PERIODONTAL CURE: DEFINITION OF HEALTH
Most definitions of periodontal health indicate a state free of inflammatory response that allows an individual to function normally. Most would argue this holistic definition seems impractical and is limiting for the purpose of clinical management of periodontal disease. It is widely accepted that Health can be evaluated at both histological and clinical levels and should be considered in the context of both a preventive starting point and a therapeutic end point.
Therefore, periodontal health exists before disease begins. It is also known that after 4 days of plaque accumulation, a significant number of leukocytes can be found in the collagen-poor connective tissue immediately beneath the junctional epithelium. In biopsies, neutrophilic granulocytes constitute 60% to 70% of the leukocyte population. In humans, a status of clinically healthy gingiva, even over a prolonged period, is always histologically characterized by a small inflammatory cell infiltrate. This is called polymorphonuclear leukocyte surveillance, which is a very important physiological (not pathological) process.
The goal behind our treatment, and this we agree, is pristine health which means: no attachment loss, no bleeding on probing (BoP), no sulcular probing >3 mm and no redness or clinical swelling/edema or pus.
It is said that most reviews do not consider gingival crevicular fluid biomarker research in periodontal health and disease, as crevicular fluid analysis is not generally practical to implement in clinical practice at this time due to the need for specialized equipment. Also “Biomarkers” are mentioned in a new 2017 diagnostic report: for Grade A, B and C which is inconsistent for a progression index of periodontal diagnostics. This only reflects some of the ignorance associated with periodontal history. Microscopy is an integral part of every form of medicinal inquiry, except dentistry.
This, in our opinion, is the biggest mistake in periodontology, as crevicular microbiota analysis with phase-contrast microscopy is effectively the most accurate and precise analysis, carried out with easily available equipment and data and with the best biomarker index readily available, all in only 3 minutes. This non-invasive procedure can be used for any inquiry, as well as for any patient diagnostic.
Excellent health is clearly characterized by a few non-motile coccoid and filamentous bacteria, Actinomyces/coccis (Corynebacterium matruchotii) of the green Socransky complex and epithelial cells in high numbers from the probe that rubs the edges of the sulcus. Double cocci are also present, often resembling S. mutans. Most short filaments remind us of lactobacilli, similar to vaginal flora, and some longer, non-motile filaments of different length. Some are fusobacterium, cited by Keyes as having an Alarm Clock form. There should be an absence of neutrophils or any granulocytes within a perfectly healthy sulcus. If ever we see one, it is a very rare occasion, often considered to be a sign of other underlying problems, giving us helpful hint toward patient assessment.
This image represents perfect health (bellow), as we clinically see this in the majority of dentists and dental hygienists (as well as cured patients). This visible microbiota is our best point of reference for complete Health. It also becomes our objective guide to complete periodontal cure. We have been personally observing the microscopic characteristic morphotype of crevicular microbiota, much like other microscope experts (Barrett, Chiavaro, Bass, Johns, Kofoid, Keyes and Lyons) for more than 32 years and have yet to find an exception in human beings (about 3000 health analysis).
Mark Bonner, DMD
Typical image of 1000x Ph Leica of Health
Example of quality microscope suggested for dentists (Phase contrast 10xPh- 100xPh objectives, Ph3 sliding tab condenser)