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Effects of Radiotherapy on the Oral Cavity
Approximately one million people will develop invasive cancer each year. Of these, 40% will receive curative benefit from surgery, radiation, chemotherapy, or a combination modality.(5) In dealing with patients with cancer of the head and neck a team approach is required for effective management. When radiation therapy is indicated, it is imperativ that health of the oral cavity be assessed initially as well as throughout therapy.
All members of the cancer treatment team should be informed of the oncologic treatment plan. Oral care should be initiated at the onset of treatment, with the goal of reducing morbidity and improving compliance. Total body irradiation and irradiation to the head and neck cause both direct and indirect effects on oral and related structures, and may be acute or chronic in nature. These complications may include mucositis, xerostomia, dental caries, loss of taste, trismus, infection, osteoradionecrosis, and abnormalities of growth and development.
Pre-radiation Therapy Management ConsiderationsOral complications can affect the patient's tolerance to radiotherapy and quality of life. Pre therapy dental evaluation can decrease the incidence and severity of these complications. Strategies include:
- A. A complete dental examination to identify preexisting problems. Cancer diagnosis, past medical history, dental history, dental charting, periodontal charting, radiographs, and nutritional status should be included. Prior to treatment, some clinicians may quantitate the amount of saliva and collect study models to assess changes during therapy. (1)
- B. Prior to treatment, potentially complicating diseases should be corrected. Poor oral hygiene, third molar pathology, periapical pathosis, periodontal disease, caries, defective restorations, ill fitting prostheses, orthodontic appliances and any other potential sources of irritation (tori) should be eliminated. Irritation and infection are important targets for early treatment to reduce the incidence of local and systemic infection. Intervention should be supplemented with plaque removal, including tooth brushing with fluoride paste and flossing if tolerable. Additional topical fluoride and chlorhexidine may be helpful to control caries and plaque. If time permits dental procedures, especially extractions, should be completed two to three weeks prior to the start of radiation.(1)
- C. Patient adherence to hygiene protocols are critical. Patient and family education, counseling, and motivation will increase the chances for success. All potential side effects should be identified.(1)
Acute reactions are those which arise during or shortly after radiation therapy and resolve within ninety days post-therapy.
One of the first symptoms of radiation complications is mucositis ,which occurs 12- 17 days after the initiation of therapy. Mucosal inflammation varies with dosage, target size and duration of therapy. Oral mucositis can present as patchy mild erythema to frank confluent ulceration. Chemotherapeutic agents such as 5FU, procarbazine, methotrexate, etc., may increase the severity of these symptoms. Currently, there are no drugs available to prevent mucositis, and it is imperative to distinguish these lesions from those caused by infections. Cultures may be needed to differentiate between fungal, bacterial and viral lesions versus those secondary to radiation effects.
Prevention, on the part of the Radiation Oncologist is essential to minimizing excessive morbidity of the oral mucosa . This is accomplished by designing portals that limit the exposure to tissues not at risk for tumor reoccurrence. When interstitial implants are a part of a treatment protocol, soft tissues of the oropharynx are at greater risk for developing soft tissue ulcerations.(5) Mucosa thickness, another important predictor of exaggerated tissue response, should be considered. The anterior commisures of the mouth and the medial surface of the angle of the mandible are sites which contain very thin mucosa and would benefit from field blocks if possible. (5)
Lack of saliva and damaged taste buds may alter the sensation of taste during radiotherapy. Often, patients complain that many foods taste excessively salty which may reduce the motivation for adequate oral intake. In response to their altered taste sensation, patients tend to compensate by increasing their intake of sugar. Counseling should be provided to avoid this behavior due to the increased risk of dental caries. However, altered taste sensorium is a transient phenomenon since the taste buds recover in two to four months post therapy.(1)
Many untested topical oral preparations can reduce symptoms of oral mucositis. Efficacy and safety of these agents has not been established. Currently accepted elixirs include a combination of Benadryl, Kaopectate, MOM, antacids, sucralfate, corticosteroids, dyclonine, and viscous lidocaine.(2) If pain is severe enough to limit eating, systemic analgesia should be considered. Extremes in mucosal inflammation which demonstrate confluent lesions may warrant a treatment break to allow tissues to continue therapy. However, cessation in treatment can be dangerous by allowing rapid repopulation of tumor cells during breaks in therapy. Commercial mouth rinses should be avoided. The alcohol and phenols contained in these preparations may further dehydrate the mucosa causing further pain. Chlorhexidine should be continued during radiation therapy and may be diluted for tolerance.(2)
Local and total body irradiation may irreversibly affect the production and quality of saliva in the major and minor salivary glands. Doses as low as 20 Gy will result in clinically noticeable changes such as sparse thick ropy saliva. In particular, if the parotid glands are in a field which received 40Gy or over, permanent dysfunction of the salivary glands should be expected and discussed with the patient prior to treatment. (1) Concomitant administration of medications which are known to induce xerostomia (i.e. psychotropics, antiemitics, antihistamines, and thousands of other commonly prescribed medications.) should be carefully considered.(1)
The diagnosis of xerostomia is based on subjective impressions by the patient and the clinician. Dry mouth may affect speech, taste, nutrition and the patients ability to wear a prosthesis. Saliva also contains antimicrobial compounds (i.e. sIgA, and mucins) which reduce pathogenic bacteria and decrease the risk of infection in the oropharynx . However, saliva's most important role lies in its ability to mechanically cleanse the teeth and soft tissues. Therefore, with radiation induced xerostomia it is common for this to lead to an increased incidence of caries, especially in the cervical portion of the clinical crown at the cementoenamel junction.(2) Similarly, the change in salivary content and quantity also leads to an increased incidence of candidiasis and periodontal disease.
Management for xerostomia is directed at several levels. First, addressing the patients chief complaint of chronic dry mouth, treatment is generally palliative--utilizing artificial saliva, carrying water bottles for periodic mouth moistening. Salivary substitutes are available in two types. All contain electrolytes commonly found in saliva including those normally used for remineralization and should be used in dentate patients. The other solutions contain dextrans which should be reserved for edentulous patients so as not to raise the caries index. Sialogogues (pilocarpine) may also be used to stimulate saliva formation if residual salivary tissue remains. These drugs alleviate many of the problems encountered during therapy (1,2)
However, the critical aspect in managing head and neck irradiated patients with xerostomia is controlling the risks for oral diseases. Therefore, initiation of meticulous oral hygiene regimens including topical fluoride trays , chlorhexidine rinses, and regular dental hygiene therapy sessions are required. In addition, dietary advice is recommended to reduce the intake of carogenic foods.(2)
Another acute effect commonly associated with mucositis is oral candidiasis. Colonization of the yeast on damaged tissue can intensify the symptomatic effects of radiation on the mucosa.(6)
The practitioner should be aware of the multiple presentation of candida including pseudomembranous (removable white plaques with an erythematous base), chronic hyperplastic (leukoplakia like plaques that do not wipe away), and chronic cheilitis. These infections should be eliminated to decrease mucositis and the chance of distant gastrointestinal infections.
Management of patients with oral pharyngeal candidasis include both topical and systemic approaches. Historically, nystatin topical solution have been used with mixed efficacy. Patients involved in this therapy should be advised that the solution must be refrigerated at all times or the solution will become inactivated. Other topical solutions include clotrimazole troche which is recommended for edentulous patients and angular cheilitis. However, this medication should be avoided by the dentulous patient for caries control, due to its high sugar content. Currently, the best medication for oral or systemic candidiasis is Diflucan. The treatment regimen includes a 200mg loading dose the first day, followed by a 100mg /day dose for the remaining thirteen days. However, it is imperative that the physician obtain liver function tests prior to initiation of treatment because of the potential toxic side effects on the liver.(2)
Bacterial Infections
Local infections can lead to sialadenitis, periodonditis, abscesses, pericoronitis, or other causes of ulceration. Emperic treatment with antibiotics are usually adequate; however, periodontal lesions usually need additional debridement. The oral cavity may be the portal of entry for systemic infections. Therefore, chlorhexadine rinses should be considered for these patients.(2)
Gingival bleeding may be the first sign of thrombocytopenia. The patients' ability to accomplish adequate oral hygiene may be limited. In these instances flossing may have to be discontinued . Again chlorhexadine rinses may be required to reduce pathogens found in plaque.(2)
Chronic Complications of Radiation Therapy
Certainly one of the most devastating complication of radiation therapy to the head and neck is the development of osteonecrosis of the mandible. Long term effects of radiation therapy on osseous and soft tissues is soft tissue fibrosis and ischemia, which may never resolve. The main mechanism of osseous involvement is injury which occurs to the small vasculature of the Haversian canals and the periosteal tissue. Fortunately, osteonecrosis is a relatively uncommon complication, with an incidence ranging from less than two percent to as high as 10%. This range in incidence varies with total dose administered to the mandible. (i.e. greater than 70 Gy yielding the larger number) Another compounding factor is location of the primary tumor. If the lesion is large and is situated at the floor of mouth the rate of osteonecrosis more than doubles to 25%.(6) Due to the decrease in healing capacity of the tissues from decreases in blood supply, infections to the jaw are devastating. The major etiologies are extraction of failed dentition after radiation therapy. Therefore, posterior mandibular teeth may be planned for extraction if more than 6,000 rads are expected in that field.
Great importance should be placed on pretreatment evaluation of all remaining dentition. Any questionable teeth that cannot be adequately maintained for years should be extracted. A period of two weeks prior to radiation therapy is advised for adequate healing of extraction sites. All preprosthetic surgery required, should be performed prior to the initiation of radiation therapy.(8)
Occasionally systemic antibiotics will be required if osteoradionecrosis develops. Technically it is not an infection of bone but rather a nonhealing hypoxic wound. (8) Systemic antibiotics are of limited value to the mandible itself due to the decreased vasculature and subsequent poor drug delivery to the site. However, in secondary infections they may have a role in preventing the spread of infection. No attempt should be made initially to obtain primary soft tissue closure of bone, since most wounds less than 1 cm or less will heal in weeks to months without surgical intervention other than removing sequestrum.(8) For large defects in the jaw, surgery will be required with osseous and soft tissue reconstruction with the aide of preoperative and postoperative hyperbaric oxygen.
The role of hyperbaric oxygen has greatly enhanced the ability to reconstruct patients with osteoradionecrosis with large boney and soft tissue defects. However, the cost is tremendous and access to treatment is limited. Additionally it is felt that patients with active malignancies should not be exposed to HBO for fear that it can accelerate the repopulation process. The mechanism of action appears to be supporting neovascularization within tissues ,increasing the oxygen tension . The protocol is 20 pre- surgical hyperbaric oxygen (HBO) sessions, each consisting of 90 minutes of 2.4 atm of absolute pressure/day x five days /week. After the reconstructive surgery, an additional ten treatments is prescribed to ensure adequate vascularization of the grafted bone and soft tissue. There are contraindications to this treatment, covered on OncoLink and elsewhere (7)
Soft Tissue Necrosis
The primary etiologies for this type of chronic complication are due to excessive doses delivered to the tissues via interstitial implants or secondary to soft tissue irritation from an inadequate fitting prosthesis.(6,8) If the patient can tolerate being edentulous, it is recommended for the first six months post-therapy to allow for adequate healing and remodeling of bone. Occasionally it is required to administer HBO and antibiotics to alleviate the necrotic tissue.(6,8)
This condition is secondary to fibrosis which occurs in the muscles of mastication after being within the field of radiation. Best management is to encourage physical therapy during and after the radiation is administered.(4) This feature can also be an important factor for adequate oral hygiene if the patient is unable to open the mouth for proper dental care.
Suggestions for the Edentulous Patients
Proper fitting of prostheses is essential, discrepancies can result in ulcers which may lead to osteoradionecrosis. New dentures should be constructed only after adequate healing time; in the interim, soft tissue liners may be used. Chlorhexidine two times a day until salivary function returns can be used to keep the mouth clean. Salivary analogues may also be used to increase retention of the dentures.(2)
Candida is often a problem and antifungals should be used. These drugs may be added into tissue conditioners or placed where needed. Dentures should be removed and cleaned every night. At first sign of discomfort, the denture should be removed, adjusted or relined. It is extremely important not to have soft tissue ulcerations, because the risk of osteoradionecrosis is a life-long threat.(8)
The advent of chemotherapy and radiotherapy as treatment modalities for pediatric malignancies has produced a significant increase in cure rates for many of these cancers. However, along with the increased success of treatment with these modalities comes a potential for multiple organ system morbidity that may last the lifetime of the patient. These modalities have found their niche in the treatment of head and neck cancers, and as such, many of these pediatric patients will survive into adulthood. With this increased survival there is an increased potential to develop significant long term complications within the treatment fields. It is therefore imperative that the health care team be familiar with not only the potential complications of therapy, but also their prevention, recognition and management.
Oral complications of radiotherapy are usually the result of the direct effects of radiation on the oral tissues. The tissues most frequently affected are the mucosa, salivary glands and mineralized tissues.
Radiation associated mucositis is a direct effect of radiation on the oral mucosa. It is a result of a decrease in the turnover rate of the basal cells of the epithelium with subsequent thinning and ulceration of the mucosa. The minimum dose of radiation that will cause mucositis is not known. However a total dose of 600 cGy given in one dose or two fractions for leukemic gingival infiltrates usually causes mucositis.(9) These changes will usually appear 12 to 17 days following initiation of treatment and heals completely 2 to 3 weeks following the cessation of therapy. Management of mucositis typically consists of saline and/or bicarbonate lavage, analgesics such as topical xylocaine to relieve pain and facilitate oral intake of food and fluids. A severe mucositis may necessitate a break in treatment to allow healing. Candidal colonization of the inflamed ulcerated mucosa may occur requiring treatment with topical anti-fungal agents such as Nystatin or Diflucan.(4)
Xerostomia, is another side effect of radiotherapy occurring when substantial salivary gland tissue is located in the portal of the radiation therapy. These effects have been observed within 24 hours of two to three fractions of 200 cGy total body irradiation. At higher doses such as 5000 to 7000 cGy these changes in salivary tissues are irreversible. These changes may result in substantial discomfort and interference with eating and speech. Prepubertal children do not experience these complications with similar doses of radiation suggesting that their salivary glands may be more radioresistant. (9)
Management of xerostomia in the child is similar to the adult and typically involves the use of synthetic salivary substitutes and baking soda rinses to break up the thickened viscous saliva.
As was discussed under acute reactions, permanent damage to the salivary glands may result following doses of 5000-7000 cGy. These patients invariably develop rampant dental caries which is discussed below.
Radiation induced dental caries
As mentioned earlier, radiation may permanently alter the quality and quantity of salivary flow. Saliva plays an integral role in the prevention of dental caries. Without its protective action, the cariogenic oral bacteria are permitted to colonize the teeth unchecked. In the absence of a strict and meticulous preventive hygiene regimen, rampant caries typically results. Carious lesions may begin to appear within three months of radiation therapy and proceed rapidly to devastate the dentition. The key to managing this problem is prevention. As will be discussed later, a regimen of strict oral hygiene, daily fluoride application, carbohydrate restriction and frequent dental follow up are essential.
Abnormal Development of the Dentition
Tooth development begins at four months in utero and continues until early adolescence when the permanent teeth complete their formation. As with many other tissues, radiation has the potential to interfere with normal growth and maturation of the developing dentition. The severity of malformation is dependent on the stage of development at which the teeth are irradiated and the total dose received. Abnormal development in humans has been observed with a total dose as low as 400 cGy.1 Dental abnormalities include crown and root dwarfism, root shortening, incomplete calcification, abnormal curvature of the roots, delayed or arrested eruption, and ankylosis of primary teeth. Shortened roots may lead to inadequate anchorage of the teeth in the supporting bone with subsequent loosening , increased susceptibility and involvement with periodontal disease, and early tooth loss. Ankylosis of primary teeth as well as delayed or abnormal eruption of permanent teeth may lead to significant malocclusion. These problems may require substantial efforts by the general dentist in conjunction with other specialists to restore adequate form and function to the dentition.
Abnormal Facial Development
In the same vein as disturbed dental development, the structures of the facial complex, which are also actively developing in the child, may also be adversely affected by radiation therapy. These changes are secondary to radiation effects on cartilagenous growth centers. These areas are located, for the mandible, in the condyles, and for the maxilla, in the sutural growth centers. Higher radiation doses on the order of 6000-7000 cGy are associated with disturbances of facial growth and associated malformations. The child with these growth disturbances may develop micrognathia, maxillary deficiency, retrognathia, skeletal and dental malocclusion as well as other abnormalities in the facial complex. The management of those long term survivors who manifest these complications involves a team approach involving the dentist, orthodontist, oral and maxillofacial surgeon as part of rehabilitation.
Fibrosis and Trismus
When the muscles of mastication are involved in the treatment field, radiation induced edema and fibrosis of the muscles may result. As a consequence of this fibrosis, difficulty in opening, or trismus, may occur. This, in turn, may interfere with oral hygiene, fluoride application, and dental care.
Osteoradionecrosis results from the compromised blood flow to the mandible secondary to radiation induced vascular damage. This decreased blood flow impairs the normal healing capacity of the bone following even the slightest insult. It also predisposes to secondary infection of the bone. This complication of radiation therapy is rarely reported in the jaws of children and therefore will not be discussed further here. (9)
In Pediatric Patients Receiving Radiation Therapy
Prevention is the key to minimizing morbidity secondary to radiation therapy. A carefully thought out treatment established by the radiation oncologist minimizing normal tissue exposure is the first step toward this end. A complete dental examination including radiographic exam, dental and periodontal charting, assessment of oral hygiene as well as patient and parental motivation in maintaining home care is also critical. It is imperative that all existing and potential conditions that may result in infection, hemorrhage or irritation are corrected prior to the initiation of radiation therapy. These conditions may include carious teeth, dental abscesses, periodontitis, gingivitis, and exfoliating deciduous teeth. Carious teeth should be restored if possible, otherwise extraction is warranted. Periodontitis and gingivitis should be treated by thorough cleaning of the dentition to remove plaque and calculus.
Also, of utmost importance, a comprehensive oral hygiene regimen should be established for all radiation patient's. Patients four years of age and older, along with the parents, should be instructed in proper brushing and flossing technique. It has been said that these procedures should be carried out as long as the granulocyte count remains above 5/mm3 and the platelet count above 40,0/mm3. Below these levels, these practices should be avoided to prevent hemorrhage and/or bacteremia.(9) In addition, the use of fluoride gels applied in custom made trays, daily, at home, is an important adjunct to brushing and flossing in preventing the ravages of rampant radiation induced tooth decay.
Once treatment is begun, daily evaluation of the oral cavity should be performed prior to each treatment dose. Any unusual findings or side effects of radiation should be identified and addressed either by the radiation oncologist or the patients dentist. Frequent dental follow up visits should be scheduled throughout the treatment period for the purpose of addressing complications, new dental problems, patient questions and concerns, as well as reinforcing the importance of continued home oral hygiene.
Following radiation therapy, and healing of any acute reactions, the long term effects of radiation on the oral tissues require continued frequent assessment by the dentist. Continued surveillance of the oral cavity for xerostomia, increased caries development, malformed permanent teeth, malocclusion and facial maldevelopment are all important components of the long term care of the irradiated child. The early recognition and management of these conditions may allow better corrective measures to be implemented. Also, the psychological and emotional consequences of potential facial deformity and dysfunction deserve to be addressed in these patients and proper steps taken to deal with these problems.
For the Adult Patient
How to maintain your Oral Health during your Radiation Therapy
- Prior to radiation therapy involving the mouth or salivary glands it is imperative that you visit your dentist to determine the appropriate treatment.
- It is recommended that all definitive dental therapy including, extractions, root canals, fillings, or crowns be completed two to three weeks in advance of your radiation treatments.
- Radiation therapy frequently will alter your taste sensation. Often, patients complain of salty tastes and are more sensitive to hot and cold foods. However, this should return to normal in two to four months.
- During your therapy, altered taste sensations may cause you to seek extra sweets in your diet. However, as mentioned before this can lead to increases in dental disease during a critical period, which could jeopardize your health. Do not use hard candy to remedy your dry mouth.
- Depending on the size and dose of your radiation treatment you may suffer from a dry mouth. Initially this is difficult to tolerate , however, with frequent application of water, or artificial saliva much relief can be obtained. Talk with your dentist about options which would be right for you.
- Many patients find themselves more susceptible to cavities, even if in the past this was not a problem. Oral hygiene must be maintained with topical fluoride to reduce the risk of disease. Your dentist will design a schedule which will meet your individual needs.
- An increased risk of obtaining periodontal disease could pose serious consequences to the health of your remaining dentition and could result in serious infections. Again meticulous oral hygiene and antimicrobials must be used.
- Radiation causes the mucosa or oral tissues to become irritated. You should be aware that this can be the start of an infection and you should be evaluated by your dentist or physician. Commonly, this is irritated tissues like a sunburn and can be treated by prescription mouth rinses or warm salt water rinses. It is best to avoid or dilute over-the-counter rinses at this time. They will only aggravate your tissues further. Hot or cold foods and smoking should be avoided at this time.
- Irradiated bone, extractions or oral ulcers my lead to bone infections. It is recommended to have all dental treatment prior to radiation or at least within four weeks of completing therapy.
- If you wear dentures please remove them from your mouth prior to going to bed. All of your soft tissues in your mouth should be cleaned every day.
- If your gums begin to bleed while brushing or flossing, contact your dentist for an evaluation.
- At the first sign of pain, contact your dentist, prolonging this may lead to greater problems in the future.
Possible Changes That You May See In Your Child's Mouth During Radiation Therapy
Mucositis: This is a reaction of the skin inside the mouth to radiation. It typically occurs within the first two weeks of treatment. Your child's mouth will become reddened and quite sore. There may even develop ulcerations throughout the mouth with severe discomfort. This reaction usually resolves completely 2-3 weeks after the cessation of therapy. The soreness of the mouth may make it difficult for your child to speak, swallow or eat. However, it is very important that your child continue to take fluid and food to maintain hydration and nutrition for proper healing. Your doctor or dentist may be able to prescribe anesthetic mouth rinses to soothe the soreness and make eating and drinking easier.
Dry Mouth: If the glands that produce saliva have been included in the area to be treated, your child may develop a dry mouth. Depending on the degree of involvement of the glands, the dry mouth may be mild to severe, and may partially return or be permanent. This too may be uncomfortable for your child and make eating difficult. It may be necessary to take frequent sips of fluids (such as water or milk) with each bite of food, as well as take smaller bites, in order to properly moisten and allow easier swallowing. There are man made saliva substitutes available that may ease the discomfort of a dry mouth and make eating and speech easier.
Tooth Decay: Saliva is an important part of the body's mechanism for preventing tooth decay. As mentioned above, radiation therapy can cause a permanent decrease in the amount of saliva produced. This, in turn, can lead to an increased rate of tooth decay in your child's mouth. It is therefore very important to follow your dentist's recommendations on oral hygiene during radiation therapy. Brushing and flossing of the teeth to remove plaque and tartar is crucial to minimizing the risk of severe tooth decay and early tooth loss. Fluoride tooth paste should be used with a soft tooth brush. In addition, fluoride gels in custom trays supplied by your dentist should be used daily according to your dentist's recommendations. Any cavities or tooth aches should be brought to the attention of your dentist right away to avoid unnecessary loss of teeth due to decay. Finally, it is very important to keep your regularly scheduled check up appointments with your dentist so that any problems or concerns may be addressed.
Abnormal Eruption of Adult Teeth: Radiation therapy that involves the head and neck has affects on the developing adult teeth that lie within the jawbone. These affects include delayed eruption (the teeth will come into the mouth later than normal), eruption of teeth in an abnormal alignment (teeth may be crooked), or fusion of the baby teeth in the jaw bone preventing the adult teeth from erupting. These abnormalities can also be corrected, most times, with orthodontics and/or oral surgery.
Abnormal Facial Development: Radiation can also effect the areas of active growth, called growth centers, in the jaws and facial region. If these areas are in the area being treated by radiation, it is possible that future growth of the jaws and/or face may be delayed or disturbed. This altered growth may result in a small jaw with a poor bite, or an altered facial appearance later in life. However, many of the resultant deformities can be adequately corrected through a combination of orthodontic and/or oral surgical procedures.
Difficulty Opening the Mouth: The muscles that open and close the mouth may lie within the area to be treated with radiation. If so, they may be affected and undergo changes which make it difficult to open the mouth, called trismus. This may require a substantial amount of time to occur, even after treatment has stopped, and may develop gradually, making it difficult to notice. This is another reason to make sure you keep your follow up visits with your radiation oncologist and dentist even though treatment may be completed.
Finally, your doctor and dentist are there to ensure the best treatment for your child. If you have any questions or concerns regarding treatment, or side effects, do not hesitate to call them.
1. National Institute of Health Consensus Development Conference Statement: Oral Complications of Cancer Therapies: Diagnosis, Prevention, and Treatment. NIH, Journal of the American Dental Association, Vol. 119, July 1989, pp. 179-184.
2. Fleming, P. Dental Management of the Pediatric Oncology Patient., Pediatric Dentistry, 1991
3. Joyston-Bechal, S. Prevention of Dental Disease Following Radiation Therapy and Chemotherapy. Int Dent Journ , 1992,42, pp. 47-53.
4. Sonis, A., Tarbell, N., Valachovic, R., Gelber,R., Schwenn,M., and Sallan,S., Dentofacial Development in Long-Term Survivors of ALL: A Comparison of Three Treatment Modalities. Cancer, 1990, 66:2645-52.
5. Wang, C.C. Radiation Therapy for Head and Neck Neoplasms: Indications, Techniques, and Results, pub 1983, Chapter 4, pp.19-21.
6. Coia,L.,Moylan,D., Introduction to Clinical Radiation Oncology, Medical Physics Publishing Company, copyright 1991,Chapter 4.
7. Marx,R., Comprehensive Review for Oral and Maxillofacial Surgeons and Residents., vol 1.,pp 17-19., University of Pennsylvania School of Dental Medicine, Aug 12-18, 1991.
8. Peterson, L., Ellis, E., Hupp,J., Tucker,M., Contemporary Oral and Maxillofacial Surgery, C.V. Mosby Company, St. Louis, 1988, chapters 14, and 18.
9. Pediatric Annals, 17 (11), November 1988, pp. 115-25.
10. Larson, D.L., Kroll, S., Jaffe, N., Serure, A., Goepfert, H., Long-Term Effects of Radiotherapy in Childhood and Adolescence, The American Journal of Surgery, 160, october 1990, pp.348-51.
11.Ruccione, Weinberg, Biologic Late Effects of Radiation Therapy, Seminars in Oncology Nursing, 5(1), February 1989, pp. 1-73.


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Liquor license holders in Boulder can expect more coordinated enforcement of alcohol, building code and other regulations in the near future, and so-called "problem" businesses will bear the brunt of that enforcement.
Boulder City Council members said Tuesday night that they support the broad outlines of a new enforcement approach recommended by the city staff and a working group of residents and business owners, and they said they want to put more money into enforcement in next year's budget.
They also want to at least look into restoring the 500-foot buffer around the University of Colorado that would limit alcohol sales in most of the University Hill business district and in the Basemar shopping center. That option wasn't recommended by the staff, but Councilman Ken Wilson, a University Hill resident, said it needs to be on the table.
Wilson proposed several variations on an outright ban on new liquor licenses, including allowing late-night service with beer and wine only or allowing full liquor service but not past 11 p.m.
"I'd like to hear from the business community whether it's better to close late and serve beer and wine or better to serve margaritas at 5 p.m.," he said.
Most council members supported the idea of creating a late-night business license that would give the city additional leverage over bars and restaurants that want to stay open past 11 p.m.
Existing bars and restaurants may be asked to apply for the new license, officials said. That idea will come back to the council later this year for further debate and public input.
Council members rejected the idea of implementing a "cost-recovery fee" on the hosts of parties that require police or medical response.
City Attorney Tom Carr said the city would have to find a way to justify charging for a response to alcohol-related party calls but not for other police response, and many council members worried about discouraging party-goers from calling about legitimate emergencies.
Council members struggled to find agreement on some of the details, including creating more distinctions in the zoning code between high- and low-intensity alcohol uses and hiring administrative hearing officers to rule on liquor license violations.
Councilman George Karakehian said it's not hard to figure out which businesses primarily operate as bars at night, despite having a hotel/restaurant license.
"I don't know how many people eat after 11 p.m., but it's not a lot," he said. "I don't want to spend a lot of money to figure out that if you're open after 11 p.m., you're mostly serving alcohol."
Councilman Tim Plass said he has concerns about separating ruling on liquor license violations from granting licenses and renewals, and Beverage Licensing Authority member Dave Zessin told the council that liquor board members want to stay in the loop. However, other council members said an administrative hearing officer, who would be an attorney, would have more expertise on considering rules of evidence, particularly as the city considers bringing stronger penalties against violators.
Despite their support for the proposed changes, several council members said they doubt any of the measures would have much effect on binge drinking and the impacts it has on the surrounding neighborhoods.
Stepping up enforcement on house parties, where a lot of drinking occurs, would be difficult, Police Chief Mark Beckner told the council. Police already respond to loud parties, but there isn't a good way to know what's going on behind closed doors if they aren't bothering neighbors.
Councilwoman Suzy Ageton said the city needs to develop concrete measurements to assess whether it's making progress.
Boulder Mayor Matt Appelbaum said many of the proposals are good ideas, even if their impact is limited.
"I would push back on the idea that everything we do here has to have an immediate and strong impact on alcohol," he said. "Some of this is just organizing our staff better and doing a better job, and if we can do that, I don't know why we wouldn't."


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Jerry Seinfeld and Jay Leno are the two car nuttiest comedians on the face of the planet. They are also two of the funniest. And the stories that come together with coffee, a 1949 Porsche Gmund 356/2, and these two are legendary.
On this episode of Comedians In Cars Getting Coffee, Jay Leno, who doesn't drink coffee at all, gets in a gorgeous 1949 Porsche Gmund that is all original. It's truly a glorious car.
For those of you who don't think Leno is funny, you need to watch this. Leno is at his best shooting the shit with another comic. The stories he has, including playing the Playboy Club, how a burnout got him hit with a frying pan, and other insider stories that you just have to here. Leno at his funniest. This is outstanding.
Watch it here or try below from Crackle.


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World Bulletin/News Desk
The next talks between six global powers and Iran on its nuclear programme are likely to be delayed until February, a diplomat said on Friday, after European officials accused Tehran of stalling on fixing a time and place for a meeting.
European Union foreign policy chief Catherine Ashton is coordinating efforts by the powers to persuade Iran to scale back nuclear activity that the West suspects is aimed at developing the capability to produce nuclear weapons.
The long standoff over Tehran's nuclear programme has fuelled concerns Israel could attack Iran's nuclear installations and thereby unleash a broader Middle East war.
Nuclear diplomacy between Iran and the United States, China, Russia, France, Germany and Britain has been deadlocked since a meeting in June last year that ended without a breakthrough.
Talks had been expected to resume soon after last November's re-election of U.S. President Barack Obama, possibly in December or January.
EU diplomats and Iranian officials have held intensive discussions on arranging a new round. But EU officials say Iran has been dragging its feet on fixing a date and location.
"It seems more likely now that the next round will take place in February," a European diplomat, speaking on condition of anonymity, said. "There is still no agreement on the next round, but contacts are ongoing."
The diplomat voiced disappointment that there was still no agreement on a meeting. "We showed flexibility when it came to date and venue. We want to present our refreshed offer (to Iran) but didn't get the opportunity to do so," the diplomat said.
At talks in Baghdad last May, the six powers put forward a proposal aimed at stopping Iran's production of higher-grade enriched uranium in return for supplying Iran with fuel for a reactor. The diplomat gave no details of the "refreshed" offer.
The six powers have used a mixture of diplomacy and economic sanctions for years to force Iran to comply with United Nations' demands that it suspend all activities related to production of enriched uranium.
The Iranian Students' News Agency reported this month that talks might resume on Jan. 28 and 29 and Tehran had suggested Cairo as the venue, but the EU said there was no agreement.
The Chinese New Year holiday in early February could complicate China's participation in talks then, possibly pushing back the talks further next month.
Separate but closely linked talks are being held between Iran and the International Atomic Energy Agency (IAEA) to allow the U.N. agency to resume a long-stalled investigation into suspected nuclear bomb research in Iran.
The IAEA signalled on Friday it would keep trying to secure Iran's cooperation with its investigation, but a senior Iranian lawmaker suggested Tehran would only cooperate if it won sanctions relief in return.
The comments by Alaeddin Boroujerdi, who chairs parliament's national security and foreign policy committee, add to Western suspicions that Iran may be using its talks with the U.N. agency as a bargaining chip to win concessions from the world powers.Last Mod: 26 Ocak 2013, 09:50


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News Release
Joslin's Latino Diabetes Initiative Launches Its First Audio-Novella for Hispanics/Latinos with Diabetes and Their Families
Release of New Spanish Educational CD Marks World Diabetes Day
BOSTON — November 14, 2006 — Rosa's Story, an audio-novella from the Joslin Diabetes Center Latino Diabetes Initiative, uses the art of storytelling to educate listeners about the challenges of diabetes faced by the Hispanic/Latino population. The first-person accounts of a fictitious Latino woman with type 2 diabetes, and a teenager with pre-diabetes, are told in the new educational package.
Designed for Spanish-speaking Latinos with diabetes and their families, the three-CD set is being launched on Nov. 14, World Diabetes Day, a day set aside by the International Diabetes Federation (IDF) and the World Health Organization to increase public awareness of the global diabetes epidemic.
The IDF estimates the number of people with diabetes will exceed 350 million by 2025. Ethnic minorities, including those of Latino or Hispanic heritage, are at greater risk for type 2 diabetes than the general population, making Rosa's Story both important and timely. Latinos are the fastest growing and largest minority group in the United States. More than 10 percent of Latinos in the United States have diabetes, and one-third of them are undiagnosed. Their risk of developing diabetes is twice as high as non-Latino white Americans.
"Our goal with Rosa's Story is to teach the Latino population, as well as their healthcare providers, about diabetes by addressing the basic knowledge that everyone needs, as well as the common myths and misconceptions associated with the disease," said A. Enrique Caballero, M.D., Director of Joslin's Latino Diabetes Initiative. "The concept behind this audio-novella is based on our years of patient care and research, which allowed us to identify a culturally appropriate way to convey important educational messages about diabetes."
Rosa's Story is a one-of-a-kind teaching tool making use of that method. Rosa's Story includes: three Spanish-language audio CDs, a patient booklet written in Spanish and a healthcare provider manual written in English. Each chapter addresses a specific issue Rosa faces due to her type 2 diabetes.
The first chapter explains how Rosa deals with her diagnosis and how the language barrier and other cultural aspects affect her access to proper diabetes care. The second chapter addresses changes Rosa makes to her meal plan while maintaining her cultural preferences. The third chapter explains how she works physical activity into her daily life as she strives to adopt a healthier lifestyle. By presenting Rosa's evolution with the disease, the fourth chapter discusses treatment options for people with type 2 diabetes. To address common misconceptions in the Latino community, this chapter also describes Rosa's fears about oral medications and insulin. The fifth chapter is dedicated to pre-diabetes and focuses on a fictitious 18-year-old named Carolina, who describes her personal experiences with pre-diabetes.
To purchase a copy of Rosa's Story and the companion materials, contact the Latino Diabetes Initiative by calling 617-264-2733 or order from the online Joslin Store.
About Joslin's Latino Diabetes Initiative
The Joslin Latino Diabetes Initiative (LDI) is a team of bilingual/bicultural providers, clinicians and administrative staff who provide culturally appropriate, state-of-the-art diabetes care and education, and who conduct clinical research, community outreach and provider education to improve health outcomes for Latinos living with diabetes and those at risk of developing the disease. Since its inception in 2002, there have been more than 4,433 patient visits to the bilingual Latino Clinic at Joslin in Boston, and the LDI staff has provided information that has been incorporated into Joslin's continuing medical education programs, reaching thousands of providers throughout the country. For more information about the Joslin Latino Diabetes Initiative, call 617-264-2733 or visit Joslin's Latino Diabetes Intiative.


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Let it snow, let it snow
Tourism industry leaders are setting the stage for winter, from bubbly new commercials tagged with "Life Elevated" to resort upgrades to a strategically-placed billboard on the road to LAX International Airport. At the annual Tourism Fall Forum Thursday, Park City Chamber/Visitor Bureau members were introduced to the big plans coming this winter, hearing from the three local resorts, the chamber and the Utah Office of Tourism.
The Tourism Fall Forum pulled in 270 chamber members to hear about business trends and get in the mindset for winter.
"This event gets the business community in mindset that winter is coming," said Craig McCarthy, the Member Service Director of the PCCVB. "It's on the way and we're pulling everyone together with this one event, get people on the same page This is our largest event each year and a lot of work goes into it."
While popular marketing techniques such as snow quality and accessibility to resorts will remain a staple, the Chamber/Bureau is adding a new tagline, "One Town, Three Top 10 Resorts," into the mix following the Ski Magazine rankings.
Chamber/Bureau representatives are traveling to China for the first time this month, and more contests are on the way to attract visitors. Advertising efforts are concentrated on television spots in major markets such as Chicago, New York City and Los Angeles, with the Chamber using roughly $1 million to promote Park City on networks such as NBC and ABC from December through February.
"Park City, and Utah as a whole, will be hard for skiers to miss," said Bill Malone, the Park City Chamber/Bureau CEO and President. " There is a lot of excitement this year, more anticipation than usual, for this ski season. People are chomping at the bit."
Deputy Director for the Utah Office of Tourism David Wallace spoke at the forum, discussing the finalized plans for winter marketing from the state.
"We have such great collaboration with our partners," Wallace said, referring to the co-op marketing fund distributed by his office to organizations such as the Chamber. "This community, this state, is very well-served because of the partnerships we have."
Familiar hashtags will appear online such as "Where #GettingDumped is a Good Thing" and "#PlanetoPow" in Less Than an Hour." Billboards are already up in certain markets and television spots are expected to launch later this year.
"Getting our message out there, it's like a pep rally for the ski season," Wallace added. "And we're staying focused on our two key points: the greatest snow on Earth and the unbeatable access from our airport."
The three resorts each had representatives at the forum to discuss changes and upgrades made over the summer. Mike Goar, general manager of Canyons Resort, said changes included upgrades to the food and beverage services and the snow-making operations. The resort has also been working on the golf course.
"The enthusiasm this year people are excited for snow," Goar said to the crowd. "There's an incredible optimism for snow."
Chuck English, the Deer Valley Resort Director of Mountain Operations, said snow making and installing a new lift were the big improvements made this year. Deer Valley Resort also added heated pavers to the Empire Lodge and remodeled Snow Park to allow better server flow into the dining area.
Park City Mountain Resort General Manager and President Jenni Smith said one of the biggest upgrades has been replacing sewer lines. The resort also invested in its snow making operations and will be introducing a new terrain park, Neffland. The new park is the result of a partnership with Neff Headwear, an up-and-coming brand, and will resemble "Candyland," Smith said, complete with a giant donut feature.
With the resort opening in two weeks, Smith said she also saw the enthusiasm for the season to start.
"We're really looking forward to the season getting started," she said.
The Town Lift is scheduled to open in early December, Smith added.
Major Canyons Village mixed-use development gets thumbs up from Planning Commission
With 40,000 square feet of retail space, 234 condos and something called a "ski beach," the Pendry project will be a major addition to Canyons Village.


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Qbees from MD, WV, and VA met this weekend in Harrisonburg, VA at the VA Quilt Museum which received us in the most delightfully friendly way. We saw the current collection of quilts from a Richmond, VA, area quilting group and the permanent collection of antique quilts, sewing machines, templates, and other memorabilia. It's a small museum but had beautiful works that inspired each of us. There was a handyman working there who joked and laughed with us and got us off to lunch on a hilarious footing! What a hoot, we wanted to take him to lunch! :mrgreen:
Angela had made darling name tags for each of us, this after just returning from Switzerland just 4 days ago!! What a gal!
So we went to lunch at a local buffet restaurant where we stuffed ourselves on home cooking and too many wonderful desserts, laughed, chatted, and got to know each other for the first time. Then we held a fat quarter "Chinese" trade where one particular red fat and one green fat were fought over, changing hands a few times. Thanks to Tami's (mymsmess) generous dozen fat quarters contribution, we were able to play twice so everybody was happy with their spoils.
Then we held our show 'n' tell right at the table in the restaurant. Many other diners had left by this time of the afternoon, but several were quite interested in what we were doing and we noticed a table of staff workers eating their lunch right next to us so they could be entertained as well. :D
Then we went to Patchwork Plus Quilt Shop in Dayton, VA, just south of Harrisonburg, VA. This weekend happened to be the Tour de Quilt (shop hop) weekend for this part of VA, so the shop was pleasantly crowded and that encouraged purchases by all. They have great stuff in this large, well-lit, well-staffed shop, and Bernina sewing machines.
The photos below show each of those attending with at least one of their show and tell projects, except my mom (Anne in VA) who forgot hers, and Tami (mymsmess) who brought all those fat quarters instead. Yay for Tami! These ladies are pictured in the group shot.
Jan in VA
Angela (angelarose) wearing her cute name tags she made for us
Carrie (scray)
Debbie (DRogers870)
Me-Jan (Jan in VA)
Linda (Linda K.) and DH hiding behind the quilt
Nancy (redturtle) Sorry this was so blurry, Nancy, but your smile was infectious!
The whole gang -- L to R Jan in VA, my mom Anne in VA, scray, DRogers870, Angelarose, mymsmess, redturtle, Linda K., and DH Bill - honorary member for a day, by coercion!


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IDX provided by Real Estate Digital.
Santa Ana is located in California.
Santa Ana, California 92706 has a population of 335,400.
The median household income in Santa Ana, California 92706 is
The median household income for the surrounding county is $75,998
compared to the national median of $53,482.
The median age of people living in Santa Ana 92706 is 37 years.


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Professor of Theater
In addition to teaching, I am also publisher/editor of PAJ Publications and PAJ: A Journal of Performance and Art, a company I founded. (www.mitpressjournals.org/paj) Over the decades my work as an arts writer and editor has brought me into contact with several generations of artists working worldwide in theatre, dance, video, music, installations, and digital culture. This first-hand knowledge of artistic process and the world of artists is an experience that I draw on in my teaching. Besides writing essays on performance and travel abroad for editing and research, I have taught and lectured in many American and European universities. At Lang I curate a series called Art Work, which invites innovative artists for evening presentations on their artistic process.
New Europe: plays from the continent, NY: PAJ Publications, 2009.
Performance Histories, NY: PAJ Publications, 2008.
American Performance 1975-2005. Rome, Italy: Bulzoni Editore, 2006 (in Italian).
Conversations on Art and Performance. Ed. Baltimore, MD: Johns Hopkins University Press, 1999.
Ecologies of Theatre. Baltimore, MD: Johns Hopkins University Press, 1996.
Plays for the End of the Century, ed. Baltimore, MD: Johns Hopkins University Press, 1996.
Interculturalism and Performance: Writings From PAJ, ed. NY: PAJ Publications, 1991.
Theatrewritings. NY: PAJ Publications, 1984.
American Dreams: The Imagination of Sam Shepard. ed. NY: PAJ Publications, 1981.
Theatre of the Ridiculous: Jack Smith, Kenneth Bernard, Charles Ludlam, Ronald Tavel, ed. NY: PAJ Publications, 1979.
The Theatre of Images: Robert Wilson, Richard Foreman, Lee Breuer, ed. NY: Drama Book Specialists, 1977.
Independent Study (Fall 2018)
Performance Histories (Fall 2018)


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|Posted: February 17, 2008
There is 'design' in nature, Brown biologist argues at AAAS
|(Nanowerk News) Brown University biologist Kenneth Miller has to hand one victory to the intelligent design crowd. They know how to frame an issue.
|The idea that there is design in nature is very appealing, Miller said. People want to believe that life isnt purposeless and random. Thats why the intelligent design movement wins the emotional battle for adherents despite its utter lack of scientific support.
|To fight back, scientists need to reclaim the language of design and the sense of purpose and value inherent in a scientific understanding of nature, he said.
|In a Feb. 17, 2008 symposium at the American Association for the Advancement of Science (AAAS) annual meeting in Boston, Miller will argue that science itself, including evolutionary biology, is predicated on the idea of design the correlation of structure with function that lies at the heart of the molecular nature of life.
|Miller will make his case in a session titled Communicating Science in a Religious America, set to run from 1:45 pm to 4:45 pm in Room 309 of the Hynes Convention Center. Miller will join seven other experts to discuss ways to craft communication efforts around evolution, stem cell research, climate change and nanotechnology that are sensitive to religious communities while remaining true to science.
|Miller is a cell biologist and the Royce Family Professor for Teaching Excellence at Brown. Miller is coauthor of four high school and college biology textbooks, which are used by millions of students nationwide, and is regarded as Americas leading defender of Darwins theory of evolution. This year in South Carolina, Miller successfully defended one of his textbooks against an anti-evolution attack before the state school board. In 2005, he served as lead witness in the trial on evolution and intelligent design in Dover, Pennsylvania. His popular book, Finding Darwin's God: A Scientist's Search for Common Ground between God and Evolution, addresses the scientific status of evolutionary theory and its relationship to religious views of nature.
|Miller will use arguments from his new book, Only a Theory: Evolution and the Battle for America's Soul to be published by Viking Press in May, for his AAAS talk. Miller will argue that the scientific community must address the attractiveness of the design concept and make the case that science itself is based on the idea of design or the regularity of organization, function, and natural law that gives rise to the world in which we live.
|He points out that structural and molecular biologists routinely speak of the design of proteins, signaling pathways, and cellular structures. He also notes that the human body bears the hallmarks of design, from the ball sockets that allows hips and shoulders to rotate to the s curve of the spine that allows for upright walking.
|There is, indeed, a design to life an evolutionary design, Miller said. The structures in our bodies have changed over time, as have its functions. Scientists should embrace this concept of design, and in so doing, claim for science the sense of orderly rationality in nature to which the anti-evolution movement has long appealed.
|Source: Brown University
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I 've written in previous columns about how your members are demanding tools in your clubs that run similarly to the technology they use on their existing personal platforms outside of the club. I've told you how important it is to provide this for members. Now, I have to tell you that some of your members are still resisting technology. Some members are so overwhelmed by having to learn new technologies in other parts of their lives that they don't want to have to learn it at your clubs. Adding another layer of complexity may make some reluctant to embrace new technology while exercising.
But don't let that discourage you. The challenge is to market and create a path for your members to understand and use technology in a simple and easy manner.
This is particularly important for the Baby Boomers in your clubs. Most of the Generation X and Millennials in your clubs are already smarter than most Baby Boomers will ever be about new technologies. The Millennials are instrumental in helping push and develop new technology for the next generation of members.
The key to success lies in highlighting technological improvements in your marketing materials, club tours and sales presentations but keeping messages simple while assuring members that the technologies that you offer — from USB keys on treadmills to scanable check-in procedures to workouts you can download — are user friendly. If you don't show how valuable and easy to use these technologies are, then you might as well save your money and energy and forget about buying them.
If you are up for it though, you should consider following some suggestions on how to market the technology to your members. First and foremost, you'll need to sell the benefits of the technology to the members rather than the technology itself. You can safely assume that most of your members, particularly Baby Boomers, are impatient and already are working on integrating new technology into other parts of their lives. The health club should not add to this stress but rather eliminate it and make exercising easier.
Marketing and integrating any new technology needs to be extremely simple. Provide just three or four messages that allow members to use any technology that builds on their current routines. In addition, invest in hands-on training for your staff as part of integrating new technology into your club. Nothing is as powerful as having a well-trained staff available (particularly in the first few months of introducing any new technology) to show members how to use the technology and answer questions. The technology must create excitement, aid in retention and adherence, and provide a monetary return on investment.
Highlight and demonstrate new technologies in all sales presentations and new-member orientations. Make sure that your fitness staff sticks to focusing on just the key points, and most importantly, only the features that are of benefit to an individual member. This can only be done if your sales team asks questions of prospective and new members before matching the features of your technology to their individual needs. The most common mistake that clubs make is to "feature dump" — provide too much information to new and prospective members. They won't care about technology unless it serves a purpose that benefits them.
Our industry is narrowing the gap between simply dazzling technology and technology that is simple and makes a difference. To be successful, you must make the connection between technology and your members. Otherwise, it might lead some members back out the door.
Gregory Florez is CEO of FitAdvisor Health Coaching Services and First Fitness Inc., which was rated as the No. 1 health coaching online training service by The Wall Street Journal. Florez can be contacted at firstname.lastname@example.com.


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Thomas Henry Stringer, 1869-1933, was my great grandfather (my father's mother's father, as I discussed a few months ago in this post [click]). Thomas was born 26 March 1869 in Statesboro, Bulloch County, Georgia, to Robert Frances Stringer (1828-1910) and Martha (Margaret) Elizabeth Sheppard (1836-1875). He is on the 1870 census with his parents living in Brier Patch, Bulloch County, Georgia. This isn't a town, but another name for Georgia Militia District 47, which is in the southeast corner of the county, essentially south of Brooklet and east of Lower Black Creek. This picture of him is from about 1904. Unfortunately, he seems to have disappeared from the census for the next thirty years. I can't find an 1880 census for his parents. There isn't a surviving 1890 census record, and I can't find Thomas in the 1900 census.
Fortunately I have a couple of other sources of information. The first is the family Bible of Thomas and Hattie Stringer (my aunt Mildred Jones Helmey has the original; the digital copies are courtesy of my cousin Michelle Winter Buhler). The second is a Spanish War Invalid Pension Application that Thomas filled out in 1924 (again the digital copy is courtesy of my cousin Michelle). The family Bible gives a basic framework, indicating that he married Hattie Mosell Williams on 21 March 1901 at Augusta, Georgia. They had five children: Essie Lee (19 March 1903), Lilian Mae (14 August 1905, also spelled "Lillie Mae"), Francis Magadelin (5 February 1907; my grandmother), Thomas Shepard (2 September 1908), and Walter Hartridge (8 August 1910). Essie Lee married Leroy "Roy" Lynn in 1919, had one daughter who died at 3 weeks of age in 1920, and died in 1935. Lillie Mae married Frank Sapp in 1921, Maggie married James Dewey Jones in 1928, Thomas married Minnie Rose Knight in 1929, and Walter married Effie Barber in 1931.
According to Thomas's Pension Application (dated 12 May 1924), he enlisted on 29 July 1898 in Company M of the 2nd Georgia [Infantry] Volunteer Regiment, and was honorably discharged at Savannah, Georgia, on 22 November 1898. On succeeding pages of the application, dated 6 June 1924, he stated that he was born on 26 March 1869 in Statesboro, Bulloch County, Georgia, and that in July 1898 when he enlisted he lived in Bulloch County but his mailing address was Rocky Ford. Rocky Ford is across the Ogeechee River, in Screven County, so he must have been living in northeast Bulloch County, in Militia District 46 (also know as Lockhart). Further, in his pension application he states the after discharge he lived at Rocky Ford from 1899 to 1901, though at some point he travelled to Augusta, for he states that he was married to Hattie M. Williams Stringer on 21 March 1901 at North Augusta, Aiken County, South Carolina, by Louis Shillers (spelled "Schiller" in the family Bible).
After that, again referring to the pension application papers, he lived in Statesboro from 1902 to 1904, Adabelle (southwestern Bulloch County) from 1905 to 1915, 1916 to 1921 in Egypt (40 miles to the northeast, across the Ogeechee River in Effingham County), and finally outside of Manassas (in the Haw Pond district), northwest of Claxton in the newly-created Evans County from 1922 through 1924, and as later supplements indicated, until his death.
All of this disagrees somewhat with the census when it picks up again in 1910, which showed him living in Militia District 1366 of Tattnall County (which was Haw Pond district of Evans County after that was formed in 1915). According to the census he was a farm laborer, renting his house of Cobbtown Road. The 1920 census places him in Haw Pond, Evans County, again farming on rented land. According to James Sapp, the oldest surviving grandchild and the only one I know of who still remembers Thomas Stringer, the family were tenant farmers, as were many other members of the Jones and Stringer families from the end of the 19th century and through the first decades of the 20th century. So it may be that he simplified the amount of moving he did for the sake of the pension application, or that he was only living at certain farms for a season, which corresponded with the census. That would also explain why he is difficult to locate, and may not even exist, in some of the earlier censuses.
|Census images courtesy of Ancestry.com (subscription required)
On 21 July 1921, Thomas' beloved wife Hattie died of "apoplexy" (a term applied to any sudden loss of consciousness followed by death). Thomas struggled on, raising his younger children with the help of the older ones, though he was apparently himself in failing health. If you notice the signatures on the 1924 pension application they are those of his two sons in law, Roy Lynn and Frank Sapp. Thomas would live with Frank and Lillie Mae Sapp the rest of his life. Thomas requested an increase in his monthly pension, from $30 to $40, in 1930 "due to increased infirmity", and requests again were made in 1931 and 1932 by his friends and relations, because he suffered increasing infirmity of body and mind, to the point of being "confused and feeble" much of the time. According to the 1930 census, he is unemployed and living with the Sapps in Militia District 1738 (Canoochee), Evans County, Georgia. (This disagrees with the location listed as Manassas, which supposedly is in Haw Pond, but the boundaries were rather fluid, and Canoochee looks to have been created out of Haw Pond, though I haven't determined when.)
Finally, on 1 Jul 1933, at the age of 64, Thomas Henry Stringer died in Claxton. According to daddy's cousin James Sapp, Thomas went into Claxton to pick up his pension check, accompanied by his son-in-law Frank Sapp. James says that when he went into town he would usually pick up some candy for the grandchildren. He collapsed on the sidewalk after leaving the general store with the candy and was carried to a doctor's office, where he died. My father was born the following year, and thus never got the opportunity to know his maternal grandparents.
That's about it for now.
Later y'all,
|Thomas H & Hattie Moselle Stringer with oldest child Essie Mae (about 1904)


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W. Douglas Boyd, M.D.
- Professor, Department of Surgery
UC Davis Medical Center - Cypress Building
2221 Stockton Blvd., Suite 2112
Sacramento, CA 95817
Driving Directions
Primary Phone:
Additional Phone Numbers
Phone: 916-734-3861
Clinic Phone: 916-734-2160
Department Phone: 916-734-3528
Physician Referrals: 800-4-UCDAVIS (800-482-3284)
Clinical Interests
Dr. Boyd is recognized for his pioneering work in cardiothoracic surgery and for his use of robotic-assisted surgical systems. He specializes in minimally invasive cardiac and robotic-assisted heart surgery. He completed the world's first closed-chest, beating-heart coronary artery bypass surgery using a robotic system in 1999 and performed the first human extracellular matrix xenograft implant for cardiovascular repair several years later. Prior to his appointment as a professor of surgery at UC Davis Health System, Dr. Boyd served as chair of the Department of Cardiothoracic Surgery at the Cleveland Clinic in Florida. As the author of more than 50 peer-reviewed, journal articles, Dr. Boyd's research interests include cardiac tissue regeneration using extracellular matrix/stem cells, new techniques for robot-assisted minimally invasive coronary artery revascularization, valve surgery and telesurgery. He is a graduate of Carleton University and obtained his medical degree the University of Ottawa.
Cardiothoracic Surgery
Center/Program Affiliation
M.D., University of Ottawa, Ottawa, 1984
B.Sc., Carleton University, Ottawa, 1980
Professional Memberships
American Heart Association
Bay Area Society of Thoracic Surgery
California Medical Association
Canadian Cardiovascular Society
Canadian Medical Association
Florida Medical Association
International Society for Minimally Invasive Cardiac Surgery
Ontario Medical Association
Society of Thoracic Surgeons
Honors and Awards
California Super Doctors, 2011
Florida's Top Doctors, Cardiothoracic Surgery, 2009
America's Top Doctors, Cardiothoracic Surgery, 2008
Good Housekeeping Top Cardiovascular Surgeon for women in the Nation, 2004
Best Scientific Presentation, International Society of Minimally Invasive Cardiac Surgery - Munich, Germany, 2001
Smithsonian Institute/Computer World Honours Award - Washington, DC 2001, 2001
Best Scientific Presentation, International Society of Minimally Invasive Cardiac Surgery - Atlanta, Georgia, 2000
American Medical Association, James S. Todd Memorial Grant For Highest Ranked Grant In Research Competition, 1999
Best Clinical Research Paper, International Society of Minimally Invasive Cardiac Surgery - Paris, France, 1999
Educating Future Physicians for Ontario Fellowship, to pursue formal training in Medical Education, 1993
University of Ottawa, Department of Surgery Award, for Outstanding Resident Teaching, 1991
University of Ottawa Department of Surgery Award,, for Excellence in Teaching, 1989
American College of Chest Physicians Award, for the Outstanding Presentation at the ACCP Affiliate forum; 53rd Annual - Atlanta, Georgia, 1987
E.I. Dupont Award, for the Outstanding Housestaff Presentation; American Medical Association Education and Research Foundation, Eastern Research Forum. University of Miami School of Medicine - Miami, Florida, 1987
C.H. Hand Memorial Scholarship, Carleton University, Ottawa, 1980
Select Recent Publications
W. Douglas Boyd, MD, William E Johnston III, MD., Parvez K. Sultan, MD,Thomas F Deering, MD,FACC,FACP,FHRS,Robert G. Matheny,MD,FACS Pericardial Reconstruction Using an Extracellular Matrix Implant Correlates with Reduced risk of Postoperative Atrial fibrillation in Coronary Artery Bypass Surgery Patients. The Heart Surgery Forum 13(5), 2010
Christopher W. Nickum, W. Douglas Boyd, Richard J. Novick, Eugene H. Blackstone, Carolyn Apperson-Hanson, John A. McAuliffe. Division of the Brachioradialis Muscle: A Modification of the Current Technique in Endoscopic Radial Artery Harvesting. The Heart Surgery Forum, 8(6). 2005
Bob Kiaii,MD, R. Scott McClure MD, Larry Stitt MSc, Reiza Rayman MD, Wojciech B. Dobkowski MD, George Jablonsky MD, Richard J. Novick Md. W. Douglas Boyd MD. A Prospective Angiographic Comparison of Direct, Endoscopic and Telesurgical Approaches to Harvesting the Internal Thoracic Artery. Annals of Thoracic Surgery. 2005
Novaro GM, Cabrales RE, Boyd WD. Mitral Valve Papillary Fibroelastoma: Surgical Considerations. Asian Cardiovascular Thoracic Annals 2006, (14) 58-59. 2005
Menkis A. H, Kodera K, Kiaii B, Swinamer S, Rayman R, Boyd, W. Douglas. Robotic Surgery, the First 100 Cases: Where Do We Go From Here? The Heart Surgery Forum, 7(7). 2004
Donias HW, Schwartz T, Tang DG, DeAnda Jr A, Tabaie HA, Boyd DW, Karamanoukian HL. A Porcine Beating Heart Model for Robotic Coronary Artery Surgery. Heart Surg Forum, 6(6): 249-253. 2003.
Novick R.J., Fox S.A., Kiaii B.B., Stitt L.W., Rayman R., Kodera K., Menkis, A.H., Boyd W.D. Analysis of the Learning Curve in Telerobotic Beating Heart Coronary Artery Bypass Grafting: A 90 Patient Experience. Ann Thorac Surg, (76) 749-753. 2003.
Patel Y.R., Donias H.W., Boyd W.D., Pande R.U., Amodeo J.L., Karamanoukian R.L., D'Ancona G, Karamanoukian H.L. Are You Ready to Become a Robo-Surgeon? American Surg, 69(7): 599-603. 2003.
Semere WG, Edwards TM, Boyd D, Barsoumian R, Murero M, Donaias Karamanoujian HL. The World Wide Web and Robotic Heart Surgery. Heart Surg Forum, 6(6): E111-9. 2003
Stahl K, Fromkin K, Bochenek A, Boyd W.D., Vassiliades T, Karamanoukian H, Cisowski M. Combined Angioplasty and Robotic Coronary Bypass Surgery in Multivessel Coronary Artery Disease. J Am Col Cardiol. 2003.
Boyd W.D., Stahl K.D. A Perspective on a New Era of Computer-Enhanced Robotic Cardiac Surgery. J Thoracic Cardiovasc Surg, 126(4): 625-30. 2003.
Boyd, W. Douglas. Robotic Surgery Using Zeus Micro-Wrist Technology. Journal of Cardiac Surgery, 18(1): 6-7. 2003.


text:
Columbus DJs - Columbus Wedding DJ - Columbus DJ
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Why Pick Columbus Platinum Party DJs for Your Wedding Reception or Party?
We are a premier mobile disc jockey and karaoke service in Columbus, Ohio founded in
specializing in
wedding receptions, anniversary parties, corporate parties, graduations, school dances, birthday parties, Christmas parties, and more!
Contact us today to find out why we are different from the other DJ companies in Columbus.
Ask us about our weekday and off season special DJ packages and pricing.
Why should you pick Columbus Platinum Party DJs for your
wedding reception or party
? We have performed in hundreds of shows in Columbus and have gained the experience and developed the skills needed to provide our clients with the best
DJ and karaoke service in Columbus
. We are not only concerned in booking the shows and moving on to the next sale, we provide a high quality service, both before the wedding with our detailed planning services and the day of the wedding with our quality performances and attention to details. We will customize our DJ services to your special event, since not all receptions or parties are created equal. We do everything we can to accommodate any special request you may have.
Another reason for selecting Columbus Platinum Party DJs is our great DJs. We hire only professional DJs in Columbus who take their job very seriously and respect our clients. Our DJs will not play dirty music, tell dirty jokes, smoke, drink, or embarrass you in front of your guests for a laugh. Some DJs like to be the center of attention, but this is your special event and you are the center of attention while the DJ is there to help provide you and your guests with the best DJ service in Columbus to make sure your event goes as planned and as smoothly as possible.
We will not charge our clients extra
for DJ system set-up or tear-down, we will not charge you for cordless microphone or standard DJ lighting. We will not charge you for event planners, event time line forms, our music library, or consultations. You should not have to pay extra for basic DJ equipment that should be a part of every DJ system. Whether you book our basic system or our platinum system, you will have full access to our website and event planning tools we offer. When you compare our DJ system to our competitors make sure you are comparing apples to apples. Ask us and we will be glad to explain to you why you want our DJ system at your special event.
When your event is over you will not remember how much you paid for your DJ service, but you will remember the quality and performance of your DJ company. That is why Columbus Platinum Party DJs takes care of all your entertainment needs, so you don't have to. We understand the million other things you need to worry about when planning your event, we like to lighten that load by taking care of your entertainment needs. We will be there for you every step of the way to make sure you have the best experience at your special event. See
About Us
page for more details.
What Makes Our DJ Service Different From The Rest
We would like to take the time to tell you a little about us and what makes Columbus Platinum Party DJs different from the other DJ companies in Columbus. The first reason is our experience in providing DJ and karaoke services for hundreds of shows in the Columbus area. The second reason is our reliability in providing our DJ and karaoke service. View wedding reception videos, party videos, event venues, and Columbus banquet centers that we have performed at on our
Client Testimonials
page and wedding reception and party
We will not overbook our services and send a subcontractor to cover your special event so we can maximize our profits. A lot of DJ companies in Columbus will overbook shows and hire low cost subcontractors to cover the extra shows. Our goal is quality over quantity, yes we like to book more shows and make money, but at what expense? We promise to provide quality DJ services and top-notch customer service without letting greed change that, and that's a promise you can count on.
We will visit every location prior to the show, meet with the event staff to make sure our DJs know all the details; such as, DJ set up location, building access, and any other details pertinent to your event. It may be a little extra work up front, but the payoff is worth it because we don't like surprises. Prior to each event your DJ will make a custom play list based on your song requests, again a little work up front will eliminate the chance that your DJ will miss one of your requested songs.
We always guarantee our DJs will be on time and appropriately attired. They will have a quick and relatively easy DJ set-up due to our all-in-one systems. DJ system set-up typically takes an hour, depending on the type of DJ package ordered. There is no additional cost to our customers for setting up or tearing down. You will not have to worry about system failures as all DJs have back-up equipment brought to the event, and the DJ systems are new and well maintained decreasing the likelihood that this would ever happen.
Additionally, we offer free personal event consultations to help answer all your questions and provide you with all the information you need to make your event a success. You can call or email us any day of the week and we will be glad to answer your questions. Our DJ event planners are simple and easy to use. They make coordinating your event and DJ service easy and hassle free. We highlight all the important facts and write it as simply and easily as possible.
We also offer a variety of options that our clients can access on our website. Clients can search our large music library and create a song list for songs they like to hear at their wedding reception or party. In addition, clients can have their guests use the guest music request feature to create guest request lists. This option is ideal for a school dance, class reunion, or corporate party. Columbus Platinum Party DJs is one of the first companies in Columbus to offer our clients a complete online music library search and music list creation system.
Our online event planners cover Anniversaries, Corporate Parties, Bar Mitzvahs, Private Parties, School Parties, and Wedding Receptions. The event planners can be filled out online and saved in the client area with the ability to access or edit any time you like. We also offer time line event planners that clients can fill out to help manage the event time line and make sure the event goes as planned.
Columbus Platinum Party DJs is one of the first companies in Columbus to offer our clients with a complete event planning and password protected client area.
Our DJ equipment is more for the money with no hidden costs. We offer top-of-the-line DJ systems with quality as our main priority. We have various DJ lights ranging from high-tech LED lights, Torpedo's, Strobe lights, to lasers. Lights look great and create the perfect atmosphere to get your guests up and dancing.
Columbus Platinum Party DJs uses only state-of-the-art DJ equipment, which was updated in September of 2009 to provide excellent DJ sound and the highest DJ system reliability. In order to be the best at what we do, we need the latest in high-tech digital DJ equipment to provide the highest quality gigs. Our clients expect the best DJ service and will get the best DJ system in the Columbus area. Our DJ business strategy is based on a high quality product for clients who want the best for their event and guests.
DJ music selection is extremely important at any event, and Columbus Platinum Party DJs has that covered. You want to know that you will get to hear your favorite songs and with our CD library of over 1,500 CD's (which are actually brought to your event), in addition to our high quality MP3 music that is stored on two laptops and are backed up on two 1 terabyte external hard drives, you can ensure you will get to hear all your favorite songs. Our DJs are trained on what music is appropriate at different events and will make sure they get your crowd up and dancing! Having a large DJ music collection is one thing, having the top hits and a large variety of music collected over 15 years will ensure your guests will have every type and year of music they would like to hear. In addition, our DJ music library contains, and our DJs use, radio edited music to provide our clients with a clean family oriented atmosphere.
Another benefit to booking your event with Columbus Platinum Party DJs is that we also offer karaoke services. You may purchase just karaoke or karaoke with a regular DJ system. Either way you are ensured hours of fun. We offer a 20 inch TV monitor so you won't have to stand on the TV to see the words. Also, we have a large selection of karaoke favorites including today's Top 40 hits. We offer up to 4 microphones so you may sing as a group without having to share one microphone.
Another ingredient to a successful event is the experience and behavior of your DJ. When you book your show with Columbus Platinum Party DJs, you can expect a DJ expert who will coordinate your event with the photographer, caterer, and any other pertinent people to ensure that your event will go smoothly and as planned. Your DJ or MC will make all announcements and dedications. The DJ will also provide musical expertise to guarantee that everyone hears music they like and makes sure your event is a great success. The DJ will be on time and conduct himself in a professional manner. Your DJ will gladly take requests and will not smoke or drink while at your event.
In the mobile disc jockey (DJ) business, performance is our product, and that is what keeps us in business. When our DJ product is excellent, we will receive referrals that lead to bookings. Consistent bookings will create the cash flow that is necessary to promote, improve, and expand our DJ and Karaoke business. Therefore our DJs focus on customer service because that is how a successful business will generate referrals. DJ customer service includes getting the crowd going, microphone skills, ice breakers such as participation dances, contests and games, karaoke, and party props. Having the right DJ skills and tools that are specific to your event and specific participation dances and contests/games is invaluable and, if executed correctly, would make any party a success.
Becoming a DJ is not a skill that is learned overnight. Like all other trades, one needs to learn the ropes first before becoming a disc jockey. DJs learn the tricks of the trade from other experienced DJs that have learned the necessary skills that make every event a success. What does it take to become a DJ? It's the ability to be able to break the ice when people seem hesitant to take to the dance floor and the skill to recognize from the movement patterns of people the music that will next be played. The one important DJ skill is being able to read the crowd; a skilled DJ can read the crowd and make adjustments in order to make the event a success.
For example, some DJs will not play music for all the different groups at the event, however, the skilled DJ would balance the music to cover all music genres, such as oldies, disco, hip-hop, top 40, rock, slow dance, etc. There is also a method to the order the music should be played. We have learned from years of DJ experience what it takes to make your party a success. The DJ experience does not come from a book or class, experience comes from years of DJ work in all kinds of events, groups, and music styles.
So, to recap, we offer state-of-the-art DJ music systems for wedding receptions or parties, great (awesome) DJ lighting, quality, no hidden costs, a large DJ music selection, reliable DJs, knowledgeable DJs, exceptional customer service, and professionalism. We are who people turn to when they want all of the above.
Venues and Banquet Rooms Where We Have Performed Disc Jockey Services
AmVet Post 89, Columbus
American Legion Post 614, Hilliard
BoMa, Downtown Columbus
58 Rocky Fork Country Club, Gahanna
Capital Club, Downtown Columbus
Cheers Chalet, Lancaster
Clintonville Women's Club, Clintonville
Columbus Dance Centre, Columbus
Conference Center at Northpointe, Lewis Center
Creekside Conference and Event Center, Gahanna
Crescent Tavern & Catering , Put-In-Bay
Crowne Plaza, In Several Locations Throughout The Columbus Area
Darby House, Galloway
Dave & Busters, Hilliard
DaVincis Restaurant, Upper Arlington
Deer Creek Resort & Lodge, Mt Sterling
Delaware Golf Club, Delaware
Doubletree Columbus Worthington, Columbus
East Golf Club, New Albany
Embassy Suites, In Several Locations Throughout The Columbus Area
Four Seasons Columbus, Hilliard
Graystone Wine Cellar, Columbus
Greater Columbus Convention Center, Columbus
Heimat Haus Party House, Grove City
Heritage Golf Club, Hilliard
Hickory Lakes, Pickerington
Hilton Columbus, Polaris
Hitchcock Hall, OSU, Columbus
Holiday Inn, In Several Locations Throughout Columbus Area
Hoover-Y Park, Lockbourne
Hocking Hills Dining Lodge. Logan
Hyatt On Capitol Square, Columbus
Jefferson Country Club, Blacklick
Jessing Center, Columbus
Kenyon College, Gambier
Lenox Inn, Pickerington
Lincoln Park West, Columbus
Little Turtle Country Club: Tennis Courts, Westerville
Marietta Country Club, Marietta
Marriot, In Several Locations Throughout The Columbus Area
Marysville Golf Club, Marysville
Morse Banquet Conference Center, Columbus
Mt. Vernon Country Club, Mt. Vernon
Muirfield Pavillion, Dublin
Murphy's Party Barn, Upper Arlington
New Albany Links, New Albany
Northstar Golf Club, Sunbury
Oakhurst Country Club, Galloway
Ohio University Inn & Conference, Athens
Olde Gahanna Sanctuary, Gahanna
Park Hotel, Put-In-Bay
Pinnacle Golf Club, Grove City
Reception House at Raymond Memorial
River Club, Columbus
Riviera Country Club, Dublin
Royal American Links Golf Club, Galena
Scioto Country Club, Upper Arlington
Sheraton Suites Columbus
St. Ceceila, Columbus
Swim & Raquet Club, Upper Arlington
Tall Timbers Banquet and Conference Center, Reynoldsburg
The Blackwell Hotel, OSU Downtown Columbus
The Columbus Renaissance Hotel, Columbus
The Concourse Hotel, Columbus
The Conference Center , Lewis Center
The Grand Valley Dale Ballroom, Columbus
The Lakes Country Club, Westerville
The Makoy Center, Hilliard
The Marriott North, Marysville
The Medallion Club, Westerville
The Vault, Columbus
The William Graystone Winery
The Worthington Inn
Trinity United Methodist Church, Grove City
University Plaza Hotel, Columbus
Veterans Memorial, Columbus
VFW, South Bloomfield
VFW, Grove City
VFW, Hilliard
Washington Country Club, Washington Court House
Wedgewood Golf & Country Club , Powell
Westgate Elementary School, Columbus
Westin Columbus, Columbus
Whetstone Park Of Roses, Columbus
Worthington Hills Country Club, Columbus
York Country Club, Worthington
YWCA Downtown, Columbus
Plus many more!
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Columbus Platinum Party DJs, Providing Wedding DJ Services, School Party DJ Events, Private Party DJ Services, and Corporate DJ Services to Columbus and surrounding communities, including Bexley, Canal Winchester, Delaware, Dublin, Gahanna, Galloway, Grandview Heights, Grove City, Groveport, Hilliard, Marysville, New Albany, Pataskala, Pickerington, Plain City, Powell, Reynoldsburg, Sunbury, Upper Arlington, West Jefferson, Westerville, Whitehall, Worthington, and many other communities in and around the Columbus, Ohio area.


text: The Combating Terrorism Technical Support Office (CTTSO) is committed to supporting equal opportunities for all small business types in contracting, whether it be prime contracting or through teaming arrangements. Small business programs help to create jobs, provide innovative solutions to complex problems, and increase the efficiency of taxpayer dollars. Within CTTSO, the Technology Transition Office is responsible for assisting CTTSO small business contractors by providing advice and assistance related to contracting, intellectual property, licensing, and teaming arrangements. Below are some of the resources available to the small business community.