Biopsies: A Slice of Life?

However, early detection of oral cancer can improve cure rates. The trouble is that early malignancies often look the same as benign lesions. By the time pre-cancerous lesions progress to the point where they look "suspicious," valuable time has been lost to treat these lesions. Now a simple, non-invasive test is available that offers a more precise way to study "early" lesions that might be cancerous. It's known as OralCDx.

OralCDx utilizes a sterile brush biopsy technique. Employing it much the same way PAP smears are taken, the oral brush biopsy is rotated five-to-ten times against the surface of the lesion. The material collected on the brush is transferred to a glass slide and flooded with a fixative to avoid air-drying. Once the slide itself is dry, it is sent for a computer analysis that searches for abnormal cells. The computer is able to distinguish between normal and atypical cells, as well as those that are cancerous. A pathologist then reviews the slides to confirm a diagnosis.

In a study published in JADA*, OralCDx was found to be equivalent to scalpel biopsies when it came to detecting pre-cancerous and cancerous lesions. It must be emphasized that the brush biopsy does not replace surgical biopsies; rather it accurately detects which lesions should be biopsied. This multi-center study showed the value of OralCDx as being able to identify benign pre-cancerous and cancerous lesions at early stages when treatments are more effective. So the next time you visit your dentist or dental hygienist, make certain he/she screens your mouth for oral cancer...you'll be glad you did.

*Sciubba, J.C.: Improving detection of pre-cancerous and cancerous oral lesions. JADA 130: 1445-1457, 1999.

Tip: patients with dentures should still have annual dental checkups to screen for oral cancers and other pathologies.

Implants? Won't they fail like my teeth did!

Sbordone et al* performed a longitudinal study to determine if titanium implants placed in patients suffering from periodontal disease were at risk. In other words, would the same disease process that caused the patients to lose their teeth compromise their dental implants?

Forty-two implants and twenty-five teeth were studied in twenty-five patients (12 males and 13 females) over a 3-year period. During this time, repeated measurements were taken including pocket depths, attachment levels, and a variety of indices that measured plaque. Reproducible X-rays were taken at various intervals, as well as microbiological samples from around the implants and teeth. At the end of the study, the researchers concluded that there was little relationship between the person's previous periodontal condition that would warrant concern about future infections or implant failures in these mouths. That's precisely what we've been saying for years!

Here's another way to answer this question: the vast majority of dental implants placed in patients around the world replace teeth lost to periodontal disease. Implants were designed to work in their mouths...and they do. No matter which study is quoted, dental implant success rates range from 87-97%. The bottom line is that patients should be reassured that although they may have lost teeth due to periodontal disease and the resultant bone loss that comes with it, these same mouths react kindly to dental implants.

*Sbordone L., Barone A., Ciaglia R.N., Ramaglia L., and Iacono V.J.: Longitudinal study of dental implants in a periodontally compromised population. J Perio 70:1322-1329, 1999.

Comment: Since most implants successfully integrate to the bone, we are always perplexed when they don't. Careful technique during implant placement is important. For example, copious amounts of water should be used during the surgery so as not to overheat the bone; this can lead to cell death. One factor we feel might be implicated in sites where implants fail is the site's past history. Was this an area where the extracted teeth experienced recurrent endodontic (root canal) problems? This is not to imply that implants cannot be placed in areas where teeth have had root canal therapy. Rather it is to consider that resistant organisms (anaerobes) are lurking in the bone that may contribute to implant failure.

Tip: patients still need to practice good oral hygiene around dental implants. Plaque and tartar attach to implants just like they do to teeth. Have professional cleanings around dental implants with the same frequency as tooth cleanings.

I had gum treatments - so how come I need "maintenance" therapy every few months?

Scaling and root planing (SRP), along with improved oral hygiene measures, are the first steps in treating periodontal disease. The benefits of SRP are many: plaque levels are reduced, calculus (tartar) is removed, and bleeding gums return to health. Pockets shrink and, in some cases, loose teeth may tighten. In essence, SRP is the workhorse of periodontal treatment. SRP is so important that it is the cornerstone of quarterly periodontal maintenance treatments.

In previous papers, Cugini et al have explored different benefits of SRP. This study* explores the microbial and clinical effects of SRP. Thirty-two patients receiving periodontal maintenance and oral hygiene instruction every three months were followed for a period of one year.

The study measured plaque, gingival redness, bleeding on probing, and pocket depths, noting the presence of suppuration (pus). A microbiological baseline assessment was made for each patient. After the initial measurements were taken, each patient received SRP quadrant by quadrant under local anesthesia. SRP was completed within four weeks. Then for every three months following this initial therapy, each patient received periodontal maintenance consisting of scaling and oral hygiene instruction. Clinical and microbiological parameters were reassessed during these sessions, and compared to the baselines.

The results not only demonstrated a reduction in the pocket depths and amount of plaque present when compared to the control group that did not receive SRP, but also demonstrated continued improvement over the 12 months. Best results were seen in patients with pockets ranging from 4-6mm.

Microbiologically, this study demonstrated a decrease in pathogens associated with periodontal breakdown. It could not be determined if the decrease in these pathogens resulted in shallower pockets or if shallower pockets contributed to the decrease in the numbers of pathogens. The results, however, were encouraging because the pathologic nature of the microbiota in the pockets "converted" into less harmful bacterial colonies.

The authors point out that while SRP reduces pocket depths and changes the nature of the plaque found in periodontal pockets, it was not sufficient to control the disease process in all periodontal patients. SRP has limitations. It is less effective in deeper pockets or around teeth with pockets next to convoluted and irregular-shaped roots. It also does not take into account the individual patient's host response to the periodontal pathogens. For younger patients, SRP is the first step in treating their problem. They often need surgery compared to older patients with similar pocket depths who may not need more treatment after having SRP. Each patient's "genetic resistance" and how it relates to their age should be a factor when formulating a treatment plan.

This study concludes that SRP is "essential in consolidating clinical and microbiological improvements achieved as a result of initial therapy."

*Cugini, M.A., Haffajee, A.D., Smith, C., Kent Jr., R.L., and Socransky, S.S.: The effect of scaling and root planning on the clinical and microbiological parameters of periodontal diseases: 12-month results. J Clin Perio 27:30-36, 2000.

Missing genes mean missing teeth

The discovery that a mutation in a gene called PAX9 was made at the University of Texas - Houston Dental Branch of Baylor College of Medicine. A detailed analysis of PAX9 on chromosome 14 discovered an extra nucleotide in the gene. This mutation interrupts gene translation that results in a smaller-than-normal amount of PAX9. As scientists learn more about the PAX9 protein, they will move a step closer to replicating tooth formation. Imagine if we could implant tooth buds instead of titanium fixtures to replace missing teeth! That would change the nature of more than a few dental practices.

Women and periodontal disease:
Protecting oral health throughout your life

Fact: 44% of women ages 55-90 (who still have teeth) have periodontal disease*.

Though women generally take better care of themselves than men, women's oral health is not much better than their male counterparts. So women can better understand their oral health, we have linked to Women and Periodontal Disease, "Protecting Oral Health Throughout Your Life", through a courtesy extended to us through The American Academy of Periodontology.

*Women & Periodontal Disease, The American Academy of Periodontology, 1998, www.perio.org/consumer/women.htm

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