Dental Care of the Future: Part I

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Dental Care of the Future Part I

• David J.Apsey, DDS
• www.futuredental.com
• 810-293-8750
• Email drdavid_at_futuredental.com

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Periodontal Disease - Changing the Paradigm

• Historical perspective - nonspecific plaque
  hypothesis (NSPH)
• Modern perspective - specific plaque hypothesis
  (SPH)
• Infectious disease nature of dental diseases

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We Used to Do Dentistry Like This!
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Now we know of a better way.
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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.

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Nonspecific plaque hypothesis has been
invalidated by data

• Invalidated by more than one hundred studies
  since 1970s demonstrating microbiologic
  specificity of disease associated flora.

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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

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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.

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Subgingival Curettage versus Surgical elimination
of Periodontal Pockets

• Ramfjord, Nissle, etal J Periodontol v39 Issue 3
  May 1968 167-175

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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.
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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.

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• Deep pockets (gt7mm) 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.

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Long term effects of surgical/nonsurgical
treatment of periodontal disease

• J.Lindhe, E. Westfelt
• J Clin Periodontol 1984 11 448-458

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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.
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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.

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Healthy and infected plaque
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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.

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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

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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.

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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.

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Nonsurgical treatment of patients with
periodontal disease

• Loesche, Giordano Oral Surg Oral Med Oral Path
  Vol 81 No. 5 May 1996 pp533-542

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References