newsletter - slda

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Newsletter of the College of General Dental Practitioners of Sri Lanka

EDITORIAL

Professor Saman Warnakulasuriya

BDS, FDSRCS (Eng & Edin),

FDSRCPS (Glasg),

Dip Oral Med (EAOM),

PhD (Glasg), DSc, FKC

Emeritus Professor,

Oral Medicine and Pathology,

King’s College London.

Oral cancer: Essentials for the Dental

Practitioner

Oral cancer remains an important public health problem, in Sri

Lanka and in many south Asian Countries. The disease affects both

men and women and all racial groups. The mean age at

presentation is around 60 years but oral and oropharyngeal cancers

are now becoming more common in younger ages. Oral cancer is

predominantly found among tobacco users, betel-quid chewers and

people who drink alcohol to an excess (1). It is estimated that

around 75% of oral cancer deaths are due to risky lifestyle habits.

A proportion of oral cancers are preceded by potentially malignant

disorders (earlier referred to as precancerous lesions and

conditions). These include oral leukoplakia, erythroplakia, lichen

planus and oral submucous fibrosis (2).

NEWSLETTER Newsletter of the College of General Dental Practitioners of Sri Lanka

December 2019 VOLUME 1- ISSUE 2

COUNCIL 2019

President

Emeritus Professor

Ganananda Nanayakkara

Secretary

Dr. Malcolm Stanislaus

Vice President

Dr. Lional Dassanayake

Assistant Secretary

Dr. S. L. Perera

Treasurer

Dr. C. H. Chang

Immediate Past President

Dr. H. Cooray

Editor

Dr. Shamilka Cooray

Members

Dr. M. Mukthar

Dr. N. Chinniah

Dr. [Mrs] S. Weerapperuma

Dr. [Mrs] Kanthi Chang

CONTENTS

Guest Editorial

Annual Sessions

Invited article I

Invited article II

SLMC approval for MCGDP

Invited article III

Invited article IV

Invited article V

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Oral cancer can affect the lip, oral cavity or the oropharynx. Lip cancer is a distinct entity, is rare in dark-

skinned populations and is mostly caused by exposure to UV sunlight among people not protected by the

melanin pigment. Oropharyngeal cancer is now considered a separate entity as it is primarily caused by

certain high-risk types (eg. types 16 & 18) of the human papillomavirus (HPV).

Clinical aspects

Oral cancer has multiple forms of presentation, and this sometimes makes the disease difficult to

recognize, especially in its early stages (3). This article describes the clinical manifestations of oral

cancer and its differential diagnosis to help the practitioner to differentiate the early forms from other

(non-cancerous) disease conditions.

Oral squamous cell carcinoma (OSCC) arises from the lining mucosa of the mouth and is by far the most

frequent type, accounting for over 90% of all oral malignancies. Other types of malignancies that arise

from different cell lineages are less frequent and include melanomas, sarcomas, malignant salivary gland

tumours and odontogenic tumours, as well as malignancies of the jaws, those metastasising to jaws from

distant organs and hematopoietic neoplasms such as lymphomas, leukaemias and multiple myeloma. Our

focus here is primarily on oral squamous cell carcinomas that are of epithelial in origin, and as stated

earlier that account for nearly 90% of all oral malignancies.

In Europe and North America over 50% of OSCCs are located on the lateral margins of the tongue and

the floor of the mouth while in Sri Lanka and in neighbouring countries OSCCs are mostly found on the

buccal mucosa, buccolabial commissure, sulci and around the retromolar trigone. However, OSCCs can

also be found in any other locations of the oral cavity such as on the palate and gingiva.

Described below are the principal clinical characteristics of OSCCs and an appraisal on their differential

diagnoses to facilitate early diagnosis.

Oral squamous cell carcinoma can be broadly divided in to initial or early stages and late or advanced

stages of the disease based on the size and extent of the tumour at presentation. As cancers grow at

different rates of proliferation what is usually referred to as early or late does not reflect on their times of

evolution but simply the size at presentation, i.e. small or large in terms of the extent of the disease.

Early stages of oral squamous cell carcinoma

OSCCs initially manifest as localized and usually well-demarcated white/red (erythroleukoplakic) areas.

Apart from their red or combined white-red colour, the only salient features of these lesions are their

hardened texture and some surface granularity.

The early lesions of OSCC are usually non-ulcerated, though over time one or more ulcerated zones may

appear on the erythroleukoplakic plaques, characterized by somewhat irregular margins, a gradual

increase in depth, elevated margins and especially some loss of elasticity.

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By the time the surface ulcerates (Fig. 1), evident hardening is noted in response to clinical exploration.

This feature is referred to as “induration” and is pathognomonic to malignancy. The practitioner should,

therefore, palpate any areas showing redness or ulceration and feel for any “induration”

Some months can elapse between the initial manifestation of the erythroleukoplakic plaques and

appearance of ulceration. In the pre-ulcerative stages, the lesions are usually painless and may cause only

some nonspecific discomfort. However, persistent pain irradiating to adjacent regions develops once the

ulcerations appear. The pain gradually increases as the ulcerated surface increases.

The above-described characteristics, when a cancerous lesion measures less than 2 cm in maximum

diameter, is considered to correspond to very early-stage OSCC. By the TNM classification (see below)

this is considered a T1 lesion. Apart from the erythroleukoplakic area and ulceration, an initial lesion may

also exhibit early exophytic tumour growth, with poorly defined margins. All of these clinical features ie

erythema, ulceration and new growth may coexist in the early stages of OSCC. The presence of rolled

margins and induration are the most significant features of malignancy.

The lesions become increasingly larger over time, and in a few months grow from less than 2 cm in size

i.e., stage T1 beyond the limit of what is regarded as early-stage OSCC, to present in stage T2, a lesion

measuring under 4 cm in size (Fig 1).

At this point, and with the described lesion dimensions, the patient presents with clear ulceration,

accompanied by an expanding and exophytic tumour and especially with intense pain. The latter is now

constant and radiates to more distant zones such as the external ear – especially in the case of tumours

located on the tongue.

Differential diagnosis of the early stages of oral squamous cell carcinoma

As commented above, these early stages are characterized by erythroleukoplakic lesions, exophytic

tumours or small ulcerations, and the differential diagnosis is established by considering the following

disease conditions that may mimic a squamous cell carcinoma in its clinical appearance.

A. Traumatic lesions caused by mechanical factors such as ill-fitting dentures, chronic trauma from

sharp/broken cusps of teeth or dental malpositioning,

B. Erythroplakia characterised by a red patch or erythroleukoplakia characterized by red or white-

red plaques that cannot be removed by scraping.

C. Median rhomboid glossitis appearing as a red, bald patch on the dorsum of the tongue. This has a

pathognomonic appearance with central depapilation and should not be confused with a

carcinoma.

D. An eosinophilic ulcer which is an uncommon self-limiting chronic benign ulcerative lesion of the

oral mucosa that it is similar to oral squamous cell carcinoma in its early stages.

E. Keratoacanthoma of the lip is a relatively common low-grade tumour originating in the

pilosebaceous glands and closely resembling OSCC.

F. Necrotizing sialometaplasia is a rare condition that mimics OSCC, which is characterized by

salivary gland metaplasia, necrosis and ulceration and often affects the palate.

G. Syphilitic chancre.

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H. Benign growths which have a soft, smooth appearance of the overlying mucosa. eg.

fibroepithelial polyp, epulis or granulomas

Some of these conditions may require biopsy verification to exclude malignancy (see later section)

Advanced stages of oral squamous cell carcinoma

Advanced stage OSCC is defined by the presence of a tumour measuring over 4 cm in size or infiltrating

neighbouring structures. These stages of the disease manifest as extensive ulceration with significant in-

depth infiltration or as exophytic growths sometimes with a verrucous component. It is common to

observe combined clinical presentations characterized by ulceration and exophytic growth within the

same tumour (Fig 2)

Advanced stage OSCC is associated with constant pain, with the need for frequent doses of analgesic

medication. Narcotic agents are commonly required to control the pain, which radiates towards

neighbouring structures such as the ear, or throat.

In addition to pain, advanced stage OSCC can be associated with mobility of teeth, bleeding and

paraesthesia, Dental mobility usually manifests when the tumour infiltrates the periodontal tissues and the

jaw bone. In the case of teeth not affected by periodontal disease secondary to dental plaque, spontaneous

dental mobility manifesting in a short period of time should cause us to suspect underlying malignancy –

particularly when the gum enveloping the tooth is swollen. If the dentist has removed such mobile teeth

the socket may not heal as expected. A patient wearing a denture may complain of a lack of fitness of the

denture.

A patient with an advanced malignancy will present with limitation of jaw movement, bad odour and

fixation of the tongue. As the disease progresses a patient may present with facial asymmetry or an

extraoral sinus tract with a fleshy outgrowth.

In the absence of antecedents of trauma (e.g., tooth extraction, dental surgery or injury), the presence of

paraesthesia in an area such as the chin is always suggestive of a malignant lesion – whether clinically

manifest or otherwise.

Neck metastasis

During the clinical examination, it is important to conduct a neck examination by palpation to assess the

status of lymph nodes. The anatomy of the neck with reference to levels of lymph nodes is shown in Fig 3

to assist proper palpation.

OSCCs of the tongue, the floor of the mouth or mandibular gingiva have a strong tendency to produce

neck metastases. The risk of regional lymph node metastasis in oral cancer is directly conditioned by the

location of the primary tumour, its size (T stage), depth of invasion and, of course, some histological

features such as lack of cohesiveness of tumour islands at the invasive front leading to vascular or

lymphatic spread.

Cancers of the oral cavity usually drain to the upper lymph node levels I, II, and III, and to a lesser extent

to lymph node level IV. Neck metastases can have a negative impact on prognosis.

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Classification by TNM system

The TNM classification considers tumour size (T), the presence of affected regional lymph nodes (N),

and the existence of distant metastatic spread (M) for staging the disease. Classifying a tumour by the

TNM staging system allows the specialist in making treatment decisions and conveys prognostic

information specific to cancer. Despite easy accessibility, most oral cancers are detected in T3 and T4

stages.

Adjunctive tests

A variety of optical devices and vital staining techniques are now commercially available to aid the

clinician to inspect morphological changes that may be found in the oral cavity. These tools are referred

to as diagnostic adjuncts or mistakenly as screening adjuncts. The most frequently reported adjunctive

test to assess oral mucosal abnormalities is the toluidine blue (TB) test (Fig 4). Staining with Lugol’s

iodine (Fig 5) is practised by maxillofacial surgeons. They have their place in secondary care facilities as

these staining tools may assist in selecting the biopsy site, to determine the margins of cancer during

surgery or in the surveillance of OPMDs during follow up. The optical devices (for example, VELscope,

Vizilite, Microlux and Orascoptic) generally detect changes in the optical properties of the surface

epithelium and submucosa based on light absorption, scattering, or fluorescence of tissue. Optical

detection systems are based on the assumption that the structural and metabolic changes that take place

in the mucosa during carcinogenesis give rise to distinct profiles of absorption and reflection when

exposed to different types (wavelengths) of light or energy. Though these tools are highly sensitive to

detect any abnormality their specificity is low and can result in false-positive detections, particularly

when used as screening devices. They are generally not recommended for use in primary care facilities

(4). There are also some novel salivary based detection systems. The OncAlert RAPID Test is a

qualitative point-of-care assay to aid in the decision to biopsy patients with a potentially malignant

disorders and or cancer. On application, the results are displayed either red (high risk of oral cancer),

yellow (intermediate risk), green (low risk). These systems need to be tested in primary care.

Referral

Once the dental practitioner notices any mucosal alteration suspicious of cancer (i.e. a red patch, a white

and red patch with soreness, ulceration or a growth persisting for more than 2 weeks or a non-healing

socket) it is paramount that the patient is urgently referred to a hospital consultant for further

investigation. The criteria for early referral when suspecting oral cancer can be found in the NICE

guidelines developed by the UK Department of Health (5). A patient arriving in a hospital with

suspected cancer should be immediately investigated by a biopsy to rule out cancer and to confirm the

diagnosis by a pathology examination.

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Discussion

Unfortunately, OSCC often progresses undetected or is misdiagnosed by primary care practitioners.

Almost half the patients experience diagnostic delays and over 50% present with advanced-stage disease.

Cancers detected in the late stages are difficult to treat and morbidity and mortality associated with oral

cancer are very high. Hence, early detection is key to a favourable prognosis. A high level of clinical

suspicion and an awareness of the early symptoms is required among dental practitioners to enable its

early detection.

References

1. Wong T, Wiesenfeld D. Oral Cancer. Aust Dent J. 2018 Mar;63 Suppl 1: S91-S99.

2. Warnakulasuriya S. Clinical features and presentation of oral potentially malignant disorders.

Oral Surg Oral Med Oral Pathol Oral Radiol. 2018 Jun;125(6):582-590.

3. Fanaras N, Warnakulasuriya S. Oral Cancer Diagnosis in Primary Care. Prim Dent J. 2016 Feb

1;5(1):64-68.

4. Warnakulasuriya S. Diagnostic adjuncts on oral cancer and precancer: an update for

practitioners. Br Dent J. 2017 Nov 10;223(9):663-666.

5. Head and neck cancers - recognition and referral. https://cks.nice.org.uk/head-and-neck-cancers-

recognition-and-referral#!scenarioRecommendation:2

Figure 1:A malignant ulcer of the tongue with rolled margins in T2 stage

Figure 2: An exophytic growth with a granular surface showing features of a squamous cell

carcinoma

https://cks.nice.org.uk/head-and-neck-

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Figure 3: Diagrammatic representation of lymph node levels in the neck

Figure 4. A palatal ulcer stained with toluidine blue. A biopsy confirmed an early in-situ

carcinoma

Figure 5. Lugol’s iodine used to demarcate margins of a tongue carcinoma.

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ANNUAL SESSIONS

37th Annual Scientific Sessions of the

College of General Dental Practitioners, Sri Lanka

Theme: Current Trends in Cosmetic Dentistry and

Management of Oral Diseases

&

33rd Britto Muthunayagam Oration

will be held on

7th, 8th and 9th February 2020

at

The Sri Lanka Foundation Institute

100, Padanama Mawatha,

Independence Square, Colombo 07.

Chief Guest: Emeritus Professor Saman Warnakulasuriya

BDS, FDSRCS (Eng & Edin), FDSRCPS (Glasg), Dip Oral

Med (EAOM), PhD (Glasg), DSc, FKC

Emeritus Professor, King’s College London and Director

WHO Collaborating Centre for Oral Cancer.

Guest of honour: Dr. Lionel Dassanayake

LDS, FCGDP, FICCDE

Senior General Dental Pratitioner, Sri Lanka.

Orator: Professor A.M. Attygalla

BDS, MS, FDSRCS

Professor in Oral and Maxillofacial Surgery,

Dept. of Oral and Maxillofacial Surgery,

Faculty of Dental Sciences,

University of Peradeniya.

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ANNUAL SESSIONS Cont.

Pre Congress Workshops 7th & 8th Feb 2020

Workshop: 1

Professor Prasad Amaratunga (Sri Lanka) & Dr. Varun Achariya (India)

DENTAL IMPLANTS

Aim: Update dental professionals regarding Dental Implants and Hands on Practicals.

Venue: SLFI Lecture room 1

Date: 07th Feb 2020 - 8.30 A.M to 4.30 P.M

Workshop: 2

Emeritus Professor Saman Warnakulasuriya (United Kingdom)

ORAL MEDICINE:

Recent advances on oral potentially malignant disorders (precancers)

Oral ulcers: how to diagnose and manage them

Aim: Update dental professionals regarding best practice in the management of oral ulcers and the

early detection and prevention of oral precancer.

Venue: SLFI Lecture room 1

Date: 08th Feb 2020 - 8.30 A.M to 11.00 A.M

Workshop: 3

Dr. Andrew Paul Dias (Australia)

DENTAL PROSTHODONTICS:

Complete Denture Problems: examination, diagnosis & management

Aim: Update dental professionals regarding complete denture problems, ascertaining the most likely

cause and management.

Venue: SLFI lecture room 1

Date: 08th Feb 2020 - 1.00 P.M to 4.00 P.M

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Sunday 9th February 2020

08.00 – 08.30 Registration

08.30 – 09.15 Lecture 1: Complete Denture Problems: examination, diagnosis & management, Dr.

Andrew Paul Dias

09.15 – 10.15 Keynote Lecture: Saving lives; The role of dental practitioners in the early detection

and prevention of oral cancer

Emeritus Professor Saman Warnakulasuriya

10.15 – 10.45 Morning Tea

10.45 – 11.30 Lecture 2: Pre-Surgical Assessment, Surgical Insertion and Implant Prosthodontics

Professor Prasad Amaratunga

11.30 – 12.15 Lecture 3: Guided Implant Surgery – Dr. Varun Acharya

(Sponsored by Duravit Dental Implants)

12.30 – 13.30 Lunch

13.30 – 14.15 Lecture 4: Endodontics: Prognosis and restoration of root filled teeth

Dr. P. Palipana

14.15– 15.00 Lecture 5: Orthodontics: Management of common orthodontic problems in developing

dentition

Dr. W M Senadeera

15.00 -15.30 TEA

15.30 – 16.00 Annual General Meeting of the College of General Dental Practitioners, Sri Lanka

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The College of General Dental Practitioners of Sri Lanka

Application for Inauguration & Oration on 08th February 2020

&

Annual Sessions on 09th February 2020

@ Sri Lanka Foundation Institute, 100, Padanama Mawatha, Indipendance Square, Colombo 07.

Name: _______________________________________________________________

Name of accompanying person: ___________________________________________

Mailing Address: _________________________________________________

Telephone: ________________________ Email: _____________________________

Registration Details

Category Registration fee paid

on or before

30.01.2020

Registration fee paid

after 30.01.2020

Conference Registration on 9th Feb. 2020

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Students

Rs. 4000.00

Rs. 4500.00

Rs. 500.00

Rs. 4500.00

Rs. 5000.00

Rs. 500.00

Accompanying Persons CGDP Dinner only Rs. 2000.00 Rs. 2500.00

Preconference Workshop 1 Rs. 4000.00 Rs. 4500.00

Preconference Workshop 2 Rs. 4000.00 Rs. 4500.00

Preconference workshop 3 Rs. 4000.00 Rs. 4500.00

Conference Registration includes…………

Inauguration and oration 08th February 2020 &

Access to all Scientific Programmes and Trade Exhibition 09th February 2020

Entry to trade Exhibition will be allowed only to registered delegates

Dinner on 08th February and Lunch and Tea on 09th February 2020

Meals will be served only on production of meal coupons

Important: All workshop participants must be registered for the conference

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Mode of Payment:

Cash/ Cheque

Amount: Rs……………

Date:………………………… Signature……………………………

Bank details:

Account name College of General Dental Practitioners of Sri Lanka

Payment reference Cash/ Cheques

Bank name Commercial Bank

Branch Borella

Account number 1050801201

Swift code CCEYLKLX

Contact number 0777347899

E mail [email protected]

Duly completed applications with payment (Account No: 1050801201, Commercial Bank, Borella) or

cheques drawn in favor of the College of General Dental Practitioners of Sri Lanka should be submitted

to the Honorary Secretary of the College, Dr. Malcolm Stanislaus, No. 50, Hekiththa Cross Rd,

Handala, Wattala. Phone 0777347899. E Mail [email protected]

Cancellation and Refund Policy:

Requests for cancellation of registration must be sent to Honorary Secretary of the College, Dr. Malcolm

Stanislaus, No. 50, Hekiththa Cross Rd, Handala, Wattala by post or email to [email protected]

All cancellations will be subjected to a cancellation fee of 50% for requests made on or before 31st Jan

2020 and no refunds or cancellations could be made after 31th Jan 2020.

For office use only

Registration number

Date received

Receipt number

mailto:[email protected]



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INVITED ARTICLE I

Dr A Jayathilaka

MBBS, MD, MRCS

Senior Registrar,

Teaching Hospital Peradeniya.

Thoracoscopic sympathectomy

Division of the thorasic ganglia of the sympathetic chain is done for following indications

Hyperhydrosis

Sympathetic dystrophy

Buergers disease

In these situations 2nd to 4th thorasic ganglia are removed. Caution is required to preserve the Stellate

ganglion in order to prevent Horners syndrome.

This procedure used to be done by open surgery via neck or axilla. However at our institute we perform

this using thoracoscopy. With minimal access approach the morbidity is reduced. In addition with

thoracoscopy only up to second ganglion is visualized protecting the Stellate ganglion.

Recently two patients with a cardiac arrhythmia were recently referred for symathectomy to denervate

heart. In this situation it was necessary to remove supply from Stellate ganglion as well. In order to

prevent Development of Horners syndrome dissection was continued along sympathetic chain and lower

half of Stellate ganglion was divided.

Thoracoscopic sympathectomy is performed under general anaesthesia. Conventionally lung collapse to

obtain space for dissection is obtained by using a double lumen endotracheal tube and one lung

ventilation. However as there are problems associated with placing a double lumen tube we use a more

convenient and safe technique. We provide ventilation using a single lumen and obtain a lung collapse

by a capnothorax. We have studied this and found using an insufflation pressure of 6-8Hgmm is safe and

effective. Surgery is done in a semi-prone or full prone position. This position allows the collapsed lung

to fall away from posterior mediastinum.

Professor KB Galketiya

MBBS, MS, FRCS, FCSSL, FMAS, FEVSI

Professor in Surgery & Honorary Consultant Surgeon

Faculty of Medicine,

Teaching Hospital Peradeniya.

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INVITED ARTICLE II

“My Rice Plate” an evidence-based model to lose excess body weight

Dietary changes of Sri Lankans have drastically changed in the past two decades with the evolving

urbanization, economic transition and technology growth. A study conducted presented that a

considerable percentage of the adult population failed to follow the recommended dietary guidelines.

Nearly 70% had exceeded the recommended starch intake, the daily intake of fruit (0.43 servings per

day) and vegetable portions (1.73 servings per day) had dropped well below national recommendations,

with only 3.5% of adults consuming the recommended five portions of fruits and vegetables per day. Sri

Lankans obtain nearly 72% of their calorie requirement by carbohydrates (mainly refined), while only

10% of calories are derived from proteins which is not surprising for a country where our staple food is

rice. Prevalence of Obesity is drastically increasing worldwide, and Sri Lanka has not been left behind.

Currently, over a quarter of Sri Lankan adults are suffering from obesity with a higher prevalence of

obesity seen among women and middle aged adults.

Obesity is caused mainly by the imbalance of energy intake and expenditure. With obesity the associated

major rising health burden on a country is the prevalence of Non-communicable diseases (NCDs), which

is the leading cause of morbidity and mortality worldwide. The obesity associated NCDs have reached

epidemic proportions in Sri Lankan adults for example; prevalence of metabolic syndrome is 25%,

hypertension is over 20%, and dysglycemia is 21%. Such comorbid factors have had a huge impact on

health care expenditures. Of total deaths, 75% of deaths were accounted by NCDs. Of these deaths, 40%

were Cardiovascular disease (CVD) related deaths alone. Epidemic of Obesity and associated NCDs are

results of unfavourable changes in lifestyle including unhealthy dietary habits and physical inactivity

which further impacts the energy balance affecting the body weight.

A typical rice plate of a Sri Lankan consists of 400g of boiled rice in average and the contribution of

vegetables and proteins are considerably very low. Therefore, the total plate would provide around

600kcal and thus if eaten thrice a day the daily energy requirement of a sedentary adult is exceeded. As

mentioned, excess energy intake is a major determinant with weight gain, obesity and associated chronic

NCDs. To tackle this “My Rice Plate” was designed according to the ‘Plate Model’ recommended by

local and international nutrition guidelines.

Dr. Ranil Jayawardena

MBBS(Col), MSc(Glasgow), PhD(QUT),

HND(UK), Nutr(SLMC), RNutr(UK), RNutr(Aus),

Clinical Nutritionist, Senior Lecturer, Department of Physiology,

Faculty of Medicine, University of Colombo, Sri Lanka.

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‘Plate model’ is a practical method to overcome the prevailing dietary patterns by reducing the average

portion size of the staple food in main meals and ensures the sufficient intake of vegetables and protein

rich foods synchronously.

“My Rice Plate” is a portion perfection plate designed for Sri Lanka complying with the internationally

used ‘Plate Model’ concept.

“My Rice Plate” model is key in addressing three common issues; Controlling portion size, Nutrition

balance and eating awareness. DR. Ranil Jayawardena’s team has conducted a clinical trial on this plate

concept. Key findings of the study revealed that the intervention group that followed the plate model

had a significant effect on weight and BMI reduction after 12 weeks than the control group.

There is a huge emphasis on dietary guidelines as its importance of a balance and varied diet. Meals

that include no servings or few servings of protein and vegetables lack both balance and variety. A

substantial proportion of the Sri Lankan population does not consume a varied and balanced diet which

results in unhealthy eating habits. ‘My Rice Plate’ is ideal as it is simple and is an efficient method to

follow a balanced diet, certainly it is an alternative to the traditional way of exchange-based teaching

and meal planning.

SLMC Approval for MCGDP

The College of General Dental Practitioners (CGDP) was

successful in obtaining the Sri Lanka Medical Council (SLMC)

approval for Membership of the College of General Dental

Practitioners as an additional qualification for the registered

dental practitioners under the section 24(1) of the Medical

ordinance. CGDP is planning to commence the course in 2020.

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INVITED ARTICLE III

Anaemia in clinical practice

Anaemia is present when haemoglobin (Hb) content is below the expected values for the age and sex.

The cut off values defined by the WHO for men, non-pregnant women and pregnant women are 13, 12

and 11g/dL respectively. In children the cut off values are even lower (6-5 yrs 11g, 5-11 yrs 11.5g and

12-14 yrs 12 g).

Anemia could result from a variety of causes which include reduction of Hb synthesis (Iron, B12, folate

deficiency, Bone marrow disorders) or excessive blood loss through bleeding or hemolysis. Anemia is

classified according to the size of red blood cells (RBC) into Microcytic Normocytic or Macrocytic

anaemia for the purpose of investigations. Mean cell volume (MCV) of a normal RBC is 80-100 fl.

The three commonest causes of anaemia in clinical practice are iron deficiency, anemia of chronic

disease and thalassemia.

Clinical recognition of anaemia

Loss of energy, palpitations, breathlessness and headache, particularly with exertion, and leg pain are

common symptoms of anaemia.

Pica, which means craving for items like raw rice or clay, is only associated with iron deficiency and is

a useful symptom to discriminate iron deficiency from other anaemias. History of menorrhagia or

bleeding hemorrhoids suggest blood loss leading to iron deficiency. Family history of low Hb in siblings

and consanguinity directs toward thalassemia or other hereditary causes of anaemia. Presence of

concomitant medical problems such as long standing diabetes, hypertension, kidney, joint or respiratory

disease may point towards the diagnosis of anemia of chronic disease.

Physical examination

A common observation in anemia is the pallor of skin and mucosa. Glossitis leading to a smooth and

shiny tongue and angular stomatitis suggests iron deficiency. In iron deficiency, the nails are flat or

spoon shaped. Nails may also be brittle, and excessive hair loss may be present. Petichiae in mucosae

and skin, fever, oral ulcers suggest thrombocytopenia and neutropenia together with anaemia and points

towards bone marrow failure. In advanced leukaemia, gum infiltration and hemorrhagic lesions on the

oral cavity are seen.

Professor C.K. Bodhinayake

MBBS (Ruhuna), MD(Col), MRCP(UK) Professor in Medicine & Honorary Consultant Physician, Department of Medicine,

Faculty of Medicine,

University of Ruhuna.

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Beta thalassemia major leads to marrow expansion and altered facies such as frontal bossing and malar

prominence. It is important to note that in Sri Lanka, minor forms of thalassemia with mild anaemia are

commoner, and are generally passed unnoticed or confused with iron deficiency.

Presence of hypertension together with anaemia suggest chronic renal disease which is also common in

clinical practice.

Investigations

A full blood count (FBC) confirms the presence of anaemia, the type of anaemia according to the size of

RBCs, as described earlier and the state of white blood cells (WBC) and platelets. Blood film is an

essential initial investigation, which is complementary to the FBC and will show the cell morphology

clearly. When Hb, WBC and platelets are all reduced which is known as pancytopenia, bone marrow

failure is indicated.

Mean cell volume(MCV) is used to classify anemia into different types and further investigations can be

planned accordingly. Iron deficiency is confirmed by the presence of microcytic RBC, and low serum

ferritin levels. Thalassemia is differentiated from iron deficiency by normal or high serum ferritin

despite the presence of microcytic RBC. Anaemia of chronic disease is increasingly common in adullts

and is distinguished by the presence of normocytic RBC, with normal or elevated ferritin.

In addition to the three common types of anaemia which need to be readily recognized by the clinician,

there are other less common aetiologies which need further evaluation beyond office practice.

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INVITED ARTICLE IV

Orthodontics in Sri Lanka, a Way Forward……..

There has been a major change in orthodontics during the second half of the last century.

Especially, with the development of straight wire technique towards the latter part of the century

which has made the life of an orthodontist much more comfortable. At present, even the general

dental practitioners with an adequate depth of knowledge in Orthodontic diagnosis, basic

Orthodontic treatment planning and moderate skill in manipulation of appliances, practice straight

wire appliance (SWA) technique worldwide.

Even though SWA looks like a simple appliance superficially, it demands a thorough knowledge

and understanding of bio mechanics involved in it. With the improvement of information

technology, patients and parents are becoming more and more aware of the facilities and

treatment modalities available for correction of Malocclusion and also of the final treatment outcome

expected. Therefore, the demand for Orthodontic Specialists’ care is ever increasing worldwide. But

in Sri Lanka the situation is completely different. We are still left with a handful of

Orthodontists who are unevenly distributed in the country making overcrowding of existing

Orthodontic units. There is also a substantial proportion of Orthodontic patients with unmet demand.

This makes the contribution of the general dental practitioner in the management of orthodontic

patients is very important in the present context.

The goals of modern Orthodontic treatment can be categorized in to five main headings. They are,

improvement of facial esthetics and dental esthetics, maintenance of functional occlusion, maintain or

improve health of periodontal support and masticatory system and also obtain a stable result. The goals

of facial esthetics differ from population to population. In general there should be adequate naso-

labial angle, reasonably prominent chin and ability to close the lips without a muscular strain.

With regard to smile esthetics, a smile line in which the crowns of the upper incisor teeth and

1-2 mm of gingival margin should be visible. The lower lip should cover 3 mm of labial

surface of upper incisors at the end of Orthodontic treatment.

There should be an adequate proclination of upper incisors, 105 degrees to the Frankfort Plane

judged by clinical observation or 109 degrees inclination to the Maxillary Plane determined with

cephalometric assessment. Upper central incisors should be 1 mm longer than lateral incisors

with flat incisal edge and upper lateral incisors should have a rounded edge.

Professor Nandani Nagarathne

BDS, MS(Orthodontics),

Professor in Orthodontics,

Department of Community Dental Health,



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The crown height of the Maxillary canines should be 1 mm longer than that of lateral incisor and

canine should have a pointed tip. The gingival margin should be symmetrical on anterior teeth

and should gradually step down towards posterior teeth. All teeth should be in correct contacts without

spacing or crowding with slightly curved or rather flat curve of Spee.

At the end of Orthodontic treatment, when upper and lower teeth are in maximum inter-

cuspation, the condyles should be in centric relation. There should be equal contacts of

centric cusps of posterior teeth. On movement, there should be sufficient incisor guidance with

posterior dis-occlusion. This needs 4 mm. of OB and 2-3 over jet in finishing occlusion. There

should be free movement of dental arches in all direction without interferences from cusps. It is

ideal if Class 1 Molar Relationship could be achieved to maintain satisfactory function. But as an

acceptable compromise, Class II full unit molar relationship could be achieved. But Class 1 canine

relationship is mandatory. Further, elimination of rotations of teeth is important in order to line up

contact point to contact point. The choice of appliance prescription and use of appropriate bio

mechanics to place individual tooth to establish centric stops of posterior teeth and obtaining

arch form which should be harmonious with original arch form of the patient which is supported by

masticatory and facial musculature are paramount. Maintenance or attainment of proper incisal and

cuspid guidance ensures adequate function. Minor surgical procedures such as Fiberotomy of rotated

teeth and eliminating tooth size discrepancies are added treatment procedures which should be

undertaken to ensure stability. Clear nasal airway and elimination of undesirable neuromuscular

habits is also important to obtain a stable result. As any tooth movement involves laying down of

irregular bone which is highly vascular which is prone to resorbtion even with slight imbalance of soft

tissue force. Therefore, adequate retention regimen should be included in the overall treatment plan.

During Orthodontic tooth movement the tooth is moved along the cancellous struff of alveolar bone.

This movement should be carried out to place teeth in planned positions without damage or minimal

damage to the tooth structure. At the end of treatment, there should be adequate periodontal support

without fenestration or dehiscence, good crestal bone height without periodontal pocketing and

gingival inflammation.

An adequate thickness of attached gingivae without any frenal pull and optimum crown root

ratios ensures health of the periodontal support. All in all health and function of periodontium and

masticatory system should not be compromised to achieve ideal esthetic goals.

The ideal goals of orthodontic treatment should be kept in mind always, otherwise there is a

risk of achieving and accepting our results as our ideal orthodontic goals. Finally we have to

save many teeth as possible, save patient from surgery, save treatment time, prevent root

resorbtion and loss of crestal bone in order to preserve tooth and supporting tissues.

All these goals could be achieved by selecting cases very carefully and timing treatment to

obtain optimal result with less inconvenience to the patient. Quality of the results achieved with

orthodontic treatment mainly depends on the detailed case assessment, correct orthodontic

diagnosis and meticulous attention given in the treatment planning stage. Selection of cases which

require adequate attention of the orthodontic specialists both in diagnosis and treatment planning stage

is mandatory to ensure quality of care provided to the patient.

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In a market oriented society there is a trend to offer short term courses in orthodontics to practitioners

without providing much emphasis on these important aspects of orthodontics. Curricula of

postgraduate courses to train orthodontic specialists are expanded and revised keeping this need for

quality assurance in mind. This makes a time demanding issue to a practitioner who opts to establish his

or her own private practice. There are many cases which do not require specialist care and these

cases could be managed by careful case selection and employing simple bio mechanics by a general

dental practitioner who updates knowledge and develops skill to manage simple cases.

It is a sad situation dividing orthodontics simply to two appliance systems, removable and fixed

appliances. We all should understand the fact that in orthodontics, it is the complexity of the case with

regard to diagnosis, need to identify limiting factors and complexity of the bio mechanics needed to

move teeth to desired position are the dividing line between the specialist and the general

practitioner. But the majority of the cases are amenable to simple mechanics.

It is the time to rethink this need and introduce a middle grade course either with short term or even

distant learning education with regular updating of the knowledge and skill of the practitioner.

It is the responsibility of the policy makers to identify this burning issue in Sri Lanka and come to an

amicable settlement to improve quality of orthodontic care provided to the public.

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INVITED ARTICLE V

Dental fluorosis

Dental fluorosis is a public health problem in many parts of the world, including the dry zone of Sri

Lanka. It is an enamel defect that results from excessive intake of fluoride during the developmental

stages of teeth. The window of susceptibility for dental fluorosis is from birth to eight years of age. The

clinical appearance of dental fluorosis varies from minor white striations to more extensive opacities

with or without pitting of enamel. Due to the disfiguring nature of severe forms of dental fluorosis it

could affect the quality of life of an individual. .From the available evidence it is clear that consumption

of water with high concentration of fluoride, infant formulas used before the age of six years, inadvertent

use and ingestion of fluoridated toothpaste during tooth development stages, use of fluoride supplements,

professionally applied topical fluorides, black tea consumption, use of amoxicillin, and some socio-

demographic factors such as socio-economic status, sex are risk factors for dental

fluorosis.

Dental fluorosis is a preventable condition. According to the WHO water quality guidelines (2017) it is

recommended that, if fluoride concentration in drinking water exceeds 1.5ppm, it is necessary to

defluoridate the water prior to consumption. If de-fluoridation is not possible, people living in high

fluoride areas should use water from alternative sources such as from wells tested for low fluoride levels,

bottled water or harvested rain water.

Dental practitioners should be aware that children are exposed to fluoride from multiple sources in recent

times. Clinicians should provide advice to parents regarding the proper use of fluoridated toothpastes.

Children under the age of 3 years should be given only a smear layer of fluoridated toothpaste on the

toothbrush while those between the ages of 3-8 years should use only a pea-sized amount of fluoride

toothpaste. Tooth brushing in young children should be supervised by parents to prevent ingestion of

fluoridated toothpaste.

Different treatment modalities are available for dental fluorosis and they include enamel micro and

macro abrasion, direct composite veneers, porcelain veneers and crown restorations.

Dr. B.K.G. Thilakarathne

BDS, MSc (Com Dent), MD (Com Dent)

Lecturer,

Department of Community Dental Health,



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