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1 2 Sally Simpson Julie Rosse BSDHT Philips Mhari Coxon 3 4 All issues are archived at: http://www.dentistryiq.com/index/enlarchive.html To subscribe to this and other Penwell newsletters, go to: Subscribe: http://www.omeda.com/cgiwin/de.cgi?NEWSLETTER and go to 5 6 Maria Perno Goldie, RDH, MS 1 August 14-17, 2017 Capetown, South Africa ORAL HEALTH – VITAL LINK IN ACHIEVING TOTAL HEALTH Overview Systemic Lupus Erythematosus Rheumatoid Arthritis (RA) Scleroderma Pregnancy Sjögren's Syndrome (SS) Product 7 http://cancerhelp.cancerresearchuk.org /about-cancer/cancerquestions/autoimmune-disease-andcancer 8 What are Autoimmune Disorders? The Hidden Link that all Autoimmune Disorders share The Immune System Genetics and Research Autoimmune Disorders and Depression Latest Medical News Links to other Websites 9 http://www.coeliac.org.uk/healthcareprofessionals/associated-conditions-andcomplications/other-autoimmunedisorders Coeliac disease Autoimmune thyroid disease Autoimmune hepatitis Primary biliary cirrhosis Addison's disease Review 10 11 NICE (2009) Coeliac Disease: Recognition and assessment of coeliac disease. www.nice.org.uk 12 Maria Perno Goldie, RDH, MS 2 The Immune System Understanding The Immune System Markers of Self Bacteria Parasite in red blood cell SARS virus Fungus Markers of Non-Self Bacteria Epithelial cell SARS virus Muscle cell Epitope Antigen Antibody Leukocyte Non-self nerve cell Non-self leukocyte Nerve cell Antigen Epitope Class I MHC protein Class I MHC self-marker protein Major Histocompatibility Complex Antibody self-tolerance Organs of the Immune System Lymphatic System Lymphocytes Tonsils and adenoids Lymph nodes Lymphatic vessels Thymus Lymph nodes Spleen Peyer’s patches Appendix Lymph nodes Bone marrow Lymphatic vessels Lymph node Lymphatic vessel Maria Perno Goldie, RDH, MS 3 Immunity: Active and Passive Active immunity Passive immunity T cells and B cells are activated, some become “memory” cells Naturally acquired “Privileged” Immunity Chorionic villi Naturally acquired Artificially acquired Artificially acquired * Immunodeficiency • Too little * Hypersensitivity • Too much * Autoimmunity • Misdirected 21 22 23 24 Maria Perno Goldie, RDH, MS 4 25 26 27 28 Women are 2.7 times more likely than men to acquire an autoimmune disease.3 Women have enhanced immune systems compared to men, which increases women’s resistance to many types of infection but also makes them more susceptible to autoimmune diseases.4 Autoimmune diseases are the third most common major illness in the U.S. after cancer and heart disease .1 Autoimmune diseases are the eighth leading cause of death for women aged 15 to 84.2 1. Rose, Noel R. “The autoimmune diseases: United they stand.” The Bridge: Quarterly Newsletter of the Thyroid Foundation of America, Inc. 15 (3): 1-2, Fall 2000. 2. Walsh, S.J., Rau L.M. Autoimmune diseases: a leading cause of death among young and middle-aged women in the United States. Am J Public Health. 2000: 90(9):14631466. 29 3. Jacobson, Denise L., Gange, StephenJ., Rose, Noel R., and Graham, Neil M.H. “Short analytical review: Epidemiology and the estimated population burden of selected autoimmune diseases in the United States.” Clinical Immunology and Immunopathology. 84 (3): 223-39, September 1997. 4. Cannon, J.G., St. Pierre, B.A. Gender Differences in host defense mechanisms. J Psychiatr Res. 1997: 31(1): 99-113. 30 Maria Perno Goldie, RDH, MS 5 Organ Specific More common among pregnant women Abnormal antibodies can cross the placenta and affect the fetus Pregnancy affects autoimmune diseases in different ways • Insulin dependent diabetes mellitus (IDDM) • • • • Type I Graves’ disease Goodpasture’s syndrome Myasthenia gravis Multiple sclerosis Systemic • Systemic lupus erythematosus • Rheumatoid arthritis • Sjogren’s syndrome 31 Thyroid Disease 32 › Graves’ Disease › Hashimotos’ Disease Crohn’s Disease SLE Myasthenia Gravis Immune Thrombocytopenic Purpura Rheumatoid Arthritis Pemphigoid Gestationis Occurs in 5-10% of all pregnancies May occur after delivery or pregnancy loss May decrease milk volume Transient hyperthyroidism followed by transient hypothyroidism May recur in subsequent pregnancies Risk may be reduced by selenium supplements 33 34 Heat Sensitivity Sweating Fine Brittle Hair Weakness In Your Muscles Light Menstrual Periods Tiredness Depression Sensitivity To Cold Weight Gain Muscle Weakness And Cramps Dry Hair Tough Skin Constipation Sometimes There Are No Symptoms 35 Weight Loss Without Dieting Irritability Insomnia Bulging Eyes Shaky Hands Sometimes There Are No Symptoms 36 Maria Perno Goldie, RDH, MS 6 Goiter Comparable to effect of moderate smoking Increased risk of preterm delivery and IUGR Higher risk if disease active at conception Careful monitoring during pregnancy 37 38 39 40 They are estimated to cost the nation $86 billion a year1 Type I diabetes Multiple sclerosis Scleroderma Lupus Rheumatoid arthritis Pemphigus Vulgaris Sjögren’s syndrome And others… 41 1. “Autoimmune Diseases: A Major Women’s Health Issue.” American Autoimmune Related Diseases Association, Inc. www.aarda.org 42 Maria Perno Goldie, RDH, MS 7 The Office of Research on Women’s Health, a unit of the National Institutes of Health (NIH), has named autoimmunity and autoimmune diseases one of the priority women’s health issues for the 21st century.1 In about 2% of cases, the body’s immune system goes awry and fails to recognize its own parts as “self,” which results in an attack on healthy cells This can occur from before birth, as in type 1 diabetes, into old age 1. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health. Agenda for Research on Women’s Health for 21st Century. Report of the Task Force on the NIH Women’s Health Research Agenda for the 21st Century. Vol. 2. Bethesda, MD. NIH Publication No. 99-4399. 43 44 Discoid (DLE) form affects the skin › Chronic, erythematous scaly plaques on head region › Rare to have systemic manifestations 45 Systemic (SLE) form affects multiple organ systems including skin, heart, lungs, kidneys, neurological system 46 An inflammation of the connective tissues, SLE can afflict every organ system It is up to nine times more common in women than men It strikes black women three times as often as white women The condition is aggravated by sunlight Systemic lupus erythematosus 47 Diseases: A Major Women’s Health Issue. American Autoimmune Related Diseases Association, Inc. www.aarda.org. 48 Maria Perno Goldie, RDH, MS 8 Also more common in Hispanic women Common complications include psychiatric problems, infections, CAD, osteonecrosis 5 year survival rate 90% and 10 year survival rate 80% Malaise, fatigue, fever, weight loss, butterfly rash across nose and cheeks Migratory arthritis, oral ulcerations, recurrent pharyngitis Renal failure best clinical indicator of patient’s prognosis Raynaud‘s phenomenon 49 50 51 52 Vasculitis “Hitch-hiking thumb Neuropsychiatric problems include psychosis, seizures, movement disorders, high risk of stroke Pulmonary risks include pleuritis, edema, hypertension Cardiac risks include pericarditis, endocarditis, valvular abnormalities 53 Antinuclear antibody (ANAs) test has 95% specificity Patient’s may have hemolytic anemia, leukopenia, lymphopenia, and thrombocytopenia Also risk for elevated PTT time, may have clotting abnormalities 54 Maria Perno Goldie, RDH, MS 9 55 No cure, not an infection Treatment is palliative Avoid sun –exposure may exacerbate disease NSAID’s,COX2 inhibitors, aspirin Antimalarials In general, clotting should occur between 25 to 35 seconds 56 LUPUS: The Disease with a Thousand Faces http://www.lupuscanada.org/english/livi ng/1000faces.html › Hydroxychloroquine or quinacrine Corticosteroids Immunosuppressive drugs › Imuran & Methotrexate Rituximab - monoclonal antibody 57 Antibiotic prophylaxis according to AHA guidelines due to high risk of heart valve irregularities Leukopenia may make patient more at risk for infection along with steroid use May need to supplement steroids for high stress procedures 59 58 High risk for altered drug metabolism due to renal disease (nephritis) Patient’s may be at high risk for excessive bleeding, a coagulation profile should be obtained 60 Maria Perno Goldie, RDH, MS 10 Seen in 5-25% of patients May resemble lichen planus or leukoplakia Oral lesions are increased with sun exposure Erythematous lesions with white spots can be seen on the lips, palate, and on the insides of their cheeks in 5-25% of patients, not associated with active disease Red ulcers surrounded by a white halo and white radiating lines, more typical "discoid" lesions May or may not be sore Also Burning Xerostomia › Meds › Salivary gland disease 61 62 NSAIDs and COX-2 inhibitors Antimalarial drugs Calcium channel blockers ACE inhibitors Cholesterol lowering agents Rituximab Cyclosporine Changes in pigment of the lining of the mouth › Common side effect of antimalarial drugs Drug reaction to medication Opportunistic oral infection 63 Herpes simplex virus infection occurs in 80-90% of the general public Candidiasis, caused by fungal organisms, can develop secondary to dry mouth, diabetes, and dentures 65 64 Treat with appropriate antifungals, antivirals, and antibiotics Disinfection of dentures with chlorhexidine Referral not necessary unless patient does not respond 66 Maria Perno Goldie, RDH, MS 11 Medical for Dentures disinfects and cleans without causing corrosion or discoloration or distortion all types of removable dentures made of acrylic, silicon, nylon and elastomer Every day for 2 weeks After, use Medical Interporous twice per week as part of the denture cleansing routine http://www.msi-lab.com/ 67 68 Orabase Paste Overview – Indication • Oral irritations / Mouth sores – Active Ingredient • 20% benzocaine – Benefits • Maximum strength pain relief • Shields wound from further irritation • ADA approved and alcohol-free Source: Pharmacy Times OTC Supplement, 2007. 69 70 http://www.aphthasol.net/professional/ 99% of toothbrushes are contaminated with micro-organism biofilm Worse if stored in the bathroom in the open air 72 71 Maria Perno Goldie, RDH, MS 12 Lupus Guide to Dental Care by Heather Galusha-Phillips http://www.niams.nih.gov/H ealth_Info/Lupus/Lupus_Gui de/lupus_guide.pdf Boutonnière deformity Hyperextension at the metacarpophalangeal joint, flexion at the proximal interphalangeal joint, and hyperextension at the distal interphalangeal joint 73 74 A systemic disorder in which immune cells attack and inflame the membrane around joints Of the estimated 2.1 million Americans with rheumatoid arthritis, approximately 1.5 million (71 percent) are women 75 76 Peak incidence: young adults and premenstrual women Common (1-2% of population) severe inflammatory disorder which can affect men and women of all ages Marked by variable course, with exacerbations and remissions 77 78 Maria Perno Goldie, RDH, MS 13 Many patients have chronic progressive course resulting in severe morbidity and mortality Main target organ is synovium › Inflammation vasculitis › Edema › Infiltration by lymphocytes and macrophages › Synovial proliferation and cartilage erosion 79 80 Inflamed and/or deformed joints, loss of strength, swelling, pain 81 82 Rest and exercise Anti-inflammatory drugs when necessary Drug treatment includes: In the morning generally lasts longer than 45 minutes Other symptoms include fatigue, anemia, weight loss, and low-grade fever › Analgesics for pain; › Anti-inflammatory drugs › Disease-modifying drugs (DMARDS) 83 84 Maria Perno Goldie, RDH, MS 14 Can be a secondary reaction to rituximab and ACE-inhibitors, used to treat hypertension This reaction can also be a result of antiseizure medications and immunosuppressants, such as calcium channel blockers Inflammation of the temporomandibular joint Secondary Sjögren’s syndrome › Xerostomia treatment (43%) Michael A. Weber and Franz H. Messerli . Angiotensin-Converting Enzyme Inhibitors and Angioedema: Estimating the Risk. Hypertension. 2008;51: 1465-1467; published online before print April 14 2008, doi:10.1161/HYPERTENSIONAHA.108.111393 85 86 Colgate® PreviDent 5000 Plus® Active Ingredient • 1.1% sodium fluoride (5,000 ppm) Before application Benefits • Significantly remineralizes caries in 3 months* • Helps prevent decay • One step brushing • Safe for ceramic crowns Following application Patient Problems • High caries risk/rate • Crown and bridge work • Xerostomia • Soda pop syndrome *Baysan, A. et al. Reversal of primary root caries using dentifrices containing 5,000 and 1,000 ppm fluoride. Caries Res 2001;35:41-46. 88 87 Chlorhexidine Gluconate 0.12% oral rinse - 16oz Narrowed joint spaces Flattened condyles Severely destroyed Erosions rheumatoid GH joint Subchondral sclerosis Cysts Osteoporosis 89 Note the narrowing of the joint spaces and the increased density around the joints due to the subchondral sclerosis (black arrows). Flattened Condyles 90 Maria Perno Goldie, RDH, MS 15 Patients with RA may require antibiotic prophylaxis http://www.ada.org/ prof/resources/pubs/ jada/reports/report_ prophy_statement.p df Difficulty brushing and flossing 91 92 Scleroderma is an activation of immune cells which produces scar tissue in the skin, internal organs, and small blood vessels It affects women three times more often than men overall, but increases to a rate 15 times greater for women during childbearing years, and appears to be more common among black women 93 From the Greek words skleros for hard, and derma for skin, it literally means hard skin Chronic; often disabling; potentially life threatening 95 94 Localized scleroderma affects the skin and underlying tissue, hardening or tightening the skin Systemic scleroderma affects the skin and internal organ systems Both forms can cause debilitating physical changes 96 Maria Perno Goldie, RDH, MS 16 Approximately 300,000 Americans 80 percent are women Between the ages of 25 and 55 Scleroderma can strike anyone at any age Currently, there is no cure for scleroderma The Scleroderma Foundation and the National Institutes of Health fund research to find answers and a cure As this is a complex disease, more research lies ahead 97 Common symptoms include: 98 › Hands or feet overly sensitive to the cold, with pain and color changes › Thickening of the skin Also known as systemic sclerosis, is a disorder that leads to thickening, hardening and tightening of the skin and connective tissue › Shortness of breath › Trouble swallowing › Stiffness of the hands › Joint or bone pain › Fatigue 99 Localized scleroderma, the damage is confined to the skin and the tissue just beneath it 101 100 Calcinosis Calcinosis Reynaud’s Esophogeal dysfunction Sclerodactyly Telangiectasia Telangiectasia. Sclerodactyly & Reynaud’s Sclerodactyly 102 Maria Perno Goldie, RDH, MS 17 The drug D-penicillamine has been shown to decrease skin thickening (Cuprimine and Depen) Symptoms involving other organs such as the kidneys, esophagus, intestines, and blood vessels are treated individually › › › › › › › 103 Hematopoietic stem-cell transplantation can be an effective treatment in patients with refractory systemic sclerosis The dermal sclerosis improved immediately after transplantation, but thrombocytopenia and Graves’ disease developed n engl j med 357;26 www.nejm.org 2736 december 27, 2007 104 Tell the dental hygienist that you have scleroderma Schedule short exam and care appointments for one area at a time or one tooth at a time Schedule appointments for the best time of day for you Wear gloves and bring a blanket in case the office is cold 105 The appointment can be made more comfortable by: › Mouth prop › Rubber dam › Patience of both parties Calcium channel blockers Prostaglandins Antidepressants Phosphodiesterase enzyme inhibitors Histamine H2 antagonists Proton-pump inhibitors Antihypertensive agents 106 Lips and tongue can become rigid and the mouth narrows The folds of skin around the mouth disappear, giving the face a masklike appearance › Short appointments and/or breaks Living a legacy: 1953-2002 107 108 Maria Perno Goldie, RDH, MS 18 Mask-like or “mouse” facies Widened palpebral fissures Xerophthalmia Xerostomia Claw like form of her hands 109 110 111 112 Resorption of the condyles and mandibular ramus bilaterally Gastroesophageal reflux disease Thickened periodontal ligament and blunting of mandibular angles on dental radiographs Microstomia Poor oral hygiene Pathologic mandibular fracture 113 114 Maria Perno Goldie, RDH, MS 19 Tongue blade exercise Antimicrobial rinses Scaling and root planing Surgery Local antibiotic administration Extraction as needed 115 TMJ, Temporomandibular Joint Dysfunction 116 http://www.myoacademy.com/ 117 118 119 120 Maria Perno Goldie, RDH, MS 20 121 122 Chronic, slowly progressing inability to secrete saliva and tears Incidence Women Men 123 ANA (Anti-Nuclear Antibody) RF (Rheumatoid FactorSS-A (or Ro) and SS-B (or La): Marker Antibodies for Sjögren’sESR (Erythrocyte Sedimentation Rate) IGs (Immunoglobulins 124 125 Schirmer test: Measures tear production Rose Bengal and Lissamine Green: Use dyes to examine the surface of the eye for dry spots 126 Maria Perno Goldie, RDH, MS 21 Salivary flow: Measures the amount of saliva produced over a certain period of time Salivary scintigraphy: A nuclear medicine test that measures salivary gland function Salivary gland biopsy (usually in the lower lip): Confirms lymphocytic infiltration of the minor salivary glands It can occur alone or with rheumatoid arthritis, scleroderma, or systemic lupus erythematosus Nine out of 10 cases occur in women, most often at or around mid-life Sjögren's Syndrome 127 The most serious condition associated with Sjögren's syndrome (SS) is malignant lymphoma The risk of developing lymphoma is up to 44 times higher for patients with primary SS than for age- and sex-matched controls Interventions to keep the mouth and eyes moist include drinking a lot of fluids and using eye drops, as well as good oral hygiene and eye care 131 Men 128 Dryness of the eyes and mouth Swollen neck glands Difficulty swallowing or talking Unusual tastes or smells Thirst Tongue ulcers Severe dental caries 129 Women 130 Loss of saliva results in the loss of the antibacterial and antifungal capacities of saliva, as saliva keeps the oral soft tissue moist and healthy, and buffers the oral environment, helping to neutralize acids that cause dental decay Destruction of the salivary glands inhibits that buffering effect 132 Maria Perno Goldie, RDH, MS 22 2% sodium fluoride (NaF) gel for four minutes in a tray 5% sodium fluoride varnish applied directly to the teeth, four times a year Daily five-minute application of 1.1% sodium fluoride in a custom tray Daily 0.05% NaF rinse for one minute Use of extremely high-fluoride-content toothpaste once daily Many xerostomic patients complain that the flavors of mint or cinnamon are too spicy › Consider using products with gentler taste profiles such as vanilla, melon, chocolate, or fruit 133 134 “Currently, there is no cure for Sjögren's syndrome, and treatment is mainly palliative” 135 136 Moisturizes the mouth, locks in moisture Helps protect from dryness Enamel-safe pH, mild mint flavor Sugar-free, alcohol-free, and contains no known allergens Available OTC 137 138 Maria Perno Goldie, RDH, MS 23 Salese is a sustained release product that delivers active ingredients efficiently and continuously in small doses Ingredients: • Xanthan gum • Essential oils • Xylitol • Sodium Bicarbonate • Zinc 139 140 141 142 5000 ppm fluoride Prescription-strength Includes acidic, bitter, or sour foods and beverages that are known to stimulate salivary flow These should be limited because low pH foods and beverages promote mucosal soreness, dental erosion, and dental caries http://www.alignpharma.com/ 143 144 Maria Perno Goldie, RDH, MS 24 Use of sugar free chewing gum to stimulate saliva Lozenges of anhydrous crystalline maltose also stimulate saliva in dry mouth patients http://www.xlear.com/ Xylitol Stevia Leaf Extract (Rebaudioside A) Kettle Cooked & Over Stirred Made in the USA Magnolia Bark Extract Natural Flavors http://www.puredentgum.com 146 145 Eight to 10 8-oz glasses of water per day promotes adequate hydration Sip water frequently to replace, at least in part, the missing saliva Using a cool air humidifier during sleep, especially during winter months, can be helpful Electrical stimulation can also increase salivary flow Electrical stimulation with a TENS (transcutaneous electrical nerve stimulator) unit is used to stimulate salivary flow › The humidifier should be turned on approximately 1 hour prior to bedtime and left on all night, and cleaned frequently 147 Acupuncture increases salivary flow, ability to eat and speak, and improved sleep in patients affected with Sjogren’s syndrome Acupuncture points on hands and ears are used to increase salivation 149 148 Limit between-meal ingestion of fermentable carbohydrate Use noncariogenic sweetening agents such as acesulfame K, aspartame, saccharin, sorbitol or xylitol 150 Maria Perno Goldie, RDH, MS 25 MS is a Demyelinating Disease The nerve damage is caused by inflammation The body's own immune cells attack the nervous system Repeated episodes of inflammation can occur along any area of the brain, optic nerve, and spinal cord Blood vessel Inflammation Myelin – provides insulation to nerve processes (axons) Blood vessel Inflammation Blood vessel Inflammation 152 151 Risk of Developing MS and Region of Origin Risk is modified by Environmental factors › Sunlight › Diet (e.g., vitamin D) › Other lifetime experiences (infections?) 153 154 A chemical messenger has been shown to have a previously unknown major role in autoimmune diseases like arthritis and lupus Investigators found interleukin 17 plays a major role on shaping B cells' ability to create more and more disease-causing antibodies, which may generate new ideas in the ongoing search for better drug targets Fibromyalgia is a common syndrome in which a person has long-term, body-wide pain and tenderness in the joints, muscles, tendons, and other soft tissues Fibromyalgia has also been linked to fatigue, sleep problems, headaches, depression, and anxiety Nature Immunology, Jan 2008 155 156 Maria Perno Goldie, RDH, MS 26 Alopecia areata Antiphospholipid antibody syndrome (aPL) Autoimmune hepatitis Celiac disease Guillain-Barre syndrome Hemolytic anemia Inflammatory myopathies Primary biliary cirrhosis Psoriasis Vitiligo American Autoimmune Related Diseases Association (AARDA), Inc. Phone: 586-776-3900; 800-598-4668 (for literature requests) National Heart, Lung, and Blood Institute (NHLBI), NIH, HHS Phone: 301-592-8573 National Institute of Allergy and Infectious Diseases (NIAID), NIH, HHS Phone: 866-284-4107 157 158 OHASA National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, HHS Phone: 301-495-4484; Toll-Free: 877-226-4267 National Institute of Diabetes and Digestive and Kidney Diseases, NIH, HHS Phone: 301-496-3583 National Institute of Neurological Disorders and Stroke (NINDS), NIH, HHS Phone: 800-352-9424 The Oral Hygienists’ Association of South Africa presents: 159 HOUSE OF DELEGATES MEETING 2013 Pre-congress HOD meeting Date: 12-13th August 2013 Venue: The Lord Charles Hotel Town: Somerset West, CT IFDH Governing body tri-annual meeting The official meeting of the house of delegates of the IFDH member countries Elections of new Executive Council members Forming IFDH policies and procedures As one of the top ten tourist destinations in the world, Cape Town is no ordinary city. So it stands to reason that the CTICC would be no ordinary convention centre—IT IS WORLD CLASS Widely regarded as one of the leading convention centres in the southern hemisphere GREEN CONFERENCE INITIATIVE [email protected] Congress Venue: The Cape Town Convention Centre CTICC Maria Perno Goldie, RDH, MS 27 WELCOME RECEPTION & OPENING CEREMONY 19TH ISDH 2013 THIS EVENT WILL TAKE PLACE IN THE CAPE TOWN INTERNATIO NAL CONVENTION CENTRE (CTICC) THE SOUND OF THE AFRICAN DRUMS WILL CALL IN ALL DELEGATES FROM AROUND THE WORLD TO TAKE PART IN THIS PRESTIGIOUS EVENT GALA DINNER M SPIER O WINE Y ESTATE O Stellenbosch Date: 16/08/2013 Time: 19:00 hrs A unique destination for a sophisticated African experience AVOID DISAPPOINTMENTBOOK NOW! VISIT US AT :http://www.embassyconferences.co.za/portfolio/present/19thinternational-symposium-on-dental-hygiene/10 Sponsored by Sunstar Foundation KEYNOTE SPEAKER PROPOSALS 19TH ISDH 2013 Please submit the attached ‘Keynote Speaker Proposal Form’ not later than 31 st October 2012 to: CALL FOR ABSTRACTS 19TH ISDH 2013 Marie Ferreira, Chair Scientific Committee . PLEASE SU B MIT T H E ‘A B STRACTS SU B MISSION FORM’ B Y 3 1 ST O C T O B E R 2 0 1 2 T O : Postal Address: 206 Kings Terrace Brooks Hill Drive Humewood Port Elizabeth 6001 MA RIE FERREIRA CH A IR SCIEN TIFIC COMMITTEE POSTAL A D D RESS: 206 KINGS TERRACE BROOKS HILL DRIVE H U M E WOOD PORT ELIZABETH 6001 SOUTH AFRICA South Africa Email Address: [email protected] We welcome your proposal, support and participation. E M A IL A D D RE SS: M A R IE FE [email protected] REGISTRATION FOR 19TH ISDH 2013 PROFESSIONAL CONGRESS ORGANIZER VISIT US AT :http://www.embassy conferences.co.za/port folio/present/19thinternationalsymposium-ondental-hygiene/10 Save the date ! Please join us for this once in a lifetime African congress experience [email protected] [email protected] www.ifdh.org Maria Perno Goldie, RDH, MS 28 Maria Perno Goldie, RDH, MS 29