Being a Knife Doctor and a Pill Doctor
Individualized risk assessment and treatment methods will improve caries management
Joel H. Berg, DDS, MS
We already are. And the science and practice of dentistry is changing in an inexorable fashion. Clinicians spend most of their practice days applying their efforts toward some combination of preventing oral disease and treating the results of oral disease. For the latter, I characterize it as such because the bulk of our treatment regimens deal with restoring teeth that are already structurally or biologically compromised as a consequence of dental disease. This is clearly the case with dental caries and also mainly the case with periodontal disease.
In the case of dental caries, which accounts for the bulk of the dental profession's time and expense, we rarely are treating the disease itself. We work hard with our patients (eg, fluoride treatment, coaching, better home care, diet, etc) to try and prevent dental caries from doing its destructive thing yet end up focusing most of our energies around efficiently and expertly restoring the teeth that have been damaged by it.
Emerging science has shown that the biofilms in our mouths are not only different in terms of their composition (ie, which bacteria and in what proportions) but also in how they interact with the host and more specifically, how they produce acid, how quickly the process of acid production begins, and how long acid production is sustained. Perhaps more importantly, when acid production has begun in response to the ubiquitous sugar encounter, differences in biofilm composition can determine how the process is halted, reestablishing a healthy and functional pH around the tooth surfaces.
There is no space in this commentary to further elucidate the details of all of the recent and ever-evolving discoveries in oral biofilm research and their implications on oral health. What is important is for us to stay closely connected to the emerging science, "translate" it into clinically important actions, and determine how and when to make appropriate changes in our practice.
We have also recently learned about better methods of dental caries risk assessment as well as how to have improved conversations with our patients about their own individual risks for disease manifestation and what they can do to prevent such tooth destruction. Imagine a time in the near future when we can provide accurate information to each patient regarding his or her individual risk profile. Although current risk assessment tools are highly sensitive and excellent for patient education, they are not specific enough. The nonspecific risk information available today provides less relevant meaning and results in a lower likelihood of patient compliance. This situation reminds me of the time when the medical community "knew" that having a high low-density lipoprotein (LDL) cholesterol level was a serious health risk, yet there was little availability of cost-effective means to measure an individual's LDL level. This is where we have been and essentially still are when trying to understand a patient's specific risk factors for developing dental caries, and it significantly mitigates our ability to offer medical management in the form of behavioral recommendations or to prescribe medications to manage the disease. When every patient hears a similar (ie, templated) message, it is easy for them to write off the recommendations as "not about me." However, when there are accurate, specific, and reliable measures of risk in play, it is harder to ignore the doctor's orders. When a patient learns that his or her blood pressure is highly elevated, the doctor may prescribe a medication, but because the patient has a reliable metric specific to his or her condition, he or she is more likely to comply with other risk reduction recommendations (eg, lose weight, reduce sodium intake, exercise, etc).
Biofilm research has recently and rapidly led to the introduction of the drug silver diammine fluoride to what is now becoming a standard of care in dental practice that greatly benefits patients. As further analysis of oral biofilms results in better risk assessment tools that are more specific and reliable, it will also result in the development of improved methods, oral health literacy tools, and drugs to manage dental caries as the chronic disease that it is, and we will further emphasize the "pill doctor" who is already inside us instead of emphasizing the "knife doctor" who merely treats dental caries after its devastation. We have not had much choice, but now we will. Medical management of caries: enter stage left.
About the Author
Joel H. Berg, DDS, MS, is a professor emeritus at the University of Washington School of Dentistry in Seattle, Washington.