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PERIODONTAL MEDICINE: AN INTRODUCTION
“A Paradigm Shift in Science, Diagnosis and Treatment”

ABSTRACT: The scientific research has produced numerous findings on the oral-systemic link. However, little has been offered on the clinical application of the facts other than increasing existing services. This course reviews all of the research and, utilizing a new methodology, applies it in a new clinical model which allows the application of a medical model based on the "staging" of periodonal disease. The utilization of "perio-systemic staging" allows multi-level periodontal diagnosis and treatment including the introduction of new therapeutic modalities such as "periodontal immunotherapy".

THE CHANGE IN MEDICAL AND DENTAL MODELS:
     - Advances in General Systems Theory and Systems Biology now permit analysis of isomorphic data:
     Termed the ‘New Science’, Systems Theory allows the design of research to study the inter-relationship between different disciplines (such as medicine and dentistry) and the validity of current scientific theories (Bertalanffy; 1969).
     -The Classical Infection Theory, as a result, is being “re-configured”:
The current model of diagnosis and treatment is based upon a 100 year old theory known as the Koch postulates. It theorizes one bacteria is responsible for a specific disease entity.
     -The Classical Infection Theory works well for acute infections, but fails to provide a clinical model for chronic infections and diseases:
     -The postulates have assisted modern medicine and dentistry to eradicate most acute infectious diseases. However, research and clinical intervention have failed to produce significant results for the Chronic Degenerative Diseases (CDDs) such as cancer, cardiovascular disease and the various metabolic disorders.
    
THE ‘NEW SCIENCE’: EPIDEMIOLOGICAL FINDINGS:
     -Systemic Infections are chronic, not acute, in nature:
Most systemic infections are chronic and hence, cannot be studied with the classical Postulates. (Haffajee and Socransky, 1994)
     -Many Systemic Infections, which result in Chronic Degenerative Diseases, originate from the oral cavity:
Besides the studies linking dental infections to the CDDs such as cardiovascular, pulmonary, pancreatic and obstetric dysfunction, an increased incidence in mortality was associated with specific dental findings. (Matilla et al, 1989; DeStefano et al 1993).

THE ‘NEW SCIENCE’: DENTAL MICROBIOLOGICAL FINDINGS:
     -Most dental infections are chronic in nature:
Although acute dental infections respond remarkably well with the classical postulates, most diseases such as caries and periodontal disease follow a chronic inflammatory course and, similar to systemic disease, do not respond to the classical model which has been applied to all dental diseases.
     -Most dental infection are dental infections are endogenous and opportunistic, that is, the result of infection from one's microbiological flora:
Almost all dental infections, with the exception of Actinobacillus Actinomycetemcomitans (AA), are chronic, endogenous infections (Socransky and Haffajee 1992, 1994, 2002, 2005, 2006). Dental infections, therefore, with respect to endogenous induced chronic inflammatory disease and oral-systemic interactions cannot effectively be addressed with the acute exogenous classical model.

DUE TO THE NATURE OF DENTAL DISEASE AND ORAL-SYSTEMIC SEQUELAE, A CHRONIC, ENDOGENOUS (OPPORTUNISTIC) DIAGNOSTIC AND TREATMENT MODEL IS INDICATED

The Classical Theory of Acute Infection and the Opportunistic Theory of Chronic Infection, as indicated below, are diametrically opposed in mechanism of action:

                                            CLASSICAL THEORY       OPPORTUNISTIC THEORY
ORIGIN OF
INFECTIOUS AGENT:          Exogenous                         Endogenous

EXTENSION OF                   Local to generalized            Localized focal infection with
INFECTION INTO TISSUE:  systemic reaction                systemic dissemination to
                                                                                       susceptible remote sites.

INFLAMMATORY
RESPONSE:                          Acute                                 Chronic
    
     Chronic Infections are far more complicated than Acute Infections and therefore more difficult to diagnose and treat:

  • Chronic Infections are comprised of complex multi-casual, multi-factorial and multi-dimensional phenomena thereby requiring a new and comprehensive approach.
  • Chronic Infections are unique for each patient thereby requiring a new approach which can be individualized for each disease and patient.

 

A NEW METHODOLOGY, BASED UPON SYSTEMS THEORY, ALLOWS ANALYSIS OF COMPLEX MEDICAL AND DENTAL (CHRONIC) PROCESSES AND SIMPLIFIES THEM.

  • The New Methodology is both evidence-based and peer-reviewed at the dental, medical and biological (life) sciences level.

  • The New Methodology allows for the incorporation of all clinical, research data, physiological and pathological attributes of one disease to be 'viewed' in a simplified, step by step, process.

  • It can be utilized in its simple linear (2-D) form, or in its multi-level (3-D, 4-D and 5-D) forms for characterizing more complex diseases and resistant cases.

  • The process can be individualized for atypical cases and for patients with multiple chronic degenerative conditions.

The clinical application of the New Methodology: 'Periodontal-Systemic Staging'

'Staging' Allows for the Creation of a Chronic, Endogenous (Opportunistic) Model:

Chronic dental diseases such as periodontitis, caries and functional disorders can be studied as can chronic medical conditions (caries and functional disorders will be discussed in the upcoming 'Dental Medicine' series).

'Staging' Allows Multi-Level Diagnosis:

Disease can be studied and assessed at its various levels of involvement such as health, the pre-disease state, local pathology, oral-systemic interactions and systemic level disease.

'Staging' Creates an Interdisciplinary Model Compatible with the Medical Model:

Dentists can utilize the staging concept to make a systemic evaluation of their patient's existing chronic degenerative conditions and make an assessment as to whether the existing (chronic) dental condition is causative, contributory or merely associative.

THE 'PERIO-SYSTEMIC STAGING' CREATES THE POSSIBILITY OF FORMULATING A NEW TREATMENT MODEL:

'Staging' Creates New Treatment Concepts:

Treatments can be collectively or strategically be directed toward a specific disease level:
- Etiological Level Treatment
- Local Pathological Level Treatment (current paradigm)
- Oral-Systemic (Metastatic) Level Treatment
- Systemic Level Treatment

'Stating' Creates New Treatment Modalities:

- Periodonal 'Immuno-Therapy', that is, treatments directed at stimulating the immune system can now be established
- Neural Therapy for pulpal exposure, inflammation, infection and degeneration can also be created.

'Staging' Assists Inter-Disciplinary Treatment:

Therapeutic cooperation between dentists and physicians is enhanced as dentists can now make a comprehensive assessment of chronic dental disease with respect to its local and systemic manifestation.

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