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Traditional vs. Perio Exam with Salivary Testing Richard H. Nagelberg, DDS

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The importance and ability to measure clinical signs of periodontal disease (clinical phenotype) is well understood within our profession. However, today, it is recognized that the biological presentation (biological phenotype) is sufficiently important for the clinician so as to improve the diagnosis of the current disease status as well as to improve risk assessment for future attachment loss.

Patients with the same clinical presentation can have very different diseases based on known causative bacterial agents. Thus, without knowledge of the specific bacterial etiological agents, treatment might be effective on one patient and ineffective on another patient when using clinical presentation as the sole diagnostic protocol.

The additional benefit of adding biological information based on our knowledge of causation and specific bacteria as a component of the evaluation and ultimate diagnosis is presented in the following two case reviews.

The clinical exam protocol clinicians follow when evaluating a patient's periodontal status includes observing and measuring a variety of clinical and radiographic parameters. We measure pocket depths, attachment level, mobility and recession. We observe and notate bone levels, bleeding, swelling redness, occlusal factors, furcation involvement and so on.

There is certainly value to this approach to data collection and case typing. Research advances in virtually every area of the dental and medical professions have changed standards and protocols considerably, including periodontal evaluations.

Some of the biggest changes we now take for granted include imaging technologies, digital radiographs, cardiac catheterization, arthroscopy and CAD/CAM applications, among many others. While the traditional approach to perio disease provides important information, there are serious limitations associated with only observing clinical signs.

Everything we observe and measure represents the history of the disease. In other words, the damage is already done by the time we diagnose perio disease. The primary shortcoming of the traditional approach to diagnosis and case typing is the complete lack of information on the specific cause of the individual patient's disease: the critical component of each person's biological presentation. These diseases are very different in each patient, plus patients respond to their unique disease based on their unique metabolic response.

We know that the etiology of perio disease is bacterial, but without the ability to test for causative agents that initiate these inflammatory diseases, we don't know which bacteria are causing gum disease in the patient currently in our chair. Taking advantage of the advances in salivary diagnostics has changed the standard of perio care.

Bacterial virulence varies; some bacteria are very powerful, virulent bugs. P. gingivalis for example is not typically found in healthy mouths. If it is present in health, then it is at a very low concentration. This particular microbe is associated with more severe diseases, particularly when it is found in sufficient concentration. It is often associated with aggressive forms of gum disease.

There are other bacteria that are also known to be true causative agents of these diseases with varying degrees of pathogenic potential. Treatment planning and understanding the predictability of treatment outcomes without knowledge of the bacteria that are responsible for the clinical disease state is educated guessing. Our treatment plans, monitoring and maintenance intervals, selection and use of the variety of adjunctive antimicrobials in our toolbox will vary depending on the causality.

Furthermore, the concept of the therapeutic endpoint has historically been limited to improvement in the same clinical parameters used in the diagnostic process including improvement in pocket depths, bleeding, bone levels, swelling etc. With the easy availability of testing bacterial species and levels from OralDNA Labs (Brentwood, Tennessee), the therapeutic endpoint now includes bacterial reduction.

There are cases in which clinical improvement is not accompanied by significant bacterial reduction. When this occurs we can conclude that the likelihood of disease recurrence is elevated. The frequency of monitoring and maintenance intervals and home care recommendations will be impacted by this information.

The patient noted in the test report (Fig. 1, click to enlarge) is a 32- year-old male in good health. The pre-op test report indicates high levels (above the threshold considered to increase risk for future attachment loss) of one high-risk pathogen and three low risk pathogens. Thus, the targets for therapy are now easily definable. He had perio pockets of 5-6mm in all four quadrants.

Non-surgical periodontal treatment was undertaken including: scaling and root planing, irrigation with 10 percent povidone iodine, placement of Arestin in all perio pockets >5mm and amoxicillin and metronidazole systemic antibiotics for eight days.

Re-evaluation 30 days after active therapy revealed improvement in all pockets to 3mm or less, reduction in bleeding, swelling and all other clinical parameters. The patient was put on a three-month perio maintenance interval.

Post-op testing was provided approximately two months after the pre-op test with the results noted in figure 2 (click to enlarge). It is immediately apparent that the bacterial levels were reduced to nearly zero for all species. In this case, the therapeutic endpoint was achieved in both clinical improvement and bacterial reduction.

By achieving both, an acceptable clinical endpoint as well as a biological endpoint based on specific causative agents, adds to the prognostic value of the treatment. Reductions in pocket depths, bleeding on probing (BOP) and putative pathogens suggest an improved prognosis compared to using clinical signs as the only measure of success.

The pre-op test report shown in figure 3 is for a 72-year-old female. The report indicates high levels of one high-risk pathogen and one low-risk pathogen. She had localized perio disease, case type 4 including an 8mm pocket on the mesio-lingual of tooth #6, in addition to several 5 and 6mm pockets in other areas.

Initial therapy consisted of the same regimen noted above. Re-evaluation approximately 30 days later revealed improvement in all clinical parameters, including a reduction in the 8mm pocket to 3mm, which is non-typical. A three-month maintenance interval was recommended.

Post-op bacterial testing was provided three months after the initial test. The results are shown in figure 4. It is apparent in this case that the therapeutic endpoint was not achieved, since there was no appreciable bacterial reduction. Without pre- and post-op testing we would have concluded that the endpoint of therapy was achieved.

The pre-op testing provides a risk assessment and the post-op testing provides an outcomes assessment. The persistence of elevated levels of perio pathogens despite excellent clinical resolution indicates an elevated likelihood of disease recurrence. This would also constitute a risk of recurrence assessment. At this point in time, a referral to a local periodontist and discussion about this risk may pinpoint the perfect time for selected site surgery to further reduce the patient's risk. Knowing when patients should be referred for more aggressive therapy is another excellent advantage when using these tests.

With OralDNA Labs salivary diagnostic technology, we now have the most powerful tool to combat perio disease. The ability to identify the causative bacteria changes everything by enabling clinicians to provide individualized perio treatment for each patient. We finally know exactly what we are fighting.

Traditional periodontal evaluation has served the profession well for decades. Bacterial DNA testing adds a critical dimension previously unavailable, significantly enhancing our ability to get better results for our patients, which is what it is really all about.
Author’s Bio
Richard Nagelberg, DDS, PC, has been practicing general dentistry in suburban Philadelphia for more than 28 years. He has international practice experience, having provided dental services in Thailand, Cambodia and Canada. Richard has served on many boards and advisory panels. He is co-founder of PerioFrogz.com, an information services company, and is a speaker, clinical consultant and key opinion leader for several dental companies and organizations. He is also a recipient of Dentistry Today's Top Clinicians in CE, 2009, 2010 and 2011. A respected member of the dental community, Richard lectures internationally on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Dr. Nagelberg can be contacted at gr82th@aol.com.
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