Primary Preventive Dentistry 6th Ed. (2004)
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We do not examine for, or monitor incipient plaque disease. Streptococcus mutans. Answers and Explanations |
Question 4 Which of the following statements, if any, are correct? A. The Periodontal Screening and Recording system (PSR) aids in diagnosis and suggests treatment options commensurate with the severity of the patients' periodontal status. B. Chlorhexidine is used to suppress both cariogenic bacteria and periodontopathogens of the plaque. C. Disease guidelines attempt to standardize disease diagnosis and to suggest treatment options based on disease severity, yet allow for professional judgment. D. A nationally accepted guideline, i.e., one accepted by the American Dental Assocition, by state dental societies, by research authorities, dental school faculties, and by practitioners, would aid in improving uniformity of care and enhance the predictability of outcome of a disease process. E. Computer storage of data contained in the initial/annual dental examination record permits convenient downloading of a patient's oral health profile ("scorecard") based on disease severity; with another keystroke, a guideline for suggested treatment, patient education, and preventive dentistry options can be displayed. The Recall Appointment The recall appointment provides an opportunity for planned screenings and prophylaxes between annual examinations with the time interval being based on CAI and PAI findings at each successive recall. Philosophically, the recall period of high-risk patients should not exceed the time necessary for a pathogenic plaque to reform and to again allow its microbial population to damage the enamel, cementum, and/or gingiva. Once the pathogenic plaque is removed by prophylaxis, several studies have documented that it requires at least 3 months for the plaque to regain its disease-causing potentialeven though there may be minimal compliance with home care plaque control programs.157,158 Since plaque and time are the key factors in the development of both incipient caries lesions and gingivitis, each prophylaxis, by removing the pathogenic plaque, essentially resets the time clock of plaque pathogenicity back to near zero. There is a need for a flexible recall interval, based on the level of treatment need, as suggested in Tables 23-3 and 23-4. Others have indicated that the same periodic oral hygiene procedures and monitoring are effective in reducing the incidence of both caries and periodontal disease.116,159 If possible, the periodontitis and the caries maintenance visits should both be kept in synchrony on the same 3- to 6-month interval recall. In this way, a requirement for a 3-month recall for caries would aid in plaque prevention control for gingivitis, or vice versa, even though the risk of the other might be low. For example, fluoride applications for coronal caries would aid prevent root caries where the cementum is exposed. Chlorhexidine varnishes are effective in helping suppress both the cariogenic and periopathodontic bacteria. Finally a high-plaque index can provide a warning sign for either caries or periodontitis. The index should ideally be 10% or less. When the plaque score increases markedly, it should cause professional concern. Additional education and counseling, laboratory tests and indices, such as bacterial quantification for caries, and/or the bleeding index for gingivitis is indicated. Thus, the accomplishment of a plaque index at each recall can alert the hygienist about the possible existence of in situ and incipient lesions for either or both of the plaque diseases, while the accompanying prophylaxes can greatly aid in averting the initiation and progression of in situ and incipient lesions for both diseases. Recall programs can be easily handled by use of computer programs. With very little training, an office manager or dental assistant can enter changes in appointments and generate programmed recall notices that are automatically printed out for regular mailing or e-mailing appointment reminders. Such timesaving and improved administrative practices are essential, even in small dental practices. Carbohydrate Intake The carbohydrate intake index provides an easy method to assess a patient's intake of refined sugars, especially if the intake is high. This sugar intake score is based on the patient filling out a carbohydrate intake short form administered by the dental office personnel. As the frequency of intake, and the retentivity of the different sugary foods increase, so does the carbohydrate intake score (Appendix 23-2). The Dental Hygienist Primary-Prevention Specialist As a primary dental prevention specialist in the dental office, the dental hygienist is salient in insuring emphasis on prevention. Academic dental-hygiene education provides a comprehensive curriculum that includes, among other requirements, clinical participation in applying pit-and-fissure sealant use, remineralization therapy, fluoride applications, patient education and oral-health promotion, dietary counseling, prophylaxis, root scaling, root planing and subgingival irrigationall areas of expertise that are needed for an optimum plaque- disease prevention and control programs. Under a total immersion approach to prevention, the "tooth-cleaning" appointments required for high-risk patients should not be perceived as prophylaxes performed mainly for aesthetic purposes, but rather as part of a caries and/or periodontal disease prevention and maintenance program which will require longer appointment periods. Shallhorn and Snider160 and Pfeifer and Pfeifer161 found that it took approximately 53 and 57 minutes, respectively, to complete a recall appointment. The multiple appointments of individuals in these more intensive preventive programs will require additional hygienist time and responsibilitiesand compensation. Additional hygienists will probably be required as well as an assistant due to the increased patient flow.162 In turn, to administratively support the increased enrollment of patients in preventive programs, there should probably be one front desk individual who can act as an appointment coordinator to ensure that recall visits are scheduled, and followed up. If patient compliance with home mechanical and chemical plaque control instructions for caries and periodontal involvement has been adequate between visits, the treatment urgency level for the average patient should drop and remain at a low score. This possibility will permit additional patients to enter the preventive program to maintain a full and expanding schedule for the office dental-hygiene sector. Patient Education Traditionally, dentistry has been considered a treatment-oriented profession. The concept of going to the dentist to prevent disease is mainly associated with a twice-a-year prophylaxis and the use of fluorides. Probably the best way to start in the changeover from a treatment to prevention orientation is to conduct a separate appointment for dental education and promotion devoted to the patient's own problems as identified at the initial/annual examination (Appendix 23-3).163 Like the annual medical examination and evaluation, this period should have a fee. It is essential to enlist the patient as a "co therapist" if a home prevention program is to be a success. For patients to assume this role, they need to know what is expected, how it is to be accomplished, why it is necessary and how much it will cost. This is the same information as is required as part of informed consent At the end of the session, the patient should fully realize that he or she is at risk, but that the plaque diseases can often be prevented or reversed as a result of recommended therapy. As a part of medicine's "one third rule," one third of all patients with chronic disease can be expected to comply with instructions, one third to comply erratically, and one third not to comply at all.164 It is also necessary to inform the patient that all treatment eventually fails without a wholehearted and effective self-care commitment. Only the patient can decide whether he or she wants to pay to prevent diseaseor to accept disease and pay for more expensive treatment. If the patient continually fails to comply with instructions, it is expedient to document a warning advisory in the dental record to counter any possible future legal repercussions.165 One individual from the dental office should be selected to carry out the main thrust of the education program. The person selected should be a dental hygienist or a health educator. The main attributes desired are that the person be mature, intelligent, and compassionate; has leadership ability; likes people; is persuasive; has the ability to improve on the daily presentations; and has the flexibility to adapt presentations to meet each patient's needs and attitudes. The entire education session can be facilitated by focusing on the "scorecard" listings for the CAIs and PAIs, especially when the Treatment Urgency level is above 2. At this time, the importance of plaque control can be introduced, using edited portions of the video camera tape to show the location and extent of plaque in the patient's mouth. The carbohydrate-consumption questionnaire previously filled out, becomes much more meaningful when discussed in context of the acid-producing capability of the bacteria in the patient's plaque. The need for laboratory tests to determine the number of acid-producing bacteria in the patient's saliva becomes equally consequential when it is made clear that the risk of decayed teeth increases as the number of acidogenic bacteria increases. As stated by Krasse, "To run a caries preventive program without using microbiological methods is like running a weight control program without a scale."166 Finally, the relationship of these CAIs to in situ, incipient or overt caries lesions can be related to the demineralization that occurs between the times of tooth health to tooth cavitation. This backdrop then provides the basis for introducing and discussing the "guidelines" for customized preventive strategies for the patient's own treatment urgency level. At this point, probably the two most important subjects related to caries prevention and requiring discussion with a patient are: (1) the need and advantages of having sealants placed in all "sticky" fissures; and (2) the need to consider all incipient smooth surface lesions (without evidence of cavitation) for remineralization therapy and careful monitoringnot restorations. The advantage of these two exceedingly important prevention actions are not generally known and understood by the public, nor actively promoted by the profession. Plaque-induced gingivitis is the most common form of periodontal disease.123 All patients should be cognizant of the fact that "pink toothbrush" is an important warning sign of gingivitis that can be self-diagnosed. If not cleared up within a week by more vigorous self-care efforts at home, an immediate visit to the dental office is indicated. A combined professional and self-care program is usually all that is necessary to return the gingival to normal. On the other hand the neglect of this critical early stage of gingivitis creates an environment in the gingival sulcus that favors a more pathogenic flora. Intermittent episodes of gingivitis at a younger age increase the risk of a later periodontitis.167 The data acquired as part of the initial/annual dental examination as summarized in the "scorecards" and guidelines can form the basis for individualizing the educational presentation. The integration of all these subjects should make the educational phase for each patient much more motivational and longer lasting than an abstract discussion of preventive dentistry. Education of the Professionals There is a need for the dental professionals to manage caries to the maximum extent possible by using non-invasive preventive measures. Both smooth-surface and pit-and-fissure lesions are preventable and reversible. Certainly, the restorative approach to caries control has not been successful, especially for those individuals without funds nor access to dental careboth in the United States and especially in nations without the resources of the United States. In the past, few dental schools provided courses in primary prevention that rival those of secondary and tertiary preventive dentistry in terms of time, money, staff and commitment. In 1989, in an editorial in the Journal of Dental Research, Thylstrup identified two major reasons that the benefits of prevention are not universally available. First, dental schools do not yet inculcate in their students the importance of preventing disease. Second, and probably, most important, no reward is given for the prevention or reversal of ongoing plaque diseases which have been proved reversible.78 Anusavice has added another reason that appears as innocuous as it is important, viz., "^ "88 Until the smooth surface and occlusal sites of incipient caries are identified and recorded for priority care, little non-invasive remedial action will occur for these pre-caries lesions. Until CAIs and PAIs as well as summarizing "scorecards" for caries and periodontal disease appear as part of the clinical record, there is no organized format to present each patient with individualized invasive and non-invasive preventive and treatment options. Two other reasons might be cited. The first is the fact that many of the older dentists find it difficult to accept the concept of remineralizing pre-caries lesions seen as radiolucent areassites that in former dental school days were considered as diseased tissue that must be restored. Concurrent with this viewpoint is the fact that once a "white spot" develops, there is an over-estimation of the velocity of caries progression through the enamel and dentin.168 Now it is realized that caries advances over a greatly varied time span that can range from months, years or to reversal.108 Equally important is the fact that the advancing front of the incipient lesion can probably be remineralized until it has, according to Scandinavian studies, advanced to half way through the dentin, i.e., if cavitation has not occurred before reversal takes place.108 In evaluating Thylstrup's charge that the preventive care curriculum in dental schools is truncated, the ADA's Survey of Curriculum Clock Hours of Instruction is enlightening. In the 1997-98 school year, U.S. dental schools devoted a mean of 66 hours of curriculum time to prevention. Didactic instruction on prevention included mean of 93 hours out of a mean of 5228 hours in U.S. dental schools' curriculaor approximately 2% of the time.169 In addition, the ADA's Accreditation Standards require that "graduates are competent in providing oral health care within the scope of general dentistryincluding health promotion and disease prevention."170 In a 1999 questionnaire, Yorty et al. detailed some of the ongoing preventive initiatives being conducted in the dental schools. Forty-two of the fifty-five dental schools (76%) responded to the polling. Not all the queries were answered uniformly. Eighty-one percent reported having formal risk training programs, with 38% having criteria for low-, moderate-, and high-risk patients. Sixty-two percent had developed specific recall schedules based on that risk. Two-thirds of the respondents (17/25) consider the option of remineralizing or sealant placement for early primary (incipient) lesions. Thirty-seven of the schools indicated that the level of penetration of the caries front before restoration, was the outer one-third of the dentin.171 Clearly, this study portends a trend towards a more conservative (preventive) approach to clinical dentistry.171 Economics can be a potent factor in changing health attitudes for both a patient and the professional. There is an acute need for a reasonable reimbursement to dentists and dental hygienists practicing preventive dental care, the same as is expected for dental treatment. The idea of purchase of good oral health is alien to Americans who have traditionally accepted restorations, extractions, and prosthetic devices as a means to cope with dental disease. The public expectations and demand for preventive dental care must change if the profession is to move into an era in which prevention replaces a need for restorations. In these opening years of this new millennium, the profession must prepare the public and itself for their new roles of dental prevention and full dentulism. Clinical methods now exist to identify, arrest, or reverse the incipient plaque disease lesions that are precursors to overt lesions. It should be so easy to move the focus of dentistry to the practice of dentistry in this direction. The difference between prevention and treatment is simply an intact tooth, a restored tooth, or no tooth. Implementing Preventive Programs There are six major treatment environments in which the aforementioned intensive preventive routines can be implemented immediately: (1) private practice environments, (2) military dental services, (3) public-health clinics, (4) public school dental programs, (5) industrial work sites and (6) dental-health maintenance organizations. In each instance, the strategies for reducing the incidence of both of the plaque diseases, involve few changes in clinical physical facilities or in daily operating routine. Only a demonstration of leadership and a commitment to primary prevention is needed to identify and reverse the risk factors of impending plaque disease, rather than limiting the examination to a search for and treatment of pathology. In the military, the economics of change from treatment to prevention should pose no major problem since appropriated funds are already available for dental care. In other dental settings, additional insurance and personal or public funds are initially required. However, a drastic reduction of later expenditures for the restoration of primary and secondary caries lesions, tooth fractures, periodontal treatment, endodontics, extractions, bridges, and dentures would soon compensate for the increased outlays from any of aforementioned sources. In private practices, it could lead to contracts to prevent, rather than treat dental disease The Immunity Factor In 1960, Keyes172 and Fitzgerald and Keys173 demonstrated that S. mutans caused caries in rodents. Once it was established that caries was an infectious disease, it was realized that caries might be controlled by use of vaccines. Several institutions in the United States and England were already accomplishing vaccine research. There was the prediction that a vaccine would be available within 3 to 10 years.174 In 1979 Cohen reported on a 9-year study where two actively immunized monkeys had zero and a small lesion respectively, whereas the three surviving control animals exhibited 56,69 and 73 decayed surfaces.175 The 3- to 10-year time-table was not realized for one major reason, viz., it was suggested that with active immunity, there might be a cross reaction with heart muscle.176 With that possibility, (1) even if a vaccine was developed, there was no assurance it would be accepted by the Food and Drug Administration (FDA). Even if approved by the FDA, potential manufacturers were wary of possible huge lawsuits.177 Besides, caries was on the wane in developed countries and there appeared to be no urgency to risk major problems since caries was not a life-threatening disease. Much of the research stopped or slowed. Anticipation turned to disappointment. However, in Guys Hospital in England, the search was continued to develop a topically applied passive vaccine against Streptococcus mutans. This would by-pass the major problem of cross-reactions. Every dentist should read the delightful easy-to-read article by JK-Ma.178 It is a fascinating account citing some of the problems and successes that were encountered by the Guy's Hospital group over the past 20 years on the way to a prototype dental caries vaccine. The test vaccine has already successfully passed animal and a small-scale human tests. It is now in a Stage II test program with a larger number of subjects. The initial test answered two crucial questions, viz, (1) it is possible with the vaccine to suppress Streptococcus mutans (SM) and (2) to prevent caries. The vaccine is topically applied to the teeth, a process called local passive immunization, thus eliminating the possibility of involving the body's immune system. The antibody that has been developed by genetic engineering has targeted the adhesins responsible for the attachment of Streptococcus mutans (SM) to the tooth. The development of the antibodies is a fascinating story in itself. In assembling the desired antibody by genetic engineering, it required four successive critical successes to develop the final antibody with the correct configuration to duplicate that of the human antibody. The amazing part of the genetic assembly process was the fact that each phase of the more-and-more complex antibody, was accomplished using the lowly tobacco plant that cannot ordinarily be induced to produce mammalian antibodies. Once developed, the continual harvesting of the plant seeds insured the perpetuation of future crops of tobacco plants, with each generation duplicating the original created antibody configuration. This plant biotechnology supplied an economical and reliable source of antibodies needed for the study. The preparation of the mouth for application of the vaccine was also ingenious. A two-week mouth rinse program using chlorhexidine was sufficient to clear the mouth of most ^ If no further action was taken at this time, the mouth was quickly repopu-lated with SM. However, if the vaccine was applied to the acquired (salivary) pellicle of the teeth, this repopulation did not occur. It is estimated that this passive immunity would possibly last from three months to a year. To increase the universal value of these antibodies, studies are being conducted as to the feasibility of incorporating them into dentifrices and mouthrinses.178,179. A possible dental caries vaccine for the future? Remember, we are now in the beginning of the 21st Century. Question 5 Which of the following statements, if any, are correct? A. The twice-a-year prophylaxis is adequate in helping to prevent, arrest, and reverse the progress of either of the plaque diseases. B. The plaque is an etiologic factor for both caries and periodontal disease; therefore, a prophylaxis at appropriate intervals and recorded observations for PAIs and CAIs should greatly help to prevent, arrest, or reverse both plaque diseases. C. Remineralization of overt carious lesions is a common practice in Scandinavia. D. The cost of primary prevention to prevent one overt plaque-disease lesion can save a much greater cost of later successive secondary- and tertiary- prevention procedures. E. Mammalian antibodies can be duplicated in plants. Summary By definition, if all incipient caries and all incipient periodontal lesions could be prevented, arrested or reversed in the incipient stages, there would be no overt lesions to treat. In order to approach this goal for all people, it will probably require an active public-health immunization program of the immensity and intensity that characterized smallpox elimination. We have not yet reached that point of dental disease suppression; however, the completion of the Human Genome Project does greatly enhance that possibilitynot only for dental disease but for all infectious and genetic diseases. At the present time, the ravages of the dental plaque diseases can be greatly minimized for those individuals who have access to a dental facility, and the commitment to comply with a dental prevention and treatment programs established by a dentist. Guidelines would help establish a level of excellence and uniformity for both treatment and prevention intervention. When called upon, it is the responsibility of the dentist to examine, detect and performor delegatethe necessary primary and secondary procedures necessary to assure maximum patient dental health in the present and in the future. The initial/annual examination is a most important event in attaining these objectives. Here it is possible to simultaneously identify and record treatment and preventive needs, establish present risk level, specifically focus counseling and education addressing patients' specific needs, as well as making recommendations for home care. Empirically, the home care involves daily oral-hygiene procedurestoothbrush (with fluoride toothpaste), dental floss, irrigation and supplemental mouthrinses recommended or prescribed by the dentist. The two most useful mouth rinses in the dentist's armamentarium are fluoride to increase tooth resistance and enhance remineralization, and chlorhexidine to suppress Streptococcus mutans, help cure gingivitis, and as an adjunct for treating periodontitis. If a short-time passive vaccine does becomes available, it will be a major step towards a lifetime of intact teeth for those who have routine access to dental care. By the end of the initial treatment cycle, all overt lesions should be restored; all incipient smooth and root surface lesions should be undergoing remineralization therapy; all necessary sealants should be in place; and, all gingivitis should be under maintenance control. Also, by this time, the patient should have the knowledge and understanding to participate with the oral-health professionals in a team effort of self-care. The outcome of such a comprehensive, integrated, and personalized plaque disease prevention program involves the participation of the entire office team plus the compliance of the patient. As a result of such a controlled prevention and monitoring program, there should be an early dramatic reduction in the incidence of the plaque diseases and their sequelae. This is as it should bethe hallmark of the dental profession should be oral-health maintenance and enhancement, not just disease treatment. ^ 1. D, Ecorrect. Aincorrect. A "white spot" can occur on any surface; however, it cannot be visually observed on every surface. For instance, it cannot be seen at the bottom of pits and fissures. It is usually first observed as a radiolucency in x-rays of the interproximal surfaces. Bincorrect. The incipient stage begins as a "white spot" and continues until there is surface cavitation, which by definition is an irreversible overt carious lesion. Cincorrect. The in situ stage of gingivitis is characterized by an infiltration of body defense cells beneath the sulcular epithelium. 2. A, C, D, Ecorrect. Bincorrect. The opposite is true. Much less x-ray energy is required for the DXR images than with the intraoral film. 3. A, B, D, Ecorrect. Cincorrect. While "white spots" are a translucent white, once remineralized, they usually take on the hue of the enamel. 4. A, B, C, D, Ecorrect. 5. B, D, Ecorrect. Aincorrect. The twice-a-year prophylaxis is adequate for the majority of people; however, there are many who could benefit from a more frequent schedule. In other words, the interval between prophylaxes should be flexible and be based on risk. Cincorrect. Remineralization can only occur BEFORE the overt caries lesion stage. Self-evaluation Questions 1. The two stages of caries development, prior to the overt lesion development are _________ and _________; the two stages of periodontal disease prior to periodontitis are _________ and _________. 2. Three advantages of the intraoral videocamera are: _________, _________, and _________. 3. Three advantages of the digital X-ray are: _________, _________ and _________. 4. List five reasons for having the problem of false-negative or false-positive diagnoses for caries: _________, _________, _________, _________ and _________. 5. How does a sealant prevent caries on the occlusal surface? _________. How does a sealant arrest early caries on the occlusal surface? _________. 6. Define substantivity: _________. Give an example of the agent in a mouthrinse with this attribute: ___________. 7. Give the reason why patients are not demanding remineralization therapy instead of restorations (YOUR evaluation). 8. Why do you believe, or not believe that a vaccine can be developed for periodontal disease? References 1. Barakow, F., Imfeld, T., & Lutz, F. (1991). Enamel re-mineralization: How to explain it to the patients. Quint Int., 22:141-7. 2. Brecx, M. C., Schlegel, K., Gehr, P., & Lang, N. P. (1987). Comparison between histological and clinic parameters during human experimental gingivitis. J Periodontol Res., 22:52-7. 3. Von der Fehr, F. R., Loe, H., & Theilade, E. (1970). Experimental caries in man. Caries Res., 4:131-148. 4. Nelson, A., Pitts, & N. B. (1991). The clinical behavior of free smooth surface carious lesions monitored over 2 years in a group of Scottish children. 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Characteristics of a recombinant plant monoclonal secretory antibody and preventive immunotherapy in humans. Nat Med, 4:601-6. 0.140625 Copyright © 2004 by Pearson Education, Inc., Pearson Prentice Hall. All rights reserved.  (+/-) Show / Hide Bibliographyهذا الكتاب بدعم من الشبكة الاسلامية للتعليم المجاني شبكة الجامعة الاسلامية التعليمية free.........free.....Univesity Welcome to the Islamic Univesity Medical Books/Dental Books/ Engineering Books www.allislam.net  Working...×  0 Copyright © 2004 by Pearson Education, Inc., Pearson Prentice Hall. All rights reserved. (+/-) Show / Hide Bibliography |
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