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。