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Subgingival microflora

My main difference of opinion with majority of periodontists and general dentists, stems from my very conservative views with regard to the monitoring of the subgingival microflora. I believe that in light of present knowledge, clinicians in state-of-the-art dental practices will monitor the microbiological status of their patients' dentitions just as physicians monitor their patients' blood pressure, cholesterol, blood sugar, etc. My opinion: absolutely nothing to lose and much to gain by so doing.

Microscopic examinations of subgingival biofilms removed from the distal surfaces of all four 1st molars, or from gingival crevices more that 3 mm in depth, will screen for pyogenic activity and disease-associate microorganisms, especially spirochetes. If disease-associated fields are found, interceptive antibacterial therapy can be immediately prescribed, and progress in infection-control can be assessed by appropriately spaced follow-up examinations.

Periodontopathic infections (and cariesogenic infections) can be prevented, if the self-care patients use provides adequate bacterial control. I believe that preventive and interceptive programs will work best when patients know what, why, and how to use reliable anti-infective measures. For periodontal infections this where a high-quality microscope-TV system can be very helpful. For example:

While my patients viewed their fields on the TV-monitor, I told them that by eliminating the germ-life they saw it should be possible to cure the infection that was damaging their dentition. This would involve a battle between them and microorganisms they were watching. I could give them the weapons and direct the strategy, but I could not fight the battle for them. I would tell them who was winning. I could set the stage, but the performance was up to them.

While my patients watched the living microorganisms removed from their tooth-surfaces, they often asked the following questions:

Does everybody have these microorganisms?

No, they are not found in disease free mouths.

Where did they come from?

Most, if not all, came from another persons saliva. (We then discussed the contagious nature of periodontal diseases).

Are there drugs that can be used to treat them?

Yes, I will use some locally. You may need some systemically, and I will recommend some for the self-care you use. (I never asked a patient to use anything I had not tested microscopically and tried in my own mouth.) I always demonstrated the bactericidal potential of the agent I selected by running a drop or slurry under the cover-slip covering an active field. Most of my patients used sodium bicarbonate (baking soda) slightly moistened with hydrogen peroxide. Others used magnesium sulfate. One used (very successfully) a solution of sodium paraperiodate (results published), another, Hartzell's solution: zinc phenol sulfonate. A few used an acidulated sodium fluoride gel (Karigel) on a toothbrush moistened with peroxide. (If this gel could have been obtained OTC, I would have had more patients on it, as it is anti-caries, antibacterial, and anti-root-sensitivity.)

Why wasn't I given this information before?

For most clinicians the therapeutic targets have been debris, calculus, and deep pockets, not bacteria.
When patients took an antibiotic, I examined them on the last day of the course. If fields were still active, I knew they had not taken it according to directions, and they were asked to continue and return for reexamination on the last day of the repeat course.

While treating advanced lesions, e.g.10+/- mm pockets and furcations, I would not have been comfortable making therapeutic decisions on the basis of clinical findings alone.

I still remember the signs of relief patients, who had been told they would need to lose a number of teeth, showed when I told them that with good infection-control these teeth might be saved.. Some teeth with periodontal-endodontal involvement were saved. For those that were lost patients appreciated my effort to save them After studying cariesogenic infections and periodontal lesions for 20 years in laboratory animals (over 10,000 hamsters and hundreds of rats), I enjoyed the clinical setting where I was able to test some of the findings my colleagues and I had made in the laboratory. Working with patients was an interesting, exciting, and very rewarding experience. This brings to mind something periodontist, Thomas B. Hartzell, MD, DDS, said many years ago. Namely, the pleasure he received from the appreciation of grateful patients far exceeded the pleasure he received from the money he obtained for his services. I received no money from the patients I treated, but I still cherish some of the gifts they gave me when I retired.

- Larry Hatkey