CDHO Advisory Juvenile Arthritis, 2020-08-20

CDHO Advisory | Juvenile A rthritis

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

ADVISORY TITLE

Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with juvenile arthritis.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Juvenile Arthritis, 2020-08-20

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE

DISEASE/CONDITION(S)/PROCEDURE(S)

Juvenile arthritis

INTENDED USERS

Advanced practice nurses Nurses Dental assistants Patients/clients Dental hygienists Pharmacists Dentists Physicians Denturists Public health departments Dieticians Regulatory bodies Health professional students

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have juvenile arthritis, chiefly as follows. 1. Understanding the medical condition. 2. Sourcing medications information. 3. Taking the medical and medications history. 4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.

1 Persons includes young persons and children

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5. Understanding and taking appropriate precautions prior to and during the Procedures proposed. 6. Deciding when and when not to proceed with the Procedures proposed. 7. Dealing with adverse events arising during the Procedures. 8. Keeping records. 9. Advising the patient/client.

TARGET POPULATION

Child (2 to 12 years) Adolescent (13 to 18 years) Adult (19 to 44 years) Male Female Parents, guardians, and family caregivers of children, young persons and adults with juvenile arthritis.

MAJOR OUTCOMES CONSIDERED

For persons who have juvenile arthritis: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Terminology used in this Advisory

Resources consulted . Juvenile Idiopathic Arthritis: Sick Kids Hospital . Juvenile Idiopathic Arthritis: KidsHealth . Juvenile Arthritis: MedlinePlus . Questions and Answers about Juvenile Arthritis: National Institute of Arthritis and Musculoskeletal and Skin Diseases . Diagnosing Juvenile Arthritis: WebMD . Juvenile Arthritis: OrthoInfo . Systemic Juvenile Idiopathic Arthritis: Arthritis Foundation

Terminology varies among centres. For the purposes of this Advisory, juvenile arthritis is used as the preferred alternative to juvenile rheumatoid arthritis or juvenile idiopathic arthritis.

Juvenile arthritis is 1. chronic arthritis in childhood (with onset less than 16 years of age) that results in joint pain and swelling 2. characterized by inflammation of one or more joints (particularly the synovium lining the joint) that lasts at least six weeks 3. is an autoimmune disease

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4. differs from adult rheumatoid arthritis, which explains why ‘rheumatoid’ tends to be used less in recent years to describe certain types of juvenile arthritis 5. consists of several types, including: systemic arthritis (also called systemic juvenile idiopathic arthritis [SJIA]; also known as Still’s disease); oligoarthritis (also called pauciarticular juvenile rheumatoid arthritis); polyarthritis (also called polyarticular juvenile idiopathic arthritis); psoriatic arthritis; and enthesitis-related arthritis.

Other terminology used in this Advisory is as follows.

1. Autoimmune disorder (CDHO Advisory), a condition that a. occurs when the immune system erroneously attacks and destroys healthy body tissue b. occurs as more than 80 different types of autoimmune disorder (CDHO Advisory) c. may be treated with immunosuppression (CDHO Advisory) to control or reduce the immune system’s response. 2. Immune system a. is a network of cells, tissues, and organs that work together to defend the body against attacks by infection-causing biological agents, for which the body is otherwise an ideal environment, such as i. bacteria ii. fungi iii. parasites iv. viruses b. recognizes and destroys substances containing antigens, which are molecules i. mostly of proteins ii. on the surface of cells, bacteria, parasites, fungi and viruses iii. of nonliving substances such as 1. chemicals 2. foreign particles 3. medications 4. toxins c. normally recognizes the body’s own cells’ antigens and, with the help of human leukocyte antigens, does not react against them. 3. Lesion, a term variously and loosely used in medicine to refer to such things as a. any abnormality of tissue in the body, including the mouth and skin b. any localized abnormal structural change in a bodily part c. a mass especially before a definite diagnosis is established d. cancer e. an injury to living tissue, such as a cut or break in the skin. 4. Opportunistic infections a. occur because of a weakened immune system b. are a particular cause of death for people with acquired immunodeficiency syndrome (AIDS) (CDHO Advisory) because the human immunodeficiency virus (HIV) (CDHO Advisory) may cause death by impairing the immune system. 5. Oral ulcer, an open lesion, often painful, inside the mouth or upper throat, an alternative name for a. aphthous stomatitis, also known as a canker sore b. aphthous ulcer

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c. cancerous ulcer d. mouth ulcer. 6. Photophobia, eye discomfort in bright light. 7. Spondyloarthropathy, a group of diseases a. characterized by i. inflammation of the facet joints of the spine ii. pain and stiffness b. originates with infection or in association with autoimmune disorders (CDHO Advisory). 8. Sicca syndrome a. a term reserved for the combination of dryness of the mouth and eyes, regardless of cause b. when accompanied by lymphocyte infiltration of the salivary glands is named Sjögren syndrome (CDHO Advisory). 9. Sjögren syndrome, a serious, systemic, persistent autoimmune disorder that may be associated with rheumatoid arthritis and which a. is considered to be one of the most prevalent autoimmune diseases b. is often under-recognized and under-treated c. most commonly i. attacks and damages the salivary, tear and mucus-secreting glands ii. results in xerostomia iii. results in swollen salivary glands d. may cause or be associated with i. arthritis ii. debilitating fatigue iii. neuropathy iv. painful, weak muscles e. may cause or be associated with inflammation of i. blood vessels ii. brain iii. gastrointestinal system iv. kidneys v. liver vi. lungs vii. thyroid gland. 10. Systemic juvenile idiopathic arthritis (SJIA, or Still’s disease), alternative terminology for a serious form of juvenile arthritis. 11. Toxins, substances that a. are released by microorganisms such as bacteria b. are created by plants and animals and that are also poisonous to humans c. include medications that are helpful in therapeutic doses but harmful when used in an excess amount. 12. Uveitis is a. swelling and irritation of the uvea, the middle layer of the eye that provides blood supply to the retina b. caused by various autoimmune disorders, among other things. 13. Xerostomia, abnormal dryness of the mouth resulting from decreased secretion of saliva, variously caused by

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a. sicca syndrome b. Sjögren syndrome (CDHO Advisory) c. some medications.

Overview of juvenile arthritis

Resources consulted . College of Dental Hygienists of Ontario: Juvenile Arthritis Fact Sheet . College of Dental Hygienists of Ontario: Rheumatoid Arthritis Fact Sheet . College of Dental Hygienists of Ontario: Sjögren’s Syndrome Fact Sheet . College of Dental Hygienists of Ontario: Joint Replacement Fact Sheet . Juvenile Idiopathic Arthritis: Sick Kids Hospital . Juvenile Idiopathic Arthritis: KidsHealth . Juvenile Arthritis: MedlinePlus . Questions and Answers about Juvenile Arthritis: National Institute of Arthritis and Musculoskeletal and Skin Diseases . Diagnosing Juvenile Arthritis: WebMD . Juvenile Arthritis: OrthoInfo . Systemic Juvenile Idiopathic Arthritis: Arthritis Foundation

Occurrence Juvenile arthritis 1. usually occurs before the age of 16 2. affects as many as 1 in 250 Canadian children under the age of 16 3. typically appears between the ages of 6 months and 16 years 4. affects boys and girls 5. is of several types, including the three main types2 below: a. oligoarthritis (pauciarticular), the most common, which i. affects about 50 percent of children with juvenile arthritis ii. involves 4 or fewer joints, most likely knees, elbows, wrists, or ankles iii. may cause eye inflammation b. polyarthritis (polyarticular), which i. affects about 30 percent of children with juvenile arthritis ii. involves 5 or more joints, including 1. jaw and neck 2. smaller joints, such as those in the hands and feet 3. large joints iii. may evolve into rheumatoid arthritis (CDHO Advisory) c. systemic (body-wide), also called Still’s disease, which i. is the least common main type ii. affects about 20 percent of children with juvenile arthritis

2 Two less common forms of juvenile arthritis are psoriatic arthritis (in which children have both arthritis and the skin disorder psoriasis, with either preceding the other; signs include pitted fingernails) and enthesitis arthritis (that tends to affect the spine, hips, eyes, and entheses [the places where tendons attach to bones], and which typically occurs in boys older than 8 years of age who have a family history of ankylosing spondylitis [a form of back arthritis] in male relatives).

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iii. involves many body parts, including joints, and internal organs, such as 1. heart 2. liver 3. lymph nodes 4. spleen iv. often begins with 1. bouts of fever and chills 2. light pink rash on the thighs and chest.

Cause Juvenile arthritis 1. is of unknown cause 2. is currently thought to be an autoimmune disorder.

Risk factors Juvenile arthritis 1. has neither specifically identifiable cause nor clearly evident risk factors in most cases 2. may be subject to genetic and environmental influences if, as currently believed, it is an autoimmune disorder (CDHO Advisory).

Signs and symptoms of juvenile arthritis 1. may start as early as age 6 months 2. may begin with a swollen joint, limping, a spiking fever, or a new rash 3. may include a. joint i. stiffness and pain ii. range of motion limitation iii. warmth, swelling or redness b. limping c. avoidance of use of an affected limb d. fever, usually high every day e. rash on trunk and limbs that varies with the fever f. pale skin g. ill appearance h. lymph node swelling i. uveitis, which may be accompanied by i. red eyes ii. photophobia iii. vision changes 4. are unpredictable, and may a. last for a matter of months and then disappear b. more commonly follow an up-and-down course for many years.

Medical investigation of juvenile arthritis may involve 1. physical examination of a. joints and skin

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b. liver, for swelling c. spleen, for swelling d. lymph nodes, for swelling 2. blood tests a. ANA b. complete blood count c. erythrocyte sedimentation rate d. HLA antigens for HLA B27 e. rheumatoid factor 3. other tests a. bone scan b. chest X-ray c. ECG d. joint X-ray e. of synovial fluid from swollen joints f. ophthalmological examination.

Treatment of juvenile arthritis 1. lacks a specific cure 2. may involve fluid in swollen joint that a. is also removed as part of medical investigation b. is removed to help relieve pain c. receives corticosteroids injected into the joint 3. may involve nonsteroidal anti-inflammatory medications when only a few joints are affected 4. may involve disease-modifying anti-rheumatic drugs (DMARDs) when a. more than a few joints are affected b. symptoms are severe 5. may involve biologic drugs (such as tumour necrosis factor blockers when a. DMARDs do not work b. patient/client has disease of the sacroiliac joint 6. involves activity and exercise to keep muscles and joints strong 7. may require help and support for depression and anger 8. may require surgery.

Prevention Juvenile arthritis has no known means of prevention.

Prognosis Juvenile arthritis 1. with proper treatment has a good long-term outcome for some half of the children affected who reach adulthood without any major physical disability 2. is influenced by remission, which may or may not be complete 3. involves consideration of a. persistent pain b. persistent disability c. social effects of poor school attendance.

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Social considerations Juvenile arthritis requires support for parents and children; resources include . American Academy of Orthopaedic Surgeons (OrthoInfo) . Arthritis Canada . Arthritis Foundation . National Center for Chronic Disease Prevention and Health Promotion

Multimedia and images

None specifically relevant found.

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with juvenile arthritis but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. Comorbidities, complications and conditions associated with juvenile arthritis include 1. anemia (CDHO Advisory) 2. adverse effects of medications that may affect the child’s oral health and development 3. persistent pain 4. growth deficiencies associated with a. joint destruction b. continuing inflammatory activity c. unevenness of growth of limbs d. slow rate of growth 5. total joint destruction of the major weight-bearing joints 6. pericarditis 7. social effects, such as poor school attendance 8. spondyloarthropathy 9. uveitis.

Oral health considerations

Juvenile arthritis 1. may affect the temporomandibular joint causing pain, stiffness and altered growth, which can a. complicate dental work b. create an overbite if the lower jaw does not develop properly c. limit jaw movement, which may i. make brushing and flossing difficult for the child ii. require jaw exercises as therapy for the pain and stiffness 2. may be treated with medications a. where the dental hygienist should or is required to consult with the appropriate primary care provider(s) about i. pain management ii. antibiotic prophylaxis prior to the Procedures, for

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1. older children who have undergone joint replacement (bearing in mind that most patients/clients with prosthetic joints do not require antibiotic prophylaxis for invasive dental hygiene procedures, as per the 2016 Canadian Orthopaedic Association/ Canadian Dental Association/Association of Medical Microbiology and Infectious Disease Canada Consensus Statement; children with juvenile arthritis, however, may be on immunossupressive medications that warrant antibiotic prophylaxis consideration) 2. children receiving immunosuppressant medication (with significant immunosuppression being a regulatory requirement for medical clearance) b. that affect the child’s teeth, gums, jaw and general development 3. when active, may deprive the child of the stamina necessary for the Procedures.

MEDICATIONS SUMMARY

Sourcing medications information

1. Adverse effect database . Health Canada’s Marketed Health Products Directorate toll-free 1-866-234-2345 . Health Canada’s Drug Product Database

2. Specialized organizations . US National Library of Medicine and the National Institutes of Health Medline Plus Drug Information . WebMD

3. Medications considerations All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.

4. Information on herbals and supplements . US National Library of Medicine and the National Institutes of Health Medline Plus Drug Information All Herbs and Supplements

5. Complementary and alternative medicine . National Center for Complementary and Integrative Health

Types of medications

1. Analgesics, which a. should be taken only under a physician’s advice b. include acetaminophen (Tylenol®, among others) tramadol (Ultram®) tramadol and acetaminophen (Ultracet®, a combination product). 2. Non-steroidal anti-inflammatory drugs (NSAIDs), which a. reduce pain and swelling

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b. decrease stiffness c. do not prevent further damage d. are available without prescription, including i. aspirin (ASA, acetylsalicylic acid), which 1. was most commonly prescribed for juvenile arthritis 2. is still considered a safe and effective medication for many children, and continues to be used 3. may be replaced by other NSAIDs that are better tolerated than aspirin ii. other NSAIDs ibuprofen (Advil®, Motrin®, among others) naproxen (Aleve®, Naprosyn®, among others) e. require prescription, including indomethacin (Indocin®) tolmetin (Tolectin®). 3. Corticosteroids, used to treat severe inflammation of joints accompanied by severe pain and stiffness, which include dexamethasone (Decadron®, Dexamethasone Intensol®) hydrocortisone (Cortef®, Hydrocortone®) methylprednisolone (Medrol®, Meprolone®) prednisone (Prednisone Intensol®, Sterapred®) 4. Disease-modifying anti-rheumatic drugs, which a. are given to children with persistent inflammation in several joints i. to inhibit the immune system from attacking the joints ii. but which do not reverse existing damage b. are used to obtain better control of the arthritis than is achieved with NSAIDs alone c. are continued often for months or years even after the disease is controlled to avoid recurrence d. include3 hydroxychloroquine (Plaquenil®) methotrexate (Rheumatrex®, Trexall®) sulfasalazine (Azulfidine®) 5. Immune system medication cyclosporine (Gengraf®, Neoral®, Sandimmune®) 6. Tumour necrosis factor blockers (a type of biologic response modifier, which entail immunosuppression) adalimumab (Humira®) etanercept (Enbrel®) golimumab (Simponi®) infliximab (Remicade®)

3 At the time of this Advisory revision (August 20, 2020), newer DMARDs – such as JAK inhibitors baricitinib and tofacitinib (used in treatment of adult rheumatoid arthritis) – are being investigated for treatment of juvenile arthritis.

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Side effects of medications

See the links above to the specific medications.

THE MEDICAL AND MEDICATIONS HISTORY

The dental hygienist in taking the medical and medications history-taking should 1. focus on screening the patient/client prior to treatment decision relative to a. key symptoms b. medications considerations c. contraindications d. complications e. comorbidities f. associated conditions 2. explore the need for advice from the primary or specialized care provider(s) regarding antibiotic prophylaxis and pain management 3. inquire about a. previous problems that i. occurred with dental or minor surgical procedures ii. were attributed to juvenile arthritis b. immunosuppressant treatment and problems with opportunistic infections c. susceptibility to infections i. generally ii. associated with dental/dental hygiene care d. the patient/client’s understanding and acceptance of the need for oral healthcare e. medications considerations, including over-the-counter medications, herbals and supplements f. the patient/client’s current state of health g. how the patient/client’s current symptoms relate to i. oral health ii. health generally h. recent changes in the patient/client’s condition.

IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE

Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

The dental hygienist should 1. record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number 2. obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider 3. use a consent/medical consultation form, and be prepared to fax the form to the provider 4. include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.

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UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS

Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to 1. the CDHO’s Infection Prevention and Control Guidelines (2019) 2. relevant occupational health and safety legislative requirements 3. relevant public health legislative requirements 4. best practices or other protocols specific to the medical condition of the patient/client.

DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

1. The dental hygienist is required to consult with the appropriate primary or specialist care provider(s) before implementing the procedures if the patient/client a. is considered a candidate for antibiotic prophylaxis (which may include the patient/client with joint replacement4 if he/she is receiving immunosuppressant treatment) b. if the patient/client has recently undergone or is about to undergo joint replacement (CDHO Advisory) c. is receiving immunosuppressant treatment. Consultation is advised if the patient/client is likely to require pain medication following the Procedures, to discuss pain management. 2. For the patient/client whose condition is in remission, there is no contraindication to the Procedures, but these may be postponed pending medical advice, if the patient/client a. has symptoms or signs of exacerbation of the juvenile arthritis b. is currently taking medications whose implications for the Procedures are unclear to the dental hygienist c. has not complied with pre-medication, including antibiotic prophylaxis, as directed by the prescribing physician d. describes comorbidities, complications or associated conditions of juvenile arthritis about which the dental hygienist has insufficient information e. not recently or ever sought and received medical advice relative to dental procedures f. recently changed medications, under medical advice or otherwise g. recently experienced changes in his/her medical condition such as medication or other side effects of treatment h. is deeply concerned about any aspect of his or her medical condition.

4 Most patients/clients with prosthetic joints do not require antibiotic prophylaxis for invasive dental hygiene procedures, as per the 2016 Canadian Orthopaedic Association/Canadian Dental Association/Association of Medical Microbiology and Infectious Disease Canada Consensus Statement. Children with juvenile arthritis, however, may be on immunosuppressive medications that warrant antibiotic consideration.

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DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client. First-aid provisions and responses as required for current certification in first aid.

RECORD KEEPING

Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) for a patient/client with a history of juvenile arthritis, the dental hygienist should specifically record 1. a summary of the medical and medications history 2. any advice received from the physician/primary care provider relative to the patient/client’s condition 3. the decision made by the dental hygienist, with reasons 4. compliance with the precautions required 5. all Procedure(s) used 6. any advice given to the patient/client.

ADVISING THE PATIENT/CLIENT

The dental hygienists should 1. urge the patient/client to alert any healthcare professional who proposes any intervention or test a. that he or she has a history of juvenile arthritis b. to the medications he or she is taking 2. should discuss, as appropriate a. the importance of the patient/client’s i. self-checking the mouth regularly for new signs or symptoms ii. reporting to the appropriate healthcare provider any changes in the mouth b. ways to overcome oral self-care difficulties associated with pain, stiffness, limited jaw movement and altered growth, including i. choice of toothpaste ii. tooth-brushing devices iii. dental flossing iv. mouth rinses and saliva control v. management of a dry mouth vi. the role of jaw exercises c. the need for regular oral health examinations and preventive oral healthcare d. the importance of an appropriate diet in the maintenance of oral health e. scheduling and duration of appointments for a child with active arthritis who i. may not have the stamina even for routine oral healthcare ii. requires appointments to be scheduled 1. when he or she has the most stamina 2. as shorter appointments iii. will be helped by attention to 1. comfort level while reclining 2. stress and anxiety related to the Procedures

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f. medication i. effects on the child’s oral health and development ii. requirements for antibiotic prophylaxis prior to dental treatment, if indicated iii. side effects such as dry mouth, and recommend treatment iv. pain management g. mouth ulcers and other conditions of the mouth relating to comorbidities, complications or associated conditions, medications or diet h. pain management.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

1. Promoting health through oral hygiene for persons who have juvenile arthritis. 2. Reducing the adverse effects, such as exhaustion of a child with insufficient stamina for the Procedures by a. taking account of the level of activity of the person’s juvenile arthritis prior to starting the Procedures b. generally increasing the comfort level of persons in the course of dental hygiene interventions c. using appropriate techniques of communication d. providing advice on scheduling and duration of appointments. 3. Reducing the risk that oral health needs are unmet.

POTENTIAL HARMS

1. Causing infection. 2. Performing the Procedures at an inappropriate time, such as a. when the patient/client’s medications have not been sufficiently reviewed b. in the presence in a medical history indicative of need for prior medical advice c. in the presence of acute oral infection without prior medical advice. 3. Disturbing the normal dietary and medications routine of a person with juvenile arthritis. 4. Inappropriate management of pain or medication.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III

ORIGINALLY DEVELOPED

2009-11-24

DATE OF LAST REVIEW

2010-07-15; 2012-01-01; 2020-03-18; 2020-08-20 (limited update – primarily addition of link to CDHO Juvenile Arthritis Fact Sheet)

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ADVISORY DEVELOPER(S)

College of Dental Hygienists of Ontario, regulatory body Greyhead Associates, medical information service specialists

SOURCE(S) OF FUNDING

College of Dental Hygienists of Ontario

ADVISORY COMMITTEE

College of Dental Hygienists of Ontario, Practice Advisors

COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY

Dr Gordon Atherley O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow MD, MHSc, MBA, DTM&H, CHE, CCFP, DABPM, LFACHE, FCFP, FACPM, FRCPC

Lisa Taylor RDH, BA, MEd

Kyle Fraser RDH, Bcomm, BEd, MEd

ACKNOWLEDGEMENTS

The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande Final layout and proofreading

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