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）”。
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