42

7OUNDHEALING56Ih6 7OUNDHEALING56Ih6
\ctnUs LK, 2ttt, Vcl , Nc T
Scarlcss lcalln,. cral ntccsa
as a sclcnllhc ncUcl
Sltarl lnccl, llll Slcjlcns
5tuart noch is 5pecia|ity kegistrar in F|astic 5urgery and
8urns, university hospita|s of Hanchester and Hanchester
university 6hi|dren's hospita|s, isiting 5cientist, facu|ty
of Life 5ciences, university of Hanchester, Fhi| 5tephens
is Frofessor of 6e|| 8io|ogy, Wound 8io|ogy 6roup, 1issue
ngineering and keparative 0entistry, 5choo| of 0entistry,
6ardiff university
Cutaneous wouno beallng's usual enopolnt ls scar |ormatlon. |n contrast to tbe skln, tbe oral mucosa beals
ln a scarless manner, oesplte unoergolng tbe same stages o| tbe beallng process. Wblle wouno envlronment
may play a part, stuoles bave oemonstrateo tbat lnberent ol||erences ln tbe pbenotyplc ano genotyplc
cbaracterlstlcs o| tbe resloent broblast populatlons may bave a role ln meolatlng tbls ol||erentlal beallng.
Tbls artlcle analyses tbe evloence surrounolng scarless beallng ln tbe oral mucosa ano olscusses |uture
areas o| researcb ano blgbllgbts tbe potentlal cllnlcal lmpllcatlons o| tbls |asclnatlng pbenomenon.
|
oa| cotaoeoos .oooo |ea||o
|ovo|ves a co,|e bot .e||-
oc|estateo se|es o eveots
|eao|o to t|e e,a| o |o,oeo t|ssoes.
|o,o to t|e s'|o ooe to soe, taoa
o boos cao eso|t |o va|o oeees
o sca|o oe,eoo|o oo t|e seve|t
aoo aoato|ca| |ocat|oo o t|e |oso|t
(|ooc| et a|, 200+a). |o ceta|o |ostaoces,
t|e sca|o cao be ecess|ve aoo
ooeo|ateo eso|t|o |o |,eto,||c
aoo 'e|o|o scas (|ooc| et a|, 2006b).
Cootactoes, a sca va|aot eooeot|
a eso|t o boos o sca|os, oteo occo
ove eoa| soaces soc| as t|e oec'
o e|bo. aoo cao eso|t |o sevee, |oo-
te ooct|ooa| ,ob|es.
history of research into scar|ess hea|ing
|a| |ovest|at|oos |oto sca|ess |ea||o
.ee ,eoo|oate| coooocteo |o oeta|
.oooos. |o|t|a| |ovest|at|oos att|boteo
t|e obseveo o|eeoce bet.eeo oeta|
aoo ooo-oeta| .oooo |ea||o to t|e
|otaote|oe eov|ooeot t|e ste||e,
.a ao|ot|c o|o |c| |o |a|ooo|c
ac|o aoo o.t| actos aoo t|e
e|at|ve |,oe|c state o oeta| t|ssoes
|o oteo (|ooa'e et a|, +8, +0).
o.eve, t||s .as sooo c|a||eoeo .|eo
t|e ca,ac|t o sca|ess e,a| |ot|os|c
to oeta| t|ssoe .as oeoostateo |o
ao e,e|eot .|ee t|e eseac|es
sobcotaoeoos| ateo |oao oeta|
s'|o (+S22 .ee's estat|oo) ooto
t|e bac's o at||c aoo|t |ce. /te
.oooo|o t|e |ce t|e |oeot|eo t|at
oo| t|e sobcotaoeoos| ateo oeta|
s'|o |ea|eo .|t|oot sca oat|oo
(|oeoz et a|, +2). ||'e.|se, |ooa'e
et a| (++) obseveo t|at |otaote|oe
eov|ooeot a|ooe .as oot soc|eot to
|oooce sca|ess e,a|. /te taos,|aot|o
aoo|t s|ee, s'|o ooto t|e bac's o 60-
oa-o|o s|ee, oetoses |oc|s|ooa| .oooos
.ee ceateo |o t|e taos,|aoteo aoo|t
s'|o aoo ao,aceot oeta| s'|o +0 oas
|ate. \|eo ea|oeo |cosco,|ca||,
oo| t|e oeta| s'|o .oooos |ea|eo
.|t|oot sca|o.
T|e |e|evaoce o t|e ste||e, o|o,
eboo|c eov|ooeot to sca-ee
|ea||o .as cooc|os|ve| oeoostateo
|o ao ooto|o|ca| |ovest|at|oo o .oooo
|ea||o aoo sca|o |o t|e ,ooc| ooo
k W0k05
Scarless beallng
Oral mucosa
Foetal wouno beallng
Flbroblasts
Skln substltutes
|o cootast to sca oat|oo
aa|s, ebos aoo ea|
estat|ooa| oetoses |o oteo |ea|
a,|o| aoo |o a sca|ess as||oo (S|a|
et a|, +S). |o ooo-oeta| t|ssoe
aoato|ca| aeas soc| as t|e oa|
ocosa a|so e||b|t t||s ',|v||eeo'
,atteo o a,|o aoo sca|ess |ea||o
(Sz,aoes'a et a|, 2003), oes,|te
.oooos |o t|e oa| ocosa aoo t|e s'|o
,oceeo|o t|oo| t|e sae staes |o
t|e |ea||o ,ocess as ot|e ,ats o
t|e boo (Sc|obba et a|, +8, \a|s|
et a|, +6). Soe c|t|cs a |o.eve
aoe t|at |ea||o |o t|e oa| ocosa
|s oot st|ct| 'sca|ess' as obseveo |o
t|e oetos s|oce, oo||'e t|e oetos t|at
|ea|s b eeoeat|oo, ooo-oeta| t|ssoes
|ea| b e,a|. /|t|oo| t||s aoeot
||t be coos|oeeo va||o | t|e t|ssoe |s
scot|o|seo b |cosco,|c ea|oat|oo,
oo||'e t|e s'|o, t|e oa| ocosa oo oot
c||o|ca|| e||b|t ao o o sca|o,
sobt|e o ovet, ate |o,o. |cess|ve
sca|o soc| as |,eto,||c scas aoo
'e|o|o scas |ave oot beeo e,oteo
|o t|e oa| ocosa. Sca|os to t|e oa|
ocosa oo oot eso|t |o cootactoes
oo||'e sca|o|o to t|e s'|o (|ooc|
et a|, 2006a). |o aoo|t|oo to |ea||o
|o a sca|ess aooe, oa| ocosa|
.oooos a|so |ea| a,|o| .||c| |s
co,aab|e to oeta| .oooos (S|oao
et a|, ++). T||s at|c|e .||| eva|oate
t|e sc|eot|c ev|oeoce aoo o|scoss
t|e coeot aoo otoe eseac| aeas
|o t||s aea aoo t|e ,oteot|a| c||o|ca|
a,,||cat|oo o t|e oo|os.
p42-48Enoch5(1) C.indd 42 13/2/09 23:34:40
#LINICALFkk61I6 0L0FHh1 7OUNDHEALING56Ih6 7OUNDHEALING56Ih6
43 \ctnUs LK, 2ttt, Vcl , Nc T
|ooeoteo ooc|e| (Cabb|ao| et a|, ++,
|oeo, 2003), aoo t|os |ave stoctoa|
,o,et|es bet.eeo t|ose o a bob|ast
aoo a soot| osc|e ce||. /|t|oo|
t|e| ,ec|se o||o |s a atte o
oebate, t|e cooseosos |s t|at bob|asts
o|eeot|ate |oto obob|asts ate
|at|oo |oto t|e .oooo oooe t|e
|ooeoce o o.t| actos soc| as
TC|-+(|o|oa et a|, 200+) aoo
ec|ao|ca| stess (|oz et a|, 200+). |o
aoo|t|oo to bob|asts, soe soot|
osc|e ce||s aoo ,e|ctes ae a|so
t|oo|t to be ca,ab|e o o|eeot|at|o
|oto obob|asts (Cabb|ao|, +6).
|obob|asts a,,ea aboot t|ee oas
ate .oooo|o aoo |ocease |o oobe
to a a|o |eve| bet.eeo oa +0 aoo
2+. T|e| a|o ooct|oo |s to cootact t|e
aoo|at|oo t|ssoe aoo oe,os|t oe. |C|.
/|t|oo| t|e ,oote .oooo c|osoe,
obob|asts ae a|so es,oos|b|e o
sobseooeot .oooo cootactoe aoo
sca|o. T|eeoe, a oe||cate ba|aoce
o bob|asts aoo obob|asts |o t|e
.oooo |s esseot|a| o o,t|o .oooo
|ea||o (|esoo||ee aoo Cabb|ao|,
+6).
|stes et a| (++) oeoostateo a
c|ea ||o' bet.eeo t|e a,,eaaoce o
obob|asts |o t|e .oooo aoo sca
oat|oo |o oeta| s|ee,. T|e oooo
t|at t|e taos|t|oo o sca|ess t|ssoe
e,a| to |ea||o .|t| sca oat|oo,
.||c| occos oo|o |ate estat|oo, |s
acco,ao|eo b ao |oceaseo a,,eaaoce
aoo ,eseoce o obob|asts |o t|e
.oooo eov|ooeot. T|e ,ec|se o|e o
obob|asts |o oa| ocosa| |ea||o
ea|os ooc|ea a|t|oo|, oo||'e |o t|e
s'|o, t|ee |s ||tt|e ev|oeoce to soest t|at
obob|asts ,|a ao |,otaot o|e |o
oa| ocosa| |ea||o.
||bob|asts ,eseot |o t|e .oooo s|te
ae t|oo|t to be eco|teo o t|e
sooooo|o coooect|ve t|ssoe. o.eve,
3oca|a et a|, (++) |oeot|eo a ,o,o|at|oo
o c|co|at|o ce||s t|at s,ec|ca|| eoteeo
s|tes o t|ssoe |o,o. T||s oove| ce|| t,e,
teeo a bocte, .as c|aacte|seo b
|ts o|st|oct|ve ,|eoot,|c c|aacte|st|cs
(,os|t|ve o co||aeos | aoo |||, v|eot|o,
C|3+, C|86 aoo |C ||), |ts eot
o b|ooo |oto t|e .oooo s,ace aoo
|ts ,eseoce |o coooect|ve t|ssoe scas.
Sobseooeot|, boctes .ee oooo
o t|e aso,|a| |ooooe|,||s ooest|ca
(/stoo aoo |eosoo, +S, +).
T|ese ea| ,ooc| ooo ae eo|a|
coota|oateo .|t| ateoa| o|oe
aoo aeces t|at cootasts .|t| t|e
ste||e ao|ot|c o|o eov|ooeot o
t|e| ,|aceota| cooote,ats. o.eve,
oes,|te t|ese st|'|o o|eeoces, s'|o
.oooos oo ea| ,ooc| ooo o |.
ooest|ca |ea| ,eect| .|t| oo scas
(/stoo aoo |eosoo, +S, +).
/ oobe o oo|ooe ,o,et|es o oeta|
s'|o e,a| |ave beeo |oeot|eo t|at
coot|bote to sca|ess |ea||o |o t|e
oetos |oc|oo|o eooceo o |ac' o ,o-
|oaato s|oa|s (Co.|o et a|, +8),
||| sot|et|c ca,ab|||t|es to |a oo.o
co||aeo a,|o| (3o||ao et a|, 2003),
o|eeot|a| e,ess|oo o taoso|o
o.t| acto- (TC|-) |soos
(S|a| et a|, +2, ++), a|teeo ba|aoce
bet.eeo at| eta||o,ote|oases
(|||s) aoo t|ssoe |o||b|tos o at|
eta||o,ote|oases (T|||s) (|oeoz
et a|, 200+), |o.e |eve|s o oeco|o
e,ess|oo (oeco|o ass|sts |o TC|-
act|v|t (3eaoes et a|, 200+) aoo a|teeo
eoe e,ess|oo ,o|es (Ste|o|c'| et a|,
+, +8).
ost as sca|ess |ea||o |o t|e oetos
.as ,ev|oos| att|boteo to t|e ote|oe
eov|ooeot, sca|ess |ea||o |o t|e oa|
ocosa .as t|oo|t to be att|botab|e to
|ts o|st eov|ooeot aoo t|e ,eseoce
o cto'|oes aoo o.t| actos |o t|e
sa||va. /oe|ov et a| (200+) os|o a o|oe
ooe|, |,ot|es|seo t|at seceto
|eo'octe ,otease |o||b|to (S|||,
a cat|oo|c se|oe ,otease |o||b|to
.|t| aot||cob|a| aoo aot|-|oaato
,o,et|es) oooo |o |ae ooaot|t|es
|o t|e sa||va a |ave a o|e |o eo|at|o
sca|ess |ea||o |o t|e oa| ocosa, a
cooce,t ,ev|oos| |,ot|es|seo
aoo so,,oteo b |o v|to stoo|es (So|
et a|, 2000).
/|t|oo| S||| ,os|t|ve| coot|botes
to ooa| .oooo |ea||o (/s|cot
et a|, 2000) t|ee |s a ,aoc|t o
ceo|b|e sc|eot|c oata at ,eseot o
|ts o|e |o eo|at|o sca|ess |ea||o.
o.eve, sca|ess |ea||o as ao |o|eeot
c|aacte|st|c o t|e oa| ocosa, at|e
t|ao ooe to ao etaoeoos |oteeeoce
o |ooeoce, |as beeo |||ostateo b
stoo|es .||c| e,oteo t|at s'|o t|ssoe
taos,|aoteo |oto oa| ocosa| oeects
eta|o t|e| ooa| aoato|c aoo
,|eoot,|c c|aacte|st|cs, aoo t|os |ea|
.|t| sca oat|oo (3oss| et a|, +S).
||'e.|se, a|t|oo| ecess|ve sca|o
cooo|t|oos soc| as 'e|o|o scas |ave
ae| beeo obseveo |o t|e oa| ocosa,
taos,|aoteo s'|o oseo to ecoostoct
a oeect |o t|e oa| cav|t |as beeo
s|o.o to |ea| .|t| |otaoa| 'e|o|o
oat|oo (|e||| et a|, +80), .|t| t|e
'e|o|o a|s|o o t|e .oooo |o t|e
s'|o at|e t|ao o t|e oa| ocosa.
|o aoo|t|oo, ||sto|o|ca| ea|oat|oo o
s'|o taos,oseo |oto t|e oa| cav|t |o
ecoostoct|ve soe |as s|o.o oo|
t|e s'|o-ocosa| |oteace to |ea| .|t|oot
a sca (eect|ve| ao oa| ocosa| t,e
o |ea||o) a|t|oo| t|e s'|o eta|oeo t|e
ab|||t to a|ota|o 'eat|o|sat|oo aoo ot|e
tetoa| ,eco||a|t|es (3oss| et a|, +S).
ko|e of hbrob|asts
||bob|asts ae ob|oo|toos ce||s t|at
,|a a s|o|caot o|e |o va|oos staes
o t|e |ea||o ,ocess. |o||o.|o |o,o,
bob|asts |ate |oto t|e .oooo,
,o||eate aoo ,oooce t|e at|
,ote|os (booect|o, |a|ooo|c ac|o,
co||aeo aoo ,oteo|caos) aoo, |o
oo|o so, o aoo|at|oo t|ssoe (|ooc|
et a|, 2008). T|e t|eo eoao|se t|e
,ov|s|ooa| etace||o|a at| (|C|)
aoo eooe| t|e eso|t|o sca (T|oas
et a|, +S). T|e a|so |oteact .|t|
'eat|ooctes, e|eas|o o.t| actos
aoo cto'|oes t|at ,|a a ot|e o|e |o
ooo|at|o .oooo e,a| (S|av|o, +6,
S|t| et a|, +). T|e co,os|t|oo o
t|e |C| (aoo t|os t|e oa| .oooo
|ea||o ootcoe) cao be a|teeo b t|e
ba|aoce bet.eeo t|e |||s aoo T|||s
eozes ,oooceo b bob|asts. |o
aoo|t|oo to .oooo |ea||o, bob|asts
ae |,||cateo |o t|e aet|o|o o ao
,at|o|o|ca| cooo|t|oos e|ateo to
.oooo |ea||o ootcoes soc| as 'e|o|o
aoo |,eto,||c scas, |o,oteo's
cootactoe, ,o|ooa bos|s aoo
eto,e|tooea| bos|s.
ko|e of myohbrob|asts and hbrocytes
Coe o t|e best-c|aacte|seo sob-t,es
o bob|asts |s t|e obob|ast, .||c|
,|as ao |,otaot o|e |o sca oat|oo.
|obob|asts ae c|aacte|seo b
t|e ,eseoce o stess bes t|at
coota|o -soot| osc|e act|o aoo
p42-48Enoch5(1) C.indd 43 13/2/09 23:34:40
7OUNDHEALING56Ih6 7OUNDHEALING56Ih6
45 \ctnUs LK, 2ttt, Vcl , Nc T
to be oe|veo o t|e booe ao.
aoo ,e|,|ea| b|ooo oooooc|ea ce||s
aoo o|s,|a bob|ast-||'e ,o,et|es,
sot|es|s|o |C| acoo|eco|es
aoo coot|bot|o to t|e obob|ast
,o,o|at|oo |o t|e .ooooeo s'|o (|o| et
a|, 200S). T|e ae t|oo|t to ,oteot|a||
o,eo|ate t|e |oaato cto'|oes,
|ave ,oteot |ooost|o|ato
,o,et|es aoo ae oooo |o |oceaseo
oobes |o |,eto,||c scas, 'e|o|o
scas aoo bot|c |es|oos (Yao et a|,
200S). ||boctes ae t|os |,||cateo |o
t|e oeve|o,eot o scas aoo ecess|ve
sca|o cooo|t|oos. Co,|eeot|o t||s
act |s t|e obsevat|oo t|at boctes
|ave oot beeo |oeot|eo |o t|ssoes t|at
e||b|t sca|ess |ea||o soc| as oeta|
.oooos aoo oa| ocosa| .oooos.
Fhenotypic characteristics of ora|
mucosa| hbrob|asts
|o ||oe .|t| eoea| bob|ast
|eteoeoe|t, |t |as beeo ,ev|oos|
s|o.o t|at oa| ocosa| bob|asts
e||b|t a o|st|oct ce||o|a ,|eoot,e .|eo
co,aeo .|t| t|e| cooote,ats |o s'|o
.oooos. Co,aeo .|t| s'|o bob|asts,
oa| ocosa| bob|asts |ave beeo s|o.o
to |ave ao |oceaseo ab|||t to |ate
aoo e,o,o|ate .|t||oa .oooo (a|-
||ateb et a|, +), aoo bocca| ocosa|
bob|asts |ave beeo s|o.o to |ate
|oto a co||aeo e| |o v|toaste t|ao
t|e| s'|o cooote,ats (|v|o et a|, ++).
||'e.|se, o|eeoces |ave beeo e,oteo
bet.eeo oa| ocosa| bob|ast's aoo
s'|o bob|ast's ab|||t to eoao|se
|C|, a|t|oo| o|eeot eseac|es |ave
e,oteo |ocooooos eso|ts. Ste,|eos
et a| (+6, 200+a) oeoostateo t|at
oa| ocosa| bob|asts |ave ao |oceaseo
ab|||t to eoao|se t|e| sooooo|o
|C|. ||'e.|se, a eceot stoo b
S|aoooo et a| (2006) oeoostateo
oa| ocosa| bob|asts |ave a bette
ab|||t to eoao|se t|ee-o|eos|ooa|
co||aeo |att|ces t|ao ,at|eot-atc|eo
s'|o bob|asts. o.eve, |ee aoo |oo
(+) obseveo t|at s'|o bob|asts
eoao|se t|e co||aeo |att|ces bette
t|ao coes,ooo|o oa| ocosa|
bob|asts, a|t|oo| t|e ,e|oo o
obsevat|oo |o t||s stoo .as s|ote
t|ao |o t|e e,e|eots b ot|es.
T|e| eso|ts .ee |o ||oe .|t| t|e
oo|os o Tsa| et a| (+S) |o a stoo
t|at co,aeo t|e cootact|oo ,oteoc
o bob|asts o |,eto,||c scas,
ooa| s'|o aoo oa| ocosa| bob|asts.
T|e oooo t|at bob|asts oe|veo
o |,eto,||c scas ,ossesseo t|e
eatest eoao|sat|oo ,oteoc aoo s'|o
bob|asts s|o.eo a eate ab|||t to
eoao|se co||aeo |att|ce co,aeo .|t|
oa| ocosa| bob|asts. T||s va|at|oo |o
t|e |C| eoao|sat|ooa| ab|||t o s'|o
bob|asts aoo oa| ocosa| bob|asts
|as beeo assoc|ateo .|t| va|at|oos |o
t|e act|v|t o ||| aoo T||| ,o|es.
Ste,|eos et a| (200+a) oeoostateo
t|at oa| ocosa| bob|asts ,oooceo
oe |||-2 aoo |ess T|||-+ aoo T|||-
2 co,aeo .|t| ,at|eot-atc|eo s'|o
bob|asts, soest|o t|at t|e ba|aoce
bet.eeo t|ese t.o ,oteases ,|aeo a
o|e |o t|e eoao|sat|oo ab|||t o t|ese
ce||s .|t||o co||aeo |att|ces, aoo t|os |o
t|e o|eeot|a| |ea||o obseveo bet.eeo
oa| ocosa| aoo s'|o .oooos |o v|vo.
ko|e of growth factors in mediating scar|ess
and scar-forming wounds
S|oce a |ae ,o,ot|oo o eseac|
oooeta'eo to oec|,|e t|e ec|ao|cs
o sca|ess |ea||o |ave beeo oo oeta| o
eboo|c .oooos, ost oata coeot|
ava||ab|e aboot t|e o|e o o.t| actos
|o sca|ess |ea||o |ave beeo obta|oeo
o eseac| oo aa||ao oetoses
aoo ebos. |oa| eboo|c s'|o
aoo eboo|c .oooos, ooe to a,|o
e,aos|oo o s'|o vo|oe, coota|o
||| |eve|s o o,|oeoet|c actos
|ovo|veo |o s'|o o.t|, eooe|||o
aoo o,|oeoes|s. /s a cooseooeoce
o a|teeo |oaato es,oose
aoo s'|o o,|oeoes|s, t|e o.t|
acto ,o|e o a |ea||o eboo|c
.oooo |s ooa||tat|ve| (t|e t,es o
o.t| acto ,eseot), ooaot|tat|ve|
(t|e aooots o soc| o.t| actos
,eseot) aoo te,oa|| (t|e |eot| o
t|e t|e o.t| actos ae ,eseot)
o|eeot co,aeo .|t| ao aoo|t .oooo
(\||tb aoo |eosoo, ++, C'|aoe
aoo |eosoo, +, S|a| et a|. 2000).
/|t|oo| t|e ooct|oos o va|oos o.t|
actos |ave beeo eva|oateo, T3|- aoo
|e,atocte o.t| acto (C|) |ave
beeo s|o.o to ,|a |,otaot o|es
|o eo|at|o t|e o|eeot|a| ,atteo
o |ea||o. Ca| ocosa| bob|asts, |o
co,a|soo .|t| s'|o bob|asts, |ave
beeo s|o.o to ,oooce oe C|
(Ste,|eos et a|, 200+b, S|aoooo et a|,
2006) aoo 'eat|oocte o.t| acto
(C'aza'| et a|, 2002).
Ct|e o.t| actos, soc| as
,|ate|et-oe|veo o.t| acto (||C|)
aoo bob|ast o.t| acto (|C|-2), a|so
s|o. sobt|e o|eeoces |o te,oa| aoo
s,at|a| a,,eaaoce |o t|e |ea||o oeta|
.oooo (\||tb aoo |eosoo, +2).
/oo|t .oooos coota|o |ae ooaot|t|es
o ||C|, .||c| |s v|toa|| abseot |o
eboo|c .oooos (o.|o to t|e |ac'
o ,|ate|et oeaoo|at|oo), .|eeas
eboo|c .oooos coota|o |||e |eve|s
o eoooeooos |C|s |ovo|veo |o s'|o
o,|oeoes|s (\||tb aoo |eosoo,
++). |oeooos ||C| |s s|o.o to
|oooce bos|s |o oeta| abb|t .oooos
(aoes et a|, ++) aoo |C| |soos 2,
S, , aoo +0 |ave o|eeot|a| e,ess|oo
|o sca|ess .oooos co,aeo .|t|
.oooos t|at sca. |ao et a| (2003)
obseveo ao ovea|| oo.o-eo|at|oo o
|C| e,ess|oo oo|o sca|ess |ea||o |o
oeta| ats.
0iscussion
|o ao evo|ot|ooa ,es,ect|ve, s'|o
.oooos e,eseot oot ,ost a ,|s|ca|
|,eo|eot ooe to b|ooo |oss o t|ssoe
oaae, bot t|eateo t|e ve sov|va|
o t|e s,ec|es o oeve|o,eot o
|oect|oo aoo se,s|s ooe to |ovas|oo o
|co-oao|ss o so|| coota|oaots.
T|e |eo|ate |,eat|ve o t|e boo
|s to c|ose t|e .oooo aoo ,eveot
estab||s|eot o |oect|oo. |t ac||eves
t||s ob,ect|ve b t|e eaos o a a,|o
aoo obost |oaato es,oose, .|t|
eco|teot o oeoto,|||s, aco,|aes
aoo |,|octes to t|e .oooo s|te.
T||s |s o||o.eo b bo,|as|a, |C|
sot|es|s aoo eoao|sat|oo, ,e|a,s
|o a |a,|azao aooe, |o ao atte,t
to eooce t|e s|ze o t|e .oooo
(.|t| t|e |e|, o obob|asts) as
ea| as ,oss|b|e. |eveot|oo o sca
oat|oo, |t cao be aoeo, |s t|e |east
o t|e ,|o|t|es o t|e boo's oeeoce
ec|ao|s. o.eve, |o t|e coeot
evo|ot|ooa stae .|t| c|eaoe .oooos
aoo aovaoces |o aot|se,t|cs, |t coo|o be
,osto|ateo t|at a ass|ve |oaato
oveo|ve eso|t|o |o a sca ||t oot
be ao evo|ot|ooa|| o,t|a| eoo,o|ot.
o. ooes t||s evo|ot|ooa |oteot|oo
e|ate to t|e sca|ess |ea||o obseveo
|o t|e oa| ocosa: S|||a to t|e s'|o,
p42-48Enoch5(1) C.indd 45 13/2/09 23:34:41
#LINICALFkk61I6 0L0FHh1 #LINICALFkk61I6 0L0FHh1 7OUNDHEALING56Ih6
4 \ctnUs LK, 2ttt, Vcl , Nc T 47 \ctnUs LK, 2ttt, Vcl , Nc T
t|e oa| ocosa |s a|so sob,ecteo to
e,eateo taoa, a|t|oo| o o|eeot
aet|o|o|es soc| as ast|cat|oo aoo t|e
||taot eects o soe ooos. T|e oa|
cav|t |s a|so co|oo|seo aoo coota|oateo
.|t| oe |co-oao|ss t|ao t|e
s'|o. |oo-|ea||o .oooos |o t|e oa|
cav|t cao ,eveot aoeooate |ota'e o
ooo, .||c| cao co,o|se t|e ve
sov|va| o t|e s,ec|es. T|os t|e oa|
ocosa |as oe |,etos to |ea| oe
a,|o| t|ao t|e s'|o. /|t|oo| t||s cao
be at|ooa||seo o ao evo|ot|ooa
v|e.,o|ot, .| s|oo|o t|e .oooos |ea|
|o a sca|ess aooe: T|e aos.e to t||s
coooooo |s |o t|e act t|at t|e oa|
ocosa |s sob,ecteo to oe taoa
t|ao t|e s'|o. eoce, as .|t| s'|o, | a||
t|ese .oooos |ea|eo .|t| sca|o (aoo
t|e assoc|ateo |,eto,||c sca, 'e|o|o
sca, cootactoes aoo bos|s), |t .oo|o
sevee| co,o|se t|e ooct|ooa||t o
t|e oa| cav|t.
So |as t|e oa| ocosa evo|veo to
|ea| |o a sca|ess aooe: | so, coo|o t|e
easoo be t|e eso|t o a eooceo o ao
a|teeo |oaato es,oose: Coo|o |t
be ooe to a o|eeot eoe taosc|,t|ooa|
,o|e o t|e bob|asts: (|ooc|, 200+,
|ooc| et a|, 200+b, 200S). C coo|o |t be
ooe to t|e ,eseoce o 'oeta|-||'e' ce||s
o ,oeo|to ste ce||s |o t|e .oooos
so t|at t|e bob|asts cao be coostaot|
e,|eo|s|eo to e,eo|te |ea||o |o t|e
oa| ocosa:
T|e obsevat|oo t|at t|e |o v|vo
es,oose o oa| ocosa to e,a| oeects
.|t|oot sca oat|oo |s oe a'|o to
eeoeat|oo (as seeo |o oetoses) at|e
t|ao e,a|, so,,ots a ,ovocat|ve bot
at|ooa| |oea t|at t|e ce|| ||oeae o soe,
| oot a||, oa| ocosa| bob|asts coo|o
|ave beeo oe|veo o a es|oeot, o|t|-
,oteot ce|| ,o,o|at|oo .|t||o t|e |a|oa
,o,|a o t|e oa| ocosa. T||s |eaos to
t|e oove| |,ot|es|s t|at a ste ce|| o a
'ste ce||-||'e' ,o,o|at|oo a be ,eseot
.|t||o t|e oa| ocosa, .||c| coot|botes
to t|e| ,eeeot|a| |ea||o. |ot|e
stoo|es ae oeeoeo to e,|oe t||s ||oe
o |ovest|at|oo aoo to cooboate t|e
t|eoe ,o,oseo |ee.
T|e o,t|oo o os|o oa| ocosa|
bob|asts |osteao o s'|o bob|asts
|o va|oos t|ssoe-eo|oeeeo s'|o
sobst|totes |s coeot| be|o e,|oeo.
| o|t|,oteot ste ce||s ae |oeot|eo
|o t|e oa| ocosa, c|ea|, |o aoo|t|oo
to o|ect c||o|ca| a,,||cat|oo, t||s oo|o
.oo|o |ave ot|e .|oe-ao|o,
,os|t|ve a|cat|oos |o t|e e|os o
t|ssoe eo|oee|o, t|ssoe e,a| aoo
eeoeat|oo. T||s |s ooe to t|e eas
access|b|||t o t|e oa| ocosa aoo t|e
act t|at t|e oa| ocosa |s |o ao |oea|
aoo ,eeeot|a| ,os|t|oo to ,ov|oe
t|e sa,|e, o |so|at|o aoo c|ooa||
e,aoo|o a ,o,o|at|oo o ,oeo|to
ce||s, s|oce |t .||| |ea| oo|c'| .|t|oot
sca|o. T|ese ,oeo|to ce||s cao
t|eo be co|toeo ooto |o v|to costo-
oes|oeo, b|o|o|ca|| co,at|b|e t|ssoe-
eo|oeeeo ate|a|s t|at .||| be ab|e to
eoeate a ooct|ooa| t|ssoe (o a t|ssoe-
eo|oeeeo s'|o sobst|tote).
T|e ab|||t o .oooos to |ea| |o a
sca|ess aooe o t|e ava||ab|||t o a
b|o|o|ca|| oeve|o,eo sooate t|at
,ootes sca|ess |ea||o .||| be o
|eose beoet o ,at|eots .|ose
|o,o|es (soc| as boos o a,o taoa)
eso|t |o a coos|oeab|e aooot o ooa|
o ecess|ve sca|o, o cotaoeoos
bos|s aoo cootactoes, t|at, |o aoo|t|oo
to be|o aest|et|ca|| ,|a|o, eso|t |o
s|o|caot ooct|ooa| ob|o|t. T|e oa|
ocosa, ooe to t|e aoeeot|ooeo
easoos, cao be eect|ve| oseo as
ao ee,|a to ot|e oec|,|e t|e
ec|ao|cs o sca|ess |ea||o.
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#LINICALFkk61I6 0L0FHh1 #LINICALFkk61I6 0L0FHh1 7OUNDHEALING56Ih6 7OUNDHEALING56Ih6
48 \ctnUs LK, 2ttt, Vcl , Nc T 1 \ctnUs LK, 2ttB, Vcl 4, Nc 4
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p42-48Enoch5(1) C.indd 48 13/2/09 23:34:42
9 \ctnUs LK, 2ttB, Vcl 4, Nc 4
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ooob|e eoeo s.oo. T|e ae
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bot t|e caose a,o co||atea|
oaae b e|eas|o a coos|ve
coc'ta|| o ,otease eozes
aoo act|ve oeo s,ec|es.
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ao oo.e|coe, oaa|o
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sta |o es|oeoce o too |oo.
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|ostate |ea||o b oea||o .|t|
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p42-48Enoch5(1) C.indd 57 13/2/09 23:34:44