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Medical Forum / General / Dentistry / July 2006

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gum surgery versus laser

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gummybear - 15 Jul 2006 01:24 GMT
I have been diagnosed with advanced periodontitis on two quads an
need flap surgery however i read laser is an option--i was wonderin
if the laser would kill the bacteria where deep cleaning and roo
planing could not get to (had that done versus the surgery two year
ago) some say that was option A but to me there is no option excep
surgery after two years of researching and hearing what second
third, fourth perios have to say--i think i still need surgery so an
thoughts or responses would be appreciated before heading for th
scalpel YIKES!!! ( i am definitely dentistphopia) due to childhoo
experience three front teeth with NO ANESTHESIA OR NOVaCAIN
Joel344 - 15 Jul 2006 02:29 GMT
Six dozen of one .... half of the other .... its marketing hype!

Show me someone who has been cured
of periodontitis and I will show you  .. well you
get the idea

--
Joel34
gummybear - 15 Jul 2006 09:14 GMT
so are you saying neither will help
Joel344 - 15 Jul 2006 13:13 GMT
Well, if you have gingivitis, and / or periodontitis (INFLAMMATION o
the supporting structures), then a thorough prophylaxis or toot
cleaning, complete with ultrasonic Cavitron debridement will reduc
inflammation.

Home care is essential.

Now some dentists call this exact procedure SRP, scaling and roo
planing at $600 a pop, others call it anything else and toss i
irrigation at $40 a quadrant, but all in all, periodontal concerns ar
best addressed through prevention and home care.

Now the APA (Periodontists' Association ~ PERIODONTISTS!) dream u
classifications, treatment modalities, everything but please remembe
this is a chronic disease. What this means is that 5 years or 10 year
goes by and its impossible to say "THIS HELPED," or "That DID NO
help."

The studies themselves are flawed as I elaborated in hundreds of post
right here. More about PerioChip, Periostat, and Arestin later, if yo
have lots of stamina to read my posts!

Some of them that is. I hear there are around 46,000 of them!

Joel

--
Joel34
ckouza@eudoramail.com - 16 Jul 2006 03:21 GMT
Joel,

My hygienist doesn't use the ultrasonic scaler ... Can you think of a
case(s) where scraping is preferred. (My old hygienist uses the
ultrasonic scaler, though.) Could it be a funding issue? ... my current
hygienist and dentist are members of a faculty group practice at USC.

Also, were you serious about being willing to look at x-rays from
posters?
gummybear - 16 Jul 2006 02:06 GMT
hi tks for your replies but i'm still not understanding you are yo
saying to skip surgery then? i had the Deep root planing
scaling and went to see another perio for his consultation and h
recommend me to do surgery and bone grafting  :shock: tk
Alexander Vasserman DDS - 16 Jul 2006 05:41 GMT
> hi tks for your replies but i'm still not understanding you are you
> saying to skip surgery then? i had the Deep root planing &
> scaling and went to see another perio for his consultation and he
> recommend me to do surgery and bone grafting  :shock: tks

Your engine block is still worn despite you cleaning all the parts and
getting 4 consults on a very typical problem.
Don't you think you should address the resurfacing issue (bone grafting
and surgery) to get better performance and longer engine life???
george1234 - 25 Jul 2006 20:56 GMT
>hi tks for your replies but i'm still not understanding you are you
>saying to skip surgery then? i had the Deep root planing &
>scaling and went to see another perio for his consultation and he
>recommend me to do surgery and bone grafting  :shock: tks

FWIIW... I went to two periodontists shortly after after SRP and they
both suggested surgery. I then went to the local dental school
(Forsythe institute) and they said there was no periodontal disease.

If you are unsure of the  opinion you are receiving, I'd recommend you
go to a local dental school. The financial incentive in favor  of
recommending surgery is less there. I'm not saying don't get
treatment, I'm saying go to a place where you can better trust the
opinion offered.
Alexander Vasserman DDS - 16 Jul 2006 05:35 GMT
> I have been diagnosed with advanced periodontitis on two quads and
 need flap surgery however i read laser is an option--i was wondering
> if the laser would kill the bacteria where deep cleaning and root
> planing could not get to (had that done versus the surgery two years
[quoted text clipped - 4 lines]
> scalpel YIKES!!! ( i am definitely dentistphopia) due to childhood
> experience three front teeth with NO ANESTHESIA OR NOVaCAINE

Translation analogy of what you are asking us.

My car has been diagnosed with advanced engine wear on 2 cylinders and
I need to get
it fixed by removing the engine however i read a power wrench is an
option--i was wondering if the power wrench would resurface the
breakdown in the engine where doing a thorough cleaning of the engine
would not fix the problem (had that done versus the taking the engine
apart two years ago) some say that was option A but to me there is no
option except taking the engine apart after two years of researching
and hearing what second, third, fourth mechanics have to say--i think i
still need to take the engine apart so any thoughts or responses would
be appreciated before heading for the traditional wrench YIKES!! (i am
definitely mechanicphobic) due to childhood experience with my tricycle
and no safety devices or Nike helmet.
george1234 - 25 Jul 2006 17:19 GMT
>My car has been diagnosed with advanced engine wear on 2 cylinders and
>...YIKES!! (i am
>definitely mechanicphobic) due to childhood experience with my tricycle
>and no safety devices or Nike helmet.

You know, most people in need of help don't come to this forum with
advanced degrees in medicine or dentistry, skilled in the art of
succinct medic al history presentation. They pose their questions in a
conversational manner, and some times meander about the point. You can
choose to help by answering the underlying question, or to belittle
the manner in which the question was posed
Alexander Vasserman DDS - 28 Jul 2006 07:40 GMT
I did not mean to sound as if I was belittling just wanted to provide
an analogy of what was being asked.

> >My car has been diagnosed with advanced engine wear on 2 cylinders and
> >...YIKES!! (i am
[quoted text clipped - 7 lines]
> choose to help by answering the underlying question, or to belittle
> the manner in which the question was posed
george1234 - 25 Jul 2006 17:11 GMT
>I have been diagnosed with advanced periodontitis on two quads and
>need flap surgery however i read laser is an option--i was wondering
>if the laser would kill the bacteria where deep cleaning and root
>planing could not get to

You can read the research (such as it is)  on perio-lase here
http://www.millenniumdental.com/research.html

The first article, IMO , gives the best overview
http://www.millenniumdental.com/pdf/MDT-GD-Sept-Oct-2004.pdf
pay attention to figure 2, for pocket depths up to 10 mm, SRP does
almost as well as perio-lase. Figure 3 compares the different
treatments, including flap surgery

As to treatment of periodontal disease, not all believe flap surgery
is the best option. Loesche has done the most work on use of
antibiotics. You can read his work here
http://cmr.asm.org/cgi/content/full/14/4/727

or the summary of the debate here
http://query.nytimes.com/gst/fullpage.html?sec=health&res=9F02E6DB1230F932A15752
C0A9659C8B63


Clinical trials in the use of antibiotics (metronidazole ) and
cleaning as alternatives to surgery continue,e.g.,  at the Forsythe
institute
http://www.clinicaltrials.gov/ct/gui/show/NCT00066001?order=3

On a more personal note, I  had a recommendation similar to yours,
considered laser surgery as an alternative to flap surgery , and
finally opted for SRP with better oral hygine. One year later no sign
of deep pockets.  I contacted Loesche by email ( he makes the offer of
help somewhere on the net, I've lost the reference). He was very
helpful in locating a local dentist that used antibiotic treatment as
an alternative to surgery, though in my case it was not necessary.
Mark & Steven Bornfeld - 25 Jul 2006 18:07 GMT
>>I have been diagnosed with advanced periodontitis on two quads and
>>need flap surgery however i read laser is an option--i was wondering
[quoted text clipped - 9 lines]
> almost as well as perio-lase. Figure 3 compares the different
> treatments, including flap surgery

    I have rarely if ever seen 10 mm pockets resolve with SRP.  Yes, the
tissue tone will improve and there may be some tissue shrinkage, but not
pocket elimination to the extent that the remaining pocket (or sulcus,
if you will) is sustainable by the patient.
    One other thing--the diagrams in this paper illustrate suprabony
pockets.  When you get over maybe 6-7 pockets most are infrabony.  I
can't say specifically whether grafting/guided tissue regeneration are
used in combination with laser surgery (I wouldn't presume one way or
another) but many of these infrabony lesions will require grafting
and/or GTR, and possibly osseous recontouring for a good result.
Therefore, I would be careful about making sweeping judgements about the
suitability of laser surgery for individual patients whose situations
may well be different from those in this paper.

Steve

> As to treatment of periodontal disease, not all believe flap surgery
> is the best option. Loesche has done the most work on use of
[quoted text clipped - 16 lines]
> helpful in locating a local dentist that used antibiotic treatment as
> an alternative to surgery, though in my case it was not necessary.

Signature

Mark & Steven Bornfeld DDS
http://www.dentaltwins.com
Brooklyn, NY
718-258-5001

george1234 - 25 Jul 2006 19:19 GMT
>> You can read the research (such as it is)  on perio-lase here
>> http://www.millenniumdental.com/research.html

>    I have rarely if ever seen 10 mm pockets resolve with SRP.  Yes, the
>tissue tone will improve and there may be some tissue shrinkage, but not
[quoted text clipped - 6 lines]
>another) but many of these infrabony lesions will require grafting
>and/or GTR, and possibly osseous recontouring for a good result.

I agree SRP is not the answer to all, the severity of the disease
influences the selection of treatment. The conclusion the perio-lase
author does reach  is "It is evident from this comparison that pocket
depth reductions from LANAP are similar to those obtained from ffalp
and osseous resection and modified Widman flap surgical procedures"  

>Therefore, I would be careful about making sweeping judgements about the
>suitability of laser surgery for individual patients whose situations
>may well be different from those in this paper.

Again we agree. My goal  was to answer the question about laser
surgery, and to  cover alternatives to surgery. My intent was to point
out alternatives that have an  outcome similar to surgery, so that
such alternatives could be explored.  There are, of course, gradations
in severity of the disease which requre different treatments.

Leaving perio lase behind.... Then there is Loesch's opinion that the
disease is caused by specific pathogens  that can be treated with
specific antibiotics. He also gives the reason why traditional
treatment recommendations have not changed:  in 8 of 10 cases
traditional methods work.

" If dental decay was a specific infection, why could periodontal
diseasenot also be a specific infection resulting from the selection
of bacteria that can grow in the stagnant pocket environment, using
nutrients which leak into the pocket in the GCF as the result of the
microbes' production of proinflammatory molecules? In the past 25
years, over 200 studies have compared the flora of disease-associated
plaques with the flora found in plaques associated with periodontal
health. The results have generally shown a limited number of bacterial
species mainly gram-negative anaerobes, to be significantly associated
with periodontal disease.These findings have not changed the
prevailing treatment philosophy in periodontal disease, because of the
powerful legacy of the nonspecific plaque hypothesis in dictating
treatment protocols that have become the standard of care in clinical
dentistry. It is difficult to change a treatment approach whose 80%
level of effectiveness is accepted by the clinician (111, 189, 190)
and which provides the economic infrastructure of clinical
periodontology. "

>Steve
Mark & Steven Bornfeld - 25 Jul 2006 19:52 GMT
>>>You can read the research (such as it is)  on perio-lase here
>>>http://www.millenniumdental.com/research.html
[quoted text clipped - 31 lines]
> treatment recommendations have not changed:  in 8 of 10 cases
> traditional methods work.

    Yes they "work", but patients hear these words and equate them with
"cure".  Many chronic periodontal conditions are refractory because
patients think they have been cured.

> " If dental decay was a specific infection, why could periodontal
> diseasenot also be a specific infection resulting from the selection
[quoted text clipped - 13 lines]
> and which provides the economic infrastructure of clinical
> periodontology. "

    The basic premise here is actually pretty well-known.  The more
interesting part is why these specific bacteria colonize some patients
and are difficult to impossible to eliminate long-term, while other
patients are resistant to these same strains establishing themselves in
the first place (even in the absence of oral hygiene).

Steve

>>Steve

Signature

Mark & Steven Bornfeld DDS
http://www.dentaltwins.com
Brooklyn, NY
718-258-5001

george1234 - 25 Jul 2006 20:19 GMT
>> Leaving perio lase behind.... Then there is Loesch's opinion that the
>> disease is caused by specific pathogens  ...
>
>    Yes they "work", but patients hear these words and equate them with
>"cure".  

Loesch posits that specific anerobes are responsible for AP. He finds

" a combination of metronidazole and doxycycline, followed if
necessary by local delivery of antimicrobial agents to the pocket in
an ethylcellulose film, resulted in an 80% reduction in the need for
surgery and extraction (153). These results have been sustained for 5
years or more "

That is as much of a cure  as traditional treatments

>Many chronic periodontal conditions are refractory because
>patients think they have been cured.

It's pretty clear  that re-infection will take place regardless of the
method of dis-infection ( debridement, surgery, or antibiotic). There
is no "cure", It is a more or less chronic condition, not a strict
division into the sick and the well

But I defer to your clinical experience here.  

>> " If dental decay was a specific infection, why could periodontal
>> diseasenot also be a specific infection resulting from the selection
>> of bacteria

>    The basic premise here is actually pretty well-known.  The more
>interesting part is why these specific bacteria colonize some patients
>and are difficult to impossible to eliminate long-term, while other
>patients are resistant to these same strains establishing themselves in
>the first place (even in the absence of oral hygiene).

Well, yes that is interesting. not to put to fine a point on it, I
think periodontists have only begun to scratch the surface (groan) The
advance from non specific theory of infection  infection to the
identification of 4 to 10 anerobic species specifically associated
with the disease is a recent result..

--G
Steven Bornfeld - 26 Jul 2006 00:52 GMT
>>>Leaving perio lase behind.... Then there is Loesch's opinion that the
>>>disease is caused by specific pathogens  ...
[quoted text clipped - 11 lines]
>
> That is as much of a cure  as traditional treatments

"Need for surgery" is a very, very fungible concept.  Need for
extraction is somewhat less fuzzy. ;-)
    I can tell you that there is nothing new in use of metronidazole,
docycycline, or intrasulcular medications.  I can also tell you that in
the real world (experience of the periodontists I refer to), the results
have been underwhelming.
    Certainly the fact that these men and women are surgeons could be seen
as a potential bias. ;-)  Call me gullible; I believe them.

>>Many chronic periodontal conditions are refractory because
>>patients think they have been cured.
[quoted text clipped - 22 lines]
> identification of 4 to 10 anerobic species specifically associated
> with the disease is a recent result..

    I am not up on the latest research, I'm afraid (I hang my head).
However, implication of specific anaerobes (as well as specific host
factors) was already being discussed during my dental school days (I
graduated in 1976), if not before.  I don't doubt that the list of
implicated pathogens is longer now than it was then.

Steve

> --G
george1234 - 26 Jul 2006 20:11 GMT
>    I am not up on the latest research, I'm afraid (I hang my head).
>However, implication of specific anaerobes (as well as specific host
>factors) was already being discussed during my dental school days (I
>graduated in 1976), if not before.  I don't doubt that the list of
>implicated pathogens is longer now than it was then.

The paper is a survey paper and he does summarize the work of others.
I'm not schooled enough in the art to identify Loesche's unique
contirbution.

I found the list of pathogens studied suprisingly small. At one point
he cites more thatn 400 species in the plaque. When he summarizes
earlier studies in table 2 and 5 he concentrates on 10. In his
conclusion he callls out only 3 (P. gingivalis, B. forsythus, and T.
denticola)

Bacterial species that were monitored listed in tables 2 and 5

Micro-aerophilic
Aa,       A. actinomycetemcomitans;
Cr,        C. rectus;
Ec,       E. corrodens;

Anerobic
Pg,         P. gingivalis;
Bf,          B. forsythus;
Td,        T. denticola;
Pi/Pn,   P. intermedia/nigrenscens;
Fn,        F. nucleatum;
Eub. Sp. = Eubacterium species;
Spir,     spirochetes;
Tv,       T. vincentii.

BTW... I hope my summaries have not mis represented Loesche's view.
I'll let him speak for himself in the conclusion to his survey paper

"The evidence presented in this review indicates that most, if not
all, forms of periodontal disease are specific, albeit chronic,
infections. Regardless of whether the host is genetically predisposed
to periodontal disease, as in Papillon-LeFevre syndrome or Down
syndrome, or if the host is compromised by leukocyte defects as in LJP
or diabetes, or is a smoker, or has poor oral hygiene, or has simply
aged, the clinical symptoms are almost always significantly associated
with the overgrowth of a finite number of anaerobic species, such as
P. gingivalis, B. forsythus, and T. denticola in the subgingival
plaque. This overgrowth can be periodically suppressed by mechanical
debridement over a lifetime, the current treatment paradigm, or the
flora can be altered by the judicious short-term usage of
antimicrobial agents targeted against the specific anaerobes. This
latter approach, while supported by several double-blind clinical
studies (147), goes contrary to centuries of dental teaching which
states that periodontal disease results from the overgrowth of plaque
on the tooth surfaces, i.e., a "dirty mouth." The challenge lies not
in proving that periodontal disease is an infection but in
implementing treatment procedures based on the fact that it is an
infection. The antimicrobial treatment of periodontal infections will
benefit from studies suggesting that periodontal disease may be a risk
factor for cardiovascular disease and stroke. If an antimicrobial
approach is as effective as a surgical approach in the restoration and
maintenance of a periodontally healthy dentition (147, 153), this
would give a cardiac or stroke patient and his or her physician a
choice in the implementation of treatment seeking to improve the
patient's periodontal condition so as to reduce and/or delay future
cardiovascular events.
Steven Bornfeld - 26 Jul 2006 23:41 GMT
>>    I am not up on the latest research, I'm afraid (I hang my head).
>>However, implication of specific anaerobes (as well as specific host
[quoted text clipped - 60 lines]
> patient's periodontal condition so as to reduce and/or delay future
> cardiovascular events.

    I remember the A. actinomycetemcomitans and Eichenella sp. as the ones
they harped on the most.
    Does "Micro-aerophilic" equal facultative anaerobe?  I'm unfamiliar
with the term.

Steve
george1234 - 27 Jul 2006 17:04 GMT
>Micro-aerophilic

Steve,

These days wikipedia is my source for technical terms I don't know

http://en.wikipedia.org/wiki/Microaerophilic

"Microaerophilic organisms are a specific type of organism that
requires oxygen to survive, but requires or can tolerate environments
containing lower levels of oxygen than are present in the atmosphere
(~20% concentration)."
george1234 - 25 Jul 2006 20:27 GMT
>    The basic premise here is actually pretty well-known.  The more
>interesting part is why these specific bacteria colonize some patients
>and are difficult to impossible to eliminate long-term, while other
>patients are resistant to these same strains establishing themselves in
>the first place (even in the absence of oral hygiene).

I'm slowly making my way through the Loesch paper quoted, but a
partial explanation is offered

However, the tooth surfaces cannot be completely "cleaned" of plaque
species by these procedures, even when surgery to get access to the
root surfaces is performed (318). If these residual organisms are
enriched per"`centage-wise for the periodontopathic species, then the
plaque community that returns could be as proinflammatory as the
plaque that had just been suppressed. This would be especially true if
there is an enrichment of the plaque flora by bacteria that are left
behind on the root surface or that have invaded the dentinal tubules
(2). Large numbers of bacteria invade these tubules and have been
shown by electron microscopic examination to repopulate the root
surfaces (3). This selection for periodontopathic species as a result
of debridement, as well as the difficulty in controlling a biofilm
such as dental plaque, might explain the failure rate of about 20%
observed in clinical practice (111, 189).
Steven Bornfeld - 26 Jul 2006 01:01 GMT
>>    The basic premise here is actually pretty well-known.  The more
>>interesting part is why these specific bacteria colonize some patients
[quoted text clipped - 19 lines]
> such as dental plaque, might explain the failure rate of about 20%
> observed in clinical practice (111, 189).

    Why would the residual bacteria be enriched percentage-wise for
specifically pathologic species?
    In fact, most of the studies we've heard over the years followed an
experimental biofilm beginning with thorough debridement.  Forgive, for
my memory is quite hazy.  The first precipitant on the root surface is a
proteinaceous "salivary pellicle", which is itself non-bacterial but
provides an excellent medium for bacterial growth.  The maturation of
plaque from this point on has been studied--the primary organisms to
populate the plaque are primarily gram-positive rods and cocci.  These
are generally considered normal resident organisms.  Only if the plaque
is left undisturbed for a longer period do you start seeing the
gram-negative bacteria, including the bulk of the usual suspects in
pathogenesis (in our day the professors always spoke of "spirochetes",
which I assume some of them are--for all I know maybe some treponema
were implicated at one time).
    In any case, it certainly is believable that residual bacteria in the
sulcus, or even in the dentinal tubules could repopulate the plaque.
    BTW, I consider a failure rate (again, what are the criteria for
failure) of 20% as exceptionally LOW.

Steve
george1234 - 26 Jul 2006 19:56 GMT
>    Why would the residual bacteria be enriched percentage-wise for
>specifically pathologic species?

I'm not sure.. I have not read the refeerences he cites. It may be
that the electron microscope observation is that  the the anerobic
pathogens preferentially occupy the tubules, and that when you scrape
the general population away when you debride, you leave the pathogens.
However.. that does not conform to my undestanding of the
symbiotic/ecological  relation among the species. By that I mean the
anaerobes don't show up  until the aerobes have created the proper
ecological niche.

>    In fact, most of the studies we've heard over the years followed an
>experimental biofilm beginning with thorough debridement.  Forgive, for
[quoted text clipped - 7 lines]
>gram-negative bacteria, including the bulk of the usual suspects in
>pathogenesis

That's my general understanding too

>(in our day the professors always spoke of "spirochetes",
>which I assume some of them are--for all I know maybe some treponema
>were implicated at one time).

Spirochetes  are found in Acute necrotizing ulcerative gingivitis.(the
trench mouth of ww1)as well as AP.  Apparently the understanding of
the "cause " shifted from the anerobic spirochetes to the
microaerophilic  A. actinomycetemcomitans and now back to the
anerobes. Because their caracteristic structure is evident in a phase
contrast microscope, Loesche suggests spirochetes  be used as an
indicator of AP. He says

"The older literature identified anaerobic organisms such as
spirochetes and black-pigmented Bacteroides species (now classified as
Porphyromonas and Prevotella species), as putative periodontal
pathogens "

"With the identification of A. actinomycetemcomitans as a putative
periodontal pathogen, emphasis shifted from anaerobes to this
microaerophilic species. "

"The findings shown in Tables 2 through 4, involving large numbers of
samples and using diverse methods, indicate that anaerobes, rather
than A. actinomycetemcomitans or other microaerophilic species, are
more likely to be present or to dominate in plaques associated with
EOP and AP. This would suggest that treatment strategies and tactics
should be designed to selectively target certain anaerobic members of
the plaque flora."

>    In any case, it certainly is believable that residual bacteria in the
>sulcus, or even in the dentinal tubules could repopulate the plaque.
>    BTW, I consider a failure rate (again, what are the criteria for
>failure) of 20% as exceptionally LOW.

By failure he means preiodontitis

" 30% <of the gerneral poulation> have periodontitis as defined by the
presence of three or more teeth with pockets of >= 4 mm ."

>Steve
--George
Steven Bornfeld - 26 Jul 2006 23:36 GMT
>>    Why would the residual bacteria be enriched percentage-wise for
>>specifically pathologic species?
[quoted text clipped - 7 lines]
> anaerobes don't show up  until the aerobes have created the proper
> ecological niche.

    It may just be that the intradentinal bacteria are in a relatively
anaerobic environment.  That would make sense.

>>    In fact, most of the studies we've heard over the years followed an
>>experimental biofilm beginning with thorough debridement.  Forgive, for
[quoted text clipped - 45 lines]
>
> By failure he means preiodontitis

    Most of the patients receiving (or who should receive) SRP already have
periodontitis.

> " 30% <of the gerneral poulation> have periodontitis as defined by the
> presence of three or more teeth with pockets of >= 4 mm ."

    If you select for a population over 35-40 years of age, every survey
I've seen shows a far higher incidence.  Certainly counting children in
your statistics would make things more grim.
    Sadly, I would say the majority of my patients under the care of
periodontists (GOOD periodontists!) show relapse at some point, or more
or less acute exacerbations.  This doesn't mean treatment is a failure,
but success must be viewed in less absolute terms.  Certainly this is a
tough concept to sell to a patient--that losing your teeth in 20 years
rather than 10 (obviously a presumption) is a worthy goal.
Understandably patients aren't happy.
    Thanks for the info--this is an interesting article.

Steve

>>Steve
>
> --George
george1234 - 27 Jul 2006 17:26 GMT
>    Thanks for the info--this is an interesting article.

It's always a pleasuer to discus an issue with you, thank you.

Another researcher in  antibiotics and bacterial infection is
Anne Haffajee.  She has an interesting interview in a NIDCR pub whre
she points out that there are geographical differences in the relative
distribution of bacterial species. She says   there are ~40 species
involved, that make up about 60% of the biofilm.

http://www.nidcr.nih.gov/NewsAndReports/Media/InsideScoop012005.htm

"Comparing the subgingival plaque obtained from patients with chronic
periodontitis, we found marked variations in the microbial profiles
from country to country.  After adjusting for age, gender, smoking
status, and other factors, these differences held up.  "

The clinical implications are

"treatment responses with a given therapy might be different
geographically.  What we want to know now is:  Which treatment works
best for a given microbial profile?"

Not to say that she has actually worked out the different treatments.

I suspect in a few years we will see DNA profiles of the biofilm as
an adjunct to asessing  periodontal disease.

--george

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