to its higher level of shear resistance without resorting to an excessively large post section (hence requiring greater removal of dentine). The evidence base would support this position as while in vitro tests seem to favour the bonded fibre-based or metal systems, most clinical studies find no significant difference in outcome between cast systems and metal/fibre post systems.

Retrievability Unfortunately a well documented fact is that there is a high degree of post treatment disease associated with root filled teeth. This is common across numerous cross-sectional studies in all countries with incidences of disease presence reported (on average) in 40% of cases reviewed. This high level of disease persistence appears to remain a chronic presentation and may be deemed a ‘survival success’ as seems to be popular in some outcome studies; however the expectation is this process will reach an acute inflammatory stage at some point warranting management. CADMUS 2012

In posts that are more closely adapted, the technique for removal also requires circumferential removal of the coronal core and luting cement (if accessible) although in order to minimise dentine removal, excessive troughing around the post is contraindicated. In these cases a combination of ultrasonic activation of the post along with application of a traction or lifting device (post puller) is required. In the ADF, a good general purpose post removal device is catalogued for use and can be ordered as an identified item (Figure 1). Known as the Ruddle Post Removal System (Sybron Endo), it incorporates a set of trephines, taps and a traction device to allow withdrawal of metal (cast or prefabricated) posts in a vertical axis. . Use of this device does not require additional specialised equipment or training, however the author would encourage the clinician to trial its use on an extracted tooth with simulated cemented post (self generated) in order to become familiar with the requirements of the system. Figure 1: Ruddle Post removal system.

Additional Armamentarium As is commonly encountered in dental practice, undertaking more advanced procedures without the ideal equipment can be a frustrating and difficult process. In regards to post removal, other than the abovementioned ‘post puller’ device, certain items are usually required to effect this procedure.

Burs Long shanked, small head, carbide burs enable the clinician to dissect the core from the post with precision, ideally minimising removal of any remaining dentine. Use of magnification (dental loupes) is essential in this task to allow selective cutting as commonly the core material is substantially harder than the surrounding dentine and errant gouging of the dentine is a risk of this process.

Ultrasonics Use of ultrasonic tips are advantageous to both remove luting cements and restorative materials as previously discussed. In addition, activation of the post itself is useful to effect a final removal and in most cases, use of an ultrasonic negates the use of any traction devices. It results in a quick removal for a great number of posts. In saying this, without the use of dedicated endodontic ultrasonic units, which can provide a far greater level of energy application, some posts can be difficult to retrieve. Without a dedicated unit, use of the EMS style ultrasonic is a viable alternative. Specialised endodontic tips are available which allow fine trephining around posts for cement removal (which can be performed dry), whilst the normal periodontal tip allows sufficient power to loosen a post once this coronal cement has

been removed. Copious water spray should be used when using the larger tips to activate metal posts with ultrasonic energy as heat conduction through the post can lead to substantial rises in temperature if not adequately cooled.

Summary The use of a post system as part of the coronal restoration of an endodontically treated tooth is not always necessary. When required, an appropriate choice of material, size and technique to minimise loss of root dentine and hence minimise any loss of tooth strength, is critical to the long term restorative prognosis of the tooth. The retrievability of the post system chosen is also a factor in selecting an appropriate option, as in some cases there is a requirement to re-enter a root canal system to treat persistent disease. Whilst challenging, removal of a post is a predictable and achievable process, although it requires care to minimise further loss of tooth structure. Due to this and the ready availability of instruments to effect this procedure, the orthograde retreatment of the root canal system remains the first choice option over a surgical approach despite the presence of a post within the root canal space. Associated reference list is not shown due to space constraints. To request a copy please contact the editor.

CADMUS

CADMUS 2012

Feature Article

Vision Keys for Precise Oral Surgery Dr Stephen MacMahon OBE BDS(Syd) FRMS FDSRCS(Eng) BA(Aviation)

Dr. Stephen MacMahon OBE has almost 40 years experience in Minor Oral Surgery. He was a staff member at Westmead Hospital in Oral and Maxillofacial Surgery Department for 20 years, having retired at the end of 2011. During his years at Westmead Hospital, he was actively engaged in teaching undergraduate and post-graduate students in Minor Oral Surgery. For 12 years, he also participated in preparing an undergraduate programme in minor Oral Surgery for Dental Students at the Fiji School of Medicine. He retired from this service five years ago but is a regular examiner to the school. He has been a member of the Dental Team at HMAS KUTTABUL for the past 10 years and continues to treat ADF patients at his rooms. Semi-retirement has given Dr MacMahon more time to finish a manual in Minor Oral Surgery.

Introduction Minor Oral Surgery, or precisely Dento-alveolar surgery, consistently falls into the realms of ‘uncertainty’ for the inexperienced Dental Surgeon. As Dentistry has exited out of the era affectionately referred to as ‘blood and guts’ dentistry, into an era of sophisticated preventive and restorative Dentistry, the art of exodontia and minor oral surgery appears to be pushed back into a minor role in undergraduate training. Hence the new graduate lacks experience when confronted with such tasks, especially when no support is available. Grasping fundamental steps in this surgical discipline, goes a long way in developing a procedure of understanding, which in practice, and when adhered to, makes the outcome a better experience for the operator and patient alike.

Vision keys for precise surgery The ideal outcome of any minor surgical procedure can be outlined as follows: 1. To successfully remove a tooth, fragment or tissue with minimal trauma to the surrounding tissues for rapid healing and low morbidity. 2. To complete the surgery with minimal stress to the patient and also the operator. 3. To maintain a high standard of infection control with the surgery. To achieve this outcome, certain ‘Vision Keys’ need to be adhered to, to get an ideal outcome and can be outlined as follows: 1. Sound Diagnosis and Treatment Planning for both the existing problem and the total patient. 2. Must utilise appropriate consultation and referral. 3. Competence for the surgical procedure. 4. Preparation for emergencies, complications or threat to patient’s safety during the intra-operative and post-operative period.

Diagnosis and Treatment planning Any treatment planning will be determined by the patient’s medical history. A methodical approach to obtaining a medical history is mandatory in the first instance. One can then ask oneself two questions: CADMUS 2012

1. Will the patient’s medical condition compromise the surgery? 2. Will the surgery compromise the patient’s medical condition? Once this information is on board, a thorough dental examination is required. Unless the patient’s dental condition requires urgent management, it is wise to consider caries stabilisation and plaque control prior to surgery. If any of the abutment teeth to the surgical site have deep caries, it is essential to place sedative dressings or pulpal extirpation prior to the planned surgery. This vital step will hopefully avoid any dental interference of the abutment teeth or neighbouring teeth during the healing phase of the surgery. Remember: All surgical cases, whether intended or emergency, must be precisely planned. This step is one of the greatest failings of the inexperienced operator. A plan should be made and adhered to unless by other unforeseen circumstances, an alternate plan needs to be made. Once this discipline has been achieved, the procedure should have a more predictable outcome. Surgical Planning There are 3 stages to surgical planning; 1, ACCESS 2. METHOD OF DELIVERY OF THE TOOTH OR FRAGMENT 3. CLOSURE 1. Access Access to a surgical site is achieved by an incision and reflection of a clean muco-perosteal flap. A flap has to be designed to achieve access for adequate instrumentation to deliver the tooth or fragment. There are a list of rules that need to be considered for flap design: 1. The margins of the flap must rest on sound bone when repositioned to achieve optimum healing. 2. The base of the flap must be broader than its apex to maintain a good blood supply for closure. 3. Two sided flaps are preferable for access and vision. 4. The flap itself must be broad enough for good access. 5. The relieving incision must, in most cases, be on the mesial side of the wound for access and vision. 6. The relieving incision must end in ‘free gingiva’ for adequate reflection.

7. The relieving incision must end on the mesial side of the abutment tooth to the surgical site. 8. The relieving incision must have a tapered flare to avoid tearing it backwards, thus compromising the vascularity of the flap. If the flap has a tapered flare, it will tear forwards. Whilst a tear in the flap is not desirable, it is better to tear forwards, thus not compromising the vascularity. 9. The flap must contain intact periosteum and mucosal tissues for better healing. Separation of the periosteum and mucosal tissue will compromise healing. As surgeons, we must think in tissue planes. The tissue plane we develop in our flap is the subperiosteal tissue plane and this is the plane of flap reflection. (i.e. between bone and periosteum) 10. The design of the flap must accommodate any potential complications of the surgery. To achieve primary closure, such as in cases of an antral communication or for any other reasons, the flap design should only accommodate the abutment teeth of the surgical site. You may also need to incorporate additional papillae in the design to avoid vital structures, such as the mental nerve. 11. The entire papilla must be taken in the flap design. Splitting a papilla will definitely lead to tissue necrosis. When working in the aesthetic zone, it may be preferable not to involve the papilla at all.

12. Try to avoid taking additional papillae in your flap design if possible, as each papilla reflected in your flap will become a nidus for future periodontal problems for the patient. Flap design can be prepared by using an imaginary grid as seen in Fig. 1. Two imaginary lines can be drawn down the long axis of the abutment teeth to the planned surgical site. A horizontal line drawn across the “muco-gingival junction” now divides the surgical site into six boxes. The two middle boxes represent the surgical site; the outer upper and lower boxes represent the margins of the surgical site where it is hoped the flap will be laid back on sound bone after the surgical delivery is complete. With a two sided flap, the relieving incision should have a curve ending in the upper right box which represents the free gingiva. If the relieving incision ends on the mesial side of the long axis line and in free gingiva, it can be reflected easily away from the surgical site without any tension, creating good access. One other important point about flap reflection, the blade MUST incise down to bone, directly perpendicular to the underlying bone. If the incision is cut on an angle, filleting of the flap will result and significant scarring post-operatively:

2. Method of Delivery There are three ways a tooth, whether impacted or standing in the arch, or a tooth fragment can be removed: a) Reconversion b) Elevation c) Sectioning and elevation.

a) Reconversion: Reconversion simply means preparing the surgical site by converting the tooth or root into a simple forceps delivery. There are certain criteria for reconversion: • This technique normally applies to single rooted teeth, but can also apply to well structured multi-rooted teeth. • There needs to be sufficient tooth structure, at or above the bony socket, on the lingual aspect of the tooth. • Very unforgiving single rooted teeth will render well to reconversion. • Very unforgiving multi-rooted teeth without complex root patterns will also render to reconversion. • Situations where buccal movements may fracture the buccal plate involving neighbouring teeth, will also render to reconversion. For example, an upper second molar when there is standing first and third molars evident.

Figure 1: Flap design

The technique of reconversion surgery involves the following steps: • A mucoperiosteal flap is raised, as planned. • Volume bone reduction using no more than a ROUND BUR. Only the buccal face is reduced. • Approximately 50% of the face of the root is exposed by bone removal. • The root is then delivered with forceps. CADMUS 2012

b) Elevation:

3. Closure

With this technique, we are preparing the surgical site for delivery with elevators.

Planning wound closure is often one of the most neglected aspects of surgical planning.

There are requirements for an elevation technique: • The operator must have good workable instruments. • The flap design must be adequate for elevation (if a surgical flap is used) • Their MUST be an adequate ‘path of withdrawal’ for the tooth or tooth fragment. (may need to use a round bur to create this access). If a root apex is left, the root must be accessible for good vision and be able to be worked with instruments. • Must follow principles of a workable gutter: – The gutter must be deep enough to allow the elevators to work – The gutter must be in cortical bone. – The gutter must be narrow enough to start working with narrow instruments and work up in size as the tooth or fragment starts to move. • There are two valuable rules to consider when deciding a method of action. – You always attack the STRAIGHTEST and/or the HIGHEST root first. – Aim to convert a horizontal root fracture to a vertical root fracture for ease of delivery. • A gutter is always prepared with a tapering fissure bur NOT a round bur.

c) Sectioning and Elevation: This technique is used mainly for removal of teeth with complex root patterns that have conflicting paths of withdrawal or when removal of the tooth may compromise an adjacent tooth or vital structures. It is also considered when excessive bone removal is required for delivery of a tooth or fragment. There are rules that must be obeyed when considering this method of delivery: • Adequate guttering is required so that the desired elevator will function. • There must be sufficient exposure of the root/roots for precise elevation. • Always make sure the sectioned roots are adequately sectioned and checked with an elevator before proceeding with delivery. • Always attack the straightest and/or highest root as a priority. • When a sectioning technique is considered for an erupted tooth standing in the arch, it is wise to decoronate the tooth before sectioning. This is better for access and instrumentation. CADMUS 2012

Closure normally involves four steps: • Meticulous wound debridement. Making sure no fragments, debris or saline remain in the wound. After wound irrigation, ensure all saline is removed as saline can weaken the vital blood clot required for healing. • Haemostasis needs to be assessed. Are there any bleeding points? Are additional clotting agents required for haemostasis? Is the patient on blood thinners? • Relocation of the flap is a vital step. If primary closure is required, such as in cases of exposure/perforation of the maxillary sinus, the flap will need to be released. Releasing the flap so that it can be advanced without any tension, can be achieved by releasing the periosteum high in the vault of the flap. Prosthodontic considerations, such as making sure the prosthodontic loading is on keratinized gingiva after flap relocation, is a vital step. The ideal method of tacking the flap down so that the mucogingival junction follows its correct line is best achieved by tacking the relieving incison with the first stitch; this will avoid dragging the flap towards the lingual. Unless primary closure is required, tacking the mesial papilla to the lingual side of the flap as a first stitch will inevitably result in having the mucogingival junction advanced into the region of prosthodontic loading, which is undesirable. • Provision for wound drainage is also an important consideration for a good post-operative outcome. Wound drainage is a MUST, whether via the open socket or a relieving incision and will prevent a collection of fluid; which will lead to excessive postoperative swelling and delayed healing. This is particularly important in lower third molar surgery where post-operative oedema can be enthusiastic.

Summary The ideal outcome of any surgical procedure can be best achieved by astute planning prior to the surgery. Consistency in planning will lead to consistent results and also personal satisfaction. The purpose of this article is to outline these basic practical steps. This paper is also a summary of a prepared lecture on treatment planning in minor Oral Surgery. Surgery is no different to any other discipline in Dentistry; a sound basis in planning and following this treatment plan to the letter, should help the young dentist to achieve more consistent results in minor Oral Surgery. Associated reference list is not shown due to space constraints. To request a copy please contact the editor.

Feature Article

The Accuracy of Cone Beam CT Radiography in Implant Dentistry Dr Haresh Kankotiya BDS

Dr Haresh Kankotiya is working in Private practice and also at HMAS ALBATROSS. He is currently pursuing a Post Graduate Diploma in Implantology at Charles Sturt University, NSW. Mentor: Dr Luke Villata Periodontist SYDNEY AUSTRALIA

Keywords: CBCT, MDCT, dental implants Abbreviation: CBCT : Cone Beam Computerized Tomography. LCBCT : Limited Cone Beam Computerized Tomography. SCT : Spiral Computerized Tomography. HU: Hounsfield Units. MDCT: Multi Detector Computed Tomography. FOV : Field of View. DICOM : Digital Imaging and Communications in Medicine. 3D : Three Dimensional. II : Image intensifier. BV/TV : Bone Volumetric Fraction. FPD : Flat Panel Detector. MSCT : Multi-Slice Computed Tomography

INTRODUCTION The pre-surgical planning of a dental implant requires accurate and specific data regarding proposed implant sites. It also requires consideration of anatomic and prosthetic factors to assess the best placement sites in order to achieve the greatest chance of success.[1] This could be achieved by radiographic examination. [2] CT (MDCT) has been used as the most accurate and reliable modality for the dental implant site assessment for many years. [3] However, it has its own limitations. In order to overcome those limitations, volumetric tomography devices, such as cone beam CT, were developed for their use in the maxillofacial area. [3] CBCT can be used for pre surgical evaluation of dental implant receptor site; to assess alveolar bone defect; to plan bone augmentation procedures; to plan sinus augmentation procedures and to validate the 3D placement of implants by postoperative scanning.[4] It can also be used to depict fine anatomic structures, which are important to avoid while planning for a dental implant. [5] However, CBCT imaging is still not the imaging modality of choice in some clinical situations, for instance complex cases. Further clinical studies are required, as this technology continues to evolve quickly.[6]

Comparison of CBCT with CT Although CT has been frequently used for pre-surgical assessment for a dental implant, information provided by CT does not always justify the high radiation dose.[7] Also, while evaluating reformatted CT images, there is a possibility of spatial distortions owing to the anisotropic nature of the voxel, resulting in

reformatted images with lower accuracy than the original axial scans.[3, 7] A radiologist is required for acquisition and analysis of the CT images and not the dentist or maxillofacial surgeon, which increases the overall cost for the CT images.[8] CT also has many other limitations, including device cost and operational limited availability. CT images can also show metal streak artefacts when metallic dental restorations are present[9] and is more significant with MDCT than CBCT.[6] However, due to beam hardening and other limitations of CBCT, when comparing MDCT and CBCT, metallic objects result in similar weaknesses.[6] The advantages of CBCT imaging modality are easy handling, improved accessibility, a single scan involving an actual-size set of data with multi-planar cross-section and 3D reconstructions with low dose radiation.[10, 11] As it is possible to produce images in any plane by primary reconstruction of the raw data, CBCT offers almost the same spatial resolution in all directions.[2, 12] CBCT offers the advantage of higher contrast resolution in all dimensions with registration of fine details of bone. This may identify CBCT as a more promising imaging modality for pre- surgical planning of a dental implant when compared to CT.[29]

Accuracy of CBCT in measuring linear dimensions Dimensional accuracy of the image by absence of spatial distortion and reproducibility of linear measurements are the prerequisites of sectional images used in pre-surgical planning of dental implants.[7] LCBCT (Limited Cone Beam CT ) can measure distance between two points more accurately than SCT (Spiral Computerized Tomography) in mandible.[2] CBCT images show high reliability of measurements independent from object position, examinerâ&#x20AC;&#x2122;s experience and high reproducibility.[7] CBCT images showed more accurate linear measurements than MDCT images.[3] However, while assessing dental implant site dimensions using CBCT and MDCT, both showed significant measurement error. When a comparison was made, CBCT measurements were more accurate but more operator dependent than MDCT measurements.[3] Therefore, when measuring implant site dimensions on CBCT or MDCT images, 1 mm of possible overestimation should be considered and correction should be performed accordingly.[3] CADMUS 2012

Geometric accuracy of the image data acquired by CBCT CBCT shows lower but acceptable accuracy for 3D surface model reconstruction when compared to MSCT (Multi-Slice CT).[13] Although geometric accuracy of CT images have been widely accepted, CBCT images can provide sufficient accuracy for pre-surgical planning for a dental implant, with the error in measurement less than 0.5 mm.[14] The slight error in measurements of CBCT images can be due to the same volumeaveraging effect as seen in the CT images.[14] The role of geometric accuracy is important in image guided surgery for registration of an accurate image and for increased safety of patients.[15] Although CBCT offers slightly lower, within fractions of a millimeter geometric accuracy, when compared to CT; it can give reasonably accurate registration and can be used as an imaging modality for image guided surgery.[15] However, there is an uneven distribution of geometric error during acquisition of imaging data with CBCT, which should be taken in to account to achieve optimum accuracy.[15] CBCT images with higher resolution, theoretically, may permit improved accuracy of the measurements; but increased noise and patient movement could counteract the benefits achieved by it.[14] However, noise in CBCT images only limits the low contrast resolution and does not affect high contrast resolution, which is the contrast needed for measuring bone dimensions at the dental implant site.[3] As CBCT has the ability to offer images with high contrast resolution, it appears to be a reliable tool for preoperative planning for dental implants.[2, 12]

Accuracy of CBCT in depicting fine anatomic structures The mandibular canal, mandibular foramen, incisive foramen and mental foramen could be observed with similar diagnostic

CADMUS 2012

information when comparing CBCT with MSCT.[5] The anatomic position; course of the bifid mandibular canal, accessory buccal foramina, accessory mental foramina, mandibular lateral and median lingual bony canals are important for pre-surgical planning of dental implants.[5] When compared, CBCT and MSCT images were consistent in depicting those fine anatomic structures in the mandible with no difference when CBCT machine with FPD and MSCT scanner were used.[5] Both CT scan images and CBCT scan images produced the anatomy with a submillimetric accuracy.[16] CBCT images with the small isotropic voxel size, in the range of approximately 0.07 to 0.40 millimeters per side, with the large number of gray levels, have resulted in accurate visualization of anatomic form. This allows for precise measurement of anatomical structure dimensions.[17] However, further clinical research in terms of location and course of anatomical structures are required. This will allow comparison of the accuracy of MSCT and CBCT images, using a different variety of CT and CBCT machines.[5]

Accuracy of CBCT in measuring bone density at potential dental implant site A standard scale for measurement of bone density is Hounsfield Units (HU)[18, 19]. It helps to study the nature of the tissue, by measuring the values of X-ray absorption by that tissue.[18] HU helps to assess bone density. Processing and scanning through 2-dimensional (2D) and 3-dimensional ( 3D) images using DICOM software can be difficult if there is no information about HU available.[18] CBCT does not have precise and objective methods to measure bone quality, as there is no calibration that has been derived for CBCT to measure bone density in HU.[20] The improvements in CBCT reconstruction algorithms and post processing may reduce or solve this problem in the future.[11]

A precise pre-surgical assessment of bone quality at the potential dental implant site is required to predict primary stability. This can result in a long term, successful outcome for dental implants. [20] There is a high correlation between bone quality evaluation by CBCT and primary implant stability. Therefore, CBCT can be used preoperatively for estimation of bone density, which may help to predict implant stability.[20] There is a high correlation between CBCT based radiographic bone density and BV/TV assessed by micro-CT at the site of dental implants in the maxillary bones.[21] Therefore, CBCT based preoperative estimation of bone density is a reliable tool to determine bone density objectively.[21] However, more clinical studies are required to validate usefulness of bone density estimation by different CBCT machines to evaluate bone density preoperatively.[21]

Relationship between imaging volume size and bone density in CBCT When compared, bone density values were more consistent and reliable in FPD based CBCT, with larger imaging volume, than the FPD based CBCT.[18] However, small FOV CBCT scan produces images with better resolution at lower radiation dose. [18] Consequently, the purpose of the CBCT examination should decide the optimal volume size.[18]

Accuracy of stereolithographic guide made by using CBCT CBCT images could be used for pre-surgical planning for dental implants, considering maximum of four degree angular and 2.4 mm of linear deviation at the apical tip when using stereolithographic drill guides.[22] However, it depends on the support and stability of the stereolithographic guide. Surgical guides without the support of the full dental arch showed more deviations. Surgical guides with neighbouring teeth showed lesser deviations in implant positioning than guides with free ends, with no teeth at their distal end.[22] There has been no precise definition for surgical navigation accuracy mentioned in the literature.[23] CBCT based surgical navigation offers equivalent geometric accuracy as compared to that of CT based surgical navigation and thus proves that the role of CBCT can be equally

important to CT in image-guided maxillofacial surgery.[23] CBCT based virtual planning and use of a surgical template for dental implant placement, shows high accuracy compared to free hand insertion of dental implants, when position and axis of dental implants were taken in to consideration.[24] CBCT can be used as an optimal method of imaging for image guided surgery, as it permits reasonably accurate registration when compared to CT.[15]

Limitations of CBCT Earlier CBCT machines used detector systems, such as an image intensifier (II), which produced halation artefact.[19] However, the artefacts with increased intensity resulted when more objects were located outside of the FOV for limited-volume CBCT.[19] New CBCT machines, with the introduction of Flat Panel Detector (FPD), produced images with less artefacts than CBCT machines with an Image Intensifier, particularly when large FOV was used. [19] However, large FOV images have larger voxel size, which leads to an image with poor object resolution and loss of fine detail.[18] It also increases radiation dose to the patient.[18] It should be noted that CBCT systems used for diagnosis in maxillofacial region, do not show enough low-contrast resolution to discriminate soft tissue structures.[11, 25] Images obtained by CBCT have more scatter leading to increased image noise and degradation when compared with MDCT images.[2, 3, 6] In addition, when compared with MDCT images, structures of interest in CBCT images do not ‘stand out’ as much. This is due to lower signal to noise ratio, resulting in a ‘flatter’ image with less variation between denser and less dense structures.[6] Low signal nature of CBCT, when compared to MDCT, results in beam hardening.[6] Newly introduced flat panel detectors in CBCT machines show less beam hardening, including artefacts due to metal, but they still show susceptibility to movement artefacts.[11] No calibration has been achieved for CBCT to measure bone density in HU.[20] Therefore, the estimation of bone density in HU cannot be done by using CBCT, due to the distortion of the Hounsfield Units (HU, CT number).[11] These limitations need to be considered, which may affect CBCT image quality and bone segmentation accuracy.[26]

Table 1. Value comparison of implant imaging modalities commonly used to evaluate implant sites.[1, 16]

CADMUS 2012

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Image quality versus Radiation Dose relationship when considering CBCT Clinicians should not solely consider the radiation dose when deciding the imaging modality for pre-surgical planning for a dental implant.[14] The optimum imaging modality should allow clinicians to fulfil the imaging goals with the lowest radiation dose, at an acceptable cost.[17] Different CBCT machines show variations in their effective dose depending upon the factors like FOV, mA setting, kilovolt (peak), scan time (pulsed or continuous), sensitivity of sensors and the number of captured images. CBCT scans, with field of view restricted to the selected areas of importance, lowers the radiation dose.[16, 17] Smaller FOV produces less scatter radiation. A reduction in the dose of radiation by 5-10 percent can be achieved by reducing the FOV by 30 per cent.[27] CBCT scans, with reduced mA or short scan time or both, can also reduce the dose but may result in poor image quality.[17] Benefits versus risks should be considered when planning a CBCT scan[4] to maximize success.[14] DISCUSSION In the pre-surgical radiographic evaluation of dental implant sites, an evidence-based literature review suggests that CBCT may be more practical and reliable than CT imaging modality.[29] However, available literature currently only depicts in vitro experimental studies, so their reproducibility in vivo is yet to be determined.[29] Also, studies were conducted by ideal practitioners under idealized conditions, so they only prove efficacy not effectiveness. Therefore, studies in practical situations, where conditions are not idyllic, may show a difference in the true clinical results.[29] Different CBCT machines with different technologies, variable FOV and variable radiation dosages can provide different image

quality.[25] Therefore technical specifications of different vendors must be taken in to consideration, when evaluating CBCT imaging modality in implant dentistry.[25] The data acquired by using CBCT should be carefully interpreted by a clinician with adequate training and experience; in order to deliver optimum results to the patient and clinician.[28] Maxillofacial imaging by CBCT will improve with further advancement in CBCT reconstruction algorithms in order to estimate and measure bone density.[11] CONCLUSIONS CBCT is the new hallmark of imaging in implant dentistry. The role of CBCT imaging modality in pre-surgical radiographic evaluation of potential dental implant sites appears to be promising. It provides reasonably accurate diagnostic images; with an absorbed dose that is comparable to other 2D imaging modalities and less than conventional CT. However, more evidence based clinical trials or in vivo studies are required. CBCT technology continues to grow rapidly, with upgrades of CBCT units and refinement of software. COMMONWEALTH OF AUSTRALIA Copyright Regulations 1969 WARNING: This material has been reproduced and communicated to you by Dr Haresh Kankotiya pursuant to Part VB of the copyright Act 1969 ( The Act) The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act.

Associated reference list is not shown due to space constraints. To request a copy please contact the editor.

CADMUS 2012

Technique Tips

anaesthesia 8 Steps to Improve Mandibular Blocks Dr Stephen MacMahon OBE BDS(Syd) FRMS FDSRCS(Eng) BA(Aviation)

1 USE OF THE FOREFINGER TO RETRACT TISSUES AND IDENTIFY ANATOMY: At undergraduate level, some have been taught to retract the tissues with a mouth mirror when giving mandibular blocks. This is fine for an inexperienced operator to avoid a “needle stick injury”. The main flaw in this technique is that you have no tactile sense where the local anatomy is represented. Resting the forefinger of the left hand for right handed dentists (opposite for left handed dentists) on the external oblique ridge will trigger to your brain a much better representation of the local anatomy. 2 PUNCTURE POINT: Once you have identified the external oblique ridge and the pterygo-temporal depression (depression formed by a folding lateral to the pterygomandibular raphe), the puncture point is ½ way between the two. With your finger resting on the external oblique ridge adjacent to the third molar, the height of the puncture point is the highest point of your finger. 3 APPROACH OF THE SYRINGE: Traditionally, the approach is from the opposite premolars. This however, is not always possible due to limited mouth opening or hyperfunction of the patients tongue. In these cases, don’t be frightened to gently bend the needle and approach from a different aspect that will give you access for the block. 4 PATH OF INSERTION: The path of insertion MUST be parallel to the occlusal plane of the lower. Despite performing blocks for 40 years, I always check this and ask myself; “am I parallel to the occlusal plane of the lower?” For a Class 2 occlusion with over erupted lower incisors, ONLY use the posterior teeth. For an edentulous case, use the posterior mandibular ridge. 5 DEPTH OF INSERTION: The ideal depth should be no more than ½ the length of a long needle (19mms of a 38mm needle). If the depth is deeper before hitting bone, you are too medial and will result in a marginal block. Withdraw and realign laterally. If you hit bone too soon, withdraw slightly and advance medially preferably along the medial surface of the ramus. The absolute ideal block is to feel the lingual, slide over the apex of the lingual into the pterygomandibular space and deposit the solution. 6 POSITIVE ASPIRATION: Remember the trunk of the ID nerve approximates the vessels. If your aspiration is positive, “withdraw” the needle and maintain CADMUS 2012

some backward pressure with aspiration until no further blood contaminant is seen. Advance again on a slightly different angle, check again and if negative, deposit the solution. Remember a positive aspiration means that you must be close to the nerve. If you get lots of positives, it usually means that your technique is good but unlucky you hit a vessel. If you don’t get any positives, you may have to rethink your technique as you most likely are shooting too deep or too medially. 7 BE GENEROUS IN LOCAL AMOUNTS: Unless you are using large volumes approaching maximum safe dose, it is quite safe to give good volumes of local. Consistent good results in achieving LA will enhance your confidence. 8 LENGTHY ANAESTHESIA: Any operative procedure that is going to be painful post-operatively, consider pre-emptive analgesia by topping up with Marcain. It is obviously desirable to have lengthy anaesthesia for surgery but also consider cases of endodontics and especially hyperaemic pulps.

Problem Solving: Q: A:

Patients lip is numb but the tooth is still sensitive. Most likely insufficient anaesthesia around the trunk of the nerve (Have I shot too deep?) Don’t live in self denial! Believe the patient.

How long should it take for a patient to be numb after a successful block? No more than 5 to 7 minutes. Any longer, the block will be marginal.

A: Q: A:

How do I check if a block is successful? Gently probe the gingival sulcus of the lower canine tooth. (If patient feels discomfort, the block has failed)

Q: A:

Is it a problem if you see any skin blanching after a block? The peripheral skin vessels have collapsed due to an intravascular injection. Reassure the patient this is only a temporary affliction. There usually is good collateral circulation in the skin to keep it viable.

What is happening if you administer LA and whilst dispensing the solution, the patient feels excessive stinging? You are administering the LA into a vessel. Stop and withdraw immediately. Be ready for some skin blanching if you have administered some solution. (Same as above problem)

Q: A:

What is happening if whilst you are inserting a needle and a patient feels an electric shock in either the lip or the tongue? You have unfortunately penetrated a nerve trunk. DO NOT ADMINISTER ANY LA but withdraw the needle and reposition. Any LA administered into a nerve trunk will automatically result in a paraesthesia.

Technique Tips

endodontics C-Shaped Canals and How to Identify Them Dr Patrick Caldwell BDSc(Hons), FRACDS, MDSc(Endo), MRACDS (Endo)

Endodontists often receive referrals for molars indicating that the dentist has had trouble locating all the canals. A proportion of these cases are the result of C-shaped anatomy which can be tricky to manage from an endodontic perspective. The canal anatomy is quite different to normal molar anatomy and often merges apically into broad thin canals. Identifying these anomalies prior to entering the tooth can save a lot of confusion. The things to look out for are:

2 Teeth without a definite separation between the roots; 3 Roots with a lucent line running between and parallel to the canals. Take a look at the pre-op radiograph below, you can see a mesial canal and just make out a distal canal. There is a radiolucent line running vertically between the two, indicating that the two roots are fused. The post-op radiograph shows the complexity of the anatomy in this tooth.

1 Conical shaped roots;

CADMUS

CADMUS 2012

Technique Tips

endodontics 8 Steps to Diagnose Oro-Facial Pain Lieutenant Commander Peter Case BDSc (Hons) DClinDent (Endo)

Conditions that affect the dental pulp and periapical tissues have the ability to cause significant orofacial discomfort for patients. Orofacial pain has been shown to have a negative impact on quality of life. In a military environment, this can lead to reduced efficiency and potential failure to complete an operational critical tasking. Careful diagnosis and thorough treatment planning is mandatory. Here are a few helpful hints to stimulate your diagnostic thought processes: 1. When diagnosing orofacial pain, listening to what the patient tells you and taking an accurate history is equally (if not more) important to what you observe clinically. How good are your listening skills? Next time you are obtaining a patient’s history, get your assistant to time how long it takes before you interrupt. You will be surprised how quickly we stop listening and start counselling. 2. A thorough clinical examination that includes both the soft and hard tissues of the oral cavity is important. Good illumination is essential and a high level of magnification is desirable.

3. Once you have established a history, you need to positively identify the cause of the patient’s discomfort. This is done by carefully isolating and testing teeth with an appropriate stimulus. It is important to accurately record sensibility test results as well as factors that stimulate or reduce the level of discomfort. 4. An accurate radiographic examination of the region is essential. The field of view of a radiograph must be appropriate. The film/ sensor must be correctly exposed to ensure good visualisation of anatomical structures. Periapical radiographs are used to examine the root structures and periapical tissues. However, don’t forget to take a bite wing radiograph to check for caries and accurately assess the depth of restorations. 5. Don’t forget to examine the occlusion. 6. If you are unsure, don’t be afraid to get a second opinion. 7. Once you have completed your history, examination and diagnostic tests, correlate the results to form a diagnosis. 8. DON’T START TREATMENT IF YOU DON’T HAVE A DIAGNOSIS!

Technique Tips periodontics Some Observations on Distal Site Progression on Second Lower Molars after Removal of Third Molars Dr Matthew Hunter BDS(Lond), BSc(Hons), MClinDent(Lond), MSc(Lond), LDS.RCS(Eng), FDS.RCS(Eng), FFD.RCSI(Perio), MRD.RCS(Eng)

Impacted mandibular third molars have many complications and the types of proximity pathology associated with the distal surface of the second molar are well documented. Prior to contact, biofilm and funnelled food debris accumulates. Root resorption was originally thought to occur infrequently, however a subsequent histological study1 indicated nearly all second molars experience degrees of root resorption when the third molar is impacted. Once contact is established and periodontal disease progresses, attachment loss extends around the contact zone. Root surface caries may become established, due to stagnation and infra-bony defects can develop. Does removing the third molar solve the problem? Unfortunately no, the attachment loss and resorption pits enable the biofilm to remain established, facilitating the progression of infra-bony defects. A series of Swedish studies originally indicated that the risk of ongoing periodontal defects increases after third molar extraction in patients over 25 years of age and pocket depths 6mm or greater2. Even in cases where no prior periodontal pathology is present; sites can develop and progress after surgery3. There have been some studies suggesting improvements in sites if the removal of the third molar is combined with a regenerative membrane procedure, but other authors indicated little improvement with membrane systems. Even suturing has been shown to be significant in attachment gain after extraction. However, the problem with all the studies is the lack of agreement on how to measure the initial site parameters, with a third molar blocking the probe! In addition, most studies did not provide a control for allocation, smoking, measurement or masking.

So if removing the third molar does not solve the site, what can we do? There is limited information from a controlled study that showed scaling and root planing with ultrasonics intra-surgically, combined with post-operative chlorhexidine rinsing for two weeks, significantly reduced the probing depths. Interestingly there was also a significant reduction in post-operative discomfort and pain. However, no significant changes in attachment level were evident4. What is the direction for future research? A systematic review, published earlier this year, isolated only four articles on the effects of biofilm removal from 674 studies; of these four only one could be interpreted, but with caveats5. As a result, there is currently a need for prospective randomised controlled trials to determine the best treatment for preventing and treating site deterioration distal to second molars after third molar removal. The first step is to identify the controlled effect of intra-surgical removal of biofilm from the distal surface of second molars, against which the effect of more sophisticated regeneration procedures can be compared. What remains after this statement for practical use? Minimal evidence suggests that effective pre-surgical debridement is important. The biofilm should also be removed from the distal surface of the second molar after the third molar is extracted and the site is accessible, or in subsequent appointments. Associated reference list is not shown due to space constraints. To request a copy please contact the editor.

Oral Health Promotion Activities across the ADF â&#x20AC;&#x201C; 2012

Left: Inter-Service brushathon; Centre: Tastings for Defence Recipe Challenge 2012 (see Pg 75); Right: Dental Health alth Week Week, Defence News News.

CADMUS 2012

Technique Tips

prosthodontics Making a Great First Impression David Sykes BDS, MDS, LDS, RCS, FRACDS, MRACDS (Pros)

Introduction To ensure you obtain accurate, reproducible impressions every time, here are some tips and tricks for improving your crown and bridge impression technique. Two commonly used materials for these impressions are polyvinyl siloxane (eg Aquasil, Extrude, Imprint, Affinis) or polyether (eg Impregum, Permadyne). Any of these will work well and choice should be made on personal preference.

The fundamentals of quality impressions 1. Thoughtful tooth preparation: Keep margins supra-gingival, if in noncritical aesthetic areas. Place #0 size cord around the tooth before refining the margins, especially in the aesthetic zone. This retracts the gingival margin sufficiently to allow preparation of the margin into the gingival sulcus. The gingiva will then rebound to hide the margin. Protect gingiva with a flat plastic as the margin is being refined. This reduces gingival trauma and thus assists in moisture control by reducing or eliminating bleeding. 2. Use an appropriate tray: The most accurate impression will be taken in a custom, rigid, special tray. This provides for an even thickness of impression material surrounding the teeth. An accurate impression can be taken in a stock tray as long as it is rigid. Most plastic stock trays are NOT rigid, so only use a metal tray. It is tempting to use the â&#x20AC;&#x2DC;Triple Trayâ&#x20AC;&#x2122; technique, but they are very flexible and it is easy to create rebound after removal of the impression. They are definitely NOT appropriate for multiple unit impressions and they do not encourage careful occlusal contour control. I recommend they are not used for definitive impressions. 3. Good retraction: Good gingival retraction is the key to great impressions. Time spent on careful cord choice and placement will pay huge dividends in margin clarity and crown fit. The type of cord is a personal choice. I prefer an impregnated braided cord. Knitted cords are easy to place, but need to be soaked in haemostatic solution. However, do not use adrenaline impregnated cord in aesthetically critical areas. Purchase a good cord placement instrument with a fine, serrated tine (Ultradent or Pascal instrument). In addition, a double cord technique is preferred. A #0 or #00 cord is placed around the tooth and left there during the impression. This greatly assists in moisture CADMUS 2012

control. A second cord size #1 is placed on top and removed just prior to the impression. There must be sufficient gingival sulcus depth to accommodate both cords. DO NOT CREATE IT in the aesthetic zone or gingival recession will occur. Consider one cord only on the buccal surface in shallow crevices.

Technique for cord placement Place #0 cord in sulcus first and leave in situ until after the impression has been taken. Do not forget to remove.

Stabilise the cord just placed with a flat plastic, as you position the next portion of cord.

#0 cord in place below the crown finish line.

#1 cord in place with full width of core visible between the tooth and the tissue. You must be able to see the full diameter of the second cord all around the preparation. 4. Good haemostasis: There are four principles regarding good haemostasis: i) Improve periodontal health at the outset; ii) Minimise tissue trauma during tooth preparation; iii) Use adrenaline impregnated cord, except in aesthetic areas; iv) Use Ferric Sulphate (Product Viscostat - Ultradent) when bleeding remains a problem. It will produce a black precipitate when used around adrenaline impregnated cord, but this is a short term discolouration. 5. Cheek, tongue and saliva control: Consider using orthodontic cheek retractors in conjunction with absorbent pads (Dry Tips - MĂślnlycke Health Care AB, NeoDrys - Microcopy). This provides a third pair of hands. Place Dry

Tip in cheek on both sides. Engage Dry tips with extensions of cheek retractor to hold against cheek. This will extend the amount of cheek retracted. Place cotton wool roll in lingual sulcus for lower arch impression. This may be left in situ whilst impression is setting. It will be necessary to rotate the tray into the mouth to minimise lip stretching and some momentary stretching will occur until tray is in the position. Warn patient of this, but the momentary discomfort is far outweighed by the tissue control gained. It is acceptable and far easier to use quadrant trays for lower impressions in single unit cases. Also consider using Swan Neck low volume aspirator tip to control unruly tongue and saliva in mandibular impressions. 6. Use a controllable, fine tipped light body syringe: I find that a tip on the end of a large, conventional impression mixing gun is impossible to place accurately. Purchase an old fashioned impression syringe (eg 3M Espe). This will fill directly from the mixing gun by placing the mixing tip inside the syringe barrel. Syringe light body around the prep, adjacent teeth and ALSO all other teeth in the arch. The occlusal surfaces especially, of all teeth, need to be accurately recorded. 7. Last of All – DON’T PANIC: Get all hands on deck. It can be useful to have one nurse mixing, one nurse retracting and sucking whilst you syringe the light body and place the tray. Have a set mixing and loading sequence that is always the same. Everyone knows their job and the order in which things are to

happen. Take your time and give sufficient time for the material to set. Most manufacturers recommend 5 minutes setting, but the materials continue to polymerise for at least another 2 minutes. I wait for a timed 7 minutes. What is 2 minutes on the end of an hour and a half appointment?

My personal impression sequence 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Place retraction cord. Place Dry Tips and orthodontic cheek retractors. Ensure all equipment is ready and tray adhesive is applied. Dentist dries tooth preparation and the whole adjacent arch using air and suction. Patient instructed to stay still and not swallow whilst dentist turns away. Dentist turns away and fills barrel of impression syringe with light body. Tip of syringe assembled. Dentist begins to remove second retraction cord and instructs nurse to commence mixing heavy body. Nurse mixes heavy body and loads this into tray. If timed correctly, Nurse completes loading tray as Dentist finishes syringing light body. Nurse hands tray to Dentist who seats tray and removes cheek retractor (Dry tips as well if appropriate). Nurse presses stopwatch to time setting. Dentist rings stockbroker to trade a few shares!

Summary An excellent impression is the key to good crown and bridge. Without it, the most ideal tooth preparation will fail to receive the crown it deserves. If you take your time, be fastidious, practice a set routine and train the team, ‘second goes’ will be a thing of the past.

Technique Tips

prosthodontics Polishing Composite Resins Michael N. Mandikos BDSc, MS, Cert Pros, FRACDS

An essential part of the process of placing a composite resin is the finishing and polishing stages. A properly polished surface is potentially more resistant to stain and biofilm accumulation; more comfortable to the patient and more aesthetic. The introduction of microfilled composites in the 1980s fundamentally changed the indications and applications for composites. These materials, with their submicron filler particles, were able to easily receive a high surface gloss with simplified polishing protocols. As a result, “composite bonding” became a buzz word and the hallmark of cosmetic dentistry. When the hybrid composites came to the market, their composition included larger filler particles and their ability to take on a high polish was diminished. These materials were subsequently revised and improved into “Fine Micro-Hybrids” which included a higher content of dispersed submicron particles into their matrix, with a consequent improvement in their polishability. Most recently, nano-filled composites and nano-hybrid materials have become the dominant restorative systems. These materials, with their significant proportion of very tiny particles (in the range of under 100nm) are also more easily polished and appear to hold this polish over the mid to longer term clinically. Whilst spoilt for choice in the modern dental market, Clinicians should choose one of these latter materials for restoring anterior teeth; whenever good physical properties and polishability is required. The process of polishing involves the use of a series of abrasive materials against the surface to be polished. Each abrasive will cut the surface to be polished, removing its surface topography. It will

leave behind scratches and other features related to the size and shape of the abrasive being used. A subsequent abrasive, of smaller particle size, is then used to remove these scratches and leave behind a new set of finer scratches on the surface. A subsequent abrasive is then used to again remove the previous set of scratches and surface features. It will leave behind its own set of still finer surface features. The process is repeated until finally the surface features left behind by the last abrasive in the sequence are so fine, that they no longer will refract and scatter incident light on the surface of the material. The light then reflects away without refraction and the surface appears glossy. This process explains why polishing protocols exist, which utilise a series of polishers that must be used in full. It also shows why it is not possible to just have one polishing instrument that will take a surface from rough to high shine in one step. Simplified polishing systems have existed for some time. Most clinicians are familiar with “pop-on” disc systems like the Soflex Discs from 3M ESPE or the Opti Discs from Kerr, which use four grades of abrasive from Coarse through Medium, Fine and Super Fine. Such systems are simple, easy to use and produce high lusters on flat surfaces. However, if the clinician is restoring an uneven tooth surface (like a posterior composite) or an anterior tooth, having spent some time developing surface anatomy and texture, then simple disc-type systems are not appropriate. Alternative polishing systems using silicone points impregnated with carbide and diamond abrasive particles, or silicone impregnated “brushes”, are an excellent means of obtaining polish on composites surfaces that are not flat.

Polishing Sequence The photo sequence below demonstrates the use of the author’s preferred finishing and polishing protocol for nano-filled and nano-hybrid composites restorations. 1

The composite as finished after hand instrumentation and light activation. Note the surface has an unset oxygen inhibited layer.

Initial shaping is performed with a diamond or tungsten carbide bur to create overall shape and surface morphology.

An Enhance point (Dentsply) is used as a pre-polisher to remove gross surface roughness and “soften” the development groove scribed into the surface.

A PoGo polisher is then used to remove the larger “scratches” left by the Enhance, and to initiate a lustre.

An Occlubrush polisher (Kerr) is then used to create the final high-gloss finish on the restoration.

CADMUS 2012

Technique Tips

prosthodontics Obstructive Sleep Apnoea Dr Po-Ching Lu BDSc(Hons) Qld, GradDipClinDent, DClinDent (Melb).

Obstructive sleep apnoea (OSA) is characterised by repetitive pauses in breathing during sleep, despite the effort to breath and is usually associated with a reduction in blood oxygenation saturation. These pauses in breathing typically last 20 to 40 seconds. OSA is commonly accompanied with snoring. The individual with OSA is rarely aware of having difficulty breathing, even upon awakening. Common signs of OSA include unexplained daytime sleepiness, restless sleep and loud snoring with periods of silence followed by gasps. In adults, the most typical individual with OSA syndrome suffers from obesity, with particular heaviness at the face and neck. Obesity is not always present with OSA; the cause of this is not well understood. Individuals with decreased muscle tone, increased soft tissue around the airway and structural features that give rise to a narrowed airway are at high risk for OSA. An individual may also experience or exacerbate OSA with the consumption of alcohol, sedatives, or any other medication that increases sleepiness, as most of these drugs are also muscle relaxants. The normal sleep/wake cycle in adults is divided into rapid eye movement (REM) sleep, non-REM (NREM) sleep and consciousness. During REM sleep in particular, muscle tone of the throat and neck, as well as the vast majority of all skeletal muscles, is almost completely attenuated, allowing the tongue and soft palate/ oropharynx to relax. In OSA, where airflow is reduced to a degree where blood oxygen levels fall, neurological mechanisms trigger a sudden interruption of sleep, called a neurological arousal. These arousals rarely result in complete awakening, but can have a significant negative effect on the restorative quality of sleep.

Diagnosis Diagnosis of OSA is often based on a combination of patient history and lab-attended full polysomnography. Polysomnography in diagnosing OSA, characterises the pauses in breathing. An event can be either an apnoea, characterised by complete cessation of airflow for at least 10 seconds, or a hypopnoea in which airflow decreases by 50 percent for 10 seconds or decreases by 30 percent if there is an associated decrease in the oxygen saturation or an arousal from sleep. To grade the severity of sleep apnoea, the number of events per hour is reported as the aponea-hypoapnoea-index (AHI). AHI

Rating

AHI

Rating

Normal

15-30

Moderate

5-15

Mild

>30

Severe

Without treatment, sleep deprivation and lack of oxygen caused by sleep apnoea increases health risks such as cardiovascular disease, high blood pressure, stroke, diabetes, depression and weight gain. Sleep apnoea sufferers have a 30% higher risk of heart attack than those unaffected. A diagnosis of severe OSA can affect deployability of a Defence member.

Treatment Some treatments involve lifestyle changes, such as avoiding alcohol and medications that relax the central nervous system (for example, sedatives and muscle relaxants), losing weight and quitting smoking. Some people are helped by special pillows or devices that keep them from sleeping on their backs or oral appliances to keep the airway open during sleep. In severe OSA cases, sleep specialists can recommend continuous positive airway pressure (CPAP), in which a face mask is attached to a tube and a machine. The machine blows pressurised air into the mask and through the airway to keep it open. CPAP treatment would be initiated by the member’s Medical Officer (MO) referring the member to a sleep specialist and may require the MO to review the member’s Medical Employment Classification (MEC). There are also surgical procedures intended to remove and tighten tissue to widen the airway. These can include nasal surgery, tonsillectomy, removal or reduction of the soft palate and some of the uvula, reduction of the tongue base, maxillomandibular advancement. In mild to moderate OSA cases, sleep specialists often refer cases for a mandibular advancement splint (MAS). Mandibular advancement splints (MAS) are a recognised and popular treatment option for OSA due to their simplicity, tolerance and non-invasiveness. It is designed to hold the lower jaw slightly down and forward relative to the natural, relaxed position. This position holds the tongue further away from the back of the airway and may be enough to relieve apnoea or improve breathing for some patients. There are many different designs and patents on various types of MAS. The most commonly used MAS in Australia is SomnoDent which allows self titration. However, there is still no consensus on how to define the optimal titration protocol. The protrusion recommended is between 60-80% which is measured with George’s gauge. Beyond that, TMJ discomfort is more likely. Patients should be warned that dental changes can potentially occur with long term use. Posterior open-bite and TMD symptoms have been reported. Improvement of AHI has been reported as high as 90% of patients with MAS use. Efficacy of MAS needs to be confirmed with a follow-up sleep study.

CADMUS 2012

Technique Tips prosthodontics 10 Clinical Tips for Predictable Fixed Prosthodontic Treatment Major Wayne Chow BDSc, PgradDipClinDent

1. A common problem when preparing posterior teeth for indirect restorations is under-preparation of the occlusal surface. Many clinicians would place several depth grooves as a guide, prior to occlusal reduction. I would extend this strategy and prepare an occlusal depth groove in the central fissure of premolars and molars; from the mesial to distal marginal ridges. A good indication is to cut a groove using half the length of a 3mm diamond operative bur to provide approximately 1.5mm of reduction. 2. Use a sectioned, silicon putty key of the diagnostic wax-up to guide the amount of reduction during tooth preparation (Figure 1). 3. Use white stone burs with adequate water spray during the finishing stage, to give a smooth finish to crown margins. 4. Make temporary restoration(s) before taking secondary impression. 5. Use a sectional impression tray to make accurate temporary crowns. Start by inspecting the tooth to be prepared. If Figure 1 necessary, modify the

shape of the tooth by adding resin composite. Then take an impression of the upper and lower segment using heavy body polyvinyl siloxane in a sectional tray (aka triple tray). After preparing the tooth, when ready to make the temporary crown, inject bisacryl material (luxatemp - DMG) into the PVS/tray matrix and ask the patient to bite into same position. Remove the partially cured temporary restoration. You will find a verywell adapted and durable temporary crown (Figure 2). 6. Good secondary impression takes time and patience. Allow adequate time during your appointment. Here are some clinical tips: a. Be friendly with using retraction cords for soft tissues control; b. Have 2 or even 3 custom trays ready to retake impressions of multiple teeth; c. Air dry the tooth / teeth completely; d. Try different moisture control techniques, including slow speed suction with the patientâ&#x20AC;&#x2122;s head tilted slightly to one side, placing cotton rolls and dry tips pads in the buccal sulcus; e. PVS contamination by latex products is significant. Its effect includes drags, a lack of surface details and smearing of the material, producing poor quality impressions. This problem is specific to certain types and brands of PVS material. For example, Flexitime (Heraeus) reacts with latex products quite consistently; and f. Apply light body material in a hand syringe for speed and control. Consider using a monojet syringe with a punched hole at the side of syringe to allow air escape. 7. Restorative dentists need to have a sound understanding of the implant system and prosthetic components. It is not ideal to leave restorative decisions and choices to implant company representatives or laboratory technicians. 8. Build a rapport with good dental laboratories through communication; not one-way instructions from the dentist. It is the quality, not the fees, of laboratory work that can determine the successful outcomes of treatment. 9. Periodontal soft tissues are just as important to the aesthetic success of fixed prosthodontic treatment.

Figure 2

CADMUS 2012

10. Assess the restorability of compromised tooth/teeth to the best of your ability prior to referral to Specialists for further treatment.

Professional and Technical Items

Clinical Governance: What can you do? Commander Tanya Burton RAN, BDS (Lon), MFGDP (UK), Grad Cert Clin Dent (Restorative)

Through the recent years of CADMUS, you will have observed that the Directorate has maintained a focus on Clinical Governance (CG). In due course, Regional Dental Advisors will be established and part of their role will include the responsibility for CG within your respective regions. Whilst we await these positions, there are elements of CG that each of us can implement. We all have a duty to continually improve the quality of our services and safeguard high standards of delivery by creating an environment in which excellence in clinical care will flourish1. So what does all this mean for you? CG should build on the good and effective systems that are already in place. Within each health facility, we are governed by 4 core components or pillars of CG: 1) Clear lines of responsibility and accountability for the overall quality of clinical care; 2) A comprehensive program of quality improvement; 3) Clear policies aimed at managing clinical risk; 4) Policies aimed at identifying and remedying poor performance. How can you implement CG? Defence health facilities already have the foundations of CG. Each of us should focus on developing the second pillar through: 1) Clinical standards; 2) Clinical audit; 3) Training and development; 4) Continuing Professional Development (CPD); 5) Regional Peer review activity; 6) Practice based audit. The principals behind two of these key elements are shown in greater detail in Table 1. What topic should you choose for your first clinical audit? This is sometimes the hardest part, but there are many resources available to help you decide. Any topic whether clinical or administrative is suitable, provided that the subject matter applies to general dental practice. To further assist you there are ‘cookbook audits’ that lead you through a pre-set methodology2. To introduce you to the clinical audit process, a short précis of one of my audits is shown here.

in Defence health facilities are: good lighting; dry, clean teeth; loupes; blunt probes; posterior bitewing radiographs; tooth separation. For reproducibility, beam-aiming devices and a grading system of lesion size can be helpful in monitoring lesion progression, or arrest, over recall visits and in deciding when operative intervention is required.3 Aims and Objectives: The aim of this clinical audit is to investigate treatment planning decisions for approximal lesions, utilising bitewing radiographs as the sole diagnostic tool. Furthermore, to identify if caries diagnoses and consequent management are standardized when a grading system of lesion size is introduced. Primarily the purpose of the clinical audit is to ensure that there is moderate inter-observer agreement between the dentists regarding treatment decisions. The secondary objective is to determine whether use of a grading tool leads to fewer invasive procedures. Method Sample: The audit is to be conducted at Cerberus Health Centre using 15 sets of bitewing radiographs from Initial Dental Examinations, which were randomly collated by reception staff for assessment. Two monthly peer review sessions are to be allocated for the clinical audit. In August, the dentists were requested to identify all lesions requiring preventive and/or restorative treatment. In September, the dentists were provided with a copy Table 1 Peer Review

• Sharing knowledge between colleagues. • Stimulus for individual learning. • Group discussion to generate ideas for improvement. • Evidence-based decision making to develop best practice in the delivery of clinical care. • Discussion to include clinical techniques and materials; treatment planning; brainstorming for an audit.

Clinical Audit

• An audit is not research. It is a process of standard setting by observing what is happening and then making changes to meet standards, where necessary. • Collects data in a simple, but systematic way to allow for evaluation of the quality of dental care. • Includes procedures used for diagnosis and treatment; the use of resources; the resulting outcome and quality of life for the patient.

A précis of a clinical audit conducted at Cerberus Health Centre in 2008: Early detection and diagnosis of caries Introduction For the General Dental Practitioner, restorative dentistry still accounts for approximately 75-80% of the work4. Therefore, early detection and diagnosis of carious lesions are of prime importance. For approximal caries, the quality of the radiographs and diagnosis are the foundations of determining treatment (preventive and/or restorative) options for the patients. Other techniques for this purpose are fibre-optic transillumination (FOTI), digital imaging fibre-optic transillumination (DIFOTI), electric resistance measurement, laser fluorescence measurement and tooth separating5. Diagnostic aids that are realistically available

CADMUS 2012

of Table 2. They were initially requested to grade the carious lesions, prior to identifying all lesions requiring preventive and/ or restorative treatment. Table 2 Criteria for scoring bitewing radiolucencies on occlusal and approximal surfaces (after Mejare, 1999). Reprinted with the kind permission from the Australian Dental Journal (Evans et al)6. Criteria for Bitewing Radiolucency Scores C0 No radiolucency evident (not recorded) C1 Radiolucency is evident within the outer half of enamel C2 Radiolucency extends to the inner half of enamel and may reach the DEJ C3 Radiolucency extends just beyond the DEJ C4 Radiolucency is evident within the outer third of dentine C5 Radiolucency extends to the inner two thirds of dentine and may reach the pulp Design: In accordance with Table 2, the patients’ radiographic carious lesions ranged from C1 to C5. Treatment planning options were grouped according to invasive (urgent/ non-urgent operative care) or non-invasive (no specific treatment or future bitewing review and/or topical fluoride application) treatments7. Statistical Analysis: When assessing the ability of a test (radiograph) to be helpful to clinicians, it is important that its interpretation is not a product of guesswork8. The kappa statistic was deemed the most appropriate method to measure the level of agreement between the dentists. Results Sample size: 87% of the PDR’s were available for assessment before and after the implementation of the grading system. Treatment decisions: Figure 1 shows the distribution of treatment planning decisions for C1-C5 lesions, using bitewing radiographs, before and after implementation of the grading system. Result Interpretation: To summarise the results using the kappa statistic, there was ‘substantial’ agreement in the use of invasive procedures before the classification system and ‘substantial’ agreement in the use of invasive procedures after the classification system. Using p value, the grading system did not lead to a statistically significant change in the number of invasive procedures: 42.8% of lesions before the tool and 44.7% of lesions after the tool (p = 0.7). Discussion Early diagnosis of the carious lesion has become even more important since the realisation that caries is not simply a process of demineralisation, but an alternating process of destruction and repair9. In the diagnosis of caries in children, the weight of expert

opinion supports the statement that posterior bitewing radiographs are an essential adjunct to clinical examination10. Although far from perfect, bitewing radiography is still the most commonly used diagnostic aid for: detecting approximal enamel lesions that can be treated for remineralisation; deciding if or when to restore approximal caries lesions by monitoring lesion progression; detecting occlusal dentine lesions; identifying individuals at risk for new caries lesions or progression of existing lesions11. Substantial agreement exists among the clinicians in this clinical audit. From review of the literature, caries diagnosis has been shown to be highly variable. Grondahl12 stated that all studies had poor intra and inter examiner agreement. Out of 1734 lesions on bitewing radiographs, dentist diagnoses were correct only 50% of the time. Caries management has also been shown to have high variability. Lewis et al13 advised that considerable variation existed in both the restorative and depth decisions among the dentists. Out of 16 dentists examining 15 pairs of experimental bitewings, 3 dentists stated it would be appropriate to restore enamel lesions; nine would wait until caries had reached the DEJ and four would wait until caries extended into the dentine. Intervention for the C3 lesions was 70.8% before and 77.1% after the implementation of the grading tool respectively. The ability of dental practitioners to identify and discriminate between lesions in the inner half of the enamel and outer half of dentine plays a dominant role in their treatment decision making14. Current literature suggests careful consideration of radiographic lesions extending just beyond the DEJ prior to treatment. There is a pressing need for a greater understanding as to the precise criteria that dictate the need for both non-invasive (reversible) preventive measures and invasive (irreversible) restorative treatment15. Although the results before and after implementation of a radiographic classification of caries were not significant, the use of a grading system was considered a useful tool by the Cerberus Health Centre dentists. It allowed for careful consideration and diagnosis of carious lesions prior to recommendations for management. Conclusion The results of this audit are extremely encouraging as there was already substantial agreement between the Cerberus Health Centre dentists on when to refer lesions for invasive procedures. This cohort of patients would receive similar treatment decisions with each of the dentists. The implementation of a lesion grading tool did not appear to have an effect on the level of agreement concerning the use of an invasive procedure, or the total numbers of lesions being referred for invasive procedures. The World Health Organisations Global Oral Health Program has recognized the importance of promoting, a new paradigm among dental practitioners, shifting from a restorative to preventive/ health promotion model16. While debate continues with the preferred caries risk assessment and risk management system, the principles of caries recognition and diagnosis remain fundamental for best-practice principles. Caries diagnosis can sometimes be difficult, even for the more experienced clinicians. A ‘watch’ on a chart implies caries has been identified, but diagnosis and management have not been fully documented. Utilising a grading system/ classification tool can assist dental health professionals to diagnose the extent of caries and select an appropriate management regime specific to the patient.

Figure 1 Treatment decisions according to bitewing radiographs before and after implementation of the grading system in Table 2. CADMUS 2012

Associated statistical analysis and reference list are not shown due to space constraints. To request a copy, please contact the Editor.

Professional and Technical Items

A review of the Australian Defence Force Classification System, with associated quiz (Part 1) Lieutenant Commander Dan Allan, RAN, BSc, BDent, Grad Dip Clin Dent (Oral Surgery)

HD402 The Australian Defence Force Dental Classification System is used to indicate a member’s level of dental fitness from a perspective of urgency of need for treatment and relates it to the degree of readiness for deployability. This system has served us well and the aim of this article is to reiterate its use and to provoke thought on some situations that occur on an almost daily basis in our clinics.

The OPG is shown below:

History has shown that oral hygiene tends to suffer in the deployed environment. This coupled with multiple stressors and a possible change in diet lead to a borderline caries case turning into a dental emergency requiring repatriation or treatment in less than ideal conditions. The following cases have been included to provoke thought along with some questions to ponder. Discussion points have been included in Part 2 of this article, located in the Articles of Interest Section of CADMUS as part of a self assessment process.

Case 1 A member presents for his ADE where you make the following findings: Past medical history - History of high cholesterol; smokes 12 cigarettes a day. Examination (Extra-oral and intraoral) – Nothing Abnormal Detected Oral hygiene – brushes twice daily, uses tepe brushes regularly, good OH D

Perio – Generalised 6mm pockets, 8 mm pockets lower anterior region Investigations – A bitewing and periapical are taken What dental classification would you make this member?

Case 2 A member attends during sick parade for pain in the lower right mandibular region that has been ongoing for 2 days. The member has been taking nurofen for the pain and it has helped, but for only a short period. The member has never experienced these symptoms before, but the pain is described as a dull ache that is present constantly. On examination you find the member has good oral hygiene and has no obvious signs of caries. The member has no medical issues and only reports taking nurofen for the dental pain. You note the 48 is partially erupted and send the member for an OPG.

What dental classification would you make this patient and what are your considerations for the treatment plan?

Case 3 A member presents with constant pain in the upper anterior region. The pain is worse when having anything hot or cold; it goes from a dull ache to a sharp shooting pain that lasts several minutes. Analgesics have been ineffective and the member was unable to sleep. On examination you identify the 12 as the suspect tooth. It is tender to percussion and palpation in the buccal sulcus. A sensibility test results in you trying to scrape the patient off the ceiling and you take a periapical You manage to anaesthetise the tooth and extirpate the infected, bloody pulp during sick parade (under rubber dam). The tooth is dressed and sealed and you make an appointment in a week to prepare the canal. (i) What dental classification would you make the patient? The patient returns in a week and has very little lingering symptoms. The canal is prepared and dressed and awaiting obturation in a further weeks time. (ii) What dental classification would you make the patient now? The patient returns for obturation and this is successfully conducted. A final periapical is taken and shows some residual periapical radiolucency, but good condensation and coronal seal. (iii) What dental Classification would you make the patient now? CADMUS 2012

Professional and Technical Items Dental Officer CL1 to CL2 Case Study

CL1 to CL2 Case Study Lieutenant Vishal Bhakoo, BDS

Introduction A 55 year old male patient presented on 12 January 2012 to the HMAS STIRLING Dental Department complaining of pain originating from his upper right quadrant. When asked to identify the tooth he pointed to the 18. He reported that the pain started three days ago and it was not aggravated or relieved with thermal stimuli or when biting. There was a dull ache that would last a few hours. The patient was on CFTS and his previous dental examination was carried out five and a half years ago in September 2006. Review of his medical history revealed that he was a non smoker and drank one standard unit of alcohol per day.

Examination Clinical examination revealed that tooth 18 was tender to percussion. Tooth 18 responded normally to sensibility tests. No tenderness was noted to be associated with tooth 17. There was some food packing between 18 and 17, and minimal bleeding on probing. Radiographic examination revealed recurrent decay under the restoration in the crown of tooth 18. Normal periapical bony architecture was noted to be associated with the root of tooth 18. A widened periodontal ligament space was noted to be associated with the root apices of tooth 17. Tooth 17 had been previously endodontically treated. The root fillings were noted to be short of the ideal relationship with the radiographic apex. Caries was noted underneath the distal surface of the crown, restoring tooth 46. The tooth had been previously root filled. Loss of lamina dura was noted around the mesial root of tooth 46.

Diagnosis and Treatment The initial diagnosis was pain due to gingival inflammation with caries present on tooth 18. The diagnosis for tooth 46 was previously root filled with asymptomatic apical periodontitis. The initial treatment plan was to carry out a deep clean in quadrant one as there was some food packing between the 18 and 17 with gingival

inflammation and a full exam and comprehensive treatment plan as other carious lesions had been noted. Periodontal debridement was carried out between teeth 17 and 18 under local anaesthesia. Oral hygiene instructions were given. It was also noted that the pain resolved upon administration of local anaesthesia to the posterior region of quadrant one. This shows that the pain was originating from quadrant one and not referred pain from the 46. The 18 would need to be reviewed to see if the cause of the pain was pulpal or periodontal in origin. Radiographic examination also showed that the 46 would need treatment. The tooth was asymptomatic, however, there was a large cavity on the distal margin of the crown, which extended subgingivally to be in close proximity to alveolar bone level. Tooth 46 had been previously root treated and was restored with a porcelain-bonded crown. Treatment options were given to the patient. In order to retain the tooth, crown lengthening would be required to achieve a biologically compatible restorative margin prior to endodontic retreatment. The other option would be to have the tooth extracted (possibly surgically extracted), with a prosthetic appliance to replace the gap once the socket was healed. When the patient returned for his review appointment, the pain in quadrant one had not resolved. Tooth 18 was still tender to percussion; no symptoms were present from the 17. The gingival inflammation had resolved from quadrant one with a marked improvement in the patients oral hygiene. This suggested that it was most likely a pulpal cause to his pain. Diagnosis was irreversible pulpitis for the 18 and due to the 18 having difficult access for root canal treatment, not essential for a functional occlusion, and patient preference, it was decided to extract the 18. The patient had decided that he would also like to have the 46 extracted. Tooth 46 was also extracted at this appointment. During the extraction of the 46 the crown fractured and a mucoperiosteal

Right and Left BWâ&#x20AC;&#x2122;s, PA of 46 CADMUS 2012

flap was raised; the roots were sectioned, buccal bone was removed and the roots were extracted using elevators. Due to the difficult extraction, analgesics and antibiotics were prescribed.

Further examination A complete examination was undertaken at his next appointment. The patient indicated that he was no longer experiencing any discomfort. A left hand side bitewing and an OPG were taken. Caries was noted in the mesial surfaces of teeth 28 and 37. A PA was taken of the 28 as a result of the large mesial cavity. There was also a PA taken of the 18 socket. The pain in quadrant one had resolved and the sockets were healing well for 18 and 46. The treatment plan was to restore the 28 and 37 with amalgam restorations. The 28 was a large restoration and the patient was informed that there is a possibility that the pulp may be irritated and lead to pulpal necrosis, which would mean extraction of the 28 if this occurred. Tooth 17 would require endodontic retreatment. The extraction of the 46 resulted in an edentulous space. The treatment options for this edentulous space are to do nothing and leave a gap, construct a removable partial denture, resin-bonded bridge, conventional fixed bridge or osseointegrated implant. The advantages and disadvantages of these treatment options are shown in table 1.

quadrant and also from teeth from the opposing quadrant5. In the above mentioned case the discomfort could have been originating from either of teeth 18, 17 or 46. Tooth 46 was excluded as the source of pain, when the discomfort resolved once local anaesthetic was administered to quadrant one. Tooth 17 was excluded from being the cause, as tooth 18 was tender to percussion and 17 was not. The treatment options (including the advantages and disadvantages) were discussed with the patient before and after tooth 46 was extracted. The patient was informed that the posting restrictions and downgrading of his dental fitness classification could have operational, employment and career implications if an implant was chosen.6 The member decided to embark on the implant option and he was willing to have this treatment undertaken with a civilian dentist at his own expense, as he completed his CFTS in September 2012. Treatment and approval time for locality restriction could take up to 12 months and therefore could not be completed before the end of his contract.

References 1.

Conclusion This case reinforces the importance of having annual dental examinations, even after a member has left the Navy. The caries on the 46 was detected late and therefore the tooth was practically unrestoreable. There were large cavities on the 28 and 37 which if caught earlier would minimise the chance of pulpal necrosis. The importance of using several diagnostic tools to localise the tooth that is causing the dental pain was demonstrated in this case. Pain can be referred from teeth in the same

3. 4. 5.

Health Directive 424. Treatment Planning Guidelines for Restorative Dentistry in Australian Defence Force Dental Facilities. 1997. Odell EW. Clinical problem solving in Dentistry, 2nd Edition. Churchill Livingstone, 2004 Cheung GSP, Dimmer A, Mellor R, Gale M. A clinical evaluation of conventional bridgework. J Oral Rehabil. 1990;17:131-6 Health Directive 426. Australian Defence Force Locality Restriction for Dental Treatment. 2000 Koyess E, Fares M. Referred pain: a confusing case of differential diagnosis between two teeth presenting with endoperio problems. International Endodontic Journal Health Directive 401. Dental Implantology in the Australian Defence Force. 1999

Table 1. Replacement options Replacement/ treatment

Advantages

No Treatment

Conservative treatment option, no damage Functional problems in the future with to adjacent teeth and no cost implications drifting, tilting, rotating, over-eruption of adjacent and opposing teeth. Also issues with mastication and aesthetics.1

Removable partial denture

Removable for cleaning; cheaper than fixed replacement: flange could improve aesthetics, especially in this case due to bone removal from surgically extracting the 46

Generally disliked by patients. If poorly cleaned will compromise gingival margin around several teeth. Retention may deteriorate with time

Resin bonded bridge

More conservative than fixed bridge, the potential for pulpal trauma is reduced

Longevity is less than that of conventional prostheses. Posterior resin bridges have higher dislodgement rates

Conventional fixed bridge

Fixed prosthesis, reasonable longevity approaching 10 years2

If undertaken straight after extraction food trapping under bridge is an issue due to bone and gingival remodelling. Difficult to repair if the porcelain fractures. Gross reduction of tooth structure on adjacent teeth leading to possible pulpal trauma3

Osseointegrated Implant

Conservative of tooth tissue; no abutment preparation needed. Long-term survival rates are good

Expensive. Involves surgical procedure and laboratory fees. May take 6-9 months to complete and Locality restrictions required.4

Disadvantages

CADMUS 2012

Professional and Technical Items Dental Officer CL1 to CL2 Case Study

CL1 to CL2 Case Study Flight Lieutenant Calum Watson, BDS

Introduction 02 June 2011, a fifty-year-old Sergeant presented to Richmond Health Centre for a routine annual dental examination. He had no presenting dental complaint. A detailed medical history revealed that the patient had an aortic valve replacement at the age of 42 in 2002, requiring him to be given antibiotic prophylaxis prior to dental treatment. His medication regimen included lipitor, tritace, folic acid, cartia and metazapine. He had a history of smoking over the past eight years and currently smoked eight cigarettes per day. His previous dental treatment included multiple simple and complex restorations and previous extractions. Extractions were performed before the member joined the ADF and the patient was unaware of why the teeth needed to be removed.

Examination and Diagnosis No anomalies were detected during the extra-oral examination. An examination of the soft tissues revealed that the patient was suffering from periodontal disease. The hard tissue exam identified numerous carious lesions and occlusal wear due to a bruxing habit. Further examination was conducted on the 36 to assess suitability for a crown. The tooth was determined to be non vital and a peri-apical x-ray revealed a radiolucency in the furcation. The furcation was determined to be class III. The patient reported some discomfort during examination of the 36 with a Fracfinder, and all controls responded normally. A specialist endodontic consult was sought in order to rule out a root fracture. The results of the consult were inconclusive. A specialist periodontal consult was requested to assess the overall periodontal condition, specifically the prognosis of 26 and 36. The patient was diagnosed as having localised moderate to severe periodontitis, modified by smoking. The 26 was given a poor prognosis and the 36 a guarded prognosis.

Treatment options Immediate treatment was focused on the control of caries, which could be achieved with simple restorations and oral hygiene education. Further treatment was aimed at addressing the periodontal condition and the following treatment options were presented to the patient: a. Periodontal therapy and maintenance – non surgical root planing in the first instance, followed by routine periodontal maintenance. The possibility of the need for surgical intervention in the case of 26 and 36 was also discussed. This treatment option would be lengthy and increases the possibility of complications arising from the patient’s CADMUS 2012

medical condition. In addition, the patient would remain non-deployable for an extended period. b. Extraction of 26 and 36 followed by root planing and periodontal maintenance. The time frame for resolution of disease using this treatment option is expected to be considerably shorter than the previous option. The patient had already shown good motivation to improve his oral hygiene and reduce the frequency of smoking. The treatment options were discussed with the patient at length. The member was made aware of the time period that he was expected to remain dentally unfit. He was also informed of the implications to his current medical condition. The patient decided to have 26 and 36 extracted with complete periodontal therapy on the remaining dentition.

Definitive treatment The extraction of 26 and 36 was completed without incident under appropriate antibiotic prophylaxis. At review, the sites had healed well. The patient is currently receiving periodontal treatment. He has been showing signs of steady improvement. Treatment to be completed includes partial upper and lower chrome cobalt dentures; an occlusal splint to prevent further occlusal trauma due to night-time parafunction.

Discussion When speaking to the patient regarding treatment options, the focus was dominated by four main points: how long would the proposed treatment take; what are the outcomes of periodontal treatment; what effect will the disease and the treatment have on the patient’s overall condition; and what will the effect be on the patient’s dental fitness classification. The length of treatment of the patient’s condition is of critical importance. In order to attempt to save the member’s teeth, there would be a need for multiple appointments over a prolonged period. Depending on the operator, the initial treatment for severe periodontal disease requires anywhere from one to four appointments1. Following initial treatment there is a need for a re-evaluation, which is generally completed three months after initial debridement. Research indicates that a pocket with a probing depth of greater than 7mm can show an improvement of 2-3mm at the three month mark2. A periodontal pocket with a depth of 4-6.5mm can be expected to show improvement of 1-2mm at three months, if effectively treated3. A periodontal pocket of 11mm, such as that on the 26, would take at least twelve months to be effectively treated and assessed as healthy under ideal circumstances. Treatment in this case is expected to be of a much

longer duration due to factors such as furcation involvement and poor access. The success rate for treatment of sites with severe attachment loss or those that have grade III and above furcation involvement is significantly lower than those with mild to moderate attachment loss4. The proposed periodontal treatment involved non-surgical debridement, with a high likelihood that both the 26 and 36 would need surgical intervention following the review. In order to potentially return the member to health a large number of clinical appointments would be required over an extended period of time. In a high activity Squadron, the availability and compliance required to attend multiple appointments needs to be considered. In accordance with Health Directive 402 The ADF Dental Classification System a member is assigned dental class three when requiring treatment for moderate to severe periodontal disease5. It is expected that if the patient chose to proceed with periodontal treatment that he would remain dentally unfit for a period of in excess of twelve months. The success rate of periodontal treatment can be as low as 64% and teeth with furcation involvement can account for up to 54% of teeth that are extracted due to periodontal disease. Studies indicate that in the long term, molars with furcation involvement are more prone to loss than non-furcated molars6. The presence of a furcation is not an indication for extraction in itself. Under conditions of good oral hygiene and good periodontal maintenance, these teeth can be successfully maintained7. However, it is suggested that while members are deployed their level of oral hygiene decreases, as does their access to preventative dental care. This would put the patient into a higher risk category for complications associated with a molar furcation. Successful treatment of areas of severe attachment loss by nonsurgical intervention alone is rare8. In addition, smokers affected by periodontitis respond less favourably to non-surgical, surgical and regenerative periodontal treatments than individuals who are non-smokers9. Due to these factors, the long-term prognosis for 26 and 36 is poor to guarded. On deployment the patient is likely to have limited access to specialist periodontal support. It is highly likely that if these teeth were retained, the patient would remain dentally unfit for an extended period of time. In addition to site specific information, the patients overall health also needs to be considered when evaluating appropriate treatment options. Health Directive (HD) 409 Australian Defence Force Periodontal Assessment refers to the risk of development and progression of periodontal disease. According to the directive, a patient who is a smoker has four times greater risk of developing periodontal disease than a patient who has never smoked. In accordance with HD409, the patient was extensively counselled about the higher risks associated with smoking and cessation advice was given10. There is a long history of links between dental health and systemic health. A study in 1989 highlighted a significant statistical correlation between poor dental health and acute myocardial infarction; independent of other risk factors such as high cholesterol and smoking11. Periodontal disease has been associated with a twenty per cent increase in cardiovascular disease and a larger increase in the risk of stroke12. With the patient having had a heart valve replaced in 2002, the importance of limiting risk factors for cardiovascular complications was even more critical. Periodontal probing has been shown to cause bacteraemia in patients suffering from periodontal disease13. As a result patients with a risk of developing infective endocarditis, such as the patient in this case, should receive antibiotic prophylaxis prior to

periodontal probing and treatment13. With the length of proposed treatment and the need for antibiotic prophylaxis, it is important to consider the risk of bacterial resistance. There is evidence to support the existence of antibiotic-resistant oral microflora14. One of the risk factors of developing antibiotic resistant bacteria is prolonged use15. With the need for the patient to receive antibiotic prophylaxis for periodontal treatment and the possible extended time period of treatment, the risk of developing antibiotic oral microflora is an important consideration.

Conclusion The successful treatment of periodontal disease can be a very lengthy process and the patient would remain dentally unfit for the majority of the treatment phase. This in itself is not going to rule out periodontal treatment as a viable treatment plan for members suffering from severe periodontal disease. However, due to the added complications associated with the member’s medical condition, a lengthy periodontal treatment plan with the requirement for antibiotic prophylaxis is not the ideal treatment to return the patient to a healthy oral state. The effect of periodontal disease on dental class and therefore its impact on deployability must always be considered when developing treatment plans. In this case the patient’s condition would render him non-deployable for an extended period of time. This was an important factor for the patient when ultimately deciding on the most suitable treatment option.

References 1. Carnevale, G., Pontoriero, R. and Hürzeler, M. B., Management of furcation involvement. Periodontology 2000 1995; 9: 69–89 2. Claffey, N. Egelberg, J., Clinical indicators of probing attachment loss following initial periodontal treatment in advanced periodontitis patients. Journal of clinical periodontology 1995. 22(9):690-6 3. Claffey, N. Loos, B. Gantes, B. Martin, M. Heins, P. Egelberg, J., The relative effects of therapy and periodontal disease on loss of probing attachment after root debridement. Journal of clinical periodontology 1998. 15(3):163-9 4. Cobb, C. M., Clinical significance of non-surgical periodontal therapy: an evidence-based perspective of scaling and root planing. Journal of Clinical Periodontology 2002, 29: 22–32. 5. Bower, R C., Furcation morphology relative to periodontal treatment. Furcation entrance architecture. Journal of periodontology 1979; 50 (1):23-7 6. Daly, C. Mitchell, D. Grossberg, D. Highfield, J. Stewart, D., Bacteraemia caused by periodontal robing. Australian Dental Journal 1997; 42(2):77-80 7. Estaniel, C. P., An update on the non-surgical treatment of periodontal disease. The Journal of the Philippine Dental Association, 1995; 47(1):19-26 8. Hamp, S.-E., Nyman, S. and Lindhe, J., Periodontal treatment of multi rooted teeth. Journal of Clinical Periodontology 1975; 2: 126–135 9. Health Policy Directive 402: The Australian Defence Force Dental Classification System 10. Health Policy Directive 409: Australian Defence Force Periodontal Assessment 11. Matilla, K., Nieminen, M., Valtonen, V., Rasi, V., Kresaniemi, Y., Syrjala, S. Jungul, P. isoluoma, M., Hietaniemi, K., Jokinen, M. & Huttunen, J. (1989) Association between dental health and acute myocardial infarction. British Medical Journal 1989; 298, 119-782. 12. Meurman, Jukka H. Sanz, Mariano. Janket, Sok-Ja., Oral health, atherosclerosis, and cardiovascular disease. Critical Reviews in Oral Biology & Medicine 2004; 15(6):403-13 13. Roberts MC. Antibiotic toxicity, interactions and resistance development. Periodontology 2000 2002, 28:280–97 14. Tonetti, M S. (1998) Cigarette smoking and periodontal disease: etiology and management of disease. Annals of Periodontology1998; 3(1):88-101 15. Walker CB., The acquisition of antibiotic resistance in the periodontal microflora. Periodontology 2000 1996; 10:79–88

CADMUS 2012

Professional and Technical Items Dental Officer CL1 to CL2 Case Study

Barodontalgia â&#x20AC;&#x201C; A Diagnosis and Management Flight Lieutenant David Y Liu, BDSc

Introduction A 46 year old male presented to dental sick parade on 25 June 2012 with a toothache resulting from a broken tooth on his upper left side. The patient reported that he had been away on leave in Vanuatu for the previous few weeks. He explained that his tooth had â&#x20AC;&#x153;explodedâ&#x20AC;? during ascent, whilst he was performing recreational diving. Since then, he has had a mild toothache with fleeting cold sensitivity. He has reported that it is sore to chew and there appears to be food trapped. He says he constantly needs to floss. His medical history indicated that he is currently taking vitamin supplements and that he had a benign tumour removed from his neck in 2006/07. The patient is an aircraft technician.

Initial Examination On examination, there was a cavitation on the mesial surface of the 27. There was also food trapped between the 26 and 27 contact point that needed to be teased out in order for the teeth to be examined. Gentle air blast from the triplex to dry the tooth surface elicited a positive response, reproducing his symptoms of cold sensitivity. There appeared to be mesial interproximal caries in 27. The teeth in quadrant 2 were percussed with a dental mirror handle. The teeth 25, 26 and 27 were not tender to percussion. A periapical radiograph was taken of tooth 27, which showed the extent of the caries. The 26 and 27 both had occlusal amalgam restorations on the distal aspect of the occlusal surfaces. A pulp sensibility test was conducted with Ethyl Chloride cold spray, with both 26 and 27 giving a positive response that did not linger for more than a few seconds. There did not appear to be any pulpal involvement or apical pathology.

CADMUS 2012

Radiographs Diagnosis Due to what appeared to be a tooth fracture resulting from trapped gas; a diagnosis was made of dental barotrauma.1 The precursor appeared to have been interproximal caries which predisposed the tooth. This resulted in symptoms that could also be classified as barodontalgia.2,3,4

Treatment Options After initial examination and diagnosis, the treatment options including risks were explained to the patient. The option of no treatment was dismissed as the patient was symptomatic and had presented to sick parade with the intention of relief of pain. Furthermore, the invasive non reversible option of extraction was also dismissed on the grounds of minimal intervention dentistry as detailed by Australian Defence Force (ADF) health policy.5 The loss of the tooth would result in a reduction in functionality by the patient and possible drifting of the remaining dentition. The two remaining options considered were direct restoration or root canal therapy. To commit the patient to root canal therapy is not a sound clinical and military decision in this case because it would also be very invasive and not in accordance with minimal intervention dentistry.5 It was decided, in consultation with the patient, to treat the tooth with a resin composite restoration due to its less destructive cavity design and adhesive properties.6 Amalgam was not used, as the material required retentive features to be cut in the cavity design. Glass ionomer cement was not used as it did not have the required strength and load bearing properties.7

Management The patient was interviewed, examined, diagnosed and treated at the initial appointment. After local analgesia was administered, the caries was removed and the cavity was prepared for resin composite. The restoration was placed and the occlusion was checked and adjusted. The patient was then reviewed post operatively, in consultation with a visiting specialist endodontist. The patient was asymptomatic. 26 and 27 were not tender to percussion and there was no sensitivity to air blast. Two bitewing radiographs were taken to screen for any further pathology. The patient was instructed not to dive until he was asymptomatic for 24 hours.

Discussion Clinical Considerations Due to the invention of manned flight and personalised selfcontained underwater breathing apparatus (SCUBA), many oral phenomena caused by atmospheric pressure changes have been described as a consequence of these activities. There are many considerations in the clinical diagnosis and management of these phenomena. Boyle’s law dictates that the volume of gas at constant temperature is inversely proportional to the surrounding pressure.2 The change in atmospheric pressure will cause the expansion and contraction of trapped gas contained in the body. Barotrauma is any adverse effects caused by a change in atmospheric pressure. Dental barotraumas can manifest as tooth fracture, restoration fracture and reduced retention of dental restoration. Barodontalgia is an intraoral pain evoked by a change in barometric pressure.1 Robichaud et al concluded that an increase in barometric stress was associated with an increase in dental deterioration.8 In this case, the patient’s interproximal caries had weakened the mesial marginal ridge on the 27. The subsequent barometric pressure change from an environment of high to low pressure upon his ascent would have caused an increase in the volume of the trapped gas in the cavity. The enamel fracture point was reached which resulted in barodontcrexis or “tooth explosion”.9,10 One study indicated that oral pathologies such as dental caries without pulpal involvement account for 29.2% of possible sources of barodontalgia.11 The use of resin composite to restore the tooth was justified as it required less tooth structure to be cut and had greater adhesion.6 Lyons et al showed that other restorative materials had significantly reduced retention as a result of microleakage.12

important an understanding of the effects of barometric pressure changes has on the dentition. Correlating this to patients who subject themselves to the in-flight and underwater environment on a day to day basis, an episode of dental barotrauma or barodontalgia can significantly affect the patient and surrounding personnel. If the patient was mission critical, the impact would be far reaching. In this case, the patient was a recreational diver and was educated. Instructions were given for prevention of future occurrences.

Conclusion This case has highlighted the need for greater awareness of the diagnosis, prevention and management of barometric pressure related dental problems. If this restricts members from performing their duties, there could potentially be serious ramifications for ADF capability. Patients need to be educated and receive regular dental examinations in order to prevent and manage any dental barotraumas. From a military perspective, this is especially true for aircrew, divers and submariners. The impact on general oral health cannot be underestimated. Barodontalgia should be included in the differential diagnoses of head and neck pain.

References 1. 2. 3. 4. 5.

7. 8.

9. 10.

Military Considerations In the ADF, members are required to maintain their Individual Readiness (IR) as part of their inherent requirements of service.13 In order to maintain their IR, the ADF requires members to be dentally fit in order that they are able to undertake their operational duties. A member is deemed dentally ready if they are Dental Fitness Classification (DFC) 1 or DFC 2, having been assessed within the previous 12 months.14 DFC is to be classified after every assessment, treatment or consultation.15 The correct diagnosis and management was required for the patient to also comply with Defence policy.

11.

While the patient was not a professional aircrew, clearance diver or submariner, the patient’s presenting complaint has shown how

15.

12.

13. 14.

Zadik Y, Drucker S. Diving dentistry: a review of the dental implications of scuba diving. ADJ Sep 2011; 56:265-271 Gradwell & Rainford. Earnsting’s Aviation Medicine. 4th Ed. Butterworth-Heinemann, 2006 ADFP 1.2.2.13 Aviation Medicine for Aircrew. Chp 3 Health Directive 411: Aviation and Diving – Dental Considerations Health Directive 424: Treatment Planning Guidelines for Restorative Dentistry in Australian Defence Force Dental Facilities Roberson TM, Heymann HO, Swift Jr EJ. Sturdevant’s Art and Science of Operative Dentistry. 5th Ed. Ch11, Ch16; pp506508, pp 694-696 Mount GJ, Hume MWR. Preservation and Restoration of Tooth Structure. 2nd Ed. Chap 19; pp 337-346 Robichaud R, McNally ME. Barodontalgia as a differential diagnosis: symptoms and findings. J Can Dent Assoc 2005; 71:39-42 Zadik Y. Dental barotraumas. Int J Prosthodont 2009; 22: 354357 Calder IM, Ramsey JD. Ondontecrexis – the effects of rapid decompression on restored teeth. J Dent 1983; 11:318-323 Zadik, Y. Barodontalgia: what we learned in the past decade? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010 Vol 206; 11-16 Lyons KM, Rodda JC, Hood JA. Barodontalgia: a review, and the influence of simulated diving on microleakage and on the retention of full cast crowns. Mil Med 1999; 164:221-227 Defence Instructions (G) PERS 36-3: Inherent requirements of service in the Australian Defence Force Defence Instructions (G) PERS 36-2: Australian Defence Force policy on Individual Readiness Health Directive 402: The Australian Defence Force Dental Classification System

CADMUS 72

CADMUS 2012

Articles of Interest – Dental Officers

2EHS Dental Officers in CAMBODIA Flight Lieutenant Adrian Sebastian, BDS In December 2011 FLTLT Liu and FLTLT Sebastian travelled to the French influenced city of Phnom Penh, Cambodia. We are both passionate about humanitarian service so sought to use our annual leave to provide dental services to the orphans of the region. We worked for Cambodian World Family, a non government organisation. Treatment provided included relief of pain, via extraction or pulpotomy; caries control in high risk patients using GIC; restorative and preventative dentistry including fissure sealing, prophylaxis and oral hygiene instruction.

The children loved visiting the clinic and many had travelled a considerable distance. Dialogue was restricted to ‘ham-wat’ (open) or-kuun (please) and ‘chu?’ (pain?), with the nurses doing the rest of the translating for us. The experience was rewarding as a DENTO both professionally and personally. Clinically it allowed us to focus on our paediatric skills; something that we may need to use on future humanitarian missions. Personally, it is gratifying to be able to use your skills to help a demographic in need. Finally, immersing yourself in a foreign culture has further broadened my perspective on the world.

FLTLT Liu providing treatment to a child in the clinic

FLTLT Sebastian with the children awaiting treatment in the clinic

Section of Defence Forces Dental Services Meeting, August 2012 Colonel Janet Scott, CSC BDS, BScDent (Hons), MOS, FRACDS, FICD, Grad Dip Def Mngt The 2012 World Military Dental Congress, the annual meeting of Section of Defence Forces Dental Services (SDFDS) of FDI World Dental Federation was held in August. A contingent of 7 Australians, including DDFD, met in Hong Kong with 120 other delegates. The meeting was hosted by the Fourth Military Medical University (4MMU) of China, based in Xi’an and delegates came from 18 countries, including Great Britain, New Zealand, Malaysia, Singapore, USA, Canada, Holland, Turkey, Sweden, India and Germany. Friendships were renewed and new ones made at the fine social events organised by our hosts. However, eating the goose foot with chopsticks proved a challenge for some of our less dextrous colleagues! Over the two days of scientific program, delegates heard papers presented on a variety of topics, including forensics, the prevention of dental casualties on deployment, reliability theories as applied to crown and bridgework and digital impression taking. I presented a paper on the long term follow up of two large mandibular cysts treated conservatively. The Australian contingent in the conference venue. From L to R are: WGCDR Steve Mason (SA) LTCOL Victor Tsang (NSW), COL Geoff Stacey (ACT), COL Janet Scott (SA), COL Genevieve Constantine (ACT), CAPT Yong Kho (SA) and GPCAPT Greg Mahoney (QLD). CADMUS 2012

A review of the Australian Defence Force Classification System, with associated quiz (Part 2) â&#x20AC;&#x201C; Case Discussion Points Lieutenant Commander Dan Allan, RAN, BSc, BDent, Grad Dip Clin Dent (Oral Surgery) Case 1 Discussion In accordance with HD 402 The Australian Defence Force Dental Classification System, the member should be a class 3 due to moderate periodontitis. The age of the patient also plays a role in decision making. In this case the member is 26 years old and considering the extent of pocketing, was made a class 3 until assessment by a periodontist. Even in an older patient with a history of chronic periodontitis, the pocketing around the lower anterior region would still necessitate making the member a class 3. If the member is undergoing supportive periodontal therapy and has been stable with these pocket depths for several years, then consideration for an upgrade to class 2 could be considered. Moderate chronic periodontitis is an area that provokes discussion regarding dental classification, as the likelihood of a member with a good OH regime becoming a dental casualty with this condition is quite small.

Case 2 Discussion At the time of the appointment the member should be made a class 3, given OHI and made a subsequent appointment to review an updated OPG. In accordance with HD 404 Indications for Removal of third Molars in the Australian Defence Force, a single episode of pericoronitis that responds to OHI is not an indication for removal of wisdom teeth. However, there is growing evidence that partially erupted and mesially impacted wisdom teeth require greater consideration for prophylactic removal due to the risk of caries to

the distal of lower 7â&#x20AC;&#x2122;s. If the wisdom teeth were partially erupted, vertically impacted and there was sufficient room for eruption into function, then the member could be upgraded to a class 2 or class 1 depending on other risk factors. For recommendations on removal of third molars, form PM591 needs to be completed by the referring clinician to support the decision making process.

Case 3 Discussion i) In all endodontic cases, the member should remain a class 4 until complete chemo-mechanical preparation of the root canal system has been completed. Until this occurs, the risk of becoming a dental casualty is high. (ii) Once preparation of the root canal system is compete, if an appropriate dressing is placed, the member may be reclassified to class 3. For posterior teeth an orthodontic band to support the remaining tooth structure is mandatory. A recommendation for a deferral of dental treatment may be appropriate if the patient is required to deploy for up to a three month period. (iii) A patient undergoing endodontic treatment may only be upgraded to class 2 once the canal system has been obturated and a permanent restoration placed. The restoration should be placed as soon as possible after obturation to prevent coronal leakage and bacterial recontamination of the canal spaces. A follow up radiograph should be taken in 12 months to assess for hard tissue healing if preoperative apical periodontitis is evident radiographically. Endodontic Specialists recommend that root filled teeth be assessed radiographically every 2 years.

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CADMUS 2012

Articles of Interest – Senior Dental Assistants

Defence Recipe Competition, August 2012 Leading Seaman Rachelle Johnson Australian Dental Association Dental Health Week is held every year to promote the importance of good dental health on overall health and wellbeing. The 2012 theme was ‘Don’t Accept Dental Decay’ and as we know, what we eat and how often we eat are important factors to maintain good oral health. Dental Health week was the perfect opportunity to increase awareness of the relationship between diet and oral health. An Australia-wide challenge was initiated for all ADF chef’s to submit dental friendly recipes. Kate Flinders, an Accredited Practising Dietician and Nutritionist from the Defence Science and Technology Organisation (DSTO) offered advice on dental friendly foods. The recipes were then reviewed, in accordance with set assessment criteria, by a judging panel: LCDR Kim Leong, OIC ADF Dental School; Bianka Probert, DSTO Nutritionist and WO

Peter Clothier, Army Catering Advisor. There was a fine array of submissions and it was good to see a bit of friendly competition among ADF cooks for the prosperity of ‘good teeth’. At a local level, STIRLING galley conducted a Cook Off and Voting Frenzy. Andrew Paton, a contestant in this year’s series of My Kitchen Rules and STIRLING personnel actively took part in the tastings. The overall winners recipes are included for your own enjoyment. The competition could not have been such a success without the involvement from the following: CMDR Tanya Burton; POCK Dave Boyles, ABCK Trent Duncan and galley chefs; Ms Kate Flinders, LCDR Kim Leong, WO1 Peter Clothier and Ms Bianka Probert; CPL Kerri-Ann Steindl and LAC/W Donna Hayes; Harvey Norman and Transfield Food Services.

1st place AB Lana Hendry, HMAS STIRLING

2nd place LAC Christopher Maddocks, RAAF Amberley

3rd place WO2 Darren Morley, y Latchford Barracks

Lana’s raspberry twirl mint yoghurt dessert

Watercress and fig salad

Breakfast Blast Smoothie

Ingredients

• • • • • • •

• • • • • •

1 cup of plain yoghurt 2 tablespoon of honey 2 tablespoon of fresh mint 1 cup of frozen raspberry 4 whole mint to garnish 1 tablespoon of mascarpone cheese

Ingredients (serves 2) 1/4 cup (45g) hazelnuts 1/3 cup (80ml) balsamic vinegar 2 cups watercress sprigs 2 ripe figs, broken into quarters 1 tbs hazelnut oil (see note) Rocket (as a bed on plate) 1 Mango (thinly Sliced)

Method

1. Mix in bowel 1 cup of plain yoghurt, 2 tablespoon of honey, 2 tablespoon of fresh mint, 1 cup of frozen yoghurt and 1 tablespoon of mascarpone cheese. 2. Place the mixture in a serving bowl and twirl the mixture to place. 3. Whole mint to garnish.

1. Preheat oven to 200°C. Place hazelnuts in a roasting pan and cook for 5 minutes or until toasted. Place hazelnuts in a clean tea towel and rub to remove skins (this is easiest when hazelnuts are still warm). Cut hazelnuts in half and set aside. 2. Meanwhile, place vinegar in a small saucepan over high heat. Bring to the boil. Reduce heat to medium-high and simmer for 5 minutes or until reduced to 1 1/2 tbs. Set aside to cool. 3. Arrange watercress sprigs, figs, mango and hazelnuts on serving plates. Drizzle with mango and hazelnut oil and serve immediately.

CADMUS 2012

Ingredients Smoothie • 1 x cup of Darren’s fresh go-go juice • 1 x ripe medium banana, peeled and sliced • 1 x cup fresh blueberries, blackberries or raspberries (frozen is fine and so is a combo) • ½ cup silken tofu • zest of ½ a lime • 1 x teaspoon flaxseed oil • 2 x ice cubes, crushed

Darren’s go-go juice • thumb size piece of fresh ginger • 2 x oranges • 1 cup of a pineapple (this provides a little sweetness) • 1 x fresh beetroot (tennis ball size) • 3 x celery sticks • 1 x carrot • ½ lime

Method Step One: To make Darrens go-go juice, place all chopped items into a juicer. You may need to add a little extra of the ingredients to get enough juice for a cup; it all depends on how juicy the fruit and veg are at the time. Step Two: Once you have made the go-go juice, simply place all ingredients into a blender and blend until smooth. Step Three: Drink and enjoy a great start to the day!!!

Oral Health Promotion for Children Corporal Kristy Mcmillen, Private Robert Maddock RAADC Introduction Teaching your child correct oral care at a young age is an investment in his or her health. Babies and toddlers are at just as much risk of dental decay as an older child or adult, so caring for your child’s teeth should begin at birth. Setting an example by taking good care of your own teeth sends the message that oral health is to be valued. By establishing good oral hygiene habits early, your child will have a greater chance of having healthy teeth for life.

Early Brushing Once your baby’s primary teeth start to appear it is essential to start implementing regular brushing techniques in order to protect the teeth and gums to greatly reduce the risk of caries. A toothbrush specially designed for babies and toddlers should be used. Up until the age of 18 months only plain water is required for brushing once a day, after the last feed. After the age of 18 months and once your toddler has become used to brushing, introduce brushing twice per day using a low fluoride toothpaste which is specially designed for toddlers, such as Colgate- My first Colgate or Macleans Milk Teeth. Once children reach the ages of 4-5 years they should begin to learn how to care for and brush their own teeth. Until the age of around 8 years children do not have the skills to effectively clean their own teeth, so it should remain a combined effort between you and your child until then. To effectively brush you must clean every surface of every tooth. Avoid side to side scrubbing as this can damage both the teeth and the gums; instead move in small gentle circles with a small soft toothbrush to clean the front surface of the teeth. Tilt the toothbrush to clean inner surfaces and use a firm back and forth motion for the biting and grinding surfaces. To encourage your child to brush their teeth and make it a more enjoyable experience, consider a coloured battery powered electric toothbrush. You should aim to brush for about 2 minutes; toothbrushes should not be shared and should be replaced every 3 months or when the bristles become frayed.

Flossing Flossing should be introduced between the ages of 2 to 2 1/2. By the time children are around 8 years old, they can begin flossing for themselves. Flossing helps to keep their gums healthy and removes the bacteria which can cause gum disease and decay. Teeth should be flossed ideally twice a week. Floss handles can make the process a lot easier, for both parents and kids. Do not snap the floss down between the teeth as this may damage the gums; instead gently slide it in between the teeth, curve it around each tooth in turn and work it up and down with a gentle back and forth motion against the surfaces of each tooth. Have your child rinse after flossing and then brush their teeth using the low fluoride toothpaste.

Primary teeth Primary teeth begin to form in the jaws before birth. At about 6 months of age a baby’s first tooth will usually start to erupt. However this can happen anywhere from birth to your child’s first birthday. A typical child will have their full set of 20 primary teeth by the time they are 2-3 years of age. Many babies go through some discomfort during the appearance of primary teeth, which is also known as teething. Almost all babies will become irritable when new teeth are breaking through their gums. Medication such as Children’s Panadol and Children’s Nurofen along with Bonjela (a mild topical anaesthetic gel) can help to relieve the discomfort of teething. Always seek advice from your dentist, pharmacist or doctor before using any pain relief medication. Gently rubbing your baby’s gums or giving them a teething ring or rusk to chew on may also provide some comfort.

Signs and symptoms of erupting primary teeth • Reduced or loss of appetite • Sucking or gnawing on toys • A mild fever • Pulling the ear on the same side of the erupting tooth • Frequent crying and crankiness • Mild diarrhoea • Reddened cheeks and drooling.

Thumb sucking Thumb sucking is a natural reflex in babies and young children. By the age of 2-4 years most children will lose interest in thumb sucking and dummies. There is a risk of developing crooked teeth in children who continue to suck their thumb or fingers after their adult teeth appear, particularly if the sucking is frequent or forceful e.g. the front teeth may be pushed out of alignment which can alter the shape of the upper jaw leading to an anterior open bite. It can also result in speech defects such as a lisp. You should strongly encourage your child to give up thumb sucking, however, if by the end of their first year at school they continue with the habit, you should seek advice from your dentist.

Healthy Eating A balanced diet is essential for your child to develop strong, decayresistant teeth. Developing healthy eating habits early will form the building blocks for strong and healthy adult teeth. A child’s diet should include plenty of calcium, phosphorous, and proper levels of fluoride. Children are now consuming more processed foods and drinks. There is an increase in consumption of bottled drinks, juices and cordials rather than drinking plain fluoridated tap water. Frequent snacking on foods that are sugary and starchy such as cookies, candy, dried fruit, potato chips and soft drinks is highly detrimental to oral health as they are used by the bacteria in the plaque on teeth to create acids. These acids attack the tooth and are responsible for the formation of cavities. It is therefore best to limit snacking to one in-between each meal and to foods which are rich in calcium and low in acids and sugars. Two healthy snacks a day such as fruit and a small portion of cheese is recommended. As many ‘healthy’ foods contain high amounts of sugar, you need to ensure that you clean you child’s teeth every morning and night. Good oral hygiene must be complemented with a healthy diet.

Early Childhood Caries (ECC) ECC is where a child is at risk of dental decay as soon as they develop their first tooth. Bacteria in plaque feed on sugar and sweet drinks to form plaque acids on teeth, which eat into the tooth’s surface and cause decay. Once your baby has teeth it is therefore best to avoid settling them to sleep with milk, flavoured milk, cordial, soft drink or fruit juice.

Preventative Measures Your child’s first visit to the dentist should be 6 months after the eruption of their first tooth, followed by annual check ups. In addition to the steps above to prevent ECC, fissure sealants can be used to create a highly effective barrier against decay on a child’s adult back teeth, where most cavities tend to form. Your dentist can advise whether or not your child would benefit from this simple procedure. One of the best ways to help prevent tooth decay is the proper use of fluoride. Fluoride is a naturally occurring mineral which combines with the tooth’s enamel, to help strengthen and protect teeth against decay. Your dentist should be able to tell you whether your local water supply has the right amount of fluoride. CADMUS 2012

Top left: Decay present between teeth & around gumline. Centre: Crowns of teeth breaking down. Top right: Child less than 5 years old

7 steps to help prevent ECC 1. Maintain a healthy diet - stick to 3 meals per day with no more than 2 healthy snacks. 2. If your baby is a mouth breather, they may suffer from a dry mouth and lack of saliva which puts them at greater risk of ECC. You should speak to your Dentist or Doctor. 3. Good oral hygiene begins at birth; regular brushing and flossing must be implemented when your child begins to teeth. 4. Ensure you clean your child’s teeth after breast or bottle feeding before they go to bed. Once a child is over 12 months, regular breast and bottle feeding through the day or night can contribute to ECC. 5. From the age of 12 months, encourage your child to drink from a toddler cup. 6. Offer a dummy,rather than a bottle if your child needs to suck on something to settle them to sleep. 7. Don’t let your child take a bottle of milk, or other sugary drinks to bed. It is fine to place a glass of water next to their bed once they are older in case they get thirsty throughout the night.

Alternatively you can contact your local water district to obtain this information. If at home you have tank water or a filter on your tap, your child may be at risk of not having enough fluoride. Your dentist may suggest using fluoride drops in water, a fluoride mouth rinse and an annual fluoride treatment in addition to using fluoride toothpaste.

Dental Injuries in Children Almost 50% of children will experience some sort of dental injury during childhood. You should contact your dentist with any dental injury that your child receives; your dentist will want to examine the affected area and determine an appropriate treatment plan.

You should visit the dentist immediately if your child is in pain from a cracked, chipped or broken tooth. Keep any part of the tooth that has broken off and take this to the dentist. The most common causes of tooth injury in children are falls, sports related injuries and fights. You must visit a dentist immediately if an adult tooth is completely knocked out and ensure that you take the tooth with you. The tooth should be handled with care by the crown of the tooth and touched as little as possible. Do not wipe over the tooth, instead immediately submerge it in a glass of water or milk until you get to the dentist. This will cause the least amount of stress on the tooth and it may be possible for the tooth to be placed back in the child’s mouth through a procedure called re-implantation. Ideally the tooth should be placed back into the socket within 15 minutes, but it can be up to 1 hour (or longer if stored in cold milk). Around 85% of teeth that are reimplanted within 5 minutes survive. The child, a parent or another adult can attempt to reimplant the tooth if unable to get to a dentist quickly. The child should then be examined by a dentist as soon as possible to give the tooth the best chance of survival. This process only applies to adult teeth; primary teeth should not be placed back into the socket due to the risk of damage to the underlying permanent tooth.

Conclusion A healthy smile, good breath and strong teeth all contribute to a young person’s sense of self appearance, as well as confidence and self esteem. If your child currently has poor dental hygiene habits, work with them to change these now. It is a lot easier to change these habits in a young child than an adult. Since your child models their behaviour after you, it follows that you should serve as a positive role model in your dental hygiene habits. Associated reference list is not shown due to space constraints. To request a copy, please contact the Editor.

Prevention for the Future Petty Officer Scott Norbury As dentistry in the 21st century has adopted an approach of conservation of the dentition, compared to years gone by, the emphasis is squarely now on prevention. In 1974 the Australian Defence Force recognised the benefit of preventive dentistry and placed into service its own specialisation of Dental Hygienists, preceding the National dental community by two years. In 2007 the Dental Hygienist trade changed its name to Senior Dental Assistant-Preventive (SDA-P). This important and vital profession is still in existence in both the Royal Australian Navy and Royal Australian Air Force. Acting as an adjunct to the services provided by Dental Officers, SDA-Ps provide oral health support and education to Defence personnel. Arbitary statistics are being collected by the Australian Defence Force Dental School (ADFDS) to highlight the value of SDA-Ps CADMUS 2012

in service. Statistics collected to date indicate that 39% of SDAPs scheduled clinical time is spent performing debridement and plaque control procedures. A further 39% of the time is taken up by the provision of OHI. The remaining 22% of time is distributed between tasks such as smoking intervention, saliva testing and diet analysis. Observational data collected at the ADFDS shows that the majority of patients show a marked improvement in their oral health after treatment by a SDA-P. If oral health is maintained, this improvement potentially translates to a decline in new carious lesions, recurrent caries and periodontal degradation. A prospective clinical study to statistically analyse the clinical benefits and cost effectiveness of SDA-Ps may be warranted to highlight their value.

RAADC Corps and Historical Members on non-Corps postings 2012 Army Recruit Training Centre, Kapooka

even Egypt. I am hoping to get on one of these, as all trips are given on merit and performance within the guard.

Corporal Jason Wilding RAADC

I have had a fantastic time so far at this Unit and I encourage any member of the RAADC who wishes to expand his or her skills and abilities in drill to give the AFG a try.

It has been an extremely busy year for all the members posted to 1st Recruit Training Battalion (1 RTB). Recruit Instructors (RI) from the RAADC at Kapooka include CPL M. Gurkin, CPL C. Dor’e, CPL J. Parlour and CPL J. Wilding. As part of the revamped 80 day Army Recruit Course CPL RIs teach the following: drill, weapons (F88, F89), night vision package, simple urban operations, fieldcraft and navigation along with the Range package (LF1-6). While training your platoon you are required to work some extremely long hours but you are remunerated with additional leave and a RI Bonus. When you are not attached to a platoon, you work a normal working day, organising the arrival of your next platoon or are allocated other tasks throughout the Battalion such as range supervision, high wire confidence course and parade allocations. Kapooka is an exceptionally challenging posting, but it is also equally rewarding with the opportunity for professional development and job satisfaction. If you have an interest in doing something outside the ‘dental comfort zone’, come and join the team at 1 RTB, you won’t regret it.

Australian Federation Guard Corporal Conor Gray, RAADC The reshaping of the RAADC has given me the chance to explore other avenues within Army for a JNCO and I was extremely happy to receive my posting order to Australia’s Federation Guard (AFG). I arrived at the Guard in early January rather flustered and lost, as for once, I was the new kid on the block! It wasn’t long though until I was back to my normal jovial self, particularly after seeing another Dragon hat badge attached to the head of CPL Sarah Fisk!! My fears were put to rest! The AFG is a Tri-Service Unit consisting of around 180 members and the Unit provides a ceremonial capability to the Australian Defence Force, both in Australia and overseas. The GSM quickly put the new people to work; whipping us into shape for the Australia Day ceremony in Canberra and every day was spent honing our skills! The Unit has a unique style of drill and has a strong focus on uniformity, dress and bearing. The use of the SLR as our main drill weapon was also a challenge and I don’t look forward to going back to Steyr anytime soon! There is a strong emphasis on PT, which I find fantastic and it provides a nice break from drill rehearsals! CPL Fisk and I have been part of ceremonial duties and parades, ranging from visiting Heads of State to visiting Dignitaries at Russell Offices in Canberra. The chance to participate in the opening of the Royal Easter Show was exciting and I think my belly expanded by three inches after a visit to the Tim Tam booth! The Unit has a number of overseas trips coming up in the next few months, ceremonial parades in Timor, Papua New Guinea and

Network Implementation Advisory Team (NITAT) Corporal Alison Rolles, RAADC Over the past two years I have been fortunate enough to undertake an out of Corps posting as an instructor at Network Implementation Advisory Team (NITAT) in Brisbane, which falls under AHQ. NITAT was raised in the beginning of 2011 and its main aim is too train the Defence Force into the digital era. Army is currently going through significant changes to improve and update our system of communications. This change will eventually affect everyone which means even us tooth fairy’s will have the opportunity to be trained in the use of the new digital communications system. The initial part of my tenure was spent learning the new 152, 150 and EPLRS radios and key loading devices. I was definitely thrown into the deep end in the Signals world!!! We were the first course in Australia to be trained on the new equipment. At the completion of our training it was up to us to collate lessons and start instructing. This was a bit nerve racking at first, however it soon became familiar and really enjoyable. There is no ‘normal’ routine at NITAT. We spend a lot of time travelling around the country to teach different Units. I have had the opportunity to work closely with Signals, Infantry, Artillery units; as well as Navy, Air Force and civilian agencies such as Harris, Raytheon and Elbert. We also support exercises such as TS 11 and Hamel, not to mention time out in the field testing the equipment. This posting has opened my eyes to the broader Army and it has provided me with unique experiences and opportunities that I would not have been able to experience in a dental unit. This posting has benefited me both professionally and personally. I would encourage anyone who is given the opportunity for an out of Corps posting to grab it with both hands. The networking with members of the wider Army will enrich our Corps in the longer term.

CPL Rolles working on the BMS system in the back of a PMV. CADMUS 2012

Update from the RAADC Association Incorporated Gayle Clare, RAADC Association Secretary 2013 Reunion, Brisbane Come and join members of the RAADC Association in Brisbane in 2013. Thu 25 Apr 2013: The RAADC Association will be marching in Brisbane Anzac Day Parade. We welcome serving and ex serving RAADC members to march with us. On conclusion, there will be refreshments at the Novotel Brisbane. Fri 26 Apr 2013: The Reunion Dinner will be held at the Novotel Brisbane on Friday evening. If it is anything like our last reunion in Canberra, we will all have a great time. Sat 27 Apr 2013: The RAADC Association AGM will be held on Saturday morning at the Novotel Brisbane. Please visit www.raadcassociation.com for further details.

RAADC Association AGM 2012 The 2012 RAADC Association (Inc) AGM was held at Montville on 26th May 2012 at the residence of our Patron, Martin Mylne. The location is on the escarpment of the Blackall Ranges, overlooking the Sunshine Coast and Nambour. 10 members of the RAADC Association stayed for the weekend. After we arrived on Friday night, we wined and dined on the wonderful food provided. On Saturday, rising early, we went for a walk to the township of Montville for a coffee and daily papers. On returning to the house, we relaxed on the deck and enjoyed breakfast. The AGM took place just after 1100 on Saturday 26th May, with 13 members attending. An era in our Association came to an end, as Mal Slattery resigned from his position as Vice President. Mal was first appointed by the SO1 Dent, Dennis Krafft, as an Admin officer in January 1988 and he progressed to the Secretary position in April 1989. With a total of 24 years, the dedication that Mal has put into our Association goes without question. The following members were elected to the Management Committee for FY 2012/13: President: Vice President: Secretary: Treasurer: Records Member: Property Member:

Mrs Dexter Purcell Mr Ron Brown Ms Gayle Clare Mr Graham Sagar Ms Dana Socal Mr Ron Brown

On the Saturday night, we all enjoyed a wonderful meal at the Le Relais Bressan French restaurant at Flaxton. The weekend came to a close on the Sunday with a great show of camaraderie when everybody chipped in, cleaned up and we said our goodbyes for another year.

ANZAC Day – Brisbane 2012 RAADC Association (Inc) members formed up in George Street, in preparation for the ANZAC Day March in Brisbane. Our contingent this year was led by Mal Slattery. He was joined by Marty Mylne, Gayle Clare, David Hua, Ray Wilkinson, Nick Read, Ron Brown, Sven Bohnstedt, Pat Jackman, Renate Provost, Martin Heppleston, Rob Hazelwood, Lindsay Myers, Graham Sager, Bob Greenhill, Geoff Austin and Dana Socal. After the parade, many of the members, along with family and friends, gathered again at Gilhooley’s Tavern in Albert Street for lunch, a few refreshments and many hearty laughs. A great day was enjoyed by all in attendance. CADMUS 2012

Vale Staff Sergeant David Buckley Dave grew up in Sydney and joined the Australian Army at age 17. He initially applied for the SAS, completed the entrance course and was selected. However, Dave had also applied to join the RAADC and when given the choice, chose the RAADC. He originally served as an Assistant Admin but changed to a Dental Tech after qualifying in that trade. He served with a number of RAADC Units through the late 60’s, 70’s and 80’s including 17 Dental Unit, Puckapunyal, 16 Dental Unit, Townsville and 9 Dental Unit, Enoggera, Brisbane. He retired as a SSGT Dental Technician. During Dave’s early service in the Army he was posted overseas to Malaysia, Borneo and Brunei. He was seconded into the British Army and spent many periods of service in the jungles of Borneo on patrols. Dave had an acrobatic background and his gymnastic talents would be a highlight night ‘with the boys’. His backward somersaults ‘off the bar’ were quite memorable. Dave loved fishing and boating and after leaving the Army he opened a bait and tackle shop. He also ran a successful Dental Laboratory. Dave passed away in August, 2011. A Service and Cremation was held at the Great Northern Garden of Remembrance, Deception Bay. A number of RAADC Association members attended the service and took part in the “Poppy Service” Military Tribute.

Staff Sergeant Mark Watson Mark was born on the 11th November, 1938. He was a country boy and was raised in Biloela, Central Queensland. He moved to the big city of Brisbane to complete the final year of his apprenticeship as a Dental Technician at the Brisbane Dental Hospital. He later became the proprietor of a large Dental Laboratory in George Street, Brisbane, before deciding to join the Australian Regular Army. Mark rose to the rank of SSGT Dental Technician and he was regarded by his fellow technicians as a skilled craftsman in his trade. He served with 16 Dental Unit in Townsville in the 70’s and later with 9 Dental Unit at Enoggera in Brisbane before deciding to take his discharge. Mark passed away at Prince Charles Hospital in Brisbane on 5 February, 2012. Members of the RAADC Association attended Mark’s funeral.

Staff Sergeant Len Stratford Len joined the part-time Army in 1937 at age 19. He was a member of the 5th Light Horse Regiment. Len joined the Australian Military Forces full time in 1940 and was discharged in 1945. He left the Army as a Staff Sergeant Dental Technician. Len spent a period of time training dental technicians at the first Dental Training School at the Exhibition Grounds in Brisbane. He was present during the first bombing of Darwin where he was on the strength of the 119th Army General Hospital. He was extremely proud of his slouch hat with the emu plume in the puggaree. He marched proudly wearing this hat with the RAADC Association Contingent on ANZAC Day some years ago. Len was also a keen wood worker and in his spare time made polished wooden trays and polished stools. He donated some of these items as a prize for our raffles for a number of years. Len passed away in February 2012 in Brisbane. He was 92 years of age. Members of the RAADC Association attended Len’s funeral.

RAADC Corps and Historical Obituaries In Memoriam PTE Alexander (Lex) William Milne (15 Jan 1920 – 07 Jan 2012) Lex discharged from the Army in April 1946. He married a Red Cliffs girl and they had four children. His wife died of cancer at the age of 41. Lex continued to live in Red Cliffs, Victoria, where he is now buried at Red Cliffs Cemetery. In his memory a précis of Lex’s experiences as part of 22 Dental Unit is reprinted below courtesy of LTCOL Peter Winstanley, who has been committed to the Prisoner of War story for the past 11 years. Please take the time to visit his website, www.pows-of-japan.net. You will find the full article for Lex Milne and there is also an interesting account for CAPT Stuart Simpson, the sole surviving Dental Officer of the six identified Dental Officers on the Railway.

Timor, Java and Sumatra experiences of Private Alexander (Lex) Milne, 22 Dental Unit (condensed version) - Lieutenant Colonel (Retd) Peter Winstanley OAM RFD JP Lex Milne was born in Swan Hill, Victoria on 15 January 1920. He enlisted into the 22 Dental Unit and in April 1941, was allotted to 2/40 Battalion as part of Sparrow Force. On 07 December Japan declared war and Lex embarked on the Westralia, leaving Darwin harbour on 10 December.

TIMOR The Force arrived in Timor on 12 December in Koepang Bay. Elements of Sparrow Force were deployed to various locations. 22 Dental Unit was initially positioned at Penfui Airfield. They were soon moved to Tjamplong, where part of the 2/12 Field Ambulance had established a hospital facility. Their team consisted of the Dental Officer, Captain John Winter, two dental mechanics and lots of portable equipment. Accordingly they frequently moved to treat patients.

The Japanese invaded Timor on 19 February 1942 and the Allied surrender took place on 23 February. It is estimated that the invading Japanese force totalled 22,000 and the Allies defending Timor were around 3,000. During the period in captivity in Timor, from February to September 1942, the Medical and Dental personnel provided support to the POWs; considering their limited resources and facilities. One of Lex’s jobs was to cleanse and sterilise bandages, by boiling them in a kerosene tin. An early treatment performed by Captain John Winter was to treat a POW who had a bullet wound through his mouth; with the complication of a shattered jaw bone and many missing teeth. They had access to a few ampoules of anaesthetic, which was provided by a Dutch doctor and the patient survived.

JAVA Many of the men were moved to Java in September 1942 on the Dai Ichi Maru, an old rust bucket. When they arrived in Java, Captain Winter was appalled at the condition of the teeth of the recently arrived British soldiers. A treatment area was organised, which involved the use of a Regimental Aid Post (RAP) stretcher in lieu of a dental chair. A British Medical Officer administered a form of anaesthetic, using an improvised gauze mask on which a small amount of ether was sprinkled. Captain Winter quickly and efficiently extracted the teeth, assisted by Lex. About 20 British soldiers were lined up for treatment, with a full view of the procedures. Lex thought the British soldiers had a lot of guts, as not one dropped out. Lex recalled working with an RAF Dental Mechanic at Tandjong Priok. He also recalls that Captain Winter managed to acquire a vulcaniser, primus, wax plaster and some duralium (there were plenty of wrecked aircraft around). Together, they made some dentures. Lex advised that the dentures initially worked well. However, with the absence of toothpaste, toothbrushes and an owner who smoked boong weed, they soon looked pretty ghastly. Whilst on Java, Lex recalls being separated from Captain Winter, but continued to assist a Dutch Dentist.

SUMATRA In May 1944, Lex was moved to Singapore and worked on the wharves. Later in July, Lex was on the move again, to Sumatra. This time the POWs travelled on an old Penang ferry the Elizabeth. Lex became part of a work force building a railway in the island of Sumatra. This railway was about half the length of the Burma Thailand Railway, just over 200 km. (This railway is frequently overlooked in the telling of POW experiences and is often referred to as the “Forgotten Railway”). In the latter stages of construction the work force numbers diminished due to poor health and the reduction in the amount of food supplied by their captors. At the end they were working 16 hour days.

PTE Lex Milne, VX 39668

Lex Milne returned to Singapore on 15 September 1945. His weight was 8 stone 5 lbs, having dropped from 11 stone. Whilst in Singapore he was reunited with Captain Winter, who came from Java. In October 1945 he returned to Australia with many other POWs, including the Australian Nursing Sisters who had been incarcerated elsewhere on Sumatra, on the Manunda. CADMUS 2012

Joint Units

Unit News

Directorate of Defence Force Dentistry Commander Tanya Burton and WO Penny Stone In 2012, the Directorate of Defence Force Dentistry has continued to focus on updating Defence Dental Policy, incorporating the revision of Health Directives, the Health Manual and Infection control protocols. A detailed process involving comprehensive research, communication with SME’s, liaison with Service representatives and discussion through JHC meetings for subsequent recommendation, has led to amendment of many out of date policies and the development of a HD for Oral pathology. Our aim is to have all HD content reviewed through the Directorate by the end of the year. Additional webforms have been released including, PM613 Oral Pathology and PM599 Aircrew Applicant Dental Examination. The Directorate has diligently drafted and finalised the Radiation Safety Management Program and Radiation Management Plan (RSMP & RMP). The Defence Health Manual is also under extensive review. All the documents have proved challenging and involved numerous stakeholders. The Directorate consists of five staff; DDFD, COL Genevieve Constantine and WGCDR Janine Tillott in Canberra; CMDR Tanya Burton in Darwin; Warrant Officer Penny Stone in Sydney; we are also assisted three days a week by LCDR Katherine Bailey, who accompanied her husband on his exchange posting to London. When LCDR Bailey is not working for the Directorate, she participates in representational activities endorsed by the Australian High Commission and Head of Australian Defence Staff in support of the Mission of the Australian Defence Force in London. In addition, we would like to thank POMED Hayley Moore for her valuable contribution in administrative support during her short tenure on Reserve days earlier in the year. A lot of time has been dedicated to providing guidance and advice to the JeHDI project. It will be pleasing to see the end product when JeDHI is implemented across the regions. It is forecast that dental reporting will become more efficient for facilities and end users, by utilising JeHDI and Cognos for report generation. The Directorate is involved with the provision of guidance for recruiting teams and personnel posted overseas. In addition, in support of Dental Officers, CHP’s and Dental Auxiliaries, numerous responses to dental queries are provided on a daily basis utilising best-practice guidelines and clarifying policy. CADMUS 2012

The Directorate continues to consult closely with representatives of all three Services, senior Specialists, Dental Officers and the ADF Dental School. These relationships have proven invaluable, particularly in maintaining open communication and feedback in policy review and dental clinical governance. We wish you all a safe and Happy Christmas. Thank you for your hard work and dedication this year.

Health Services Reserve Agency SEQLD Colonel Gerald Thurnwald AM This past year has seen a significant reorganisation of the RAADC ARA and ARES elements. At this stage the final status of the RAADC ARES elements is unknown. In Queensland some consultant positions have been absorbed into 3HSB (under command of Army) and others into the Regional Health Service (under command of JHC) as an interim measure. Despite all of the turmoil the delivery of our most important product, professional development, has continued. The main activity has been to run the Dental training nights, where invited speakers deliver presentations on topics of (mainly) dental interest to an audience of service dentists (Regular and Reserve) and civilian contract health practitioners. This year, three nights were organised. The caliber of the speakers was first class with COL Rick Olive (orthodontics), LTCOL Paul Monsour (Oral and Maxillofacial Radiology), LTCOL Rob Hazelwood (Endodontics), LTCOL Sven Bohnstedt (Periodontics) and SQNLDR Alex Forrest (Forensic Odontology) delivering up to date lectures on their specialty areas. To hear these gentlemen in a civilian setting would cost thousands of dollars, so no one attending could argue that they weren’t getting value for money! A highlight was a presentation by LTCOL Ken Lilley from the Army Malaria Institute (AMI) on “Microscopic Identification of Malarial Parasites”. This talk had a practical component which highlighted the difficulty in diagnosing malaria in the field. It also showcased the world leadership of the AMI in the fight against malaria. As the training year continues, we are looking forward to supporting the annual Health Services QLD Conference on 8 Sep 2012. I would like to thank the consultants for giving up their valuable time to pass on their hard earned knowledge and to MAJ Chris Butson for his organisational skills.

Regional Health Service

Southern NSW Duntroon Health Centre – Dental Miss Audrey Gildea It has been another busy year here at the Duntroon Dental Department. We have had staff departures, new staff arrivals, engagements, wedding planning, contract changes and quite a few patients to keep us busy in between. Mid year we sadly said farewell to COL Geoff Stacey and Dr Serge Chan after many years of wonderful service for our Defence patients. COL Stacey was our specialist Prosthodontist. Although COL Stacey is no longer working at Duntroon Dental Department, we still consider him part of the team as we continue to utilise his services in private practice for our Prosthodontic patients. Dr Chan was one of our General dentists. He has been a part of the team for 4 ½ years, generously giving us a few days a week away from his private practice. However, Dr Chan has finally been persuaded to retire with the lure of wonderful travel plans in his imminent future – we wish him all the best. On a happier note we have welcomed back a beloved staff member with the return of Dr Bruce Peet. He has taken on the role of the Senior Dental Officer for the SNSW region and is a grateful addition to the Dental team, not only for Duntroon. Dr Peet has hung up the tools of Oral surgery and now works in an administrative role. He provides much needed clinical support to all the Dentists working in the SNSW region, a role we all greatly appreciate. Two of our Dental Assistants have become engaged this year, Rebecca Wullaert and Amanda Smith. Drs Sue and Rick Worboys also have a wedding coming up for their daughter Sandy. As you can imagine we are all very excited for the girls and are passing around ideas, themes and wedding magazines. We wish the girls all the best for their upcoming nuptials. Our lab tech had a tough year with an ongoing injury, but has now recovered and is back to work. There is talk of a new lab bench arriving any day now, a process that has been a long time coming. Peter Quintus-Bosz has been without a lab bench for over a year and has managed to continue to be a productive member of the Dental team while working under these difficult circumstances.

Dr Ian Brown came on board late last year in the role of General Dentist bringing with him a wealth of Defence knowledge. Our current Dental team is as follows: Dr Sonja Kuehl (Dentist), Dr Ian Brown (Dentist), Dr Rick Worboys (Dentist) and Dr Sue Worboys (Dentist), Mrs Sandra Lawry (Hyg), Mrs Joanne Petrie (Hyg), Mrs Margo Townsend-Evans (Hyg), Miss Rebecca Wullaert (SDA), Mrs Christine Fysh (Receptionist/DA), Mrs Jillian Paff-Hayes (DA), Mrs Ollieann Claven (DA), Miss Amanda Smith (DA) Miss Audrey Gildea (Practice Manager), Mr Peter Quintus Bosz (Technician) and Dr Bruce Peet (Senior Dental Officer). Thank you to all the other SNSW Dental units for your help and support over the last 12 months.

Russell Health Centre – Dental Dr Sioban Blaney-Brown Russell Dental Clinic is situated in the heart of Canberra, close to the RMC Duntroon. Although Duntroon has a dental Unit, we are extremely busy catering to the dental needs of about 3028 Defence Force Members. We have five dentists (one full-time and four part-time); three hygienists, one full-time and two part-time; a practice manager; two receptionists and at the moment three full time dental assistants. Luckily the receptionists also have surgery experience and can help out in the surgeries, when necessary. Only occasionally do we resort to ‘borrowing’ a dental assistant from Duntroon, who are always very helpful! Our Senior Dental Officer resides at Duntroon and comes to Russell on a monthly basis. We can of course call him at any time for advice, on any aspects of the job. We are also lucky enough to have several specialists here in Canberra including Oral Surgeons, Periodontists, Endodontists, Orthodontists and Prosthodontists ensuring that all Defence Force Members are able to access a high standard of dental care at all times.

Albatross Health Centre – Dental Able Seaman Christian Fehrenbach The last 12 months have had a continued focus on Individual Readiness statistics at HMAS ALBATROSS Dental Department. With reduced staffing levels, the dental fitness statistics had dropped considerably. However, with a lot of hard work and the help of a few other Dental staff from outside our department, our stats are back in the green! The end of 2011 saw CMDR Ma and LS Lantry post to Sydney, without replacement and AB Cree discharged from the RAN at CADMUS 2012

the end of her maternity leave. One of our civilian staff members, Ashley Brady also left us to work at HMAS KUTTABUL. This meant LEUT Webster had to take over the reins in the SDO position, with Dr Kankotiya and Dr Shah job sharing our CHP Dentist position. Our other staff members are PO Boge (Dental Supervisor) and LS Hetherington (SDA-P) who is on part time leave without pay. Our SDA’s are AB Fehrenbach and AB Boer. AB Boer joined the ALBTROSS team in June, after an 18 month posting with Fleet Dental. We also have Jacquie McCarthy full time in the front office and three civilian Dental Assistants that job share; Belinda Hales, Janelle Ford and Amy Hillman. We wish to thank LCDR Jesse Green for joining us for a week on reserve days to improve our stats. At one stage we even borrowed a civilian Dental Assistant, Emma Byrnes from RAAF Base Richmond. ALBATROSS has seen quite a few challenges in the last year. 817 Squadron decommissioned, which included the last flight of our Sea King helicopters. Large portions of the base have become a construction zone with the base redevelopment kicking off. The redevelopment project will see the addition of new Level 5 accommodation blocks for Junior Sailors, Senior Sailors and Officers. The Dental Department has also had its own challenges with the switch from HMAS ALBATROSS Command to Joint Health Command. As well as work, we have all been keeping ourselves very busy. At the end of last year CMDR Ma, LEUT Webster and AB Fehrenbach participated in the second annual Tour the T, which is a charity fun run/walk on the two runways here at ALBATROSS. PO Boge trekked to the top of Mount Kilimanjaro in Africa and AB Boer has just completed the Sydney City to Surf. The Dental Department was well represented on ANZAC Day throughout the Shoalhaven Region, with members attending services at Nowra, Bomaderry, Greenwell Point and Shoalhaven Heads. Quite a few of us are also studying externally and between assignments and exams, are kept very busy. Dr Kankotiya is studying for a Post Graduate Diploma in Implant Dentistry, PO Boge her Advanced Diploma of Oral Health (Dental Hygiene), LS Hetherington a Diploma of Community Services, AB Boer a Diploma of Practice Management and AB Fehrenbach a Diploma of Theology. The end of 2012 will also bring exciting changes with a new SDO joining us from HMAS STIRLING; PO Boge studying full time for 1 year on LWOP; LS Hetherington discharging from the RAN and AB Fehrenbach posting to HMAS STIRLING.

Wagga Health Centre – Dental Sergeant Jason Randell WAGHC DENT is a busy section providing initial examinations to recruits from 1RTU and also ensuring that Initial Employment trainees are dentally ready prior to their posting to their first unit. 2012 saw a 100% dental auxiliary changeover with the employment of Malinda Picciolo in Jan 12 and the subsequent posting in of SGT Jason Randell in Jun 12. Malinda ran the unit for the first half of 2012 with some assistance from Shona Graham and Melinda Holden from KAPHC DENT. Excitingly, Malinda will soon commence maternity leave, as she prepares for the birth of her first child with husband Trent. Continuity of dental services by long term dentists Dr. Miles Connell, Dr. Sharma Nand and Dr. Robert Vella continues at both the WAGHC and KAPHC sites. CADMUS 2012

Kapooka Health Centre – Dental PTE Sarah Anderson A friendly hello to you all from our lovely team down at Kapooka, Wagga Wagga. What an exciting year it has been. In April the township of Wagga Wagga was evacuated, due to the Murrumbidgee River rising, threatening to burst the levy banks. We played a supporting role in the management of dental care for the residents of Wagga during this time. With an intake of 4500 recruits this year, our induction parades have kept us on our toes!! There have been significant changes to our team as we farewelled Kate Skeers to join her husband in Albury. We wish her well in her new job. Unfortunately we also had to farewell Susan Mc Connell, as she retired due to serious illness. She will be greatly missed from the team! Warren Hartshore, our receptionist, has been transferred to another position within the KMA. I would like to take this opportunity to congratulate Warren and his wife Jing, as they eagerly await the arrival of their first born child in December. This year we have welcomed PTE Sarah Anderson, who just recently completed the SDA course, as well as civilian staff, Melinda Holden and Lisa Vidler. We would also like to congratulate Shona Graham who was recently promoted to SDA! Our other existing staff from last year include Debra Griffin ( Practice Manager), Miles Connell (SDO), Clive Connell, Sharma Nand and Robert Vella, who believes the only diet to be followed is lots and lots of cake.

Northern NSW Richmond Health Centre – Dental Flight Lieutenant Calum Watson It has been a turbulent year here at Richmond dental with 2012 bringing a changing of the guard. SQNLDR Alex Kwaan discharged from the Permanent Air Force to pursue a career in the private sector. His skills and experience aren’t totally lost, however, as he is anticipating being an active member of the RAAF reserve. FLTLT Khai Nguyen has taken up a Defence scholarship to study Periodontology at the University of Sydney. He will return in 2015 as a qualified Periodontist, where he will continue to mentor and support junior dental officers armed with a wider set of skills. FLTLT Harry ‘forklift’ Mohan is currently on LWOP and has been accepted into Melbourne University to study Endodontics. We also said goodbye to our fantastically fun DAs Debbie Jardine and Reagan Smith. Emma Byrnes followed her heart to tropical Nowra. The only remaining military DO, FLTLT Calum Watson was left to hold the fort. His unique leadership style, mixed with his charismatic personality, had section morale at an all time high in time for the new arrivals. FLTLT Kate Aitken returned from extra study and took the reigns as 2IC. She managed the teething problems / uncertainty of the split between Garrison and Operational so well that dental was able

to power on without a hiccup. FLTLT Amy Dempster returned from MATL in March and has quickly become an integral part of the section. FLTLT Mark Atkinson arrived fresh from OTS with youth and enthusiasm. He has eagerly jumped into the life of a junior DO. We gained a SDA-P in LACW Terri-Anne Dehnke who was with us in the section only briefly before heading of to the MEAO filling an ANYA position. Terri-Anne was promoted to substantive CPL on 30 Mar 2012 – well done! She has been enjoying her time in the MEAO as well as the care packages that have made their way there from RICHC. We look forward to her return later in the year. LACW Natalie Summersgill hit the ground running, having to assume the CPL position and even stepping in for the Dental Supervisor while she was deployed. She has performed extraordinarily well in those roles and was identified for promotion. Congratulations Nat! Hannah Martin joined the DAs in the first half of the year for a change of pace from private practice. She quickly became part of the team and her exceptional clinical skills are invaluable to the section. With so many coming and going it has been hard to keep track, especially with close to half of our military personnel being deployed in an operational role at some point during the year. LACW Dehnke is doing a fantastic job flying the dental flag in the MEAO. SGT Rachel Dudgeon was lucky enough to be selected for the first contingent of Pacific Partnership. While the section missed having her smiling face around, she was able to come back and regale us with interesting stories from the Exercise. FLTLT Aitken and LACW Summersgill participated in the second contingent of Pacific Partnership. They also had an extremely rewarding experience. FLTLT Aitken was lucky enough to celebrate her 30th birthday whilst on board the USNS Mercy, however apparently birthdays don’t count when you are at sea. Just when we had the Dental section running like a well oiled machine, the signing of the AFOD promised to shake things up again. After shining so brightly at RICHC, LACW Summersgill is off to impress at 1EHS along with LACW Kelly Peters and FLTLT Watson. 2013 promises to be a challenging year for RICHC Dental section. This should be no trouble at all for this team of adversity hardened professionals. They will no doubt take to the changes like a duck to water, all the while with big smiles on their faces.

Holsworthy Health Centre – Dental Mrs Sandra Iturra, SDA and Ms Sue Tattler, DA We have had some big changes this year. We saw the departure of all our wonderful Army personnel in December 2011; the retirement of Dr Judith Robinson after 22 years of providing dental services to Defence members and Brian Mitchell, our fabulous receptionist. On the 1st June 2012 we also had to say goodbye to our specialists Dr Adams (Orthodontist), Dr Po Ching Lu (Prosthodontist) and Dr Russell Vickers (Oral Surgeon). All these wonderful friendships and personalities will be greatly missed as variety is the spice of life. Holsworthy Dental Centre is now occupied by civilian staff; Dr Neil Morris, SDO, supported by the enthusiastic auxiliary team: Sandra Iturra SDA, Sue Tattler, Michelle Cachia, Eva Pioro, Debbie Herbert, Maribel Sanchez, Anna Charman and Daniela Talevski. In addition we have our hard working dentists, Dr Mark Lerche, Dr Neil Stackpool, Dr Liz Martin, Dr Mahes Wanigesekera, Dr Annie Badve, Dr Louise Hogan; and Lab technician Marc Morris and Hygienist Peter Watson.

These sensational people are the essence of the Holsworthy Dental Centre. We carry on with a proud history of serving the ADF and all its members.

Kuttabul Health Centre – Fleet Base East Dental Chief Petty Officer Kenneth Swinbourn Fleet Base East Dental, KUTTABUL Health Centre is not the place one would choose to pop in for a yarn over a brew, not unless of course you are ready for work. The buzz of the department only dulls to a pleasant rumble around 1600 Monday to Friday, once we get the patients out of the building and we start to secure. To highlight our tempo we have seen over 7,600 patients for almost 23,000 procedures in the last twelve months. That is approximately 160 patients per week, each receiving 3 procedures per visit. The resultant overall dental fitness has climbed out of red and into amber. Before Christmas we were almost fully staffed, with most admin and all clinical positions filled, but since then numbers have gradually declined. For some staff we have had replacements, but we are still waiting for others. One of the hardest losses was at the end of June 2012, when the contracted dental specialists’ contracts were not extended. This has lead to some sadness and a change in procedure for patients under their care. To relax we managed a couple of late starts so that all staff could enjoy breakfast together at the Holiday Inn, Kings Cross. Although one planned breakfast was lost to a lockdown exercise as part of the Enhanced Self-Defence Capability program – hardhat, hi-visibility vest, Maglite and two-way; such a good look. In addition, we have been meeting up outside of work hours for dinner at some of the local restaurants, either up the hill or on the waterfront. We continue to enjoy departmental PT each week. Although some days when weather and numbers are good, we will book one of the outdoor courts to play a team sport. For those of you that know the staff here, you will also know that we have very competitive people. A friendly game of basketball with the Fleet Dental personnel is a hard run event, leaving everyone with a good workout. Fleet Base East Dental was required to don our best dress for the time honoured tradition of ANZAC day. We marched behind the Joint Services Dental Banner and it was a great day to catch up with familiar faces from the past and the bases around Sydney. Some of our staff had their families and friends with them for the day. A few of our contract staff even turned up at the Masonic Club to enjoy the day with the old Diggers. The base itself has been busy with a couple of cruise ship visits and the new ship HMAS CHOULES. When she arrived there was a lot of interest from all levels and we managed to arrange tours of the ship for all available staff. The tour highlighted just how big CHOULES is – from the amount of space on the tank deck to the number of decks that need to be climbed to reach the bridge. There is no need for climbing nets and ladders when the ship goes to swimming station; they just need to flood the rear of the tank deck to have an Olympic sized swimming pool (almost)! For those of you looking for a challenge, wanting to be a part of history, 2013 looks like being a big year for FBE and the Navy in Sydney. Major activities and visits are planned, culminating in October with the International Fleet Review. There will be 30 plus ships from our neighbours and allies joining RAN ships to CADMUS 2012

celebrate life at sea. Also we really do have some of the best views from our naval bases in Sydney. So if you want to be part of this speak to your poster.

Watson Clinic – Dental Able Seaman Kylie Skinner and Lieutenant Simon Flanagan HMAS WATSON Dental Department is the minor dental unit (MDU) located in beautiful Watsons Bay, Sydney. The training establishment HMAS WATSON has a complement of over 500 personnel and at times can have up to 200 members undergoing training with varying states of dental readiness. The courses conducted here are maritime warfare specific and include; Combat Systems, Electronic Warfare, Junior Officer seamanship training, Navigation, Principle Warfare Officer training and the training of new Command and Executive officers to RAN ships and establishments. The staffing of the department consists of ABDEN Kylie Skinner, LEUT Simon Flanagan, and Dr John Ashton (CAPT RANR). Recently we have had the assistance of SMNSTD Caitlin Carter, who is a qualified dental assistant hoping to transfer category. 2012 has been a very challenging year. The clinic has been without a clinical manager (POMED) for most of the year, which has significantly increased the administrative burden on all other staff. Stores have also been difficult to obtain with the transition to MILIS. ABDEN Skinner also had an extended period of absence and due to staffing shortages in the branch her position was unable to be back-filled. This left LEUT Flanagan to attempt an Olympian triple feat of dentist, dental assistant and OIC. Despite the challenges we have managed to maintain our KPIs above 80% and assisted to keep the Navy ‘Fit to bite, fit to fight’!

Penguin Health Centre – Dental Leading Seaman Mark Smith Administration Supervisor – Sydney Area Minor Dental Units HMAS PENGUIN, located above Balmoral beach on Sydney’s north side, celebrated its 70th anniversary during 2012 and is currently undergoing a major $63.34m redevelopment. The works are to improve the facilities which date back to 1941, including the ‘Submarine Underwater Medicine Unit’, ‘RAN Dive School’, ‘Re-Compression chamber, the front gate (gangway) and the Clearance Diver’s off-base facility located at Pittwater. Since demolition and re-construction began in December 2011, disruptions to the on-base traffic and pedestrian movement, as well as vehicle parking, have been experienced. Yet considering the major works, the contractor has worked well with meeting the base requirements and disruptions to our working days have remained minimal. The past 12 months have seen much of the transition of our Health Facilities to Joint Health Command. This transition has included changes to the Command of health personnel; equipment and facilities; our Work, Health and Safety procedures/ reporting; the management of the Supply Customer Accounts; logistic support and consumables procurement procedures. Our ADF health personnel also have additional responsibilities to meet new logistic and equipment management qualification requirements. CADMUS 2012

RHS-NNSW Penguin Health Centre Gangway 1941 – 2014 During 2012 we have provided dental support to members from HMAS ships PARRAMATTA, BALLARAT, TOBRUK, GASCOYNE and HUON; also personnel from HMAS KUTTABUL, WATSON and WATERHEN. The KPI’s at HMAS PENGUIN reached a peak of 95% during the year, but declined to 84% due to mandatory repairs being conducted on essential equipment. During this period, we were required to improvise and limit appointments to ADE’s and consultations. Through prioritisation and liaison with our local dental Units, we were able to continue normal operation. This allowed us to provide appropriate support to our Defence members and keep our contracted staff employed. By maintaining communications between the local Sydney dental units and cooperating as a wider, integrated team, we have managed to provide the required services to our members and keep our Fleet at sea. Dr Roscoe Morze replaced Dr Liz Close as the contracted dentist in December 2011. Dr Morze brings with him an excellent knowledge of ADF health policy and the processes of ADF dental clinic operations. During the year Miss Amelia Harris, the roving dental assistant, was loaned to us to cover staffing shortfalls at the HMAS WATERHEN Dental Dept. Yet between us we have continued to maintain the administration / reception day on Mondays, with Tuesdays and Wednesdays being devoted to clinical days. LS Smith continues to operate as the Administration Supervisor to the Sydney Minor Dental Units (MDUs). This role remains a catalyst for producing our various departmental reports and ensuring a uniform system of operation within our MDUs. We maintain high levels of dental fitness to ensure that we remain a force that is Fit to Bite and Fit to Fight.

Waterhen Clinic – Dental Lieutenant Michelle Morze HMAS WATERHEN, located on the northern shores of Sydney in Waverton, has been a hive of activity over the last 12 months. It is the home for over 600 personnel, including personnel from four Mine Hunter Coastal (MHC) Crews, Australian Clearance Diver Team One (AUSCDT1), reserve Australian Clearance Dive Team 5 (AUSCDT5) and YOUNG ENDEAVOUR. All resident units have been engaged in numerous deployments throughout the period, some soon after the Reduced Activity Period. As with many schedules, the routine of the MHC crews and AUSCDT1 often change with short notice. This increases

the demands on the small two chair dental facility as personnel are required to be dentally fit at short notice. Some members of AUSCDT1 in particular, spend little time at HMAS WATERHEN, as they are often on operations or training. This has meant that the dental department has needed to remain flexible to accommodate these demands, especially in the period immediately prior to a scheduled deployment. Forecasting individuals due for their annual dental examination (ADE), in advance, through MIMI and in consultation with the MHC crew medics, helps to preemptively improve dental readiness. This also reduces a surge in the requirement for predeployment ADEs. The dental individual readiness statistics at WATERHEN Clinic (WHN-C) have ranged from 87.83- 94.27 over the past 12 months. The changes in readiness tend to correlate with the annual (or six monthly) posting cycle, document mustering, staffing levels, scheduled deployments and availability or non-availability of the crews or dive team members to attend appointments. In order to improve Key Performance Indicators (KPIs) readiness levels are reviewed monthly via MIMI and members are contacted in advance to book appointments. The crew medics have also been instrumental in chasing down members out of date and forecasting the need for bulk bookings in preparation for a deployment. There have been numerous dental staffing changes over the last 12months at WHN-C. ABDEN Melissa Lavelle posted to CERBERUS Health Centre, without replacement, in April 12 to complete her Senior Dental Assistant Preventative Course. She is due to return at the end of Sept 12, before posting to ALBATROSS Health Centre in 2013. We have been grateful for the support of Amelia Harris from PENGUIN and KUTTABUL Health Centres during AB Lavelle’s absence. This has allowed our department to remain operational. Civilian dental assistant Dani Delahunt ceased working at WHN-C in March 12 and Kalee Mant joined the team soon after. Kalee’s experience from years of dental assisting at KUTTABUL Health Centre has made her an invaluable member of the team. Dr Elizabeth Close was working one day per week at WHN-C in 2011 but moved back to Newcastle with her husband in Jan 12; thank you for all your efforts Dr Close. Dr Roscoe Morze filled her position in Jan 2012. The Sydney Minor Dental Unit Supervisor LS Mark Smith has continued to support the Minor Dental Units administratively and even clinically (on some occasions). We have been very appreciative of his support.

12, which outlined the basics of emergency dental presentations and their management. This proved invaluable at revising the necessary skills and reviewing the dental emergency kits prior to their deployment. Lastly, continuing professional development (CPD) events held internally, at KUTTABUL Health Centre on Endodontics (by LCDR Peter Case) and Periodontics (by Dr Matthew Hunter) in the second half of 2012 were found to be very informative and enjoyable by all who attended. 2011-12 has been a very dynamic and busy year for dental at WHNC. We look forward to the next 12 months with further transition to JHC and supporting HMAS WATERHEN with attached mine countermeasure units.

Randwick Health Centre – Dental CPL Kerri-Ann Steindl We have had a busy start to the year with a couple of changes along the way. After farewelling WO2 Ursula Friend, the Dental Centre saw a command change. We now have WO2 Sharon White (WOMED) taking the reigns of both the medical and dental facility. Although I was not fortunate enough to be given the opportunity to work with WO2 Friend, I do know her absence within the facility has been felt. She is greatly missed by staff and patients. Our second change saw the closure of Victoria Barracks Dental Clinic, resulting in the amalgamation of its patients into our facility at Randwick. This was a smooth transition and although the patient load has significantly increased, it had no real impact on the day to day running of the surgeries. LTCOL Daly, our visiting Periodontist, still maintains a steady flow of patients on his monthly visits. Dr James Sullivan continues to divide his hectic working week between his private practice and Randwick. When he is not working, he fills his time training for running events, including the Sydney Half Marathon and the City to Surf. Dr Williams maintains a busy work schedule juggling her days here treating patients, as well as fulfilling a role as a Clinical Tutor at both Westmead and Sydney Hospital’s.

A significant change in the last 12 months has been the transition of the health department across to Joint Health Command which has seen policy and structural changes. The medical department now operates more independently from the greater HMAS WATERHEN in terms of Command, security, OHS, logistics and reporting. This has required the incorporation of new responsibilities and also the training for these roles. For example, completion of MILIS training for stores ordering and the logging of jobs has been required. Through theses changes we have developed a stronger affiliation with our parent unit PENGUIN Health Centre, which continues to be very supportive.

Sharon Hunter, CHP Dental Assistant, has well and truly settled in. She has become part of the loved furniture. Sharon continues to count down the days to her daughters wedding, which she has helped organise. CPL Kalisa Winn keeps herself busy as usual with work and PT commitments. Kalisa coordinated the closure of Victoria Barracks Dental Clinic. She has also been responsible for administering the return of all our lab equipment and other clinical stores back to DNSDC Randwick. CPL Linda “Bobbi” Barry and her partner Dave welcomed the arrival of their beautiful baby girl, Georgie, in September last year. We always look forward to our baby cuddles with Georgie during Bobbi’s frequent visits.

2012 has seen numerous training opportunities arise, which have greatly benefited the staff involved. ABDen Melissa Lavelle delivered a presentation on Oral Hygiene and the factors influencing oral health to WHN-C staff, which was received positively by everyone. Infection control training was also conducted for WHN-C staff, towards the end of 2011, covering topics such as sharps management, cross contamination and a practical exercise on personal protective equipment. Dental emergency training was delivered to the MHC medics in June

CPL Kerri-Ann Steindl, as the newest member of the team, joined the Unit in January 2012. Since marching in, she has been kept on her toes completing Subject 1 Sergeant and preparing for the Subject 2 course in August. She is also looking forward to completing the CFL course later this year. As she has been absent quite a bit, we have been lucky enough to have CPL Maryann Broadway TDY’ed to us from 1 INT BN, pending her transfer to RAAF as a DA. The dental team is grateful and has welcomed the extra help that Maryann has provided.

CADMUS 2012

Singleton Health Centre – Dental Sergeant Heidi Mayall We have had a change or three to report! Our long standing dentist, Dr Paul Morton, has left the Singleton Health Centre to concentrate on his farming and to no doubt travel more of the untouched areas of the globe. Fortunately we have another fantastic new dentist/doctor, Dr Dan Ghaly. Dan is providing dental support for one and a half days per week and is then over at Medical on his non dental days as the base GP. Dan has a great sense of humour and fits in well with the Singleton Health Centre staff. SGT Heidi Mayall, our long standing Military Hygienist, has left us. She is now working in an admin role for the School of Infantry for her two reserve days per week. Heidi misses Dental and still visits every opportunity. She also works as a Dental Hygienist on “Civi Street”, but misses RAADC immensely. Still serving us proudly are Dr Allan Hicks, Mrs Elizabeth Burke (Liz) and Mrs Karen Turner. Allan moved into one of the districts finest old houses recently. We are lucky enough to get invites to parties and gatherings at beautiful “The Mount”. The views are amazing and the food provided by Allan’s wonderful Jeanie, as always, is to die for. Another fantastic initiative of Allan’s is “Pie day”, which half the health facility seems to have also adopted. Once a week, the aroma of warm yummy pies fills the corridors. Liz is with us three days and is still filling many “boots” in her role as “everything”. She has done a marvellous job and has stepped up to the plate graciously, even though she has been near run off those “boots” at times! Well done Lizzie, we know it’s been a huge task. We appreciate all your efforts and time. Karen is like part of the furniture now and we could not have asked for a nicer person to be here in our team! She is wonderful and has been alongside Liz doing her bit to help. She is also in the surgery as our full time dental assistant. PTE Leesa Rowan has been working over at medical for the past 12 months and is in the process of a Corps transfer or sourcing an alternate career. She is enjoying her time at Singleton as she is close to family. We miss her but luckily she is only 10 metres across the waiting room. We will have been in our new building just over twelve months at the time of writing this article and would you believe, we only just got our x-ray machines up and running a few weeks ago! We wish all CADMUS readers a wonderful year and we look forward to reading what the rest of the Dental world is up to.

Williamtown Health Centre – Dental No 2 Expeditionary Health Squadron Flight Lieutenant David Liu RAAF Base Williamtown Dental Section began 2012 brilliantly with everyone refreshed and eager to get on with the job. Throughout the year there have been some major changes that have had a great impact on the Department. The Williamtown Healthy Facility officially separated into the Joint Health Command and 2 Expeditionary Squadron. SQNLDR Neil Fitzgerald arrived from Sydney and hit the ground running as OIC of Williamtown Health Centre. WGCDR Glen Storrar remained CO 2EHS, while those posted to JHC have come under the command of WGCDR Heidi Yeats. FLTLTs David Liu and Adrian CADMUS 2012

Sebastian were transferred to JHC. They have been working hard to improve their military and clinical skills for progression to CL2. During their Christmas break, David and Adrian both volunteered to work in orphanages in Cambodia and are about to undertake the Dental Forensics course. Dr Claire Novak, the Senior Dentist, has led a fine example in promoting oral health and a healthy lifestyle. Her lunchtime runs have even rubbed off on others in our Section. Together with Dr Jan Eveleens, they have been providing outstanding clinical care and mentorship. These two members of our team are a constant source of knowledge and provide a wealth of clinical guidance. FLTLT Georgina Seto has also been very busy this year. She went on the first contingent of Exercise Pacific Partnership and helped extract many carious teeth in disadvantaged areas overseas. We congratulate her on her engagement to her partner Matt. We were overjoyed to learn that two of our members were pregnant. Specialist clerk Amanda Ward surprised us all with her third child – a beautiful baby daughter Ava. She has been visited by numerous members of our section and both mum and baby are doing well. LACW Justine Hourihan joined us after graduating from ADF Dental School as student of merit. Justine is expecting her first baby and we have already cast our votes on whether it will be a boy or girl. We are all very happy for Justine and her husband Dale. We were sad to farewell many people earlier this year. With regards to our military Dental Assistants, LACW Nat Summersgill left for her posting to Richmond. LACW Joy Fletcher discharged to pursue her studies in Nursing. We have had no dental hygienists this year since LACW Teagan Walker and CPL Margaret Galvin left for greener pastures at the end of last year. Regrettably, we have lost the services of our civilian contracted dental specialists. We no longer have the clinical guidance of our Oral Surgeon Dr Ian Wilson and Orthodontist Dr Steve Cave. We would like to take this opportunity to thank them for their invaluable contributions to this Unit and to the Defence Force as a whole. We wish them all the best for the future. Fortunately, we still have our visiting Specialist Reservists WGCDR Mark O’Sullivan (Endodontist) and WGCDR Matthew Ma (Prosthodontist) to provide military and clinical mentorship. LACW Kirrie Waldon has been keeping busy running the Orderly Room and organising her stud dog Basil to squire gorgeous puppies. Jane Leach has had an active year with moving houses, buying a blue cattle dog and has recently taken up motorbike riding with great enthusiasm. Keryn Slade has been busy juggling her two children and has now completed her Certificate III in Sterilisation services. Kylie Bradford recently took a couple of weeks leave and ventured to Bali. She has returned with a beautiful glow and is eager to pass on the health tips she learned whilst overseas. Ellie Welsh has left us for a new job in Darwin after many years as a dental assistant. She will be sorely missed. FSGT Sheryl McPherson has kept the section running smoothly throughout all the changes we have encountered this year. In the face of adversity she is like the glue that holds the section together. We are happy to report that Sheryl will be staying at RAAF Base WLM for 2013. Regrettably, though, we were informed that our wonderful dental technician, Richard Brodie, will be leaving. His versatility with all aspects of lab work, as well as his keen eye for the art of dentistry, has made our jobs much easier. 2012 has been a year of many changes. We are still providing high quality dental services to the RAAF, although the dynamic nature of our work environment has certainly proved a challenge. We wish everyone all the best! If you are ever in the region, come and say hello.

Queensland Cairns Health Centre – Dental Lieutenant Sally Cochrane Cairns Health Centre provides dental support, not only to Navy personnel, but also to 51 Far North Queensland Regiment and ADF personnel posted to remote localities including Mt Isa, Thursday Island and Papua New Guinea. In the last 12 months CAIRNS Dental Department has seen a complete change in staff. LSDEN Kortney Inmon posted to CAIRNS in September 2011 and LEUT Sally Cochrane in January 2012. Fortunately PODEN Tracey Morris, who has continued to work as a reservist in the department for over ten years, has only moved across the hallway to medical. Tracey still manages to provide us with much assistance and must be congratulated for her COs commendation earlier this year. Although Cairns has a wonderful relaxing lifestyle, CAIRNS Dental Department is not the sleepy hollow many may perceive it to be. With only a team of two catering for a dependency of approximately 1000 ADF personnel, our first seven months as a team has mostly consisted of ADEs. Unfortunately with the current demand for ADEs and treatment to ensure members are dentally fit to deploy, we do not have the capacity to provide hygiene services for all members. It is hoped that hygiene services can be resumed in the not too distant future. Being a remote locality, Cairns does not have the specialist support many of us are accustomed too. Without an endodontist or prosthodontist we are fortunate HMAS KUTTABUL and GALLIPOLI BARRACKS are willing to see our members, despite their already high demands. Although this comes with the additional administration burden of travel, it has ensured our members retain a high standard of dental fitness. With structured appointment books and daily routines, we have improved efficiency. LS Inmon has managed to train LEUT Cochrane as a receptionist, sterilising assistant and even logging jobs for repairs. Unfortunately, at times, we still struggle to keep up with the workload. We are grateful to CAPT Lines and PTE Mayo, from GALLIPOLI BARRACKS, who provided two weeks of assistance in June. Unfortunately both sterilisers became unserviceable during their second week, so as the instruments ran out they were sent home early. LS Inmon has taken on the additional role as the Unit Safety Advisor for Cairns Health Centre, becoming the sole WH&S expert for both medical and dental. This is an extremely demanding role. LS Inmon has put in many hours of hard work, including weekends and must be commended for her efforts. We recently had an external audit and LS Inmon was praised for her high standard of work. As we continue with the unrelenting tempo, we are already planning for next year. Although we may only have a team of two in Cairns, we have received much support from the Dental Branch. A special thanks to CMDR Burton, as our SDO and LCDR Case for seeing so many of our members. We would be lost without their ongoing support.

Practice Manager towards the end of 2011. Sadly we have had to say a fond farewell to almost all of our military staff from last year. All of their hard work and friendly faces are greatly missed. We are privileged to still have with us CPL Kristy McMillen and PTE Robert ‘Bob’ Maddock, who are valiantly striving to provide a ray of green amongst the sea of blue. They have coped with what has been a difficult adjustment, with grace and good humour. We hit the ground running at the beginning of 2012 with no Practice Manager, no admin staff and numerous deployments. It started with FSU-6 and was followed by MTF-5, resulting in a very high tempo. We also welcomed the members of 3RAR to Townsville at the beginning of the year. All of this has resulted in a significant increase in the workload for our SDO, Dr. Pushpa Karat, who took the phrase ‘multi-tasking’ to a whole new level. February saw the arrival of two flyaway teams from 33 Dental Company, Enoggera. CAPT Van Heumen, CAPT Lines, CPL Keast and PTE Redshaw provided surge support during the predeployment craziness. Many thanks. In April we congratulated Kellie Ringberg on her appointment to the Practice Manager’s position. She has risen to the challenge admirably and is learning fast!! May saw the arrival of prosthodontist WGCDR Neil Peppitt for a week to provide much needed specialist services, especially in the field of TMD for which he is renowned. His visit also provided valuable learning opportunities. Many thanks to WGCDR Peppitt for all your hard work and advice. It was greatly appreciated. This year we had to say goodbye to PTE Robin Paul, who has now discharged so she can spend more time with her family back in WA. We wish her the best of luck for all her future endeavours and thank her for her time spent in the RAADC. Following Robin’s departure, Sally Whittaker has stepped up to the role of Specialist DA, to the great relief and thanks of all the dentists. There have been a lot of little additions to the LDC family – PTE Paul gave birth to baby Michael; PTE Maddock has welcomed baby Annabelle and Dr. Sabrina Ali has recently seen the arrival of baby Noah. We have also welcomed several new members to the Lavarack Dental Centre team including Dr. Peter Farrow; DAs Danelle McShane, Celeste Marrington, Kylie O’Neil and Ashlee Wilson. Dr. Mary Love, Dr. David Cullen and Hygienist Natalie Wehlow continue to join us on a part time basis. Dr Ryan Butler has been keeping Sabrina’s chair warm whilst she has been on maternity leave. Our thanks must also go to our long standing members – Dr. Pushpa Karat, Dr. Sabrina Ali, Dr. Adrian Buell, Dr. Alan Martin and Dr. Helen Yie; Hygienists Kylie Greaves and Sarah Tang; DAs Sally Whittaker, Sarah Billing and Sue Collins; CSD technicians Lesley Turner and Nicole Rickard. Together, with the rest of the team, they have kept the place going with their hard work and enthusiasm. The remainder of the year will see us continue to provide a high standard of dental care to our now greatly increased dependency. We look forward to the rest of the year and to the challenges that lay ahead.

Townsville Health Centre – Dental

Lavarack Health Centre – Dental

No 1 Expeditionary Health Squadron Detachment Townsville

Corporal Kristy McMillen and Private Robert Maddock

Flight Lieutenant Timothy Keys

Greetings from sunny Townsville – the heart of the tropical north. It has been a challenging year for us all, since the withdrawal of most of our uniformed dental personnel and the loss of our

Hello from Sunny NQ! Thankfully the start to this year was incident free with no weather events to report other than the usual buckets of rain in summer and sun in winter.

CADMUS 2012

Following the delay of redevelopment to the Townsville Health Centre, the end of 2011 saw the return of dental from Lavarack Barracks to RAAF Townsville in preparation for 2012. Many patients expressed their gratitude at the return of the local service! Huge movements have also taken place within Dental with the discharge of SGT Kathy Shaw, LACW Carly Caseur and FLTLT Genie Kelloway (60% of the team). 2012 saw the arrival of FLTLT Tim Keys and LACW Kym Monck. As with other units the split into JHC/1EHS has created some interesting situations with LACW Donna Hayes, Dr Deirdre Ryan, Allanna Sturgiss and the left hand side of FLTLT Tim Keys and LACW Kym Monck transitioning to JHC. The right hand side of FLTLT Tim Keys and LACW Kym Monck were the deployable dental team for 1EHS. They fulfilled their duties on both sides of the split admirably. FLTLT Tim Keys, LACW Donna Hayes and LACW Kym Monck completed a multitude of dental and military courses in 2012, leaving Dr Ryan and Allanna Sturgiss to continue providing dental services the vast majority of dental patients in Health Centre Townsville. In the spirit of NQ, holidays have been abundant this year, with Dr Ryan taking time off to see the homeland of Ireland and Canada. Allanna has enjoyed the sights of the Great Barrier Reef from aboard a Catamaran. LACW Hayes took some much needed time off from her acting supervisor duties to return home and LACW Monck also visited her home state of NSW. FLTLT Keys travelled to Indonesia for EX Tendon Valiant to provide dental treatment to the local populace. We would like to thank our visiting specialists SQNLDR Jeff Stanton and WGCDR Neil Peppitt for their invaluable assistance and time. All the best from the largest population centre north of the Sunshine Coast, with a hill 14m shy of a mountain.

Amberley Health Centre – Dental No 1 Expeditionary Health Squadron Flight Lieutenant Ajitha Naidu Sugnanam Once again a very eventful year at RAAF Base Amberley is coming to an end. The Dental Section at Amberley underwent numerous major changes as did the rest of the Air Force. The Health Facility has transitioned to a distinct separation between Joint Health Command (JHC) and Operational roles. The year began with a drastic change in the Chain of Command as the dental unit at Amberley no longer belonged to CO 1EHS. SQNLDR Clint Morton was appointed OIC of Amberley Health Centre, which was the new title for all JHC personnel. This separation allows for reliable operational numbers, as well as an efficient training environment for new junior military officers. FLTLT Steve D’Arcy handed over the SDENTO job to a civilian Senior Dental Advisor. Dr. Jesse Green and Dr. Christine Cordery share this role and both have previous military experience. Dr. Jesse Green took the lead in mentoring all the new dentists in their clinical development. Dr. Christine Cordery took the role of CADMUS 2012

mentoring in the policy aspects. This combination has provided Amberley Dental centre staff with a diverse range of information and skills for guidance and mentoring. With the posting of FLTLT Timothy Keys to 1EHS Det Townsville earlier this year, Amberley was left without a CL2 DENTO. FLTLT Ajitha Naidu Sugnanam is well on her way to completing her CL2. In 2013 she will post to 1EHS, which is still at Amberley but will involve moving from the JHC position to the operational side. FLTLT Ben Cosson is the newest CL1 DO to our team and has taken up the JHC position. He joined us mid-way through this year after completing OTS in East Sale. He is always cheerful and willing to lend a hand. We began this year with limited access to our two most knowledgeable Senior NCOs, due to both SNCOs belonging to 1EHS and not JHC. With SGT Kerry Sears on deployment and FSGT Heather Fitzgibbon working in an OPS position at 1EHS, we miss the guidance and wisdom that we had previously taken for granted. Both SNCOs are currently augmented to Amberley Health Centre from 1EHS, so we have each of them for two days a week. 2012 saw the posting of LACW Bianca Goodhill to RAAF Base Pearce, after completing her SDA course and AC James Nichols discharged. This left only ACW Hannah Sunasky. ACW Sunasky looks forward to completing her CTJ in the forthcoming months. Our competent team of civilian assistants includes our Practice Manager, Mrs Catherine Van Der-Westen; our extremely knowledgeable dental assistants Mrs. Michelle Gibbon, Mrs Stacey Saunders, Mrs Jenny Richards; our Steri-technician Mrs Amy Harnell; and the newest members of the dental assistant team, including Mrs Lacey Evans and Mrs Edith Langton. Sadly, we have had to say goodbye to our visiting Specialists. We no longer have the unwavering sound clinical guidance from our Endodontist, Dr Andrew Sainsbury. As of the end of this year we will also lose our very experienced Periodontist, Dr David Keys and Oral Surgeon, Dr Ben Erzetic. We would like to take this opportunity to thank them for their invaluable contributions to this Unit and Defence as a whole. We wish them all the best in the future. Dr Anoop Thakur and Dr Andrew Wong are our civilian contract dentists. They have outlasted the military personnel with their presence at Amberley creeping up to five and 12 years respectively. These two members of our team are invaluable assets to Amberley Health Centre. Their wealth of clinical knowledge, selfless attitudes and patience make them excellent, approachable clinicians and mentors. Mrs Pamela Scamakas and our new permanent addition, Mrs Stacey Newham, have adjusted to the base’s dental orderly room chaos so well, that to onlookers it runs nothing less than a well oiled machine. Last but not least, where would we be without our two hygienists, Mrs Jany Skeates, and Mrs. Joanne Thorpe. These two work tirelessly and never cease to amaze with their efficiency in keeping up with our increasing base population. As the year nears an end, we are preparing for the changes and challenges that the New Year will bring. We look forward to maintaining our amazing work environment to ensure another great year in 2013.

Enoggera Health Centre – Dental 33 Dental Coy, 2 General Health Battalion Corporal Rhianon Farley 2012 has been a massive change for the RAADC. This year has seen the amalgamation of the deployable dental assets into one location to form 33 Dental Coy. Our members have hit the ground running

We are eternally grateful to our remaining civilian staff, Mrs Karla Hapel (hygienist) and Mrs Ida Cuylenborg (steri-tech). We hope they don’t feel too overwhelmed by the sea of green which surrounds them! Fortunately their numbers should double shortly, when we get our new dental receptionist and lab manager! Thanks also go to our civilian specialists; Dr David Keys (periodontist), Dr David Thomson (prosthodontist), Dr Sam Tseng (endodontist) and Dr Rob Hazelwood (endodontist). At the end of June we said goodbye to our endodontists and at the end of November we will say goodbye to our prosthodontist and periodontist. Fortunately, we will still have specialist support from our uniform periodontist (MAJ Harvey) and a uniform prosthodontist in 2013 (MAJ Chow). trying to adapt to all the changes. Enoggera Dental Centre has seen many fresh new faces and the return of some old ones too. This year has been all about reminding Army that dental is ready and willing to provide support (and deploy!). Ok, let’s get started, out with the old, in with the new! In 2012 we regrettably farewelled the following members: CAPT George Lathouras, CAPT Nick Palfreyman, CAPT Michael Robinson, PTE Morgaine Miscamble, PTE Tamara Axford and PTE Kelli Huckin. All six members have discharged and have moved on to civilian life. We also have had SGT Kirstyn Davies take LSL, before proceeding on discharge in mid 2013. We had a few staff jump ship: LCPL Nicole Morrissey, PTE Talya Dellow and PTE Lauren Morgan have all successfully Corps transferred to other trades in the Army. We wish you all the best in your new career paths. We welcomed seven new Dental Officers: CAPT Will Pye, CAPT Shymron Coilparampil, CAPT Sharon Lau, CAPT Craig Hatchwell, CAPT Dan Johnston, CAPT Dominic Maher and CAPT Mick Curtis. CAPT Curtis, being an ex-pilot from the Navy, still has a salty air about him. They have settled into the military lifestyle well and have all successfully completed their SSO course. They still have a few more clinical and military courses to complete to transition to CL2. Let’s not forget the two DAs who have joined us from the dental school this year; PTE Jasmine Howard and PTE Hannah Gardam. All nine new members have been welcomed with open arms and open surgery doors. The year got off to a busy start, with people eager to learn what this year would bring. There was the expected confusion of who was in surgery; when and what the dress was for PT. However, once we worked through the teething problems and under the strong leadership of LTCOL Kittie Dugan, 33 Dental Coy was ready to face the year head on. Before we had chance to take a breath, 33 Dental Coy personnel were involved in multiple Exercises. These Exercises have been mentioned earlier in CADMUS in more detail and include EX GIANT VIPER, EX PREDATORS RUN, EX HAMEL, EX SAUNDERS and Pacific Partnership. While 33 Dental Coy provide most of the workforce for the Enoggera Dental Centre, the RAADC has four members who are posted to the facility as part of Joint Health Command. These members are SGT Hall, CPL Mueller, PTE Blencowe and PTE Kulk. SGT Hall and her team provide the backbone of the garrison dental support for Gallipoli Barracks, which 33 Dental Coy augments. In addition to the military staff of Enoggera Dental Centre, we have had a wonderful group of civilian staff who have been a constant in the facility. In March we farewelled Dr Fallon Lee, Dr Richard Streit and Mrs Ros Pini. In September we will sadly farewell Dr Grant Dawson and Dr Michael Stevens, both of whom have been part of the Enoggera Dental Centre for a number of years. Dr Dawson’s & Dr Stevens’ hard work and dental experience will be sorely missed by all the staff.

In other news, we are pleased to announce that our hardworking boss LTCOL Dugan, her husband David and son Zac welcomed a little girl, Eve, to their family in August. We would also like to send best wishes to CPL Natasha Tippett and her partner, Keith, for the upcoming arrival of their first child later this year.

Oakey Health Centre-Dental Dr Gerald Little This year has seen some staff changes, attainment of important milestones and happy events for the Oakey Dental Centre. At the end of 2011, Major Jane Tait made the big decision to retire from service at the Oakey Dental Centre. Everyone said she was too young to retire!! Major Tait has attended to the oral health of members at Oakey and Cabarlah for over 25 years, with many members having had her as their dentist for similar time frames. We hope Major Tait has a well deserved rest, though with her husband, Mr Chris Tait, being recently elected to the Toowoomba Regional Council that may not be the case. Taking over from Major Tait, is Dr Gerald Little, a Toowoomba Dentist, who had been working in private practice in the town. Thankfully PTE Yasmin Hampton and Mrs Jacky McGrath have educated Dr Little in doing things the Army way! Long standing members will still have a familiar face at the Centre as Mrs Jacky McGrath continues her commitment to members of the Oakey community as receptionist and Dental Assistant. Jacky, like Jane, has given long service to the Dental Centre, 21 years. In a time when high staff turnover is the norm, this reflects a strong commitment to their profession by Jane and Jacky. Further staff changes have seen Ms Lucy Kilsby join the Oral Health Team three days a week as Hygienist. Lucy has replaced Ms Jodie Hayden, who left for full time work in private practice on the Sunshine Coast. We understand it is warmer up there!! PTE Yasmin Hampton, Dental Assistant, was presented with her four year Defence medal by the Health Centre CO, Major Matthew Fitzgerald, in April this year. PTE Hampton has been at Oakey for two and a half years and maintains a well run surgery. PTE Hampton is looking to leave the Army next year. Her skills, thoroughness, positivity and care for members will be missed. A happy event for the unit was the arrival of a baby boy, Caleb, for PTE Cherise Kite, Dental Assistant. Those familiar with the story line from Pirates of Penzance will understand the significance of CADMUS 2012

Caleb’s birthday, 29th February!! PTE Kite has been on maternity leave and has now discharged from the Army.

Mandy Walker is now back to being the lone oral hygiene sheriff in town and is booked out for at least five months.

A recent and most welcome initiative to the Dental Services now on offer to members at Oakey and Cabarlah are the regular visits of Major Geoff Harvey, Periodontist, who is based at Enoggera. Major Harvey is looking after the periodontal needs of members with periodontal assessments and placement of dental implants.

The dental department is made a much more enjoyable place with the constant chirpiness (which does vary depending on the size of morning coffee) of the Dental assistants Cecilia Grebe, Linda Kingsada and Megan Ripley. They provide the light relief that is needed when things get busy. Although their workload has increased significantly, they remain hard working and enthusiastic.

Central and West Edinburgh Health Centre – Dental Dr Ed Wilson What a busy year! This past year has seen the addition of a seemingly endless number of new members, with around 40,000 extra teeth to service, give or take. It has also seen the complete relocation of all dental services to our new rooms in a new hospital; a wedding, a baby and the removal of some long-term braces. The relocation itself was executed with military precision. However, once relocated there were a few teething problems. This lead to a tactical withdrawal to the old building for a couple of days until everything was sorted out. Everyone remained in good spirits throughout and we are now feeling quite comfortable in our new space. Our practice manager, Lisa Merritt, finally has her own bunker from where she can keep everyone in line. She has once again kept the department running through difficult times, with the help of the other front desk regulars CPL (soon to be SGT) Rachael Greenshields, LACW Charlene (all singing, all dancing) Duncan and Rachelle Harris. In some establishments, the front desk is the natural enemy of the clinician, but at Edinburgh they manage to coexist amicably. There have been changes amongst the dentists this year. Dr Desi Lipapis left on maternity leave, but has now thankfully returned. Dr Melissa Benier made a brief but important contribution, until she also left on maternity leave. Dr Ash Patel has also been a fantastic addition to the ranks and the ever-popular, Edinburgh stalwarts Dr Peter Wong and Dr Ella Chronowski continue to provide amazing service to the base. The increase in ADF members has hit the hygiene department the hardest. We were given the brief help of an extra full time hygienist, Sandra Thring, but unfortunately that was short lived.

The clinic time this year was dominated by a couple of significant phases of pre-deployments for both Army and Air Force. This occupied a large amount of time and significantly increased our waiting times for appointments. Although there is no obvious relief in sight, spirits remain high and there is general optimism for the coming year.

Keswick Clinic / Woodside Clinic – Dental Miss Shiralee Roberts Welcome to another submission of CADMUS for 2012 from Adelaide. It feels like just yesterday that we were putting in submissions in for 2011. So much has happened in the mean time, where do I start? We have had a busy start to the year with the return of our Reserve contingency from HQ 9 BDE. OP ANODE is the force assigned to Combined Task Force (CTF) 634 to support the Australian –led Regional Assistance Mission Solomon Islands (RAMSI). RAMSI assistance is known as Operation HELPEM FREN (Pidgin English for “Helping Friend). The OP ANODE mission is to assist the Solomon Islands Government (GOSLB) in restoring law and order, economic governance, and improving the machinery of government. The military component of OP ANODE is to be a CTF comprising a number of troop contributing nations (TCN) including Australia, New Zealand, Papua New Guinea and Tonga. The main task for the military component is to provide security for RAMSI multinational Participating Police Force who works alongside the Royal Solomon Islands Police Force (RSIPF) in maintaining law and order. Last edition, I mentioned that we had lost our last remaining military member PTE Talya Dellow. Well this is not the case! We have been fortunate enough to have PTE Karla Hosie join the team at Keswick Clinic. PTE Hosie arrived December 2011 after a two year posting to 1CSSB Darwin. PTE Hosie is actually posted to 9CSSB and detached to JHU-SA. Here is an update on all of our Keswick Clinic staff for 2012: PTE Hosie, Army Dental Assistant, has been a positive and proactive member of our team. Currently she is assisting the RAAF Base for a fortnight, assisting in the conduct of Pre-Deployment dental checks for 7RAR soldiers. Dr Gill, CHP Dental Officer, does not seem to take a break. If he’s not busy working at his own practice, he’s on a flight to Sydney to attend courses. Dr Gill also assists in theatre once a month at North Eastern Community, where he is developing his craft in implantology. Dr Gill has not only improved the range of services he provides to his own private patients, but also he has proven to be a cost effective asset to our military patients.

Top: (From left) LACW Charlene Duncan, Dr Despina Lipapis, Megan Ripley, Cecelia Grebe, CPL Rachael Greenshields, Lisa Merritt, Dr Ed Wilson. Bottom: Linda Kingsada, Dr Peter Wong, Dr Ella Chronowski, Mandy Walker. CADMUS 2012

Dr Clarke, CHP Dental Officer, has also had a vey busy start to the year. He has seen a significant number of members from the RAAF Base and surrounding areas suffering from erosion and attrition. The time required to build up the remaining dentition with composite resins is a long process, usually resulting in a number of lengthy appointments.

Shiralee Roberts, Practice Manager, with her trusty practice planner and monthly e-mails. Without Shiralee Keswick or Woodside would not keep on top of all the monthly submissions of Non-Techs; 100% Muster on Equipment and Documents; KPIs; Due/Overdue ADEs; Maintenance; Clinical and Reporting Requirements; Infection Control Submissions; Radiation Monitoring; and reviewing SOPs. WGCDR Horton (aka Marathon Man) if he’s not running a marathon, he keeps himself busy working three days a week at Woodside and two days for the South Australian Dental Service (SADS). Rebecca, CHP Dental Assistant, the dental section would not run or even function without the expertise of Rebecca (Bec). Bec is not only the dental assistant, she is the specialist clerk, procuring officer, infection control officer, moral officer, receptionist and the list goes on. Well done Bec! Keswick Clinic has also welcomed Mental Health, Psychology and a Clerk Admin Officer into the dental area, where they are utilising office space that once was occupied by the OC and Dental Supervisor. Woodside Clinic detachment has also been kept busy. The RAAF takeover of the Medical and Dental Sections is clearly evident. Woodside continues to support a number of rotations to OP SLIPPER and recently assisted the RAAF Base with PreDeployment dental checks for 7RAR soldiers. We are looking forward to 2013 ready to meet the inevitable challenges that the New Year will bring. Adelaide is a rewarding and challenging posting dealing with satellite reserve units and the diverse range of Army, Navy and RAAF members within SA and we encourage anyone who is looking for a change of pace to come and experience it for yourself.

Stirling Health Centre – Fleet Base West Dental Lieutenant Commander Maria Cicchini The past twelve months has been a very busy period for HMAS STIRLING. The focus has been on maintaining greater than 90% compliance, for dental deployability and in-date ADEs for all personnel. This was achieved through a high level of commitment and hard work by the dental team at Stirling. There was also the odd fun-filled team building activity throughout the year. A number of team members at Stirling were recognised for their outstanding contributions. At the 2011 DBM, CMDR Blenkin was awarded the Outstanding Contribution Award for Officers, for his leadership at Stirling Health Centre. CPO Watkins and LS Cox were both awarded the Australia Day Medallion, in recognition of their work ethic and significant contribution to dental. AB Todd was awarded the Outstanding Sailor Achievement Award for the month of February at Stirling, due to his outstanding performance and commitment to the delivery of dental services at Stirling. Ms Jayne Groves was also awarded the APS 20 Year Long Service Medal. The last twelve months has seen a commitment to academic achievements and qualifications. Both LEUT Bhakoo and LEUT Wolff successfully completed their requirements for progression to CL2. CPO Watkins completed the Dental Practice Manager course. LS Cox completed Dental Supervisor’s course and AB Byzdra successfully completed the SDA course.

A couple of members were fortunate to work in other countries. LS Johnson was selected for the first contingent of Pacific Partnership 2012 and was deployed to Indonesia and the Philippines. She returned with a wealth of experience and some wonderful stories. The Fleet Mobile Dental Team 3 has also been busy during this period. They had a three month deployment on HMAS BALLARAT with the highlights being visits to Singapore, China and Japan. During the last year, a couple of members were selected for representation on Defence sporting teams. CPO Watkins represented WA in the National Volleyball Titles in Brisbane. AB Burr represented both the WA Basketball and Netball teams. The last twelve months have proven to be a very busy, productive and above all enjoyable time for Stirling. We look forward to the next year and welcome more of the same.

Pearce Health Centre – Dental Dr Anthony Bartels and Leading Aircraftwoman Sacha Brown Another busy year has gone by here at Pearce with the team continuing to look after the 430 permanent staff, our Singaporean Air Force colleagues and of course the trainee pilots who come and go. Sadly at the end of 2011 LACW Michelle Sheils was posted to RAAF Base Williams. We all miss PTE Shiels but know that she is happy to finally get to Melbourne. LACW Bianca Goodhill arrived from RAAF Base Amberley. LACW Goodhill loves Perth and is already famous here on base for her baking skills. We think she is feeding half the base with sweet treats. LACW Sacha Brown has returned as a reservist helping out for three days per week. Since leaving the permanent RAAF she has married Nick and had a beautiful baby girl. Life is good for LACW Brown and the Unit is delighted to have her back. CPL Charmaine Gurney has been away for a large part of the year and we all look forward to her return. Dr Tony Bartels is still here and in his fifth year. He entertains the staff with tales of his banjo lessons (old dog, new trick!), while providing his normal high level of care to the patients. A disappointment this year was the postponement of the building of our new Dental Centre. We are hopeful that 2013 will bring good news. From all the staff at RAAF Pearce Dental, best wishes for the next twelve months.

Leeuwin Health Services – Irwin Dental Miss Amanda Ashcroft Earlier this year our unit name changed from “MDSK” (Medical Dental Services Karrakatta) to “Leeuwin Health Services- Irwin”. This has caused much confusion for anyone trying to find us as we are physically located at Irwin Barracks (Karrakatta) not Leeuwin Barracks (East Fremantle). We have had heaps of “march ins” this year and not too many march outs. We finally received a new filing cabinet to cope with the capacity. Our main priority for AIRN purposes are the SASR based at Campbell Barracks, Swanbourne as well as our ARA members at Irwin and Leeuwin Barracks. In addition to keeping our ARA members and local reserves dentally compliant, we have been busy with the pre-deployment phase for OP ANODE including a platoon from the Tongan Army. CMDR Mark Brazier (CO JHU-WA) has been helping us out with our ARA members, as well as giving us a much appreciated hand with treating the Tongan Army members. Thanks for all your hard work CMDR Brazier! CADMUS 2012

We have three dentists sharing one full time position; Dr Victor Olsson White, Dr Neela Nath & Dr Richard Lee. Our fantastic DA and Queen of sterilising, Amanda Ashcroft, does a tremendous job keeping on top of everything. Joanne Reed does an outstanding job at the front desk, often wearing many hats throughout the day; receptionist, facility supervisor and, when the need arises, even Dental Assistant! On occasion we have WO2 Ursula Friend (a dental hygienist currently posted to 13 CSSB) to help out. Thanks to 13 CSSB for their support of her visits. We are also lucky enough to have a reserve team that parades regularly on Tuesday nights; CAPT Ben Feng, Dentist and CPL Jane Roberts, Dental Assistant. All in all it has proven to be a very busy, yet productive year and we are looking forward to 2013.

Robertson Health Centre – Dental PTE Sela Havili 1 CSSB Dental Platoon changed its name to Robertson Health Centre – Dental (ROBHC Dental) and is now part of Joint Health Command. In late 2011, we said farewell to most of our uniform members. WO2 Feillafe, CAPT Lines, CAPT Lathouras, CPL Farley, CPL Rowland, PTE Kouflidis, PTE Huckin, PTE Badenhorst and PTE Hergarty migrated south to Gallipoli Barracks in Brisbane. CPL Gray and CPL Fisk expanded their career options joining the Federation Guard in Canberra. PTE Hosie received a posting order to Keswick Barracks in Adelaide and PTE Anderson followed her husband to Wagga Wagga in New South Wales. For those of us stranded in Darwin, the drop in numbers meant an increase in workload. Given the circumstances, 2012 started off with a melancholy feel in the air. Nonetheless, there was work to be done. We were soon confronted with members needing to be dentally fit for Exercise Hamel and the overseas deployment due at the end of the year. Dr Pham (aka MAJ Pham) traded his green for a more fashionable look. Dr Pham is still the Senior Dental Officer for ROBHC Dental Centre. His role includes sighting and raising dental locality restrictions; specialist referrals and providing oral surgery under I.V. sedation and G.A. LCDR Allan has been visiting us fortnightly to help with minor oral surgery and the removal of wisdom teeth for our members. We have

also had the pleasure of the company of our peers at the RAAF Base, who have organised monthly peer review sessions where discussions of a clinical nature take place. These sessions have been very helpful in assisting with clinical governance, standardisation of practice, sharing of ideas and keeping updated with new developments in dentistry. In May this year, LTCOL Daly visited ROBHC Dental Centre for a week to provide periodontal services as well as providing mentoring for the dentists. During his visit, LTCOL Daly provided hygiene and consultation appointments to those who were considered high risks patients. From all of us in Darwin, a big thank you to LTCOL Daly for taking time out of your already busy schedule. In addition, we wish to thank you for imparting your knowledge and wisdom to us during your visit. We enjoyed your presentation at our monthly peer review session and we look forward to seeing you again next year. CPL Clark took over the role as the clinical practice manager just prior to his discharge in June. CPL Clark served in the Australian Regular Army for a total of sixteen years and was employed in a number of different roles over that time; from dental assistant, SDA-P, dental technician and finally as the Dental Supervisor. His skills will be missed. We wish you and your family all the very best for your future career. With the loss of CPL Clark, CPL Capstaff is hard at work organising bulk pre-deployment dental checks for members that are deploying; ordering stores for the dental clinic and running the facility as the new practice manager. CPL Capstaff is managing well in her new role although she is due to post out at the end of the year. Well done and keep the good work up. PTE Havili has been responsible for conducting surgery inspections and being in charge of organising the oral surgery clinic. She will be remaining in Darwin for the forthcoming year. PTE Havili looks forward to the challenges ahead. PTE McKay is the newest member to join the team. He completed his dental assistant course in April this year and is in the process of finishing his dental assistant competency log book. PTE McKay is due to post to Brisbane at the end of the year. As always, we have been well supported by our civilian staff. Dr Hosking, Dr Kerslake and more recently Dr Fogg. They work alongside their counterparts: Ms Hallas, Ms Lewis, Ms Bates and Ms Santez. With Ms Pammit controlling the front desk and Ms Greenwood managing sterilisation; we would like to thank our civilians for their help and hard work this year. We have managed to complete a 99.86% audit of all our dental documents and we are currently preparing patients who are due to deploy. As part of the deployment preparation we requested two dental teams from Brisbane to assist us with the surge. CAPT Van Heumen, CAPT Craig, PTE Ivey and PTE Gardam were the lucky ones to get selected for the support. Other than the minor drama with their transportation from the airport, the team soon settled in and were keen and ready to be put to work. Although they were only with us for a week, the presence of uniform members will be missed. Thank you and we hope to see more uniform members return.

Darwin Health Centre – Dental Lieutenant Commander Dan Allan 2012 saw the Darwin Health Centre Dental department at full strength for the first time in many years, although that luxury was short lived! This year saw the addition of LCDR Dan Allan and LS Pip Denholm to Dr. Chris Mansfield, SGT Di Beningfield and LACW Shenelle Douch. It didn’t take long for the team to come CADMUS 2012

together and with the addition of DA’s Sam Power and Nikea Grant it wasn’t long before the stats started going up and the waiting list coming down. There have been numerous challenges during this year with people trying to get their head around having a full time permanent dentist at the RAAF base. The message seems to be getting through now that ADEs are not optional. We also don’t have as many members ringing for ADEs three or four months in advance.

filling the roles of dentist and hygienist, due to staff shortages. On weekends his roles continue as OIC of the base cinema, but he and his family are enjoying the relaxed lifestyle of the NT. SGT Alana McKeon loves the time off with her new baby girl Kinley who arrived in May 2012 (Tindal Health Centre Dental baby number 3!). After recently being promoted she has enjoyed her new rank and responsibilities as SGT. In her absence FSGT Thomas Lunn who is an ADG by trade has taken over the role of dental supervisor. Not surprisingly our FTA list has reduced dramatically since having an ADG at the counter. We admire his hard working attitude and he is a valued member of our Unit.

As always staffing seems to be an issue in Darwin and it was with great sadness that we saw the loss of LACW Douch, our dancing DA. We were lucky enough to get assistance from 2GHB with CPL Rhiannon Farley joining us for a month, her help was invaluable in getting the dental department back on track from an administrative perspective and gave the department a truly purple feel.

LACW Amy Johnson has been busy adjusting to being a solo DA for the past couple of months, but has enjoyed using her RLLT for some exciting trips overseas with her partner John, including Thailand, Bali and soon Japan. She has been busy throwing numerous baby showers and modelling for base fashion shows and charities.

In October we welcome back SQNLDR Helena Ryan from maternity leave. She is looking forward to getting back into the swing of seeing patients and we look forward to having another clinician to bounce ideas off.

Tindal Health Centre Dental Flight continues to work hard and provide outstanding treatment to our dependency. Even with so many changes to staff this year we have managed to keep base IR currency above 96%. If you are considering a posting or just a visit to this fantastic base, please come in and say hello. Tindal has a lot to offer and there is no other place like it in Australia!

We have been extremely lucky to have CMDR Tanya Burton work with us one day a week. In addition, she has been a driver in getting all the Northern Territory dentists into peer review sessions and clinical audits. Having another Navy uniform at the RAAF base has also helped! We have been well supported in 2012 by the CO, LTCOL Elson. It seemed that every time we came up against road blocks for stores, staff or reserve support she was there to give us guidance to overcome the problem and her assistance is greatly appreciated. 2012 has been a challenging year for the dental department but with the personnel we have, we have been able to rise above most challenges. Our goal for the rest of 2012 is to ensure we continue to provide outstanding treatment for all our members.

Tindal Health Centre – Dental No. 2 Expeditionary Health Squadron Detachment Tindal Leading Aircraftwoman Amy Johnson There has been quite a baby boom this last year at RAAF Tindal. The Unit has said goodbye to SQNLDR Helena Ryan who has moved just down the road to RAAF Darwin and hello to FLTLT Troy McGowan who arrived in August 2011. This year we have also celebrated two members being identified for promotion, Alana McKeon to SGT and Amy Johnson to CPL. SQNLDR Helena Ryan and her husband Justin have had a very exciting year, welcoming their little baby girl Audrey (and Tindal Health Centre Dental baby number 1) into the world on 08 Nov 2011. She is a much missed member and we wish her all the best on her posting with her new family. FLTLT Troy McGowan and his lovely wife Kelly welcomed their first child Max (and Tindal Health Centre Dental baby number 2) on 22 Nov 2011. Since arriving in Tindal he has been busy

Victoria and Tasmania Albury Wodonga Health Centre – Dental, Latchford Barracks Mrs Kate McAuliffe The staff here at AWHC have had an eventful year. We would like to thank the ADF dependency who keeps us busy on a daily basis. Our Senior Dental Officer, Dr Geoff Webster and the amazing Dr Sam Zahedi, are our in-house dentists. Our hygienist, Mrs Christine Anderson, is still probing away and giving our dependency a sparkling smile. We have two fantastic Dental Assistants; Ms Jasmine Corben and Ms Laura O’Keefe. They have very busy days attending to our patients’ need, whilst also trying to meet our dentists’ demands. There is definitely something in the air here, as in the last 12 months both of these girls have become engaged. Wedding plans are now high on the priority list. We have also had the honour of Mrs Jen Brown giving us a helping hand in our sterilising room. Her assistance helps to lessen the load in carrying out our daily tasks. Regrettably a few staff have moved on to new beginnings. Ms Adelle Gormly decided she would further herself and study a Bachelor in Oral Health. Our ex trainee, Ms Terri Bevan, moved to sunny QLD taking her new developed skills with her. Ms Genna Barber also got engaged and decided to move back home to QLD. Mrs Kate McAuliffe, the Practice Manager would like to personally thank the team for all their effort and input. Each day is different, but one thing for sure is that there will be guaranteed laughs and stories throughout the day, especially around the lunchroom table. AWDS would lastly like to thank the other Dental facilities who have worked with us to ensure a smooth transition for our members. CADMUS 2012

Cerberus Health Centre – Dental Lieutenant Commander Mark Page and Chief Petty Officer Andrea Marsh The Dental Department HMAS CERBERUS continues to motor along at a steady pace. Civilian staffing has not changed since the last CADMUS submission: three civilian dentists: Drs Rachel Smith, Peter Johnstone and Spiros Kolivas. Dr Johnstone and Dr Kolivas work full-time and Dr Smith attends three days per week. We have two civilian hygienists; Deb Kennison and Paulette Smith who job share. Paulette is also a trainer for civilian dental assistants. She has a wealth of knowledge with regard to Professional Development for both dentists and assistants. Our civilian dental assistants are Darlene McCarthy, Allza Dabbs, Ellen Neilson, Casey Hearn and Kellie Jovic. They all job share to provide chairside assistance to the dentists and fulfil our CSR requirements. Kay McAuliffe is our APS receptionist and the Practice Manager, CPO Marsh, is the only military member in the department. We said farewell to AB Christie Woodleigh, who left the Navy to pursue a civilian education in February 2012. In March AB Vanessa Gamble posted in and then promptly volunteered for the SDA-P course, which commenced in April. In June the Senior Dental Officer, LCDR Mark Page, was lucky enough to be posted to civil schooling and is undertaking a Masters in Health Policy and Administration at the Uniformed Services University in Washington DC. Unfortunately we had to say goodbye to Dr Graham Woolley, our visiting prosthodontist in June. Dr Woolley provided an invaluable clinical service to our patients as well as delivering tutorials to the dentists on a monthly basis. The Department have had a few challenges this year. Oral surgery cases were previously seen in the Health Centre’s Operating Theatre on a monthly basis. On closure of the theatre, strong liaison was required between the Department and the Oral surgeon, to identify a suitable solution to ensure continuation of these Specialist services. Acquisition of an OPG machine has been a lengthy process. We have adapted to the best of our ability and are looking forward to the machine’s arrival. At the time of writing, CERBERUS has a Dental Fitness of 89% for Permanent/CFTS members and 84% for trainees. This is based on a dependency of 817 and 362 personnel respectively. Since July 2011 we have carried out approximately 901 Initial Dental Exams on new entry Recruits. The CERBERUS Dental Dept also continues to support the ADF Dental School, by providing clinical placement for the Dental Assistant trainees and identifying patients for the SDA-P course. The trainees on the SDA course also assisted CMDR Cusack and LCDR Page with an intravenous sedation and oral surgery list for 12 patients over a two day period in February.

East Sale Health Centre – Dental

Dr Barned, who is occupied with decoding the mysteries of ADF policies, ‘Herald Sun’ quizzes and his golf swing. As always, CPL Morrison holds the fort. In addition to her further studies and dental administration, she also sits on the Airmen’s Mess committee as the secretary. Mrs Jo Rietschel is our primary clinical dental assistant and Renae Hawkins assists during OTS induction. At East Sale, we continue to maintain a high level of base dental fitness. OTS induction week provides much needed hustle. As always, we strive to build on the existing relationship with different schools to better support their demands. Travel was on everyone’s agenda. FLTLT Sribalachandran kicked off with a US/ Canadian holiday. He attended the Yankee Dental Congress in Boston, before heading up to Toronto and Las Vegas. Jo Rietschel went on a cruise along the East coast to relax for the Easter break. CPL Morrison had a bit more than travel on her mind when she escaped the Gippsland monsoon. She had her picturesque wedding on a beautiful Balinese beach. Congratulations Ash and Mel. Lastly, Dr Barned is iPad ready and counting down the days for his six-week cross-country Canadian adventure. While ADF Health is undergoing numerous changes, one thing that remains the same is the dedication of the dental team at East Sale.

Puckapunyal Health Centre – Dental Mrs Sandra Edwards What an interesting time we have had in the past year at Puckapunyal! We have had a wedding, lots of maternity leave culminating in three births and quite a few locums. We would like to thank everyone who has helped us out over the last 12 months, including: Taurie Slater, Leonie Morgan, Christine Teekens, Fay Cotter and Natasha Butler. We would also like to congratulate both Trish Stewart and Lizzie Hemming on their beautiful boys, Raylan and Lachlan respectively. Both new mothers are relishing the joys of motherhood. With all the excitement, our staffing levels have reduced to Dr Rishi Siriwardane, Dr Deepesh Sanduja and Sandra Edwards. Dr Siriwardane is about to celebrate nine years at Puckapunyal Dental. We congratulate him on his dedication to highway driving. Dr Sanduja completed six weeks in the Solomon Islands in August, giving his beloved VW a much needed break. Newlywed, Sandra Edwards, returned to the clinic after a sunny honeymoon in October. We hope to see you all again next year! A Merry Christmas to you all.

Flight Lieutenant Srishyam Sribalachandran

Simpson Health Centre – Dental It has been smooth sailing at East Sale this year. Our dental team remains unchanged. At the beginning of the year, FLTLT Sribalachandran stepped into the combined role of OIC 4EHS Det ESL and SDENTO. He has been diligently balancing his time between his OIC responsibilities, clinical dentistry and part-time private practice. He has been well supported by civilian dentist, CADMUS 2012

Anna Pachioli Hello to all! It has definitely been a hectic year at Simpson Barracks Dental with members deploying, health service contract and staff changes. Mid year we welcomed LEUT Tom Yong who has come on board

as our Senior Dental Officer. LEUT Yong is studying his Post Graduate Diploma in Implants. He is a remarkable addition to the Unit with his wealth of skill and Defence knowledge. We also welcomed Sussan Sien, a dental assistant working primarily with LEUT Yong and assisting the centre with administration work. Sussan is a mother of two beautiful children, who keep her very busy and she also has a keen interest in travelling. Melissa Gioutsos has been on her toes organising member’s documents for deployments to Op Anode and TLG4. If you’re trying to find dental documents, she is surely the person who will find them. Great job Mel! Mel also completed her Certificate in Dental Assisting and spends her time as chair side assistant in the surgery with Dr. Kym Trewin. Dr Tony Doan and Anna Pachioli form a good team in surgery three. Dr Doan left the Army as a Captain to work at Simpson Barracks as a civilian and has been part of the team for 13 years. Elizabeth Volpato-Coyle, known as Liz to some, is our dental hygienist. She is a gentle operator, always finding something positive to say to our members. Liz works relentlessly educating people in the importance of oral hygiene, in order to keep a healthy body. Liz is patient, repetitive and develops a good rapport with members. She also empowers them to take responsibility for their oral hygiene. Not to mention, Liz’s love for animals. From adopting a wild kitten born at Laverton Barracks to resecuring a duck at Simpson Barracks, she will always care for them. We look forward to continuing the provision of dental support for our fantastic and dedicated Defence members through the coming year.

Laverton clinic – Dental No 4 Expeditionary Health Squadron Detachment Williams Leading Aircraftwoman Michelle Sheils This year has seen a few staff changes for the Dental Section at LAVC, with more on the way. PROF Tyas reached CRA at the end of 2011 and we finally managed to fit in his farewell lunch in May, to thank him for all of his years of hard work in the RAAF. He works one day a week as a CHP and always brings in yummy goodies to spoil us all when he visits. We have just lost our resident Prosthodontist, Dr Graham Woolley. Dr Woolley has given us the best part of 10 years and we are very grateful for his service. Dr Woolley is still providing amazing dental care for our patients, who we are now sending out for external appointments. Dr Melinda Johansson is still here three days a week and along with the provision of excellent dental services she provides plenty of amusement with her love of all things Daniel Craig. FLTLT Robyn Barrie is still here but unfortunately her time in the RAAF will be coming to an end as 4 EHS DET WIL is disbanding and our positions have been moved elsewhere. It will be sad for her to say goodbye after 18 years service. 14 of those years have been spent in Laverton. We will miss you! The same

will occur for CPL Corryn Johnston and LACW Michelle Sheils. CPL Johnston has been here for the past four years and in that time has added two beautiful baby girls to her growing family. The latest addition is gorgeous baby Jasmine Mia who Greg and Corryn welcomed into the world on the 3rd June. LACW Sheils posted into Laverton in January and is only here for a short stay. LACW Shiels is currently replacing Corryn as the practice manager while she is on MATL. We are lucky to have two clerks working in our section, SGT Lisa Brown and CPL Adrian Ritson. SGT Brown is PAF and CPL Ritson is a reservist who works with us twice a week. They have been tasked with the rather large job of archiving for the medical and dental sections. They also handle all of our admin needs. We are very appreciative of all of your hard work. SGT Brown is off to Sudan for a six month deployment in August and we wish her a safe and enjoyable trip. When she returns to Australia she will be posting to 21SQN. CPL Ritson will also be leaving us at the end of the year. Our contractors Jane Tapp, Sharon Smith and Elizabeth Coyle are all still here. has a wealth of corporate knowledge and has been a helpful addition to the orderly room, along with the demanding duties of being Dr Woolley’s PA. Sharon is our section ‘mum’ and her caring attitude towards us also transcends onto the patients. Elizabeth Coyle is our funny and lovable hygienist. Along with continuing to provide excellent dental care, Liz always has insightful and worldly stories to share. So farewell from all of us here at Laverton Dental. We wish everyone all the best for the remainder of the year.

Victoria Barracks Clinic Melbourne – Dental Dr Peter Apostolopoulos We are a small dental team of civilian contractor staff located at Victoria Barracks Melbourne. Our location is across the road from the Botanical Gardens; a short walk to Southbank and the Yarra River. Following last year’s temporary move to RAAF Base Laverton, due to building redevelopments, we have now settled in to our new two-chair dental facility. We work alongside the rest of the Health Centre and all is operating very smoothly. We continue to provide dental care to our dependency of approximately 400 full-time military staff at Victoria Barracks. We also cater for the Defence Force Recruiting staff in the CBD, military recruit exams, Navy Dive Team, 2CDO Regt and various other full-time or reserve members scattered around Melbourne. Our morale is always high and we achieve our clinical and administrative goals with a minimum of fuss. Waiting times for dental appointments are short, often available within a day or two and Dental IR compliancy is above 90%. This year has presented several challenges; including MIMI document mustering/auditing, CDSS/JeHDI Project record amalgamation, ARPANSA radiation safety audit and First Aid/CPR training. Most of our dental team will remain at Victoria Barracks: Dr Anne Marie Maltby (General Dentist), Mrs Elisabeth ValpatoCoyle (Dental Hygienist), Mrs Michele Holian (Dental Assistant), Mrs Kay Hambly-Clarke (Dental Assistant). They will continue to provide the best service they can to ADF members, for the rest of this year and beyond. Unfortunately, the change in contracts has led to the departure of our following valued dental staff: Dr Graham Woolley (Prosthodontist, returning to private practice), Dr Nathan Cochrane (General Dentist, starting Postgraduate Orthodontics) and Dr Peter Apostolopoulos (General Dentist, starting Postgraduate Periodontics), whom we thank for their contributions and wish them well for the future. CADMUS 2012