1. Dental Care of the Future: Part I David J.Apsey, DDS www.futuredental.com 810-293-8750 Email: drdavid@futuredental.com

2. Periodontal Disease - Changing the Paradigm Historical perspective - nonspecific plaque hypothesis (NSPH) Modern perspective - specific plaque hypothesis (SPH) Infectious disease nature of dental diseases

3. We Used to Do Dentistry Like This!

4. Now we know of a better way.

5. 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.

6. 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.

7. 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

8. 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.

9. Subgingival Curettage versus Surgical elimination of Periodontal Pockets Ramfjord, Nissle, etal J Periodontol v39 Issue 3 May 1968 167-175

10. 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.

11. 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.

12. 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.

13. Long term effects of surgical/nonsurgical treatment of periodontal disease J.Lindhe, E. Westfelt J Clin Periodontol 1984: 11: 448-458

14. 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.

15. 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.

16. Healthy and infected plaque

17. 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”.

18. 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

19. 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.

20. 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.

21. Nonsurgical treatment of patients with periodontal disease Loesche, Giordano Oral Surg Oral Med Oral Path Vol 81 No. 5 May 1996 pp533-542

22. References