Download Dental Care of the Future

Dental Care of
the Future: Part I
David J.Apsey, DDS
www.futuredental.com
810-293-8750
Email:
[email protected]
Periodontal Disease Changing the Paradigm
• Historical perspective - nonspecific
plaque hypothesis (NSPH)
• Modern perspective - specific
plaque hypothesis (SPH)
• Infectious disease nature of dental
diseases
We Used to Do Dentistry Like
This!
Now we know of a better way.
Nonspecific Plaque
Hypothesis
• All plaque is equally pathogenic - no
qualitative differences in plaque exist
• Proposed by Miller 1890s after failure to
isolate specific bacteria in caries.
Nonspecific plaque hypothesis
has been invalidated by data
• Invalidated by more than one hundred
studies since 1970’s demonstrating
microbiologic specificity of disease
associated flora.
Diagnostic Parameters of NSPH
• No specificity of plaque is recognized
therefore no need to differentiate between
healthy or pathogenic plaque
• Diagnostic testing is limited to historical
factors such as examination, radiographs,
probing depths and inflammation scores
• Diagnosis consists exclusively of
description of anatomic factors
Treatment According to NSPH
• Historically evolved standard of care.
• Plaque must be thoroughly removed
continuously to maintain healthy gums.
• Failure to remove plaque will cause disease
process to continue.
• When disease causes bone loss and deep
pockets around teeth, surgery is used to
remove tissue to make hygiene easier.
Subgingival Curettage versus
Surgical elimination of
Periodontal Pockets
Ramfjord, Nissle, etal J Periodontol
v39 Issue 3 May 1968 167-175
1)A statistically significant gain in
periodontal attachment occurred
following curettage of deep
periodontal pockets.
2) Subgingival curettage was followed by
more favorable results than surgical
elimination of periodontal pockets.
3) Slight loss of attachment followed
surgical elimination of periodontal
pockets.
Comparison of surgical and
nonsurgical treatment of
periodontal disease
• Pihlstrom, McHugh etal J Clin Periodontol
1983: 10: 524-541.
• Pocket depth in shallow pockets (1-3mm)
did not change for either treatment.
• Pockets 4-6mm – both treatments resulted
in sustained pocket reduction.
• Deep pockets (>7mm) – no difference
between treatments after two years.
• Shallow pockets suffered sustained
attachment loss following flap surgery.
• Scaling alone resulted in sustained
attachment gain in 4-6mm pockets.
• Conclusions - scaling alone and scaling plus
surgery were effective – decisions for or
against surgery must be made on the basis
of individual patient considerations.
Long term effects of
surgical/nonsurgical treatment of
periodontal disease
J.Lindhe, E. Westfelt
J Clin Periodontol 1984: 11: 448-458
Sites with initial pocket depths greater
than 3mm responded equally well to
nonsurgical and surgical treatments based
on initial and multiple recall probing
depth, attachment level measurements.
It is suggested that the critical
determinant in periodontal therapy is not
the technique (surgical/nonsurgical) but
the quality of debridement of the root
surface.
Specific Plaque Hypothesis
• First scientifically developed standard
of care in periodontics.
• Only certain plaque causes infections.
• Diagnosis of anaerobic infection is
required.
• Microscopic and BANA analysis can
detect the statistical pathogens.
Healthy and infected plaque
Diagnosis With SPH
• All patients are screened.
• Pathogens are detected primarily with phase
contrast microscope and BANA assay.
• Anaerobic infection diagnosis is made.
• Progress is documented with follow-up
bacteriology.
• Diagnostic testing including culture and sensitivity
for nonresponsive patients “refractory cases”.
Why Do We Use Microscopy in
Diagnosis?
• Provides qualitative
analysis of bacterial
types and WBC
• Increases confidence
and accuracy of
predictive decisions
• Establishes
microbiologic end
points of treatment
• Enables formulation of
custom recall intervals
for maintaining treated
patients
• Microscopy provides
quick, inexpensive
results - up front cost
high due to equipment
cost
Treatment According to Specific
Plaque Hypothesis
• Diagnosis of anaerobic infection is used to
determine who needs treatment.
• Treatment is targeted towards elimination of
specific anaerobic bacteria from plaque healthy types are selected by treatment.
• Antibiotics are more successful when used
after debridement.
• Need for surgery is virtually eliminated.
Success of treatment assessed
using bacteriology
• Progress is documented by repeated
microbiologic screening.
• If patient still harbors anaerobic bacteria,
treatment is continued until they are
reduced.
Nonsurgical treatment of patients
with periodontal disease
Loesche, Giordano Oral Surg Oral
Med Oral Path Vol 81 No. 5 May
1996 pp533-542
References