Welcome to: “How Microbiology Can Save Teeth & Lives” December 2, 2011 Texas Oral Health Coalition Jennifer P. Seider, RDH

Course Outline & Objectives Redefining Periodontal disease as an infection Understanding what bacteria we need to be concerned about Facts on bacteria Systemic antibiotic approach Microbiology test systems How to read DNA-PCR results Ideal simple protocols

Jennifer P. Seider, RDH 1999 -Graduated Lake Land Dental Hygiene School Worked as a “traveling” hygienist with Heartland Dental Group 2005-Became one of the 1st hygienist here in the US to use the micro-IDent® test through Hain Lifescience Germany 2008-Become clinical director/US sales rep when Hain decided to bring test to the US full time. 2009 –Joined Gary Takacs and Tobias Hain to partner US distributorship, Hain Diagnostics

Oral Bacterial Growth How Fast Do Oral Bacteria Grow? Now we know the # & regeneration rate, we can calculate how fast they grow. Facts: Total oral biomass = 20 billion but 100 billion (5x more) are swallowed every 24 hrs. Therefore: The bacteria must be doubling 5x a day 24 hrs  5 = 4.8 hours Oral bacteria double in number every 4.8 Hours! Dr. Walter Loesche: Dental Caries: A Treatable Infection

“Oral bacteria can get into the bloodstream.” Robert Genco, professor of oral medicine and microbiology at the University at Buffalo The gum tissue is just skin, just like the skin on your arm if it was bleeding and irritated you would go to the Dr to have it checked right???

From health to disease: imbalanced subgingival flora Periodontal pathogens in regards to periodontal disease… From health to disease: imbalanced subgingival flora Target: Regeneration of the natural balance between aerobic and anaerobic bacteria

Health vs. Periodontal Disease Microbiological Differences Non-Motile Cocci / Rods Spirochetes Motile Rods Gram (+) Gram (-) Aerobic Anaerobic Few WBC’s Many WBC’s Max Listgarten, Infectious Disease Symposium, Temple Univ, 07-01

Probing & Pathogen Transmission You probe a contaminated pocket. On average, how many pathogens adhere to the probe afterwards? Conclusion: Periodontal probes harbor relatively high numbers of bacteria found in periodontal pockets & may be able to carry them over to other sites. 1,000,000 “Measuring pocket depths doesn’t diagnose periodontal disease because pocket’s aren’t the disease. They are the sequella of a long standing disease, not the disease itself” Bollen et al, J Perio 1996 Barnett et al, J Perio 1982 RDH magazine, Bill Landers “What does information theory have to do with perio?” Sept 2011

Health vs. Periodontal Disease Microbiological Differences Why do implants fail…..? Peri-Implantitis Same reason natural teeth fail! DPR Implant Survey, 11/03

Subgingival Microbial Complexes Journal of Clinical Periodontology, 1998 “Microbial Complexes” by Socransky & Haffajee

Purple Complex early colonizers low to moderately pathogenicity A. odontolyticus V. parvula early colonizers low to moderately pathogenicity express receptors to dock on subgingival surfaces create metabolic niche for fastidious bacteria first layer of biofilm - basis for other bacteria Therapy: mechanical debridement is sufficient Journal of Clinical Periodontology, 1998 “Microbial Complexes” by Socransky & Haffajee 12

Green Complex E. corrodens Capnocytophaga sp. facultative anaerobic bacteria moderate pathogenicity less cognitively associated with other complexes concentration increases with probing depth E. corrodens Capnocytophaga sp. Therapy: SRP, (antibiotics) resistance against Metronidazole  amoxicillin (± clavulanic acid) Journal of Clinical Periodontology, 1998 “Microbial Complexes” by Socransky & Haffajee 13

Orange Complex P. intermedia moderate to strong pathogenicity F. nucleatum P. nigrescens M. micros moderate to strong pathogenicity “bridging species“ binding sites for bacteria of the red complex reduction of oxygen tension production of exotoxins, enzymes Therapy: SRP is sufficient with high bacterial concentration or severe clinical outcome: SRP + Metronidazole (Clindamycin) Journal of Clinical Periodontology, 1998 “Microbial Complexes” by Socransky & Haffajee 14

Orange associated Complex C. rectus E. nodatum C. showae C. gracilis S. constellatus appear directly after early colonizers low pathogenitciy (except E. nodatum) adhesion to enamel surface enhancement of the biofilm create metabolic niche for fastidious bacteria Therapy: SRP is sufficient with high bacterial concentration or severe clinical outcome: SRP + Clarithromycin Journal of Clinical Periodontology, 1998 “Microbial Complexes” by Socransky & Haffajee 15

Red Complex P. gingivalis T. forsythia T. denticola primary causative periodontal pathogens strictly anaerobic, very fastidious (“metabolic cripples“) strong to very strong pathogenic production of virulence factors, exotoxines, enzymes  inflammatory immune response  tissue destruction high correlation with pocket depth and BOP P. gingivalis T. forsythia T. denticola Therapy: SRP + Metronidazole (Clindamycin) Journal of Clinical Periodontology, 1998 “Microbial Complexes” by Socransky & Haffajee 16

Aggregatibacter actinomycentmocmitans A. Actinomycetemcom. high correlation with severe clinical outcomes indicator organism for juvenile and aggressive forms of periodontitis resistance against Metronidazole and Clindamycin Therapy: SRP plus amoxicillin (ciprofloxacin) Journal of Clinical Periodontology, 1998 “Microbial Complexes” by Socransky & Haffajee 18

SRP RESISTANT MICROORGANISMS Aggregatibacter actinomycetemcomitans (Actinobacillus actinomycetemcomitans ) Porphyromonas gingivalis Prevotella intermedia Tannerella forsythia Peptostreptococcus micros Gram-negative enteric rods Yeasts Journal of Clinical Periodontology, 2006 Cerero, Ballesta “Rapid Detectio of Periodontopathogenic species from subging paperpoints samples PCR basced”

Bad Bug Facts… A.a and P. g cannot be removed from a significant part of deep periodontal lesions by mechanical therapy alone. Slots J, Ting M. Systemic antibiotics in the treatment of periodontal disease. Periodontol 2000 2002: 28: 106–176. The percentage of A. a and P. g may even increase following scaling and root planning. Mombelli A, McNabb H, Lang NP. Black-pigmenting gramnegative bacteria in periodontal disease. II. Screening strategies for detection of P. gingivalis. J Periodontal Res 1991: 26: 308–313.

It’s contagious too…. Parent to child…(Vertical) If Parent is red complex positive, child is 35–54X more likely to be infected. Saliva is the major vector for transmission. Periodontal pathogens are communicable. Horizontal… The Transmission of Anaerobic Periodontopathic Organisms Y Lee et al, J Dent Res 85(2):182-186 2006 The Transmission of Periodontopathic Organisms Between Children and Caregivers Y Lee et al Pre-publication Data

“Bless you”.....nice way of saying…YUCK! Health care workers must be made aware that full mouth disinfections may reduce the risk for cross-infection of oral pathogens between individuals in close contact The AAP recognized that treatment of gum disease may involve the entire family If one family member has perio disease the AAP recommends that all family members be screened Can you Sneeze Heart Disease, AAOSH Dr. Paul Jacobs

Baby’s death linked to pregnancy-related gingivitis?? “This current report is a term stillbirth. Thus, oral bacteria affect not only preterm birth, but also other adverse pregnancy outcomes such as stillbirth” “Postmortem microbial studies of the baby found the presence of Fn in the lungs and stomach. The baby had died from the septic infection and inflammation caused by bacteria” Obstetrics & Gynecology, Feb 2010 Vol 115 Yiping Han, Ph.D., Case Western Reserve University School of Dental Medicine

Obesity and Risk of Gum Disease T. f are in greater proportions in periodontally healthy people who are obese A change in periodontal tissue status that is due to metabolic changes associated with obesity might affect the microbial defenses, altering the progression of perio disease. Dr. Anne Haffajee, BDS head of Department of Periodontology at The Forsyth Institute

Traditional Diagnostics Disclosing solutions X-rays Pocket dept BOP

Disclosing Solution & Plaque Index Only measure supragingival plaque. (typically Gram (+) & aerobic → i.e. health) Cannot distinguish between pathogenic & non-pathogenic biofilms Mostly useful for patient motivation

Radiographs Mostly ID historical damage Cannot identify pathogenic risk factors Exception: Intact Lamina Dura (No loss for 12 mo.) Intact Absent

Systemic Antibiotic Info and Proof…. Systemic antibiotic therapy can also potentially suppress periodontal pathogens resides on the tongue and other oral surfaces, thereby delaying subgingival recolonization of pathogens. Systemic antibiotics may even be required to eradicate Aa. Perio pathogens frequently colonize on the oral mucosa and dorsum of tongue and tonsils and may translocate from non-periodontal sites to periodontal crevices Slots J, Ting M. Systemic antibiotics in the treatment of periodontal disease. Periodontol 2000 2002: 28: 106–176

Systemic antibiotic therapy may improve radiographic alveolar bone levels. Enhance the effects of mechanical periodontal treatment and reduce the risk for refractory or recurrent disease. In nonsmokers but not in smokers found that 7-day systemic metro therapy led to increased alveolar bone height compared to baseline. Systemic antibiotics may reduce the # of teeth that may need periodontal surgery Slots J, Ting M. Systemic antibiotics in the treatment of periodontal disease. Periodontol 2000 2002: 28: 106–176 Winkelhoff A, Winkel E. Microbiological diagnostics in perio. Periodontology 2000, Vol 39 2005, 40-52

Sequencing of Antibiotic Therapy 5 approaches… AAP Position paper….. Sequencing of Antibiotic Therapy 5 approaches… Initial periodontal therapy should include through mechanical root debridement followed by surgical access if needed. Antibiotics maybe prescribed on the basis of the clinical need for further treatment, the findings of microbiological testing, and the medical status and current medications of the patient The clinical response should be evaluated 1 to 3 months after completion of the mechanical therapy. If periodontal disease appears to progress or if inflammation does not resolve, a microbiological examination of the subgingival microbiota may help determine the presence and amount of the remaining putative periodontal pathogens. If the clinical examination warrants it, 1 to 3 months after systemic antimicrobial therapy, another microbiological test maybe needed to verify the subgingival elimination of target pathogens and screen for possible superinfecting organisms. After resolution of the periodontal infection, the patient should be placed on an individually tailored maintenance program. Supragingival plaque control in the supportive periodontal therapy phase may help prevent recolonization by putative perio pathogens. Recurrence of progressive disease may prompt repeated microbiological testing and subsequent antibiotic therapy targeted against the specific microorganisms detected. AAP Position Paper, Nov 2004, Vol 75

Microbial testing Initial: Patients suffering from aggressive periodontitis run the risk of continuing perio disease activity after mechanical therapy and can benefit from microbial testing prior to initial treatment… Control testing after active treament: Microbial testing can assist in determining the endpoint of periodontal treatment and in establishing the length of the recall interval. Winkelhoff A, Winkel E. Microbiological diagnostics in perio. Periodontology 2000, Vol 39 2005, 40-52

“Lander’s Column” RDH Magazine “Even though researcher have known about perio pathogens since 1960s, it’s taken almost 50 years to develop clinical microbiological tests..” BANA-zyme BioScan (phase contrast) Anaerobic bacterial cultures DNA analysis RDH magazine, Bill Landers “What does information theory have to do with perio?” Sept 2011

BANA Enzyme test Advantages Chairside Species specific P. gingivalis T. forsythus T. denticola Fast: 5 minutes Inexpensive $300 + $6 /test

Bana Enzyme test 3 Deepest Pockets Smear on test strip Don’t scrub (enzyme on surface) Insert strip into processor Process cycle is automatic 5 minutes total time

BANA Enzyme test Compare the Color Strong Positive Distinct blue spots or wide coverage Weak Positive Faint blue or scattered spots Negative No change

BANA Test Results Strong Positive: Distinct blue spots or wide coverage Weak Positive: Faint blue or scattered spots Negative No change Sensitivity: As few as 100 microorganisms

Phase Contrast Video Microscopy Advantages Chairside Fast: 2 minutes Cheap: 25¢ / test ID’s: Morphotypes Spirochetes WBC’s Protozoans Antibiotic Verification (efficacy/compliance) Patient Motivation!

Anaerobic Bacterial Cultures **Most periodontal pathogens are very difficult to culture due to them being either obligate or facultative anaerobes. Paperpoint samples are places on species-specific media along with a panel of antibiotics. Growth reveals which pathogens are present and which antibiotics are most effective against them. 2 labs OMTS –USC in LA $125 OMTL- Temple University $115 Both have a turn around time of 10-12 days. RDH magazine, Bill Landers “What does information theory have to do with perio?” Sept 2011

DNA•STRIP®-technology Sampling Isolation of DNA & PCR Reverse hybridization

DNA-PCR Process….

micro-IDent®plus Early Diagnosis Specific marker for diagnosis Choice of appropriate antibiotics Monitoring of therapeutic success Sampling sets are free of charge, free mailing Doctor charge is $89

Antibiotics: Before or After Sc/Rp? When should Metronidazole be used? Better clinical results when metro was prescribed: following whole mouth periodontal debridement vs. at the beginning of treatment. … because of biofilms Loesche, W Compendium 1:1198, 1994

Medication Directions: Always take antibiotics within 4-6 hours of FULL mouth disinfection Make SURE the patient takes the antibiotics correctly Maybe a good idea to call meds in the day before Remember Metronidazole can be harmful if taken with alcohol Slots J, Ting M. Systemic antibiotics in the treatment of periodontal disease. Periodontol 2000 2002: 28: 106–176.

Antimicrobial Subgingival Irrigation Viajet Heated Professional Irrigator (shown) Ultrasonics (in lieu of water) Hand Syringes (tedious)

Dental & Medical Codes D0415- micro-IDent® 523.0 Acute Gingivitis 523.1 Chronic Gingivitis 523.3 Acute Periodontitis 523.4 Chronic Periodontitis 87999 Microbiology procedure (attach narrative)

Thank you and you now have a new friend! Call or email me anytime: Hain Diagnostics Jennifer Seider, RDH Cell: 615.587.2558 jennifer@hain-diagnostics.com www.hain-diagnostics.com www.hain-lifescience.de