TREATMENT ACCORDING TO THE NONSPECIFIC PLAQUE HYPOTHESIS (NSPH)
以”非特定菌班假說”（Nonspecific plague hypothesis NSPH）為根據的治療
Plaque is considered the etiologic agent of dental diseases by most dentists. In this regard, no bacteriological differences are acknowledged to exist between plaque from diseased and nondiseased sites, nor is there any need for such differences to exist. This approach to an understanding of dental disease shall be called the nonspecific plaque hypothesis (NSPH). Plaque is viewed as an accumulation of bacteria which produces a variety of irritants, such as acids, endotoxins, antigens, and hydrogen sulfide, which dissolve and/or inflame the teeth and/or the supporting dental structures.
牙菌斑被大多數的牙醫師視為是牙科疾病的原因。就這個論點看來，因為未認知到染病區與非染病區的牙菌斑之間有細菌學上的差異，因此這樣的差異也是不需存在的。這個對牙科疾病解讀的觀點我們將之稱為”非特定菌班假說”（Nonspecific plague hypothesis NSPH）。牙菌斑被視為是細菌的累積，它會產生多種刺激物，比如酸、內毒素、抗原以及硫化氫，這些物質會造成牙齒與其支持組織的溶解及/或發炎現象。
Plaque Reduction
減少牙菌斑
The obvious approach to the control of dental diseases under the NSPH would be the elimination of the bacterial flora. If this is done completely, as in germfree animals (which will be discussed in Chapter 8), no caries develop, regardless of how genetically susceptible the individual is, or how cariogenic the diet. Inflammatory periodontal disease is minimal in germfree animals, even though hair and food impaction leads to some bone loss, and calculus formation occurs. Germfree animals provide an experimental model, which demonstrates that the absence of bacteria is associated with optimal dental health.
在”非特定菌班假說” 之下，要控制牙科疾病，一個顯而易見的方法就是消除細菌菌叢。假如這個概念可以徹底執行，如同在無菌動物的身上（將在第八章討論），則無論個體本身的基因是否傾向於容易致病或是飲食很有致齲性，理論上都不會有齲齒的發生。在無菌動物身上，即使有牙結石累積，甚至食物或毛髮的阻塞造成一些齒槽骨喪失的狀況下，其發炎性牙周疾病情況也很輕微 (其牙周發炎的情況也很輕微)。無菌動物提供了一種實驗的模式，顯示出沒有細菌存在與良好的口腔健康狀態是相關的。
Control based upon a germfree mouth is not possible in the human. Reduction of the bacterial mass would seem a more realistic approach for caries and periodontal disease control. As Miller noted, dental diseases occur on retentive sites on the teeth. If plaque can be prevented from accumulating on these sites, then no disease should occur. Since plaque is forming all the time, a successful treatment would have to be universally and continuously applied.
在人體實驗中，要設計一個無菌的口腔環境是不可能的。盡可能減少細菌的量似乎是一個控制齲齒和牙周疾病較實際的方法。由於Miller發現牙齒的疾病多發生在牙齒上容易累積牙菌斑的區域；假如可以避免牙菌班在這些區域累積起來，那麼應該就不會有疾病的發生。而由於牙菌斑是無時無刻都在形成，那麼治療應該是全面地並且持續地進行才會成功。
The demands of such an open-ended treatment are so great that they eliminate from consideration the use of potent antimicrobial agents because with frequent use, these agents often give rise to adverse reactions. With the important exception of water fluoridation and fluoride dentifrices, the dental profession has abandoned the usage of chemical agents in the treatment of dental infections. Instead, great reliance has been placed on mechanical debridement, as embodied in such procedures as dental scalings, polishings, flossing and brushing, as safe and effective methods for disease prevention.
像上述這樣一個無止盡的的治療需要，使得人們打消了使用強力抗微生物製劑的考慮。因為高頻率的使用這些製劑，隨之而來就會有負向的反應產生。在牙醫專業中，除了飲水加氟及含氟牙膏這兩個重要的例外，其他的化學製劑均不被建議使用在牙科疾病的治療上。取而代之的是把重點放在物理性的清創，例如洗牙、磨光打亮及牙線牙刷的使用，同時認為這些都是安全且有效的疾病預防方法。
However, the adequacy of mechanical debridement, especially in terms of control of dental caries, is suspect. There are no documented data which show that flossing and brushing, as performed by the subject, prevent or lessen decay, although improvements in gingivitis can be obtained. This is not the case, when professionally-delivered debridements are given at frequent intervals. Studies in Sweden demonstrated that a professionally-administered dental prophylaxis and fluoride treatment, given at two to three-week intervals to children, or at two-month intervals to adults, resulted in about a 90 percent reduction in decay (See "Karlstad Studies" in Chap. l3). These impressive results show what can be obtained in a preventive-oriented, socialized dental health care system. But the cost of transferring such a professionally-mediated preventive program to a fee-for-service delivery system, as exists in the United States, would be prohibitive except in individual cases.
What, then, should be the preventive strategy in countries such as the United States. This should be addressed by defining the magnitude of the problem.
然而，只用物理性的清創是否足以控制齲齒，是受到質疑的。並沒有數據顯示一般人自己使用牙線和刷牙可以預防或減少齲齒，雖然這些可以改善牙齦發炎。而瑞典的研究顯示，頻繁地給予牙科專業的清創及塗氟，例如對兒童是2～3週一次，針對成人為2個月一次，可以降低90％齲齒發生率（見第13章的Karlstad 系列研究）。這些令人印象深刻的結果顯示，以預防為導向的社會主義牙科健康照護制度可能達到的成效。但是要在像美國這種 “使用需付費 fee-for-service”的制度下實施這樣一個專業預防治療計畫，除了個別案例外基本上是不可能的。在美國這樣的國家，其預防的策略就應該由問題的幅度上來考慮處理。
Table 1-1 shows dental needs found in young male army recruits in the late l960s. Approximately 8.5 surfaces per subject were in need of operative dentistry, another tooth per subject needed extraction, and approximately one prosthetic unit per subject was required. If these needs were representative of the entire U.S. population, then the dental needs of the U.S. were not being met by the dental profession, nor by its preventive philosophy based upon plaque debridement. Government economists estimated that United States expenditures on dental care in l960's were about two billion dollars. They further estimated that another eight billion dollars would be required to replace or to restore the untreated diseased teeth.
表1-1顯示1960年代晚期年輕男性陸軍新兵的牙科需求。平均每人需要補綴的面數是8.5，另外每個人需拔一顆牙，也大約每人需要1組假牙贋復。假如這樣的牙科需求是普遍呈現在美國一般民眾中，則美國牙醫界所提供的專業協助無法達到到這樣的數目，而以牙菌斑清創為根據的預防理念也達不到。政府的經濟學家估計，1960年代美國在牙科照護上的支出約為20億美元，而仍需另外80億美元以修復或治療其餘尚未治療的患牙
These estimated needs were of such a magnitude that the government provided financial assistance for the education of new dentists, which led to the enlargement and modernization of many dental schools. The most viable solution to the overwhelming dental morbidity of the public was to increase the professional work force.
這些估計的需求是如此龐大，所以政府就提供財政援助來教育新的牙醫師。導致許多牙醫學院擴大規模並加以現代化。就這種大多數人均有的牙齒發病率最可行的解決辦法，當時就是增加專業的人力。
By l991 the actual cost of dental care in the United States was over 31 billion dollars, as judged by the reported income of general dentists. The real expenditures would be higher after the income of dental specialists are included. As such, the cost of dental treatments, in the total United States health bill, ranks fourth behind the cost of heart disease, cancers and injuries due to accidents. Expenditures of this magnitude warrant close scrutiny in terms of the cost efficiency of preventive procedures.
到了1991年，美國在牙科照護上實際的花費超過310億美元，這是由一般的牙醫師收入來估算的。若將專科的牙醫師收入也納入計算，則真正的花費將更高。因此，在美國醫療支出上，牙科治療上的花費佔第四位，僅次於心臟病、癌症及意外傷害。如此龐大的支出值得我們密切注意在預防措施上的成本效益。
The same dentists who responded to the survey were asked to report their income as a function of the treatment procedure or service rendered. As shown in Table l-2, 72 percent of the expenditures were for restorative or reparative treatments. Preventive procedures accounted for 7.7 percent of their income, and almost all of this was for the prophylaxis or dental cleanings performed by the hygienists. There is no documentation that such cleanings, given annually or semiannually, prevent decay, although they may be of value in the treatment of gingivitis. Only 0.4 percent of the dentist's income was generated by preventive procedures such as topical fluorides, dietary counseling or other preventive modalities. From this, it would appear that preventive procedures, other than extension for prevention, are not utilized by American dentists.
上述調查中，同一位牙醫師並被問及他所提供的各項服務收入分配的比例，如表1-2所示，72％的收入來自補綴，預防性治療僅佔7.7％，而後者幾乎都是由口腔衛生士所執行的一些預防或牙科清潔的工作。關於這類每年一次或半年一次的清潔工作，沒有文獻報告會預防齲齒，但對於牙齦炎的治療則可能有一些幫助。只有0.4％的牙醫師收入是來自於一些預防措施，包含塗氟，飲食諮詢及其他預防的模式。由此似乎可見，大部分的美國牙醫師除了做補牙上的延伸性預防外，並未利用預防措施。
But extension for prevention, as well as plaque control, has failed to change the course or incidence of dental disease. From this, it would seem that prevention has to precede extension. This probably is impossible under the tenets of the NSPH. What is needed is a treatment hypothesis which offers a realistic, cost-efficient approach to prevention. This hypothesis can be formulated from existing experimental data on the bacteriology of dental plaque and will be described in this book as the specific plaque hypothesis (SPH).
但是延伸性的預防，如同牙菌斑控制，並未能改變牙科疾病的進程或發生率。就此而言，預防的原則似乎應優先於延伸的原則。但在非特定菌斑假說基礎之下，要達到預防效果卻不延伸似乎是不可能的。因此現在需要的是一個假說，來提供可以達到預防效果而且切合實際與成本效益的方法。這個假說可由已知的牙菌斑細菌學上的實驗證據來形成，也就是接下來將介紹的”特定牙菌斑假說（SPH）”。
2010年1月26日 星期二
第一章 追尋一種預防的理念-1
CAPTER ONE In Search of a Preventive Philosophy
第一章 追尋一種預防的理念
I. Introduction
II. Treatment According to the Nonspecific Plaque Hypothesis (NSPH)
A. Plaque Reduction
III. The Specific Plaque Hypothesis (SPH)
A. Nondisease-Associated Plaque
B. Caries-Associated Plaque
C. Periodontal-Associated Plaque
IV. Treatment According to the Specific Plaque Hypothesis
I. 前言
II. 以非特定菌斑假說（Nonspecific plague hypothesis, NSPH）為根據的治療
A. 減少牙菌斑
III. 特定菌斑假說(Specific plague hypothesis, SPH)
A. 非致病性的牙菌斑
B.與齲齒相關的牙菌斑
C.與牙周疾病相關的牙菌斑
IV. 以特定菌斑假說（Specific plague hypothesis SPH）為根據的治療
INTRODUCTION
The teeth are unique in that they are the only body part that is not subject to metabolic turnover. Once formed, the teeth are essentially indestructible, as shown by their importance in fossil records and forensic medicine. Yet, beginning in the mid 19th century, the integrity of the teeth was assaulted by a microbial challenge so great that dental infections, such as dental caries and periodontal disease, soon became the most universal of human infections. The epidemic of dental decay that spread throughout the western world, soon after the introduction of sucrose in the diet, caused so much suffering among so many, that the medical profession recommended and initiated an accelerated program to train clinicians in its treatment. And thus the dentist became the first medical specialist.
前言
牙齒是非常獨特的，因為它是人體身上唯一不必代謝週轉的部位。一旦形成之後，牙齒基本上是堅不可摧的，我們從它們在化石紀錄或是法醫學的重要性就可見一般。然而就在十九世紀中期開始，牙齒的完整性受到一種微生物的挑戰，這些攻擊相當嚴重，導致這種牙科的感染 (如齲齒和牙周病) 很快就變成人類最普遍的感染之一。這種牙齒損害的疫情在蔗糖進入飲食圈中不久就席捲整個西方世界。因為有許多人為此深受其苦，醫學界當時就建議且開始一個速成的臨床醫師養成計畫來治療它。因之牙醫師成為第一個醫學的專科醫師。
Miller and others in the late 19th century quickly implicated bacteria as the cause of human dental decay. When they could not identify any specific bacterial types that were uniquely associated with decay, they introduced the concept that all bacteria that resided in the mouth could collectively cause decay. Miller pointed out that decay occurs at retentive sites on the teeth and advocated that these sites should be kept as clean as possible. This opinion is espoused today under the rubric of plaque control. G.V. Black recognized at the turn of the century that certain areas of the teeth are not caries prone (those sites cleansed by the saliva) and recommended that the cavity preparations used to remove dental decay be extended out into these self-cleansing areas.
Miller等學者在19世紀末期很快就指出細菌是人類齲齒的原因。但是當時他們無法確認有任一種特定的菌種會獨特地與齲齒相關，因此他們提出了這個觀念，就是: 居住在人類口腔中的所有菌種可以集體地造成齲齒。Miller指出齲齒通常發生在牙齒上會累積牙菌斑的區域，因此建議應該盡可能的將這些區域保持清潔。這個看法在現代被信奉於”牙菌斑控制（plague control）” 的旗幟之下。 G.V. Black接著在世紀交替之際，注意到牙齒上某些區域是不易產生齲齒的區域（就是那些唾液可清潔到的區域），並且建議移除齲齒時的窩洞修形，應該延伸到這些可以自我清潔的區域。
(到了1930和1940年代，Jay及Becks提出易患齲齒的病人應該限制飲食中碳水化合物的攝取的概念。因此牙菌斑控制（plague control）及飲食控制都成為牙醫師面對齲齒預防的重要觀念。1950和1960年代，飲水加氟及含氟牙膏也成為齲齒預防的的一部份。)
This 19th century science, which implicated plaque overgrowth or the "dirty mouth" as the cause of decay, has dominated clinical practice throughout the 20th century. There is scant evidence that good oral hygiene ever was of value in reducing the prevalence of dental decay. Poor dental health was the leading cause for rejection from the military in World Wars I and II, the Korean war and the Vietnam war. The pervasiveness of dental decay was such that when a caries-free individual was found s/he was viewed as possessing some rare genetic trait that made him caries resistant. The remaining 99% of the population, however was on a predetermined course that would inevitably lead to dentures. In this process the cost of treating or restoring the damage caused by these infections was enormous. In the United States the cost of dental treatment in 1984 was $24 billion dollars, and in 1991 had increased to $37 billion. These expenditures make the treatment of dental decay more expensive than the treatments of diabetes, arthritis and eye diseases. Put into this economic context dental infections are extremely important,
這個十九世紀的科學思維，所謂牙菌斑過度成長或是 ” 骯髒的嘴巴 (dirty mouth) " 是齲蛀的原因，主導了整個二十世紀的臨床作法。沒有什麼證據顯示良好的口腔衛生對於降低齲齒的盛行率有所價值。牙齒健康不良曾是在第一次與第二次世界大戰，韓戰與越戰被軍隊拒絕的主要原因。蛀牙在當時非常普及，以致於任何一個人被發現沒有蛀牙時，他(她)是被視為具有某些稀有的基因特性使他不會蛀牙。其他99%的人口，則在一條既定的過程中，最後都無可避免地導致假牙一途 (的成為假牙一族)。在這個過程中，為了治療或修復因為這些感染造成的傷害的代價是極大的。在美國，1984年在牙科治療的花費是240億美元；1991年已增加到370億美元。這些支出使得齲齒的治療比治療糖尿病，關節炎及眼疾還要昂貴。放在這樣的經濟考量下，牙科的感染是非常重要的。
As we prepare to enter the 21st century there is considerable concern over the cost of dental health care. The 19th century paradigm that dental decay comes from a "dirty mouth", which I have called the non-specific plaque hypothesis, has been shown to be deficient in its ability to prevent decay. Plaque control, extension for prevention, and dental cleanings, (euphemistically called dental prophylaxis), are bankrupt procedures when it comes to preventing dental decay. If it were not for water fluoridation and fluoridated dentifrices, both of which are used outside the purview of the dentist, the epidemic of dental decay might still be occurring.
當我們準備進入第二十一世紀之際，牙科醫療的花費引起相當大的關切。這個十九世紀的典範( 齲齒來自骯髒的嘴巴 ；我所稱的” 非特定菌班假說 “) 已經被證明不足以預防齲齒。牙菌班控制，延伸性預防，與潔牙 (委婉地叫做牙齒預防)等步驟，在避免齲齒這方面上是破產的。如果不是因為有了飲水加氟和含氟牙膏 (兩者都不在牙醫師的職掌中)，現在可能還是會發生齲齒的大疫情呢。
In this monograph, a new paradigm for the prevention and treatment of dental decay based upon a specific bacterial etiology, the specific plaque hypothesis (SPH), will be developed. The treatment strategies and tactics of the SPH lend themselves to the economic realities of the 21st century where under universal health coverage, it becomes essential to prevent diseases, rather than to treat at a costly terminal stage. Nowhere will this be more applicable than in dentistry, where a single tooth may be treated multiple times before it is finally extracted and replaced with a prosthetic tooth.
在這本書中，一個著眼於特定細菌原因來預防與治療齲齒的新典範，特定菌班假說 (specific plaque hypothesis (SPH))，將被發展出來。SPH的治療策略與方法本身，提供了在第二十一世紀最符合經濟現實的做法；在全面醫療保險下，基本上應該去預防疾病的發生而非治療昂貴的疾病末期。沒有一個地方比牙科更適用這個原則，因為一顆牙齒可以先被治療很多次，然後最終還是拔掉再作假牙。
第一章 追尋一種預防的理念
I. Introduction
II. Treatment According to the Nonspecific Plaque Hypothesis (NSPH)
A. Plaque Reduction
III. The Specific Plaque Hypothesis (SPH)
A. Nondisease-Associated Plaque
B. Caries-Associated Plaque
C. Periodontal-Associated Plaque
IV. Treatment According to the Specific Plaque Hypothesis
I. 前言
II. 以非特定菌斑假說（Nonspecific plague hypothesis, NSPH）為根據的治療
A. 減少牙菌斑
III. 特定菌斑假說(Specific plague hypothesis, SPH)
A. 非致病性的牙菌斑
B.與齲齒相關的牙菌斑
C.與牙周疾病相關的牙菌斑
IV. 以特定菌斑假說（Specific plague hypothesis SPH）為根據的治療
INTRODUCTION
The teeth are unique in that they are the only body part that is not subject to metabolic turnover. Once formed, the teeth are essentially indestructible, as shown by their importance in fossil records and forensic medicine. Yet, beginning in the mid 19th century, the integrity of the teeth was assaulted by a microbial challenge so great that dental infections, such as dental caries and periodontal disease, soon became the most universal of human infections. The epidemic of dental decay that spread throughout the western world, soon after the introduction of sucrose in the diet, caused so much suffering among so many, that the medical profession recommended and initiated an accelerated program to train clinicians in its treatment. And thus the dentist became the first medical specialist.
前言
牙齒是非常獨特的，因為它是人體身上唯一不必代謝週轉的部位。一旦形成之後，牙齒基本上是堅不可摧的，我們從它們在化石紀錄或是法醫學的重要性就可見一般。然而就在十九世紀中期開始，牙齒的完整性受到一種微生物的挑戰，這些攻擊相當嚴重，導致這種牙科的感染 (如齲齒和牙周病) 很快就變成人類最普遍的感染之一。這種牙齒損害的疫情在蔗糖進入飲食圈中不久就席捲整個西方世界。因為有許多人為此深受其苦，醫學界當時就建議且開始一個速成的臨床醫師養成計畫來治療它。因之牙醫師成為第一個醫學的專科醫師。
Miller and others in the late 19th century quickly implicated bacteria as the cause of human dental decay. When they could not identify any specific bacterial types that were uniquely associated with decay, they introduced the concept that all bacteria that resided in the mouth could collectively cause decay. Miller pointed out that decay occurs at retentive sites on the teeth and advocated that these sites should be kept as clean as possible. This opinion is espoused today under the rubric of plaque control. G.V. Black recognized at the turn of the century that certain areas of the teeth are not caries prone (those sites cleansed by the saliva) and recommended that the cavity preparations used to remove dental decay be extended out into these self-cleansing areas.
Miller等學者在19世紀末期很快就指出細菌是人類齲齒的原因。但是當時他們無法確認有任一種特定的菌種會獨特地與齲齒相關，因此他們提出了這個觀念，就是: 居住在人類口腔中的所有菌種可以集體地造成齲齒。Miller指出齲齒通常發生在牙齒上會累積牙菌斑的區域，因此建議應該盡可能的將這些區域保持清潔。這個看法在現代被信奉於”牙菌斑控制（plague control）” 的旗幟之下。 G.V. Black接著在世紀交替之際，注意到牙齒上某些區域是不易產生齲齒的區域（就是那些唾液可清潔到的區域），並且建議移除齲齒時的窩洞修形，應該延伸到這些可以自我清潔的區域。
(到了1930和1940年代，Jay及Becks提出易患齲齒的病人應該限制飲食中碳水化合物的攝取的概念。因此牙菌斑控制（plague control）及飲食控制都成為牙醫師面對齲齒預防的重要觀念。1950和1960年代，飲水加氟及含氟牙膏也成為齲齒預防的的一部份。)
This 19th century science, which implicated plaque overgrowth or the "dirty mouth" as the cause of decay, has dominated clinical practice throughout the 20th century. There is scant evidence that good oral hygiene ever was of value in reducing the prevalence of dental decay. Poor dental health was the leading cause for rejection from the military in World Wars I and II, the Korean war and the Vietnam war. The pervasiveness of dental decay was such that when a caries-free individual was found s/he was viewed as possessing some rare genetic trait that made him caries resistant. The remaining 99% of the population, however was on a predetermined course that would inevitably lead to dentures. In this process the cost of treating or restoring the damage caused by these infections was enormous. In the United States the cost of dental treatment in 1984 was $24 billion dollars, and in 1991 had increased to $37 billion. These expenditures make the treatment of dental decay more expensive than the treatments of diabetes, arthritis and eye diseases. Put into this economic context dental infections are extremely important,
這個十九世紀的科學思維，所謂牙菌斑過度成長或是 ” 骯髒的嘴巴 (dirty mouth) " 是齲蛀的原因，主導了整個二十世紀的臨床作法。沒有什麼證據顯示良好的口腔衛生對於降低齲齒的盛行率有所價值。牙齒健康不良曾是在第一次與第二次世界大戰，韓戰與越戰被軍隊拒絕的主要原因。蛀牙在當時非常普及，以致於任何一個人被發現沒有蛀牙時，他(她)是被視為具有某些稀有的基因特性使他不會蛀牙。其他99%的人口，則在一條既定的過程中，最後都無可避免地導致假牙一途 (的成為假牙一族)。在這個過程中，為了治療或修復因為這些感染造成的傷害的代價是極大的。在美國，1984年在牙科治療的花費是240億美元；1991年已增加到370億美元。這些支出使得齲齒的治療比治療糖尿病，關節炎及眼疾還要昂貴。放在這樣的經濟考量下，牙科的感染是非常重要的。
As we prepare to enter the 21st century there is considerable concern over the cost of dental health care. The 19th century paradigm that dental decay comes from a "dirty mouth", which I have called the non-specific plaque hypothesis, has been shown to be deficient in its ability to prevent decay. Plaque control, extension for prevention, and dental cleanings, (euphemistically called dental prophylaxis), are bankrupt procedures when it comes to preventing dental decay. If it were not for water fluoridation and fluoridated dentifrices, both of which are used outside the purview of the dentist, the epidemic of dental decay might still be occurring.
當我們準備進入第二十一世紀之際，牙科醫療的花費引起相當大的關切。這個十九世紀的典範( 齲齒來自骯髒的嘴巴 ；我所稱的” 非特定菌班假說 “) 已經被證明不足以預防齲齒。牙菌班控制，延伸性預防，與潔牙 (委婉地叫做牙齒預防)等步驟，在避免齲齒這方面上是破產的。如果不是因為有了飲水加氟和含氟牙膏 (兩者都不在牙醫師的職掌中)，現在可能還是會發生齲齒的大疫情呢。
In this monograph, a new paradigm for the prevention and treatment of dental decay based upon a specific bacterial etiology, the specific plaque hypothesis (SPH), will be developed. The treatment strategies and tactics of the SPH lend themselves to the economic realities of the 21st century where under universal health coverage, it becomes essential to prevent diseases, rather than to treat at a costly terminal stage. Nowhere will this be more applicable than in dentistry, where a single tooth may be treated multiple times before it is finally extracted and replaced with a prosthetic tooth.
在這本書中，一個著眼於特定細菌原因來預防與治療齲齒的新典範，特定菌班假說 (specific plaque hypothesis (SPH))，將被發展出來。SPH的治療策略與方法本身，提供了在第二十一世紀最符合經濟現實的做法；在全面醫療保險下，基本上應該去預防疾病的發生而非治療昂貴的疾病末期。沒有一個地方比牙科更適用這個原則，因為一顆牙齒可以先被治療很多次，然後最終還是拔掉再作假牙。
2010年1月25日 星期一
齲齒:一種可治療的感染疾病 序文 P. vi
在撰寫這本專書的時候，我受益於很多人，也與我的同儕們做了很多非正式的訪談。我虧欠我的朋友們，譬如 Paul Keyes，Ronald Gibbons，Johnes van Houte 及 Salam Syed，他們的著作與思想均協助了我觀念的形成。在這個領域的許多出版物中，我希望特別提醒大家注意到在過去十年來由國家齲齒計畫(National Caries Program)在幾次關於齲齒的專題研討會所出版的專冊。我相當借重這些出版物，同時也推薦它們是對於齲齒的各個層面想要有詳細資料的人無價的資料來源。
每一件這麼大的工程都需要許多人的貢獻。特別致謝Dr. David Starks， 密西根大學牙醫學院教育資源系主任；隨時提供他的人員與設備。Dr. Thomas Green 很小心地審議這本專書及之前幾版的口腔細菌學來增進其組織與可讀性，他的貢獻良多也始終扮演支持的角色。Karen Smith，Chris Jung 及Pam Rav 製作了大部份的插圖。John Squires建議了這本書的電腦製作與最終付印。Natalie Grossman閱讀並對內文做了修正，這些總是增進了詞句的明瞭性，她同時做了所有的文書處理，基本上就是我的常駐編輯，我衷心地感謝她。如果有發現任何思考上或文法上的錯誤，責任都在於我。
這本1994年再印本代表了這本"可治療的感染疾病"專書的友善版本，因為原來1982年由Charles Thomas出版發行時是採用螺旋裝訂而顯得笨重。這本書除了密西根大學為了自己學生印過一些之外原已絕版。許多人都問起如何買得到這本書，也介紹給他們的牙醫學院做教科書。但是這本書的版式從來就不是很吸引人的，直到ADD公司(Automated Diagnostic Documentation, Inc.)的Mike Riolo 提供以平裝版再出版，我立即欣然同意再印新書。大部分包含在1982年版本的材料直到今日仍是貼切適用且及時的。在編輯這個新的版式時，我也做了一些修改。例如， Streptococcus mutans 現在指的是 mutans streptococci。中心的議題基本上沒有改變，也就是說齲齒是一種基於 mutans streptococci(後期階段則為 lactobacilli)的特定的、可以治療的細菌感染疾病。Carol Gerlach 有功於製作這個最終版本，也艱辛地把原來版本中的表格重新打字。
每一件這麼大的工程都需要許多人的貢獻。特別致謝Dr. David Starks， 密西根大學牙醫學院教育資源系主任；隨時提供他的人員與設備。Dr. Thomas Green 很小心地審議這本專書及之前幾版的口腔細菌學來增進其組織與可讀性，他的貢獻良多也始終扮演支持的角色。Karen Smith，Chris Jung 及Pam Rav 製作了大部份的插圖。John Squires建議了這本書的電腦製作與最終付印。Natalie Grossman閱讀並對內文做了修正，這些總是增進了詞句的明瞭性，她同時做了所有的文書處理，基本上就是我的常駐編輯，我衷心地感謝她。如果有發現任何思考上或文法上的錯誤，責任都在於我。
這本1994年再印本代表了這本"可治療的感染疾病"專書的友善版本，因為原來1982年由Charles Thomas出版發行時是採用螺旋裝訂而顯得笨重。這本書除了密西根大學為了自己學生印過一些之外原已絕版。許多人都問起如何買得到這本書，也介紹給他們的牙醫學院做教科書。但是這本書的版式從來就不是很吸引人的，直到ADD公司(Automated Diagnostic Documentation, Inc.)的Mike Riolo 提供以平裝版再出版，我立即欣然同意再印新書。大部分包含在1982年版本的材料直到今日仍是貼切適用且及時的。在編輯這個新的版式時，我也做了一些修改。例如， Streptococcus mutans 現在指的是 mutans streptococci。中心的議題基本上沒有改變，也就是說齲齒是一種基於 mutans streptococci(後期階段則為 lactobacilli)的特定的、可以治療的細菌感染疾病。Carol Gerlach 有功於製作這個最終版本，也艱辛地把原來版本中的表格重新打字。
2010年1月24日 星期日
齲齒:一種可治療的感染疾病 序文 P. v
華德 J 羅許 (Walter J. Loesche) 1993年6月16日 於美國，密西根州，安納堡
我於1969年來到安納堡不久之後，我接受了一個教授口腔細菌學的工作。這個課程基本上和一般微生物學不同，它同時是設計來把口腔細菌學的研究發現轉移到臨床上來。當時就齲齒的細菌學而言，很多的發現是很令人興奮的。S. mutans已經在動物模型中很清楚地被顯示出來是齲齒的一個致病菌，而S. mutans和蔗糖之間的主要互動關係也被描述出來。
剛開始的時候，我會在現成的牙科微生物教科書中指定閱讀部分，但隨著研究發現快速超越教科書能跟上的腳步，我發現我是提供我自己的筆記給學生使用。後來這些筆記就集結成冊為一本書就叫做口腔細菌學(Oral Bacteriology)， 這本書由密西根大學牙醫學院在1974年出版，隨後並經五次的改寫與擴編來與時俱進。
然後，我在1975年為Oral Science Review寫了一篇名為"牙菌斑感染的化學療法(Chemotherapy of Dental Plaque Infection)"的文獻回顧。當我在收集整合那篇文章的材料時，我發現一個明顯的事實，那就是牙醫界都是把牙科感染的治療目標指向牙菌斑控制本身(plaque control per se)。這個方式雖然理論上可以治癒牙科感染，在臨床上卻是不實際的。同時，這個方式忽略了當時口腔細菌學研究的一個重要的發現，也就是:由有病的地方取下來的牙菌斑和健康的地方取下來的牙菌斑在細菌學上與生化學上是截然不同的。在那篇文獻回顧中，我重新確認一個舊的觀念:齲齒和牙周病是特定的細菌感染(盡管是一種慢性的)，同時給這個觀念下了一個"特定菌斑假說 (Specific Plaque Hypothesis)"的標題。後來這個"特定菌斑假說"就成為該課程與口腔細菌學後繼版本的主題。
在完成那本口腔細菌學的上一版本時，裡面已有相當大的篇幅談到根據"特定菌斑假說"的治療策略與作法。因此也很合適把這些材料重新為更多的牙醫同仁寫一本專書。牙醫師都了解到齲齒率已經改變了(譯者註:當時美國的齲齒率因為飲水加氟與氟化物的使用已呈現明顯的下降)，將來牙醫師的執業內容將不再只是補牙。但是牙醫師若要得到這些訊息，在大多數的情況下，他必須去閱讀基礎科學期刊的詳細報告。這本專書就是要來符合這個需求:將許多研究的發現放到"齲齒是一種可以治療的感染疾病"這個觀念架構下呈現出來。這本專書可說相當詳盡，附有表格和圖片，因為這個"可以治療的感染疾病"對許多牙醫師與牙科學生而言都是新的觀念，他們會想要看看得到這個結論所根據的資料。參考的文獻會集中放在表格和每章的結尾，讓讀者容易閱讀。
目前在繁重的牙醫學院課程中，幾乎沒有時間可以提供一個單獨的口腔微生物學課程。這種情況造成我們對牙科學生教育相當大的為難。因為我們是有系統地讓他們在齲齒與牙周病的細菌病理學上缺乏足夠的洗禮。不久的將來，牙醫學院的主事者與教師們，將會需要把基礎研究和臨床訓練的重心由形態科學轉移到以生物科學為根基。個人化的齲齒與牙周感染的細菌學診斷應該，也終將是牙醫師與他的病人互動的基本要素。最近相當豐富的口腔微生物學、口腔生理學、齲齒學教科書及許多專書，例如本書，都將為這樣的改變提供一些輔助。
我於1969年來到安納堡不久之後，我接受了一個教授口腔細菌學的工作。這個課程基本上和一般微生物學不同，它同時是設計來把口腔細菌學的研究發現轉移到臨床上來。當時就齲齒的細菌學而言，很多的發現是很令人興奮的。S. mutans已經在動物模型中很清楚地被顯示出來是齲齒的一個致病菌，而S. mutans和蔗糖之間的主要互動關係也被描述出來。
剛開始的時候，我會在現成的牙科微生物教科書中指定閱讀部分，但隨著研究發現快速超越教科書能跟上的腳步，我發現我是提供我自己的筆記給學生使用。後來這些筆記就集結成冊為一本書就叫做口腔細菌學(Oral Bacteriology)， 這本書由密西根大學牙醫學院在1974年出版，隨後並經五次的改寫與擴編來與時俱進。
然後，我在1975年為Oral Science Review寫了一篇名為"牙菌斑感染的化學療法(Chemotherapy of Dental Plaque Infection)"的文獻回顧。當我在收集整合那篇文章的材料時，我發現一個明顯的事實，那就是牙醫界都是把牙科感染的治療目標指向牙菌斑控制本身(plaque control per se)。這個方式雖然理論上可以治癒牙科感染，在臨床上卻是不實際的。同時，這個方式忽略了當時口腔細菌學研究的一個重要的發現，也就是:由有病的地方取下來的牙菌斑和健康的地方取下來的牙菌斑在細菌學上與生化學上是截然不同的。在那篇文獻回顧中，我重新確認一個舊的觀念:齲齒和牙周病是特定的細菌感染(盡管是一種慢性的)，同時給這個觀念下了一個"特定菌斑假說 (Specific Plaque Hypothesis)"的標題。後來這個"特定菌斑假說"就成為該課程與口腔細菌學後繼版本的主題。
在完成那本口腔細菌學的上一版本時，裡面已有相當大的篇幅談到根據"特定菌斑假說"的治療策略與作法。因此也很合適把這些材料重新為更多的牙醫同仁寫一本專書。牙醫師都了解到齲齒率已經改變了(譯者註:當時美國的齲齒率因為飲水加氟與氟化物的使用已呈現明顯的下降)，將來牙醫師的執業內容將不再只是補牙。但是牙醫師若要得到這些訊息，在大多數的情況下，他必須去閱讀基礎科學期刊的詳細報告。這本專書就是要來符合這個需求:將許多研究的發現放到"齲齒是一種可以治療的感染疾病"這個觀念架構下呈現出來。這本專書可說相當詳盡，附有表格和圖片，因為這個"可以治療的感染疾病"對許多牙醫師與牙科學生而言都是新的觀念，他們會想要看看得到這個結論所根據的資料。參考的文獻會集中放在表格和每章的結尾，讓讀者容易閱讀。
目前在繁重的牙醫學院課程中，幾乎沒有時間可以提供一個單獨的口腔微生物學課程。這種情況造成我們對牙科學生教育相當大的為難。因為我們是有系統地讓他們在齲齒與牙周病的細菌病理學上缺乏足夠的洗禮。不久的將來，牙醫學院的主事者與教師們，將會需要把基礎研究和臨床訓練的重心由形態科學轉移到以生物科學為根基。個人化的齲齒與牙周感染的細菌學診斷應該，也終將是牙醫師與他的病人互動的基本要素。最近相當豐富的口腔微生物學、口腔生理學、齲齒學教科書及許多專書，例如本書，都將為這樣的改變提供一些輔助。
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