Trisha E. O`Hehir, RDH, BS
A two-day symposium titled, "Frontiers in Clinical Dentistry, Caries, and Perio-dontal Disease - Risk, Health, and Prevention," was sponsored by the University of Washington last May. The symposium was promoted as the "future of dentistry." Many distinguished speakers from the United States and abroad presented the latest scientific information. Panel discussions stimulated questions and participation from the audience.
Despite many interesting presentations, very little time was devoted to prevention. This point was eloquently captured in a statement by Dr. Nigel B. Pitts of Scotland`s University of Dundee when he said, "...dentistry is obsessed with technical rehabilitation." Dr. Pitts made a plea for caries prevention, pointing out that, while caries rates diminished during the past few decades, the rates have now stabilized and are no longer reducing. People at high risk for caries need to be targeted, Dr. Pitts urged, rather than the "average" person. Caries prevention should focus on high-risk groups as well as "population" approaches.
A question from the audience asked who should take responsibility for prevention. Dr. Chester W. Douglass from Harvard University answered that question. I`ll paraphrase his response, "...this is a perfect opportunity for dental hygiene to step up and take responsibility for prevention."
I nearly cheered, but I managed to restrain myself! There were no other comments from the panel on that question. Dr. Douglass had said it all. Seems dentistry has enough to do with restoration and rehabilitation; there was little or no interest in discussing prevention.
In all fairness, I must point out the commitment and dedication of public-health dentists to prevention. Their voices were hard to hear at this symposium due to the excitement generated by new materials and restorative techniques.
I`ll share a few of the interesting points covered in the symposium.
In many countries of the world, topical fluoride seems to be more popular than systemic fluoride. Despite the systemic nature of fluoridated water, it also has a topical effect. This effect is not direct, but through saliva. It seems ingested fluoride is released through saliva, thus bathing the teeth in high levels of fluoride. For this reason, saliva turns out to be one of the best remineralization solutions!
Remineralization of decalcified enamel was discussed as a revolutionary new idea, which surprised me! It has been years since I`ve treated kids, but way back then we were recommending daily topical fluoride use at home to remineralize incipient lesions.
The reason this was presented as a paradigm shift for dentistry had more to do with dental school curriculum than clinical practice. It seems this is one of those things that is part of everyday practice but not part of undergraduate dental education. As with so many things first discovered in practice, research takes a while to catch up.
Studies done in the 1950s and 1960s to evaluate the effectiveness of fluoride measured areas of decalcification as well as actual caries. When the researchers examined the kids a number of months later to see if the rate of caries had changed, they couldn`t find all the decalcification spots recorded at baseline. The assumption at that time was that the baseline examiners had made mistakes - not that fluoride had remineralized so well that the lesions were no longer detected. If an area of decalcification was not now visible, it couldn`t have been there at baseline. It took several decades, but remineralization has now been scientifically documented and will be included in dental school education.
Not yet available, but moving closer to reality is the potential to genetically engineer enamel. This would become an ideal restorative material.
Risk factors associated with periodontal diseases were also discussed. Smoking is a risk factor serious enough to overcome genetic protection. In other words, a person who is lucky enough to be quite resistant to periodontal disease can cancel out that protection with smoking. Dr. Panos N. Papapanou, originally from Greece but now teaching at Gothenburg University in Sweden, stated that a cost-benefit analysis would suggest that putting all our energy and money into smoking cessation programs would have a far greater impact on controlling periodontal disease than everything we do currently. The latest findings linking periodontal infections and systemic conditions were highlighted. The speakers stressed the fact that links and associations have been found, but as of yet, no direct cause and effect have been established.
U.S. leaders in the area of low birthweight and cardiovascular disease are Dr. Steven Offenbacher and Dr. James Beck. These two researchers were the only speakers in this ONew FrontiersO symposium to make use of computer-driven presentations, which were quite impressive. They have definitely moved into the next millennium.
It seems the fetal membrane is the target for bacteria and substances associated with periodontal disease. Bacterial vaginosis can lead to transmission of bacteria into the placenta. Bacteria associated with periodontal disease are also linked to bacterial vaginosis. Governmental agencies want to mandate the use of antibiotics to treat both vaginosis and periodontal disease in pregnant women. No prevention, just antibiotics. No decision has yet been made on such a mandate.
Inflammatory mediators associated with periodontal disease have been shown in an animal model to result in 20 to 25 percent reduction in birthweight. The first link was seen with prostaglandin, which is produced during periodontal destruction and is coincidentally also used to induce labor. Recent findings have shown tissue necrosing factor (TNF) and interluken (IL), both associated with increased periodontal disease, to cause problems in pregnant animals. We will see many more studies in this area in the next couple of years as researchers in both medicine and periodontics collaborate.
The link between periodontal disease and cardiovascular disease was also discussed. These studies take a great deal more time than those dealing with birthweight. However, large scale studies have demonstrated a strong link. In these studies heart disease and death from heart disease were linked to men with periodontal disease.
New findings relating stress to periodontal disease have shown the release of stress-related hormones in gingival crevicular fluid, thus providing nutrients for the pathogens.
Genetic investigations are also being done in the area of periodontics. Having identified a genetic marker for inflammation, this research will continue to uncover interesting information. Not only will genes be identified, but genetic manipulation may lead to disease prevention.
Trisha E. O`Hehir, RDH, BS, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics.The Web site for Perio Reports is www.perioreports.com. Her e-mail address is trisha @perioreports.com.