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					Unconventional Dental Treatment
Presented By Riham Mohamed Aly

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Unconventional Dental Treatment
 It’s an alternative way of treatment other than what we usually think of when confronted with dental problems.  The majority of the treatment modalities are drill and fill ,but the alternatives are actually various thanks to the scientific advances which is now directed to lesion specific approach.  The purpose of this study is to present and evaluate the available modalities from the most basic practices to the far more sophisticated scientific technology.
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So What Are The Alternatives?
1- Unconventional medicine 2- Biological Dentistry 3- Vaccines 4- Tooth Regeneration
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1- Unconventional Medicine
 These diagnostic and treatment approaches have been variously described as “Alternative”, “Integrative” , “Environmental”, “Complementary”  The ADA describes it as encompassing scientifically unproven practices and products that do not conform to the generally accepted dental practice.  It is characterized by the lack of sufficient documentation on their safety and effectiveness also its absence from the dental curriculum.
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The Unconventional Care Patient:
The reason for the Popularity and the increasing use of UD is complex , it may be due to the fact that patients seek new hope or because it less invasive and appear to be safer than conventional treatment
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Classification Of UD
I- Alternative medical systems a- acupuncture b- homeopathy
II- Biologically based dental therapies a- phytotherapy or herbalism b- natural and synthetic dental products

III- Biofield Through the use of subtle energy fields in and around the body. IV- Bioelectromagnetics
Using electromagnetically fields for dental & medical purposes e.g. wearing magnetic rings for TMJ problems & arthritis.
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Unconventional medicine
Acupuncture •It describes a range of procedures that stimulate certain points on or near the skin based on the ancient Chinese medical philosophy that the disruption of a normal pattern of energy flow is responsible for the disease. •The dental application is mainly for Pain Relief , but due to the danger of chocking when using needles in the oral cavity , local injection of saline or local anesthetic in these points is performed.
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Unconventional medicine
•The principles of homeopathy include the belief that disease presents a disturbance in the body’s ability to heal itself. •Dental promotions for homeopathy range from treatment of fear and anxiety, TMD, facial paralysis, aphthous ulcers, toothache, infections ,halitosis and periodontal disease •“Remedies” are determined by noting the symptoms produced by large doses of a substance in a healthy individual and applying these substances in highly diluted doses to relieve the same symptoms

Homeopathy

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Unconventional medicine
Phytotherapy or Herbalism

•Herbal medicine uses drugs of plant origin to treat disease or maintain condition of improved health. •Some conventional drugs like morphine are originally extracted from plants •In dentistry clinical trial of producing herbal mouthwash in preventing oral mucositis from chemotherapy •Also it is largely used in formulating mouthwashes and toothpastes •It is also promoted sometimes as vitamins and mineral supplements
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ADA positions and statements: (Policy Statement On UD)
 This is the statement published by the ADA on the subject of UD  “The ADA consistent with its object to encourage the improvement of the health of the public and to promote the art and science of dentistry supports those diagnostic and treatment approaches that allow both patient &dentist to make informed choices among safe and effective options . The ADA encourages advocates of UD to pursue scientifically valid systematic assessment of treatment efficacy and safety”
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So What Are The Alternatives?
1- Unconventional medicine 2- Biological Dentistry 3- Vaccines 4- Tooth Regeneration
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2- Holistic Or Biological Dentistry
 It adopts a humanistic philosophy considering the whole patient including both physiological and behavioral disorders.
 It is remote from scientific practice and is used to treat chronic conditions that can not be cured by scientific dentistry.  This is done by saving all healthy tooth structures and using bioenergetic medicine including:
 Neural Therapy  Cold Laser  Mouth Balancing and Nutrition

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2- Holistic Or Biological Dentistry
 It adopts a humanistic philosophy considering Neural Therapy the whole patient including both physiological •It claims disorders. and behavioral that when inflammation or infection is is  It ispresent infrommouth,there practice and is remote the scientific usedusally blockage in the body's to treat chronic conditions that can not be cured by scientific dentistry. every normal energy flow, since cell possess its own specified  This frequency rangesaving all healthy tooth is done by structures and using bioenergetic medicine •Injection of LA around the tooth including: in question  Neural Therapy to remove the energy  Cold Laser blockage will resolve the problem
 Mouth Balancing and Nutrition
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2- Holistic Or Biological Dentistry
 It adopts a humanistic philosophy considering Cold Laser the wholean alternative formboth physiological •It is patient including of and behavioral disorders. accupunture for patient who refuse needles.  It is remote from scientific practice and is used•It is supposed to kill bacteria & can not be to treat chronic conditions that aid in wound dentistry. cured by scientifichealing and treat TMJ dysfunction.  This •The done by saving the light is power output and all healthy tooth structures and using bioenergetic medicine spectrum used doesn’t cause any including: thermal damage thus called  Neural Therapy “cold “  Cold Laser
 Mouth Balancing and Nutrition
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2-Holistic Or Biological Dentistry (cont.)
 Biological dentistry is different from UD that it is not based on scientific research in fact unconventional dentistry practioners do not approve of it.  It is only mentioned in this presentation so as not to confuse between it and the UD , especially with the spread of information that is not usually reviewed especially over the Internet.

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Amalgam/Mercury Toxicity Controversy :
 Among the major promotions of biological dentists is amalgam toxicity  They claim that the amalgam being used as a filling is very toxic to the body and is the cause of many diseases and demand that every filling should be removed  The World Health Organization in reply to these claims stated that the overall toxic risk of amalgam is very low and that the removal of any filling on the ground that health may improve as a result is unethical  The ADA also produced a statement with the same meaning
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So What Are The Alternatives?
1- Unconventional medicine 2- Biological Dentistry 3- Vaccines 4- Tooth Regeneration
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3- Vaccines
 The possibility of developing a caries specific vaccine became possible with the identification of specific micro organisms associated with the etiology of caries  All studies have been directed towards acid production ignoring that the glucans produced by bacteria plays an important role , since caries is a “dieto-bacterial“ disease.
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3- Vaccines (cont.)
 It is important to know here that the main causing microorganisms are the streptococcus mutans  The purpose is not to strengthen the enamel but preventing either the action or the colonization of the tooth causing bacteria  The immunization results in the elevation of antibodies against the products of the Strept. Mutans specially Glucans and Glucosyltransferase
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 Glucans function in plaque accumulation and in strengthening the attachment of the microorganisms to the tooth surface.  Glucosyltransferasse is the enzyme that synthesize glucan.  The antibody created by the vaccine binds to the and prevents it from making glucans that cause bacteria to colnize and accumulate on the tooth surface.

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Criteria to be considered:
 Is there evidence that the immunization will work ?  What will be the microbial target?  Which component of the immune system will be targeted ?
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Evidence that the anti-caries vaccine will be effective:
 Several studies indicated that it is possible to protect lab animals against caries  The results of these studies is shown in this table: i) protection against smooth surface caries is very high in contrast to pits and fissure caries. ii) It also shows different effects based on location

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What will be the microbial target?
 Immunization against whole cell S.mutans seems appealing but unfortunately Smutans posses antigens which are cross reactive with heart muscles therefore it is not accepted as an antigen.  Other alternatives are: i) purification of candidate Ag and using subunit vaccine which are Glucans and glucosyltransferase. ii) Recombinant DNA method to place virulence factors from cariogenic organisms into a noncariogenic non reactive bacterium.
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DNA vaccines
 Encouraging results were reported for DNA vaccine whereby DNA coding for the foreign antigen is directly injected into the animal so that the foreign Ag is directly produced by the host cell.  Therefore it would be extremely safe and devoid from side effects since the foreign Ag is produced by the host.  In addition DNA vaccine is relatively inexpensive and is easier to produce than conventional vaccines.  Also the time for development is relatively short and it also results in more long term and stable than traditional vaccines.
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Which component of the immune system will be targeted ?
 There is a difference in opinions regarding whether IgG or IgA is responsible for the defense mechanism.  IgA is the dominant immunoglobulin in the mouth and is resistant to protease and is the mucosal immunoglobulin therefore it may be effective against smooth surface caries.  IgG is found in low conc in the saliva but in high conc in sulcular area and is susceptible to proteases it is effective against root caries.
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How and When it is introduced ?
 This vaccine triggers immunity in saliva and mucous tissue ,therefore it swabbed into the nostrils.  The best age is at one , after the deciduous teeth have erupted and before the mutants bacteria have started to increase in number.  Also a booster dose can be given after the permanent teeth have erupted to provide life long immunity.

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Active and Passive Immunization
 Active immunization is the previous method discussed ,requiring subunit vaccines to avoid cross reactivity as mentioned before.
 Passive immunization either through Maternal or Xenogenic immunization( cows will be immunized against cariogenic bacteria and Ab will appear in the milk).

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So What Are The Alternatives?
1- Unconventional medicine 2- Biological Dentistry 3- Vaccines 4- Tooth Regeneration
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4- Whole tooth regeneration
 Last but not least is the tooth regeneration.  Although the day when dentists will be able to build new teeth is still a few years away ,the Bioengineering researches claim that dentures will be replaced with patients own teeth regenerated from tissue sample ,where the ultimate goal is to grow it in same place of the missing tooth.  Scientists claim that we are getting to closer to the era of replacement body parts instead of prosthetics.
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Tooth Regeneration &Biomimetic
 Biomimetic is science that tries to mimic biological structures, function and synthetic pathways to create a material that will resemble to some degree the original structure in this case a tooth.  The main idea behind tissue regeneration is to employ the use of Multipluripotent Stem cells harvested from the pulp.  Then loading it to a scaffolding which allows for their stable transfer into the target where they can grow to form dentin.
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Tooth regeneration and Biomimetics (cont.)
 The identification of genes and genes products of enamel formation (amelogenin,ameloblastin) made it possible for enamel regeneration which due to its complex constituents was still far from regeneration.  So far this has worked on immunosuppresed mice but not yet in humans.  Another success is the regeneration of whole tooth using pigs (a second mammalian species) which gives hope to its application on humans.
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Important information that needed to be discovered
 What cells involved in forming the various parts of the tooth ?
 Also how these cells communicated with each other ?

 What genes were involved with the development ?
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Three key element for Regenerative Dentistry
 A) Inductive Morphogenetic signals (morphogenes )  B ) Stem Cells
 C ) Extra cellular matrix scaffold

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Three key element for Regenerative Dentistry

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A ) Inductive Morphogenes
 Morphogenes : are extracellularly excreted signals governing morphogenesis during epithelial mesenchymal interaction.  They govern patterning and morphogenesis of teeth and associated PD structures.  With the appropriate use of Morphogenes and stem cells with the appropriate scaffold dental tissue will be gained.  Four distinct families of morphogenes are involved in embryonic morphogenesis.
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A) Inductive Morphogenes (cont.)
 But Bone morphogenic proteins seem to be sufficient in dental tissue engineering.  BMP play the following role in craniofacial development: • Have a role in mesenchymal diffrentiation. • Associated with the diffrentiation of ameloblasts and odontoblasts. • It was present in the pulp during odontoblast development.
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B) Stem Cells
 Stem cells are: Cells that can differentiate into many different cell types when subjected to the right biochemical signals.  The most versatile stem cells, called pluripotent stem cells, are present in the first days of embryonic development.  Researchers believe they can control stem cells to become whatever tissues patients need. Stem cells come from embryos, bone marrow and umbilical chords
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B) Stem Cells (cont.)
 Stem cells have two notable characteristics: - They divide and multiply rapidly—and they can keep on dividing for a long time. (Most cells in adult tissues are permanent— they no longer grow and divide). -They can differentiate, or become different types of tissue, such as heart muscle, nerves, or blood components.
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B) Stem Cells (cont.)
 Stem cells are present in dental pulp and PDL  Recent studies also report their presence in exfoliated deciduous human teeth and porcine third molar tissue.  No one had ever looked for stem cells in teeth before, because no one expected stem cells in teeth. That's because, unlike bone, teeth never grow bigger or repair themselves  When transplanted in immunocompromised mice they gave rise to dentin like structures which proved that the pulp contained stem cells.
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C) Extracellular Matrix or Biomimetic scaffold
 Tissue engineering of teeth and associated tissues requires the scaffolding of the extracellular matrix be finely duplicated.
 The extracellular matrix usually includes collagen, and non collagenous glycoprotiens.

 The extracellular matrix scaffolding is a critical component to odontoblast diffrentiation and tubular dentin formation
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C) Extracellular Matrix or Biomimetic scaffold
 The methods used to sterlize the scaafold and the dose of irradiation profoundly affects the outcome  Also the geometry of the scaffold play a role in determining the outcome  Role of extracellular matrix : i) to hold active morphogenes together to confer the optimal conformation during morphogenesis . ii) protect from proteolysis . iii) it modulates the interaction between the inductive signaling by morphogenes and the responding cells .

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Regeneration of dentin pulp complex
 Together the role of morphogenes in inductive epithelial-mesenchymal interaction in tooth development,and the effects of the matrix on the stem cells regenration of dentin pulp complex is acheived.  In vivo studies showed that BMP deleivered in a scaffold of decentralized dentin induced classic tubular dentin.  But when used on collagen matrix osteodentin was induced.
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Regeneration of the dentin pulp complex
 The size and shape of the inductive material controls the size and shape of the repartive dentin formed .  The reparative dentin initially appears with cellular and soft tissue inclusions , then changes into a more tubular form of matrix with odontoblast like cells attached to a mass of a tubular matrix .  Optimally engineered reperative dentin may consist of osteodentin and tubular dentin , where tubular dentin is critical for tooth function including resistance to caries .
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Conclusions
 Further work is still needed to be done to 1) characterize the stem cells involved in the development of dental tissue. 2) mapping of their differentiation .pathways. 3) determining the role of local conditions such as the type of scaffold and the presence of the microflora .  The development of whole tissue engineered tooth though possible is still some way off from now.
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Thank You

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