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

2. 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

3. 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

5. 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

6. “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???

7. 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

8. 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

9. 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

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

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

12. 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

13. 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

14. 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

15. 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

16. 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

18. 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

19. 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”

20. 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 : 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.

21. 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):
The Transmission of Periodontopathic Organisms Between Children and Caregivers
Y Lee et al Pre-publication Data

22. “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

23. 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

25. 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

26. Traditional Diagnostics
Disclosing solutions
X-rays
Pocket dept
BOP

27. 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

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

29. 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 : 28: 106–176

30. 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 : 28: 106–176
Winkelhoff A, Winkel E. Microbiological diagnostics in perio. Periodontology 2000, Vol , 40-52

31. 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

32. 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 , 40-52

33. “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

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

35. 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

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

37. 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

38. 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!

39. 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 days.
RDH magazine, Bill Landers “What does information theory have to do with perio?” Sept 2011

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

41. DNA-PCR Process….

47. 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

48. 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

49. 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 : 28: 106–176.

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

55. Dental & Medical Codes
D0415- micro-IDent® Acute Gingivitis Chronic Gingivitis Acute Periodontitis Chronic Periodontitis Microbiology procedure (attach narrative)

56. Thank you and you now have a new friend!
Call or me anytime:
Hain Diagnostics
Jennifer Seider, RDH
Cell: