New Treatments Hold Perio Promise
By David G. Jones
Bacteria lurking below gumline and creating havoc for periodontal health soon may be
consigned to the microbial scrap heap, because dentists have some new, more potent
weapons to battle periodontitis.
Three recently adjunctive treatments recently approved by the Food and Drug Administration
hold promise for interceding against the condition which affects about 20 million Americans.
Periostat, Atridox, and PerioChip are now part of the arsenal in the fight against gum- and
bone-destroying bacteria and its after-effects. The therapies, considered an adjunct to scaling
and root planing, appear on the market during a surge of interest in suspected links between
periodontal disease and increased risk of heart attack and stroke.
"We're going to discover more relationships between oral and systemic disease," says Dr.
Daniel M. Meyer, associate executive director of Science for ADA. "So this is one of many
things to come down the pike to address that."
Two of the new treatments, PerioChip and Atridox, work by delivering anti-microbials to the
patient's periodontal pocket. Periostat works by blocking the body's natural response to
periodontal disease, resulting in oral tissue destruction.
Dentists can prescribe Periostat in pill form as the first drug approved to treat the body's
response to gum disease, rather than directly fighting the bacteria that has already
accumulated on teeth. The pill, developed by Collagenex Pharmaceuticals, Inc., of Newton,
Pa., contains a low dose of the antibiotic doxycycline hyclate, which blocks the body's
natural response to periodontitis. Periostat works by suppressing the bone-destroying enzyme
collagenase, produced by the body in response to oral bacterial infection. Collagenase fights
the infection, but also breaks down collagen, a protein found in healthy teeth and gums.
Atridox is a site-specific anti-microbial delivery system intended for use in the non-surgical
treatment of chronic adult periodontitis. Developed by Atrix Laboratories, of Fort Collins,
Colo., Atridox involves applying high doses of doxycycline directly into periodontal pockets.
It then forms a gel that solidifies in the pocket's shape, releasing the antibiotic during a
weeklong period as it is absorbed.
PerioChip, which like Atridox is biodegradable, is manufactured by Astra Pharmaceutical in
Westborough, Mass. It is a firm gelatinous strip soaked with the antibiotic chlorhexidine and
placed directly into periodontal pockets greater than 5mm deep. The strip dissolves in about
a week while it administers the antibiotic.
Meyer stresses that dentists want more detailed studies of the drug's long-term effects, and
patients must still properly brush and floss to help fight the bacteria that cause gum disease.
"But," he adds, "these new treatments have the promise of slowing down the disease."
Gerald J. Pieroni, DDS, president of the California Society of Periodontists, says the
products would be appropriate for certain uses, but may have some limitations.
"For instance, these products are basically the second or third generation of anti-microbials
delivered in pocket settings, or in the case of Periostat, in pill form," he says. "Studies that
came out during the first six months of use of the previous generation of products was very
favorable, but after the first year the majority of the cases returned to or near their original
preoperative condition."
Pieroni also says fair assessment of the new products can be made only after a track record
is established during a year or two of their use.
Steven G. Detsch, DDS, a periodontist and chairman of CDA's Council on Research and
Developments, says that while the antibiotic effects of the newly approved treatments is well-documented, there is a downside.
"Over time, because of the increasing use of antibiotics, some pathogens have become
resistant to tetracycline and its derivatives," he says. "The anti-collagenase effect (in
Periostat) will always be present, but you stand the chance of developing 'superbugs.' This is
like any other tool -- in the right hands it is great. With the wrong bug in the wrong place,
though, it can cause problems."
Detsch says dentists don't normally do microbial testing, so general practitioners may not be
able to do a culture insensitivity test every time they use the doxycycline on patients.
But he adds that "there will be cases where its use would be indicated where other forms of
standard therapy were not effective."
Pieroni says dentists contemplating use of the new products should provide full disclosure of
additional therapeutic needs to the patient and to weigh expected results against the
limitations.
"We would just want anyone considering their use to realize they may not be a panacea," he
says.
In Search of Cyber-Snickers
Dentists always need the facts, but sometimes they just want to have fun.And just as many web sites offer important information about dentistry, some also offer a bit of humor. The following sites address the lighter side of the profession:
* The "Virtual" Dental Center at www-sci.lib.uci.edu/HSG/Dental.html has oodles of links to a variety of dental sites with an odd assortment of unrelated links thrown in. One can find just about anything there, from dental literature search engines to the current time in Singapore.
* For a good listing of dental resources and news groups for dentists, check out indy.radiology.uiowa.edu/Beyond/Dentistry/boards.html.
* Dental Cyberweb at www.vv.com/dental-web offers original articles, case studies and newsletters for dental professionals as well as virtual education opportunities and links to other dentistry-related sites. While there, be sure to visit tales from the dental crypt.
* Good (to some) jokes can be found at Entertainment at gbsystems.com/ingles.htm. That site also features scientific articles, classified ads and information about dental associations. Much of the information is in Spanish.
Other sites that offer general information for dentists and also have a substantial number of links include www.dental-resources.com, a service of Proctor & Gamble, and www.dentalsite.com/dentists/.
(Mention of a web site does not imply endorsement by the Journal of the California Dental Association. All of the web addresses listed were active and accurate at the time of publication. However, because of technical considerations and other factors, links may change.)
Young Drinkers May be in Your Chair
The use of alcohol is so pervasive in society that attention to its use by young people has not
drawn attention comparable to that given to smoking, except possibly when a college student
dies during a fraternity hazing, writes H. Barry Waldman, DDS, in the May-June issue of
the Journal of Dentistry for Children.
Trying to "fit in" was the reason most often given by elementary schoolchildren to explain
their use of drugs and binge drinking (five or more drinks in a row at least once in the past
two weeks). According to Waldman, in 1996, by eighth grade, one of four children had used
alcohol in the past month. Fifteen percent had binged.
Among family factors that lead to alcohol use by children, Waldman cites both poor family
management practices -- including failure to set clear expectations for behavior, lax
monitoring of children and excessively severe and inconsistent discipline -- and low bonding
to family. Drinking by parents also has been linked to an earlier age of alcohol drinking by
children.
How does all this relate to pediatric dentistry? Waldman reports that 5.9 million 12- to 17-year-olds indicate they are heavy alcohol drinkers. Many children in dental operatories may
use alcohol, Waldman notes, and may have been drunk the previous night and may still have
a hangover.
Pediatric dentists must extend patients' medical and family history review formats by taking
into consideration the changing environment within which their young patients live. Alcohol
now must be included in history reviews, he notes.
"We cannot assume that the 9- and 10-year-olds (and their parents 'in the best of families')
are not heavy or binge alcohol drinkers," Waldman says.
Dental Personalities: It's No Contest
Researchers at the Creighton University School of Dentistry, in Omaha, Neb., have determined there is little difference between personality types of general dentists and dental specialists, according to a study published in the Journal of the American Dental Association.The researchers analyzed surveys completed by 472 dentists who graduated from the Creighton University School of Dentistry between 1964 and 1984. Researchers used the Myers-Briggs Type Indicator, a psychological measure designed to determine personality preferences, learning behavior and management styles to assist with career choices. Previous research using the MBTI on medical specialists found several correlations between personality types and choice of medical specialty career.
The researchers found that 23.4 percent of general dentists and 20.9 percent of specialists are most likely to fall into the ISTJ category -- people who are introverts, sensing types, thinkers and judgers.
ISTJs also can be described as people who prefer to work alone and need quiet to concentrate; prefer established procedures and standard methods for resolutions, use logical analysis, are task-oriented and prefer to develop, schedule and implement plans.
The Creighton researchers also found that almost 14 percent of general dentists and 14.3 percent of specialists fit into the ESTJ category -- extroverts, sensing types, thinkers and judgers.
The third most common category among general dentists and specialists is ISFJ, or introverts, sensing types, feelers and judgers. Researchers concluded that once an individual has selected dentistry as a career, personality characteristics are not a significant variable regarding the type of dentistry performed.
Say What?
Listening is a key element in communication and people skills, and most people listen to respond, not to understand.
According to an article in the October issue of the Journal of Dental Technology, a good listener hears not only the words, but also the pace and the tone of the conversation. Poor listening skills can lead to misunderstandings, hurt feelings, arguments and problems in one's practice.
How good a listener are you? The following test might offer a clue. Answer each of the following questions by putting U for usually, S for sometimes, or SE for seldom ever.
* When you talk with another person, do you . . .
1. Look directly at the individual?
2. Watch the individual while listening?
3. Decide from the individual's appearance and delivery whether he has something important to say?
4. Listen primarily for ideas and underlying feeling?
5. Determine your own biases, if any, and try to allow for them?
6. Keep your mind on what the other person is saying?
7. Interrupt immediately if you hear a statement you feel is wrong or that you don't like?
8. Ensure that you've considered the other person's point of view before answering?
9. Try to have the last word?
10. Make a conscious effort to evaluate the logic and credibility of what you hear?
11. Ask questions after you have heard the other's point of view to show that you understand what they have said?
Your Scores:
On questions 1, 2, 4, 5, 6, 8, 10 and 11 give yourself:
* 10 points for each answer of Usually
* 5 points for each answer of Sometimes
* 0 points for each answer of Seldom Ever
On questions 3, 7, and 9 give yourself:
* 10 points for each answer of Seldom Ever
* 5 points for each answer of Sometimes
* 0 points for each answer of Usually
If your score is:
* 110 -- You are a good listener.
* 109-85 -- This is acceptable, but you could improve.
* 84 or less -- You definitely need to work on your listening skills.
Becoming a good listener has many benefits -- personal, social and professional. Much miscommunication can simply be the result of not listening to others. And if you expect others to listen to you, you must become a good listener yourself. If you are not a good listener, the people talking with you feel that you are disinterested. Then, when you wish to inform them or give directions, they may refuse to listen. You know how it feels when you talk to your employees and they look as if they are not paying attention. So to communicate better, you have to become a responsible listener.
This article appeared in its entirety in the October 1998 issue of the Journal of Dental Technology, the official publication of the National Association of Dental Laboratories.
Healthy Smiles For Everyone
Keeping a healthy smile poses special obstacles for children and adults with physical or mental handicaps that inhibit adequate brushing and flossing.For many people, tasks that most people can accomplish easily -- such as brushing and flossing -- require complete concentration or special assistance. But according to a report by the Chicago Dental Society, adults and children who have a physical or mental handicap have a greater risk of developing dental problems such as tooth decay and gum disease.
Some factors are dietary. For example, an inability to chew adequately may mean that some people need to consume food that is pureed. The carbohydrates in these foods can stick to teeth and promote cavities. Other disabled people must eat frequent, small meals which increase exposure of teeth to cavity-causing acids. Other disabled people take medications that include large amounts of sugar to make them taste better. The sugars promote tooth decay.
Combine those problems with the fact that many disabled children are unable to brush or floss their own teeth. Individuals who have spinal cord injuries, muscular dystrophy, multiple sclerosis or cerebral palsy have limited dexterity. Older people who have suffered a stroke or have arthritis have difficulty brushing. People with mental retardation or Alzheimer's disease do not remember to brush regularly.
In many cases, health professionals, home care providers, or family members can help provide the appropriate dental hygiene tasks. The following suggestions may help people to brush and floss without assistance:
* Attach the toothbrush handle to the person's arm with a wide elastic band.
* Enlarge the toothbrush handle by enclosing it with a sponge, bicycle handle grip, or by sticking the handle of the brush through a pliable rubber ball. Lengthen the toothbrush handle with a piece of wood or plastic such as a ruler or wooden tongue depressor.
* Bend and mold the toothbrush handle by running hot water over the handle -- not head -- of the brush.
Many disabled people should consider switching to electric toothbrushes because they are easier to operate and are thorough. Disabled people also can use floss holders and even electronic flossers that are reaching the market.
An Oasis of Development
Significant strides in the fields of dentistry and dental surgery have been made by Arab
doctors and surgeons, notes an article in Arab Dental News, by Dr. Mohamed Bitar, a dentist
who practices in Beirut.
The lead story of the publication reminds readers of the contributions Arabs have made in the
dental professions, which are documented in Western texts that focus on the history of the
profession.
Perhaps the greatest contributions were made by Abu-al-Qasim Khalaf ibn-Abbas al Zahrawi,
known as Albucasis, who lived in the 10th century and is recognized as one of the first
important oral surgeons. Albucasis understood that calculus on teeth is a major cause of
periodontal disease and he created explicit instructions for scaling using instruments he had
designed.
Albucasis advised that one should be very slow in deciding to remove a tooth, "as this is a
very noble organ, the want of which cannot in any way be perfectly supplied." He cautioned
that patients who have toothaches should carefully determine which tooth was at fault, since
often a patient is deceived by pain and asks to have removed what proves to be a sound
tooth.
Albucasis also noted that when teeth are missing they should be replaced with artificial ones
made of ox bone and splinted to sound teeth.
Other significant contributions were made by the following pioneers who lived in the
same time frame:
* Abu-Bakr Myhammad ibn-Zakariya al-Razi (841-926), know as Rhazes, wrote many
books, but his greatest achievement was "Kitab al-Mansuri," a survey of Arabic dentistry
from the 7th through 10th centuries. The survey is probably the first book since ancient times
to discuss dental anatomy in detail. Rhazes identifies not only the individual teeth but the
mode of action of the mandible, or lower jaw.
* Ali ibn'l-Abbas al-Majusi (died in 994) published an excellently organized work known as
the "Royal Book," which covered the entire spectrum of Arabic medicine and included one
chapter on diseases of the teeth.
* Abu' Ali al-Hysayn ibn-Sina (980-1037), known as Avicenna, was a prodigious writer and
creator of "Al-Qanun" (the canon), one of the best-known medical texts of all time.
Concerning dental treatment, he stressed the importance of keeping teeth clean and
recommended a number of toothpastes including salt, and burnt and powdered snail shells.
Avicenna examined in detail the causes of toothache and prescribed fumigation of
toothworm. One of the most significant sections of the canon deals with the treatment of
fractures of the jaw: The correct setting of the jaw can be accomplished by putting a
supportive dressing around the jaw, head and neck and a light splint along the teeth. If
necessary, gold wire might be used to reinforce the stability of the bandage.
Clearing Hurdles
After competing in the hurdles since his high school days, Dr. Fred Johnston, an orthodontist
and CDA member who practices in Fremont and Pleasanton, finally accomplished his
running goals.
On July 31, at the Masters National Track and Field Championships, held at the University
of Maine campus, the 52-year-old Johnston won the gold medal in the 100-meter high
hurdles. The next day, he took second place in the 400-meter hurdles. On Aug. 13, he won
the gold medal in the 400-meter hurdles at the Nike World Masters Track and Field
Championships held in Eugene, Oregon. He is now training for the Masters World Track and
Field Championships, to be held in Gateshead, England in July 1999.
Johnston, a father of two teenage children, trains three times a week thoughout the year.
Upcoming Meetings
1999
Jan. 14-16 Denver MIDWINTER Dental Convention (800) 637-6337
Feb. 3-6 Academy of Laser Dentistry's Sixth Annual Conference and Exhibition, Palm
Springs, Calif. (248) 548-7171
Feb. 11-13 East Coast District Dental Society Miami Winter Meeting and Dental Expo,
Miami (800) 344-5860 or (305) 667-3647
April 8-11 CDA Scientific Session, Anaheim (916) 443-3382, Ext. 4470
April 13-17 International Dental Show, Cologne, Germany, http://www.koelnmesse.de/ids
April 23-26 UOP/ADA Second National Conference on Over-the-Counter Dental Drugs and
Products, San Francisco (415) 929-6486
April 27-May 1 The American Academy of Oral Medicine 53rd Annual Scientific Session
(410) 602-8585
Sept. 16-18 CDA Scientific Session, San Francisco (916) 443-3382, Ext. 4470
Sept. 17-18 Society for Advanced Dentistry Annual Meeting, New Orleans (317) 290-2613
To have a meeting included on this list, please send the information to Upcoming Meetings,
CDA Journal, P.O. Box 13749, Sacramento, CA 95853 or fax the information to (916) 443-2943.
