Download Salivary Testing for Periodontal Disease Diagnosis and Treatment

Continuing Education
Course Number: 126
Salivary Testing for
Periodontal Disease
Diagnosis and
Treatment
Authored by Thomas W. Nabors, DDS, Ronald C. McGlennen, MD,
and Doug Thompson, DDS
Upon successful completion of this CE activity 2 CE credit hours may be awarded
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American Board of Medical Genetics, with a specialty in
Clinical Molecular Genetics. He is internationally recognized as
an expert in Molecular Biology and Genetics. His focus in
research has been on reducing the complexity of gene-based
testing, including DNA chip technology and simple analytical
instrumentation to better serve the community laboratory. He
serves on a series of governmental and regulatory committees
focused on the growth of molecular diagnostics. He has
published more than 70 scientific articles and book chapters,
and is the editor of 5 journals. He holds 9 issued and pending
patents. He can be reached at (952) 942-0671.
Salivary Testing for
Periodontal Disease
Diagnosis and Treatment
LEARNING OBJECTIVES
After reading this article, the individual will learn:
• An effective method for dentists and dental hygienists to
communicate to patients that oral health is an essential
component of general health.
• How saliva and advanced DNA-polymerase chain
reaction (PCR) technology can provide biological
information that helps to determine periodontal disease
causation and risk for future disease progression, and
how to personalize therapy for each patient based on
his/her specific infection.
Disclosure: Dr. McGlennen serves as the medical director
of OralDNA Labs, a laboratory that offers testing servies for
salivary diagnostics.
Dr. Thompson began his dental career
working as an in-house laboratory
technician. He graduated from University
of Michigan School of Dentistry and then
completed a one-year hospital-based VA
Residency Program in General Dentistry.
Dr. Thompson bought an established private practice in
Bloomfield Hills, Mich, where he practices today. He has
completed hundreds of continuing education hours and has
studied extensively at the Kois Center in Seattle, Wash, led
by Dr. John Kois. He became a mentor to students, and in
2008 he earned the distinction of Clinical Instructor. Also,
he currently leads an interdisciplinary study club attended
by more than 50 dentists, which has representation from all
dental specialties and is focused on comprehensive
treatment planning. Dr. Thompson is the founder of Impact
Dental Solutions, a company focused on assisting dentists
with implementation strategies to put knowledge to work in
their daily practices. Among other topics, he coaches
risk assessment treatment planning, digital photography,
and systems to transform traditional hygiene services into
value added experiences of personalized periodontal
medicine. He can be reached at (248) 642-1000 or
[email protected].
ABOUT THE AUTHORS
Dr. Nabors was a practicing dentist for
more than 38 years, during which time he
developed a national reputation in the area
of periodontal disease testing and
treatment. Dr. Nabors treated periodontal
patients using a variety of treatment
philosophies: nonsurgical, surgical, laser therapy, as well as
antimicrobial models. He is a distinguished lecturer at the
national and state levels on personalized periodontal disease
treatment and the application of molecular testing
methodologies within oral medicine, and he has authored
numerous articles on the subject. He can be reached at
[email protected].
Disclosure: Dr. Nabors co-founded OralDNA Labs in 2008
and serves as the company’s Chief Dental Officer.
Dr. McGlennen is president, founder, and
medical director of Access Genetics. He is
also associate professor of Pathology at
the University of Minnesota Medical
School. He is board certified in Anatomic
and Clinical Pathology, and also by the
Disclosure: Dr. Thompson reports no conflicts of interest.
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Continuing Education
Salivary Testing for Periodontal Disease Diagnosis and Treatment
INTRODUCTION
infection of bacterial origin.6 The body’s immune system
responds to the bacteria, their endotoxins, and their antigens,
thereby stimulating an inflammatory response that leads to
the destruction of hard and soft tissue in the mouth.
Medical and dental research reveal that the resultant
inflammatory mediators increase the risk for a variety of
diseases and conditions, including heart attack, stroke,
diabetic complications, and adverse pregnancy events,
among others.7-9 The inflammatory mediators are
transported to the liver, which is stimulated to produce Creactive protein (CRP).10 CRP is produced by the body in
response to injury, infection, or inflammation. Patients with
periodontal disease have significantly elevated levels of CRP
compared to healthy patients.11,12 Recent studies indicate
that CRP promotes platelet adhesion to endothelial cells, a
potential mechanism for the high incidence of
cardiovascular events associated with high CRP levels.13
Several species of periodontal bacteria have been
positively identified in the perio/systemic disease connection,
with emerging research continuing to implicate additional
species and their harmful effects on the body. For example,
certain studies show that Porphyromonas gingivalis can
adhere to, invade, and replicate within gingival epithelial cells,
and induce apoptosis (cell death) of host cells, which results in
the destruction of periodontal tissue.14,15 Other studies
demonstrate that periodontal pathogens, specifically
Treponema denticola, Actinobacillus actinomycetemcomitans,
and P gingivalis, are present in atherosclerotic plaques in
coronary blood vessels.16,17
According to the ADA, approximately 75% of adults in the
United States are affected by some form of periodontal
disease, including gingivitis.1 Periodontitis, the most
advanced form of the disease in which there is active
destruction of the periodontal supporting tissues, affects at
least 23% of women aged 30 to 54 years.2 Additionally,
44% of women aged 55 to 90 years who still have their
teeth have periodontitis.2 Of the US male population aged
45 to 64 years, 43% have severe periodontal disease.2 That
number rises to 65% in men aged 65 years and older.2 In
fact, in the United States alone, dental infections rank third
in medical costs, behind heart disease and cancer.3
According to research presented at the 85th annual
scientific meeting of the International Association for Dental
Research, ethnicity and socioeconomic status can also be
influencing factors for periodontal disease.4 The study linked
periodontal disease to ethnicity and country of origin, even
among immigrants who have lived for many years in the United
States and have increased income and education levels.
Significant differences were found among the ethnic groups,
and were found to be deeply rooted in an immigrant’s country
of origin, where early cultural influences, such as diet, oral
health practices, and environmental influences can set the
stage for oral health problems later in life.
Other periodontal disease risk factors include smoking,
malocclusion, diabetes, cardiovascular disease, and other
systemic diseases.5 Clearly, periodontal disease, in all of
its stages, is a microbial challenge so great that dental
infections rank as the most universal affliction of humankind.
This article discusses how saliva and advanced DNApolymerase chain reaction (PCR) technology can provide
biological information that helps to determine periodontal
disease causation and risk for future disease progression,
and can serve as an effective method for dentists and dental
hygienists to communicate to patients that oral health is an
essential component of general health. Further, using this
technology to personalize therapy for each patient based on
his/her specific infection is discussed.
HISTORY OF METHODS FOR DIAGNOSING
PERIODONTAL DISEASE
Efforts toward improving the understanding of the
epidemiology and prevalence of periodontal disease began in
the mid 1950s, following the development of Russell’s Periodontal Index (PI).18 The PI was a method for dental
professionals to score, or grade, a person’s periodontal
condition based on a mostly visual assessment of the mouth.
The criteria were based on the outward signs of periodontitis
and the sequence in which they usually appear: inflammation,
pocket formation, and loss of function.The major disadvantage
of the PI is its reliance on subjective rather than objective
THE PERIO-SYSTEMIC LINK
Clinical research establishes that periodontal disease is an
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Salivary Testing for Periodontal Disease Diagnosis and Treatment
measurement of the clinical presentation of disease. The PI
scores all periodontal pockets the same, and inflammation is
graded subjectively, with no apparent differentiation between
gingivitis and periodontitis.
In 1959, Sigurd P. Ramfjord19 introduced the
periodontal disease index (PDI). The PDI was similar to the
PI, except that it added a new tool called a periodontal
probe, which measured gingival pocket depths. Today,
dental professionals continue to rely on a visual assessment
of the patient’s overall oral condition, in addition to charting
pocket depths with a periodontal probe. While clinical signs
and symptoms are important, they alone cannot determine
causation and genetic susceptibility. They do not indicate
what pathogens are present and responsible for the
disease, and they do not provide insight into the patient’s
genetic propensity to periodontal disease. Without this important information, it can be difficult to determine the best
course of treatment; whether or not antibiotics should be
prescribed and, if so, the kinds of antibiotics that offer the best
results in fighting the specific pathogens. This is why, in
addition to probing and charting, microbial testing (bacterial
inflammatory burden) and genetic testing (genetic
susceptibility) should be considered an integral component in
the diagnosis of periodontal disease.
the infection, such as in the case of chronic and aggressive
periodontitis, adjunctive therapies such as systemic or locally
applied antibiotics and mechanical debridement of the
infected tissues are recommended to help the body regain
homeostasis in the oral cavity.
A dilemma is that clinicians often see patients with
similar clinical presentations whose disease progresses
very differently. One patient may experience very little
tissue destruction while another may develop severe
attachment loss.
THE ROLE OF THE INTERLEUKIN-1 PERIODONTAL
GENOTYPE
During the past 10 years, many studies have been
published demonstrating that the severity of periodontitis in
adults is closely linked with increases in local inflammatory
mediators. The results of these studies have shown that
most of these local inflammatory factors are controlled by
the interleukin-1 (IL-1) gene, making it a key regulator in
the inflammatory process and a prime candidate for a
genetic association with periodontal disease.20-24 IL-1
polymorphisms are found in approximately 30% of the total
population.24-26 The mere presence of the IL-1 genotype
does not confer an expected periodontal disease diagnosis
by itself; however, the gene has been implicated as a
contributory factor in determining the severity of adult
periodontitis.27 Studies have shown that the presence of
the IL-1 genotype is not equally distributed among all racialcultural groups. For example, research reveals that there is
a low prevalence of the periodontitis-associated IL-1
composite genotype in individuals of Chinese heritage.28 At
less than 3% prevalence, too few persons of Chinese
heritage are positive for the IL-1 polymorphism to establish
any relationship with the susceptibility to periodontitis. This
low prevalence holds true for most Asian populations,
whereas ethnic populations descended from northern,
central, and southern Europe reveal a genotype-positive
prevalence of approximately 30%.26
For the first time, 2 unique salivary DNA tests are
available to all dental practitioners. The MyPerioPath test is
used to determine both the quality (type) and quantity
(bacterial inflammatory burden) of specific pathogenic
CLINICAL AND BIOLOGICAL PRESENTATION OF
INFLAMMATION
A sequence of events, called the inflammatory cascade,
occurs during an inflammatory response. This sequence
can vary depending on the type or cause of injury (ie,
bacteria, heat, cold, trauma, etc), the site of injury, and the
state of the body. In a localized infection, the sequence is
comprised of the following physiological events: entry of
infectious microbes; vasodilation of the microcirculation,
resulting in increased blood flow; an increase in vascular
permeability to protein; filtration of fluid into the tissue which
leads to swelling; release of neutrophils (a type of white blood
cell), and later monocytes (another type of white blood cell),
from the blood vessels into the tissues; phagocytosis and
destruction of the microbes; and, finally, tissue repair.
However, when the microbial burden becomes greater
than the body’s own ability to successfully fight and eliminate
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Continuing Education
Salivary Testing for Periodontal Disease Diagnosis and Treatment
microorganisms associated with periodontal infections,
while the MyPerioID PST test is used to identify a genetic
polymorphism that affects the body’s immune response.
This genetic variation, which affects the production of IL-1,
is associated with an increased risk for more severe
periodontal infections, as well as increased risk for periimplantitis. Both tests are intended as supportive adjuncts to
conventional diagnostic methods, such as recording probing
depths and the visual assessment (clinical presentation) of
periodontal tissues based on swelling, redness, bleeding,
and halitosis, as well as radiographic examination and a
personal and family history of periodontal disease.
Virtually any DNA test that uses blood can also be
performed using saliva as the DNA source. Salivary DNA
testing has advantages and benefits to both the healthcare
practitioner who administers the test and the patient
receiving the test. Saliva is easy to obtain, and it is a
noninvasive procedure.
TYPES OF DNA FOUND IN SALIVA
Saliva is also known as “oral fluid” or “total” saliva because it
consists of the fluid excreted from the major and minor salivary
glands. Salivary fluid itself contains proteins, enzymes, and
buffers that are designed to have a number of functions,
including protection, buffering, digestion, and aid in swallowing.
Saliva also contains gingival crevicular fluid. In inflamed
tissues, this serum exudate serves as a protective
mechanism to cleanse the “pocket” of the bacteria and debris
that reside within the sites. Gingival crevicular fluid contains
bacteria, viruses, serum, white blood cells, inflammatory
mediators, and matrix metalloproteinases. Thus, regardless
of the pocket depth, the fluid that is secreted from the gingival
crevice approximately 40 times per hour finds its way into
saliva. Thus, saliva contains bacterial and human cells that
are an excellent source for DNA.
FUNDAMENTALS OF SALIVARY DNA TESTING
DNA testing is a relatively new science that began in 1984
when Alec Jeffreys, a genetics professor at Leicester
University in England, developed what is now known as DNA
fingerprinting or DNA profiling. The process was first used in
forensic science to assist police detective work by positively
identifying criminals by matching DNA evidence found at a
crime scene to the DNA of the suspect(s). Since then, DNA
tests have been developed for hundreds of applications.
Genetic tests can be broken into 5 categories:
diagnostic testing, predictive testing, presymptomatic
testing, carrier testing, and prenatal testing:
Diagnostic DNA tests are used to confirm a diagnosis
when a person has signs or symptoms of a genetic
disease.
Predictive tests can show which individuals have a
higher chance of getting a disease before symptoms
appear.
Presymptomatic testing shows which family members
are at risk for a certain hereditary condition.
Carrier testing can indicate if an individual is a carrier of a
gene alteration for a type of inherited disorder called an
autosomal recessive disorder that could be passed on to
one’s children.
Prenatal testing is used to screen for common genetic
disorders such as spina bifida and Down syndrome.
Prenatal testing is typically performed on pregnant
women who are age 35 years or older, because they
are at higher risk for having a child with a
chromosomal abnormality.
HOW DNA IS IDENTIFIED IN SALIVA
As mentioned, saliva contains both human and bacterial
DNA. Both kinds of DNA can be extracted and analyzed
through a laboratory process called polymerase chain
reaction (PCR).
In molecular biology, PCR is a technique for detection
and elongation of DNA strands. In order to perform PCR,
the laboratory must know at least a portion of the sequence
of the DNA molecule it wishes to replicate. Developed in
1983 by Dr. Kary Banks Mullis, an American biochemist and
Nobel laureate, PCR in its most modern form has become
an indispensable technique for duplicating DNA so that it
can be analyzed for the identification of hereditary
diseases, as well as the detection and diagnosis of
infectious disease.
In simple form, the PCR process is as follows: Once the
saliva samples are received at the laboratory, a portion of the
sample is syringed into separate reaction tubes and placed
into a testing block. Specific polymerase enzymes and other
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Continuing Education
Salivary Testing for Periodontal Disease Diagnosis and Treatment
components are added to each sample, which are necessary
for DNA synthesis in the laboratory.
The sample-containing tubes are then placed into a
thermocycler device. PCR usually consists of a series of up
to 40 repeated temperature changes called thermal cycles.
The thermocycler heats and cools the reaction tubes to
achieve the temperatures required at each step of the
reaction process. When the DNA sample is heated to 90° F,
its strands separate and mix with the added components.
When the components find their complementary
sequences in the DNA, they bind to them; this effectively
creates a duplicate of that DNA strand. The process is
repeated, and those 2 DNA strands are separated and
once again duplicated, resulting in 4 strands. The process
is exponential—those 4 strands become 16, those 16
become 256, and so on. After approximately 30 complete
thermocycles (requiring approximately 90 minutes in total),
over 1 billion DNA strands are produced from the original
single strand.
DNA-PCR plays an integral part in the early diagnosis of
diseases and also in confirming the presence of a genetic
polymorphism, or variant, which can reveal whether a person
has a predisposition or increased susceptibility to a specific
disease or condition. DNA-PCR also permits identification of
mycobacteria, anaerobic bacteria, or viruses from several
sample sources, including saliva.The basis for PCR diagnostic
applications in microbiology is the detection of infectious
agents and the discrimination of nonpathogenic from
pathogenic strains by virtue of specific genes.
The primary components of a salivary DNA diagnostic
test include a collection tube with a detachable funnel, a
cap to seal the tube after sample collection, and a 3-mL
ampule of sterile saline solution. The salivary collection
process is completed in about one minute, is easy and
comfortable for the patient and clinician, and is entirely
noninvasive. After labeling the sample, the patient simply
swishes the saline solution around in the mouth for 30
seconds and then expectorates into the funnel/collection
tube. The funnel is removed; the cap is secured to the top
of the collection tube. This concludes the in-office part of
the test. The sample is then placed in the provided shipping
box, sealed, and is now ready to be shipped to the
laboratory.
All of the DNA-PCR procedures are done by OralDNA
Labs, and a result report is sent to the clinician via a Health
Insurance Portability and Accountability Act secure portal
within 4 to 5 days. This pathogen result report contains a
comprehensive interpretation of the periodontal pathogens
that are detected and the quantity of detection. The genetic
test report reveals comprehensive information that pertains
to the (IL-1 A and ß) inflammatory cytokine. OralDNA Labs
is a state-of-the art accredited clinical laboratory and
follows all the guidelines for accreditation that all medical
laboratories are required to follow in the United States.
The clinical laboratory report (test result) should be read,
shown to, and discussed with patients, as they serve to help
define the diagnosis and make the condition “real” (ie,
“seeing is believing”). These clinical lab reports, as in
medicine, serve to help further define risk for disease and/or
disease progression. It also helps patients make decisions
based on biological information that confirms more specifically the disease itself and the risk associated with their
specific infection. It thus serves as a persuasive means to
instill the need for periodontal therapy and patient
compliance in order to achieve the best possible treatment
outcome. Furthermore, a “control analysis” post therapy
using the MyPerioPath test also serves to confirm the
efficacy of the treatment. Depending on the severity of the
periodontal disease, a patient can be retested as often as
deemed necessary by the practitioner; test results can be
compared and monitored over time, and treatment
parameters can be maintained or adjusted as necessary
CLINICAL LAB OUTSOURCING—PROVEN IN
MEDICINE, READY FOR DENTISTRY
Clinical laboratory medicine and the clinical laboratory
report have become an essential component in medicine
for a variety of reasons. The most compelling reason is that
a physical examination that looks only at the clinical signs
and symptoms of disease is not sufficient for a complete
risk assessment. Many biological factors that help to
determine risk can be assessed by a wide range of
laboratory tests using a wide variety of body fluids. Saliva,
as with blood, can now provide a variety of potential
analytes that, as adjuncts to clinical signs, provide a more
comprehensive risk assessment.
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Continuing Education
Salivary Testing for Periodontal Disease Diagnosis and Treatment
before further attachment loss has occurred.
Clinical laboratory reports have been used in medicine
for decades for a variety of reasons: diagnosis, prognosis,
monitoring of therapy, and treatment decision making, to
name a few. The data presented in the clinical lab reports
for oral diseases such as periodontal disease and
eventually other disease stats, helps to provide a more
definitive diagnosis. Clinical signs, while still important as a
means of determining the damage that has been done by
the infection, do not tell what the “damaging” or causative
agents actually are. While inflammation is known to cause
most of the damage, the initiation of the host response and
the progression of this response are known to be caused by
a variety of specific microorganisms. Further, even early
forms of infections can have potentially very virulent
pathogens that will not be detected by clinical signs alone.
Thus, a diagnosis that is based on actual causative agents
in conjunction with clinical presentation provides a more
definitive diagnosis and risk assessment.
This modern movement toward a biological diagnosis
that includes biological risks, medical history, along with
clinical history, is becoming a major theme in periodontics.
Since periodontal diseases are polymicrobial biofilm
infections, it is important to know which specific bacteria or
combinations of bacteria are responsible for the
inflammatory response in each patient. These biofilm
communities are not all the same and do not create the
same risk. Based on the actual species that are causative
agents for these inflammatory diseases, some are high risk
for attachment loss, some are considered to be associated
with refractory and chronic infections, others are at lower
risk, and some are more often implicated in systemic
infections. This information is important to know at the
earliest possible time in order to treat the actual causative
agents of the inflammatory response.
The pathogens indentified by the MyPerioPath test are
classified in 2 taxa: facultative and anaerobic. This
classification is important, as it helps determine if an
antimicrobial strategy is important for each patient. Today,
the use of antiseptics, locally applied medications, systemic
antibiotics, and host modifying medications are all part of
the arsenal for potential use. However, without knowing the
virulence and pathogenic properties of the bacteria that are
found, there is no organized way to determine which
patients are best suited for which antimicrobial or surgical
therapy. The clinical laboratory report provides the
information that will help the clinician make those decisions
in a rational and organized manner.
The graphical portion of the report shows the types of
pathogens present, the pathogen load, and the risk of each
pathogen based on virulence factors. Longitudinal studies
have shown the potential risk for each one. All of this
information is important and clinically relevant to the existing
disease itself and to disease progression. This information
gives the clinician the ability to “target” pathogens with the
goal of elimination or suppression of the pathogen
associated with disease.
In addition to the laboratory result, the result report
includes a relevant medical history of the patient that is
provided by the clinician. This provides a more complete risk
analysis for treatment planning. The medical history is an
important component for establishing a treatment plan, to
determine the most appropriate antimicrobial therapy, and to
consider the importance of interdisciplinary therapy. Finally,
the report also lists the patient’s clinical signs and
symptoms. These patient characteristics further help refine
the treatment planning for the patient. Clinical signs and
symptoms provided by the clinician at the time of sample
collection have a significant impact on the report. An ADA
classification of 2 or greater may yield a suggestion of a
specific antibiotic that is targeted to the taxa of the
pathogens detected in the report. The purpose for this is to
provide this information so that antibiotics are used based
on the actual causative agent(s) rather than indiscriminately.
Of course, the doctor will make the final decision as to
treatment decisions and when antibiotics are necessary as
a consideration for therapy.
CASE REPORT
Historical Data
The patient, a 52-year-old white male, had a history of
regular dental care since age 4 years. Chart history showed
repeated recommendations to have his wisdom teeth
removed since 16 years old. Chart history also showed
periodontal deterioration related to teeth Nos. 1 and 16 with
5 mm pockets and recession resulting in clinical attachment
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Continuing Education
Salivary Testing for Periodontal Disease Diagnosis and Treatment
loss. The chart mentioned only
occasional bleeding but no
significant recommendations
other than the removal of the
wisdom teeth and saline rinses.
In 2001, at age 45 years, an
additional recommendation was
made to have the wisdom teeth
removed. He had probing depths
in the maxillary posterior molars of Figure 1. Full-mouth radiograph series from 2007 showing generalized mild bone loss but
6 mm, in addition to recession of 4 localized severe bone loss associated with the maxillary posterior molars.
mm, but no report of active
bleeding. At this time, the patient accepted the
recommendation to remove the wisdom teeth. After
the removal of teeth Nos. 1 and 16, the significant
clinical attachment loss on teeth Nos. 15 and 2 was
evident (Figure 1). A recommendation for localized
periodontal therapy was denied.
With the increased emphasis on the
oral/systemic connection, a recommendation was
made for a comprehensive periodontal health
review in 2008. His periodontal charting at the time
showed the attachment loss and listed no bleeding
on probing (Figure 2).
Current Assessment
The patient reported no major medical concerns
and no known allergies. He had been diagnosed
with borderline diabetes, and there was a history
of diabetes in his immediate family. Other
significant issues were a history of smoking one
Figure 2. Periodontal chart from September 2008 shows no bleeding but
pack of cigarettes per day for 11 years between
severe attachment loss distal to both maxillary second molars.
the ages of 17 and 27 years. He also informed us
that his brother had a history of juvenile periodontitis. With
this information in mind, the patient had an increased
interest in maintaining his long-term health. His full-mouth
retracted view is shown in Figure 3.
Diagnosis
The patient was referred to a periodontist to evaluate teeth
Nos. 2 and 15 for potential regenerative procedures. These
teeth were deemed hopeless due to the attachment loss
Figure 3. Full-mouth
retracted view.
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Continuing Education
Salivary Testing for Periodontal Disease Diagnosis and Treatment
and furcation involvement (Class II). His
vertical bitewings from early 2009 are
shown in Figure 4.
Despite the diagnosis from the
periodontist, the patient asked if there was
anything other than the removal of these
teeth that could be done to help him maintain
them and manage the risk to the
approximating teeth. Due to vacation plans for Figure 4. Vertical bitewings from periodontal maintenance visit in May of 2009.
the summer, his desire was to return in the fall
for a nonsurgical treatment plan. His September
2009 periodontal chart showed an increase in
bleeding points, with a diagnosis of active
generalized moderate chronic adult periodontitis
with active localized severe chronic adult
periodontitis. His September 2009 periodontal
charting is shown in Figure 5.
Utilizing the recently available testing protocol
from OralDNA, a personalized bacterial profile of
the patient’s infection was obtained. It was also
suggested to test for his genetic susceptibility
using OralDNA’s MyPerioID PST report. Due to his
family history, he assumed he was genetically
susceptible and declined this diagnostic screening
test. Other modifying risk factors were his young
age and the fact that he had previously lost bone.
His initial MyPerioPath 2-page report is shown in
Figures 6a and 6b.
This report showed the presence of, and
Figure 5. Periodontal charting from September of 2009, suggesting an
above threshold levels for, both high- and
increase in disease activity.
moderate-risk periodontal pathogens. After seeing
periodontal breakdown over the previous 45 years. His right
the report, the patient’s motivation level increased, and he
and left retracted views are shown in Figures 7 and 8.
wanted to pursue the possibility of stabilizing his infection
and altering his bacterial profile. A personalized treatment
Treatment
plan with an emphasis on total mouth disinfection was
Treatment for this patient consisted of nonsurgical periodontal
developed. One of the important findings with this patient
therapy. Other than the recommended extraction of teeth Nos.
was the absence of visible clinical inflammation and
2 and 15, the periodontist determined all other initial treatment
bleeding, which left the impression that his generalized
would be nonsurgical. The following active disease therapy
periodontal condition was “not that bad.” This is evident in
was carried out in our office:
the repeated chart notes over the years that did not mention
Occlusal analysis to ensure bilateral simultaneous
bleeding. He had suffered gradual episodic generalized
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Continuing Education
Salivary Testing for Periodontal Disease Diagnosis and Treatment
equal-intensity contact with
no interferences or inefficient
use of the closing muscles
upon chewing.
Four quadrants of scaling
and root planing with
ultrasonic
and
hand
instrumentation.
Irrigation during scaling and
root planing with chlorhexidine.
Pocket disinfection with a
sodium hypochlorite-based
rinse disinfectant (CariFree
[Oral BioTech]).
Application of a locally applied
antibiotic (Arestin [OraPharma])
in all pockets equal to or
greater than 5 mm.
Take-home oral rinse that
Figures 6a and 6b. Initial MyPerioPath report results.
penetrates and alters biofilm
(CariFree). Chlorhexidine could be used in this situation
as a home care rinse as well.
Systemic antibiotics, Metronidazole 500 mg bid for 8
days and Amoxicillin 500 mg tid for 8 days, as an
adjunct to scaling and root planing, based on the
OralDNA test report.
Physician consult to discuss the use of the antibiotic
combination for this patient and his specific medical
issues.
Oral hygiene instructions with emphasis on using a
power brush, dental floss, and a Waterpik (Water Pik).
Dispensing of a high-fluoride paste to reduce risk to
exposed root surfaces (Clinpro 5000 [3M ESPE]).
Request for a 7-week reevaluation and a potential
OralDNA retest based on the stability demonstrated by
the periodontal charting results.
Figures 7 and 8.
Lateral retracted views
showing generalized
clinical attachment loss
and severe attachment
loss in the posterior
maxillary molar regions,
and lack of visible
inflammation.
had no visible inflammation and some decrease in probing
depths. The 28 bleeding sites were reduced to only one. He
had the greatest decrease in probing depths (3 mm)
associated with the distolingual area of tooth No. 2. His
post-treatment periodontal chart is shown in Figure 9.
Reevaluation
The patient returned in 7 weeks to be reevaluated. He
reported no complications following initial therapy, and no
problems following his home care regimen or taking his
prescribed antibiotics. His clinical results were excellent. He
9
Continuing Education
Salivary Testing for Periodontal Disease Diagnosis and Treatment
Figure 10 shows a periodontal chart
comparison from a fall 2008 periodontal
chart to the present.
The patient had significant staining on the
teeth, perhaps due to his oral rinse regimen.
This staining is removed without complication
during periodontal maintenance, and is much
like the stain observed when using
chlorhexidine. His post-treatment photos are
shown in Figures 11 to 13.
It was also decided to perform a posttreatment OralDNA MyPerioPath test to
reassess
the
bacterial
profile.
A
representative sample of the bacteria was
obtained and a copy of the post-treatment
test result is displayed in Figures 14 and 15;
this is a 2-page report. The post-treatment
bacteria profile shows a marked decrease in
pathogenic bacteria. For comparison, Figure
6a shows page 1 of the initial pathology
report from OralDNA. Altering the patient’s
bacterial load may result in lower risk for
future periodontal breakdown and allow
better maintenance of his periodontal
structures. This patient will be on a tight 3month periodontal maintenance protocol to
monitor his future periodontal and general
health. He has been informed that the longterm retention of his maxillary posterior
molar teeth is unlikely.
Figure 9. Post-treatment periodontal charting showing less bleeding and some
improvement in probing depths.
THE FUTURE OF DNA TESTING IN THE
DENTAL OFFICE
The application and clinical relevance of
DNA-PCR testing should hold equal
importance among virtually all professional
dental disciplines, including periodontists,
general practitioners, prosthodontists,
hygienists, and pediatric dentists. In the mid
1980s, genetic testing was used by forensic
medical specialists to help solve criminal
cases. Soon after, it became indispensable
Figure 10. Periodontal chart comparison showing a decrease in bleeding sites
and a decrease in some probing depths.
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Continuing Education
Salivary Testing for Periodontal Disease Diagnosis and Treatment
for geneticists as a diagnostic tool for genetic
polymorphisms responsible for hereditary diseases and
conditions. More recently, DNA testing has become
increasingly commonplace in the medical field to assist
physicians in the early “presymptom” diagnosis of patients
with a family history of diseases such as those affecting
the lungs and heart, degenerative disorders (such as
Parkinson’s), brain diseases (such as Alzheimer’s), and
certain types of cancer. Now that salivary DNA testing is
available to the dental profession, it too can benefit from
the clinical and hereditary insights the test results can
provide.
SUMMARY
For more than 50 years, clinicians have relied primarily on
the same visual and mechanical assessment methods to
diagnose and classify periodontal disease. Clinical signs
are simply a measurement of the past damage of a disease
process. While clinical presentation and probing depths are
indicators that the disease exists, these alone cannot
determine the types and quantities of the responsible
pathogens. Likewise, clinical signs alone cannot determine
if therapy has achieved the goal of suppression of the
etiological agent(s).
Genetic presymptomatic testing complements bacterial
DNA testing by providing insight into the patient’s genetic
predisposition to periodontal disease before symptoms
appear, or when disease is already present. DNA-PCR
testing of saliva can help the clinician provide an earlier and
more specific diagnosis of disease based on causation.
Treatment planning is also enhanced, as therapy can be
appropriately modified based on both clinical and biological
inflammatory factors. Finally, patient communication and
case acceptance can be more readily achieved because
the test reports elicit a persuasive “seeing is believing”
attitude when reviewing test results with patients.
Through the use of accurate periodontal charting,
medical and dental risk assessments, and other diagnostic
screening tests such as OralDNA’s MyPerioPath and
MyPerioID PST tests, highly personalized periodontal
therapy can be developed and carried out by the general
practitioner. There has never been a better time to become
Figures 11 to 13.
Post-treatment photos
show lack of visible
inflammation and some
staining from the rinse
regimen.
more aware, and keep tighter control, of the periodontal
status of one’s patient base. Many patients are asking
dentists about the connection between periodontal health
and general health. While it currently would not be
appropriate to suggest a causative relationship, there is
abundant ongoing research that suggests a correlative
relationship between periodontal disease and other wholebody ailments.
Many patients have refused periodontal care or denied the
importance of maintaining their periodontal health. The use of
tools such as the OralDNA test report can assist in achieving
patient acceptance of needed treatment and cooperation with
the clinician to improve their periodontal health. The contents of
the report and the visual presentation demonstrate that many
patients have an active infection that can be stabilized if treated.
Patients also provide more information about other factors that
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Continuing Education
Salivary Testing for Periodontal Disease Diagnosis and Treatment
may contribute to their periodontal condition. Further, the
OralDNA report enhances dentist-physician communication
and a team approach to patient care.
REFERENCES
1. American Dental Association. For the dental patient.
Women and periodontal disease. J Am Dent Assoc.
2002;133:671.
2. US Department of Health and Human Services. Oral
Health in America: A Report of the Surgeon General—
Executive Summary. Rockville, MD: US Department of
Health and Human Services, National Institute of
Dental and Craniofacial Research, National Institutes
of Health; 2000.
3. Loesche WJ, Grossman NS. Periodontal disease as a
specific, albeit chronic, infection: diagnosis and
treatment. Clin Microbiol Rev. 2001;14:727-752.
Figure 14. Page 1 of the post-treatment test
report from OralDNA.
4. Cruz GD, Chen Y, Salazar CR, et al. The association
of immigration and acculturation attributes with oral
health among immigrants in New York City. Am J
Public Health. 2009;99(suppl 2):S474-S480.
5. Burt B; Research, Science and Therapy Committee of
the American Academy of Periodontology. Position
paper: epidemiology of periodontal diseases.
J Periodontol. 2005;76:1406-1419.
6. Gendron R, Grenier D, Maheu-Robert L. The oral
cavity as a reservoir of bacterial pathogens for focal
infections. Microbes Infect. 2000;2:897-906.
7. Iwai T. Periodontal bacteremia and various vascular
diseases. J Periodontal Res. 2009;44:689-694.
8. Dunning T. Periodontal disease—the overlooked diabetes
complication. Nephrol Nurs J. 2009;36:489-496.
9. Lockhart PB, Brennan MT, Thornhill M, et al. Poor oral
hygiene as a risk factor for infective endocarditis-related
bacteremia. J Am Dent Assoc. 2009;140:1238-1244.
10. Hein C. Proceedings and consensus opinion from the
Global Oral and Systemic Health Summit: present
evidence and future directions. Grand Rounds in
Oral-Systemic Medicine. 2007;2(suppl 1):1-19.
Figure 15. Page 2 of the post-treatment test
report from OralDNA.
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Continuing Education
Salivary Testing for Periodontal Disease Diagnosis and Treatment
21. Socransky SS, Haffajee AD, Smith C, et al.
Microbiological parameters associated with IL-1
gene polymorphisms in periodontitis patients.
J Clin Periodontol. 2000;27:810-818.
11. Noack B, Genco RJ, Trevisan M, et al. Periodontal
infections contribute to elevated systemic C-reactive
protein level. J Periodontol. 2001;72:1221-1227.
12. Salzberg TN, Overstreet BT, Rogers JD, et al.
C-reactive protein levels in patients with aggressive
periodontitis. J Periodontol. 2006;77:933-939.
22. Parkhill JM, Hennig BJ, Chapple IL, et al. Association
of interleukin-1 gene polymorphisms with early-onset
periodontitis. J Clin Periodontol. 2000;27:682-689.
13. Yaron G, Brill A, Dashevsky O, et al. C-reactive protein
promotes platelet adhesion to endothelial cells: a
potential pathway in atherothrombosis. Br J Haematol.
2006;134:426-431.
23. Havemose-Poulsen A, Sørensen LK, Bendtzen K,
et al. Polymorphisms within the IL-1 gene cluster:
effects on cytokine profiles in peripheral blood and
whole blood cell cultures of patients with aggressive
periodontitis, juvenile idiopathic arthritis, and
rheumatoid arthritis. J Periodontol. 2007;78:475-492.
14. Andrian E, Grenier D, Rouabhia M. Porphyromonas
gingivalis-epithelial cell interactions in periodontitis.
J Dent Res. 2006;85:392-403.
24. Caffesse RG, de la Rosa MR, de la Rosa MG.
Interleukin-1 gene polymorphism in a well-maintained
periodontal patient population. Braz J Oral Sci.
2002;1:1-6.
15. Brozovic S, Sahoo R, Barve S, et al. Porphyromonas
gingivalis enhances FasL expression via up-regulation
of NFkappaB-mediated gene transcription and
induces apoptotic cell death in human gingival
epithelial cells. Microbiology. 2006;152(pt 3):797-806.
25. Caffesse RG, de la Rosa MR, de la Rosa MG, et al. Effect
of interleukin-1 gene polymorphism in a periodontally
healthy Hispanic population treated with mucogingival
surgery. J Clin Periodontol. 2002;29:177-181.
16. Zaremba M, Górska R, Suwalski P, et al. Evaluation of
the incidence of periodontitis-associated bacteria in
the atherosclerotic plaque of coronary blood vessels.
J Periodontol. 2007;78:322-327.
26. Caffesse RG, de la Rosa MR, de la Rosa MG, et al.
Prevalence of interleukin 1 periodontal genotype in
a Hispanic dental population. Quintessence Int.
2002;33:190-194.
17. Padilla C, Lobos O, Hubert E, et al. Periodontal
pathogens in atheromatous plaques isolated from
patients with chronic periodontitis. J Periodontal Res.
2006;41:350-353.
27. Laine ML, Leonhardt A, Roos-Jansåker AM, et al. IL1RN gene polymorphism is associated with periimplantitis. Clin Oral Implants Res. 2006;17:380-385.
18. Russell AL. A system of classification and scoring for
prevalence surveys of periodontal disease. J Dent
Res.1956;35:350-359.
28. Armitage GC, Wu Y, Wang HY, et al. Low prevalence
of a periodontitis-associated interleukin-1 composite
genotype in individuals of Chinese heritage.
J Periodontol. 2000;71:164-171.
19. Ramfjord SP. The Periodontal Disease Index (PDI).
J Periodontol. 1967;38(suppl):602-610.
20. Ferreira SB Jr, Trombone AP, Repeke CE, et al.
An interleukin-1beta (IL-1beta) single-nucleotide
polymorphism at position 3954 and red complex
periodontopathogens independently and additively
modulate the levels of IL-1beta in diseased
periodontal tissues. Infect Immun. 2008;76:3725-3734.
13
Continuing Education
Salivary Testing for Periodontal Disease Diagnosis and Treatment
2. Periodontal infections elicit an inflammatory
response that leads to destruction of the
periodontium. This response is initiated by:
a. Any bacteria within the subgingival biofilm.
b. Bacteria of specific origin.
c. Harmful products in smoke.
d. C-reactive protein.
POST EXAMINATION INFORMATION
To receive continuing education credit for participation in
this educational activity you must complete the program
post examination and receive a score of 70% or better.
Traditional Completion Option:
You may fax or mail your answers with payment to Dentistry
Today (see Traditional Completion Information on following
page). All information requested must be provided in order
to process the program for credit. Be sure to complete your
“Payment,” “Personal Certification Information,” “Answers,”
and “Evaluation” forms. Your exam will be graded within 72
hours of receipt. Upon successful completion of the postexam (70% or higher), a letter of completion will be mailed
to the address provided.
3. Periodontal diseases create both local and systemic
inflammation. Research has shown that periodontal
disease may increase risk for the following systemic
conditions:
a. Cardiovascular disease.
b. Diabetic complications.
c. Platelet adhesion.
d. All of the above.
4. The diagnosis of periodontal infections can be more
accurate when the clinical findings are combined
with biological information. Important biological
components are:
a. Bacterial inflammatory burden.
b. Genetic traits.
c. Both a and b.
d. Periodontal disease index.
Online Completion Option:
Use this page to review the questions and mark your
answers. Return to dentalcetoday.com and sign in. If you
have not previously purchased the program, select it from
the “Online Courses” listing and complete the online
purchase process. Once purchased the program will be
added to your User History page where a Take Exam link
will be provided directly across from the program title.
Select the Take Exam link, complete all the program
questions and Submit your answers. An immediate grade
report will be provided. Upon receiving a passing grade,
complete the online evaluation form. Upon submitting the
form your Letter Of Completion will be provided
immediately for printing.
5. Saliva has been validated as an important analyte for
providing biological information in diagnosis and
prognosis of oral diseases. This is possible because
of the following:
a. DNA is found in saliva.
b. Gingival crevicular fluid (GCF) is found in saliva.
c. Saliva contains DNA from bacteria, viruses and
human cells.
d. All of the above.
6. Advancements in molecular biology provide accurate
information that is contained in saliva. The most
precise and useable advancement today for
identifying patients at risk or with specific diseases
are from which of the following?
a. Enzymes that are found in GCF.
b. Electron microscopy.
c. DNA-PCR technology.
d. Electrophoresis.
General Program Information:
Online users may log in to dentalcetoday.com any time in
the future to access previously purchased programs and
view or print letters of completion and results.
POST EXAMINATION QUESTIONS
7. Clinical research establishes evidence that
periodontal infections/diseases are caused by which
of the following?
a. Occusal interferences.
b. Smoking.
c. Specific bacteria that have been identified as
causative agents.
d. Diabetes.
1. Periodontal infections include both gingivitis and
periodontitis. These infections are estimated to occur
in what percentage of the American population:
a.
b.
c.
d.
57%.
65%.
75%.
44%.
14
Continuing Education
Salivary Testing for Periodontal Disease Diagnosis and Treatment
13. The data presented in clinical lab reports for oral
diseases helps to provide information and levels of
risk that cannot be obtained with only subjective
analysis. Which is NOT true about a clinical lab
report?
a. Can determine specific bacterial risk.
b. Can help determine specific genetic risk.
c. Can predict who is going to have a specific systemic
disease 100% of the time.
d. Can help to personalize therapy.
8. Risk factors for periodontal diseases include the
following:
a. Genetics.
b. Diabetes.
c. Smoking.
d. All of the above.
9. During the past decade, studies have demonstrated
that the severity of periodontitis is closely linked to the
genetic variation of the interleukin-1 (IL-1) genotype.
IL-1 is connected to the immune response in a number
of ways. Which of the following is NOT correct?
a. IL-1 is a key regulator in the inflammatory process.
b. IL-1 is found in 3% of the American population.
c. IL-1 is found in approximately 30% to 35% of the
total population.
d. IL-1 positive individuals are at increased risk for
severe periodontal disease.
14. DNA testing can help add value to the clinical exam
by providing which important additional information?
a. DNA testing determines risk based on specific
bacteria and bacterial concentration.
b. DNA testing can determine which patients have a
genetic trait that presents increased risk.
c. DNA testing can help to determine if antimicrobial
therapy is appropriate and which antimicrobials may
be helpful for the specific infection.
d. All are true.
10. Saliva is known as “oral fluid” or “total saliva”
because it contains the following. Which is the most
correct answer?
a. Proteins.
b. Fluid from the salivary glands.
c. DNA/RNA.
d. All are found in total saliva.
15. A more complete examination and risk analysis
would include the following information:
a. Initiators/Causes of inflammation.
b. Medical/Dental histories.
c. Clinical signs and symptoms.
d. All of the above.
11. The importance of DNA-PCR diagnostic applications
in medicine (including oral medicine) is the detection
of which of the following:
a. Genetic polymorphisms from human cells.
b. Specific bacteria from bacterial cells.
c. Specific viruses.
d. All of the above.
16. DNA clinical lab reports contain the following. Which
is most accurate?
a. Specific biofilm information.
b. Risk based on specific inflammatory burden.
c. Multiple causative agents associated with these
diseases.
d. All of the above.
12. Clinical laboratory medicine and the clinical
laboratory report have become essential
components in medicine for which of the following
reasons:
a. A clinical exam of signs and symptoms only is not
the standard of care today.
b. A physical exam only is not sufficient for a complete
risk assessment and diagnosis.
c. Biological factors found in body fluids are essential to
determine risk and validate diagnosis.
d. All of the above.
15
Continuing Education
Salivary Testing for Periodontal Disease Diagnosis and Treatment
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16