Periodontal disease is a multifactoral problem, and cannot always be answered by the traditional methods of mechanical debridement (scaling and root planing) and periodontal surgery. Although in most cases,  debridement and improvement of oral hygiene can do wonders, unique cases always arise which leave periodontists baffled.  What happens when you have a 30 year old patient, with no radiographic calculus or significant plaque buildup but has severe bone loss and 8mm pockets? Clearly debridement of the pockets isn’t going to work. Understanding the microbiology of periodontal disease is of increasing importance to the general dentist and working with specialized labs is vital to the successful treatment of the disease.

The Oral Microbiology Testing Service (OMTS) at Temple University School of Dentistry was designed specifically to assist dentists with identifying and treating difficult cases of periodontal disease. It is one of only 4 state and federally-licensed clinical periodontal microbiology reference laboratories in the United States.

The process:

How do you get the culture?
The dentist should first use college pliers and a cotton pellet to wipe away supragingival plaque. Then a medium cotton point should be placed into about six different sites with the deepest periodontal probing depths. The cotton point should be left in for 5 to 10 seconds and then quickly placed in the culture medium, which is then sent to the lab.

Once the lab has the culture, they incubate and culture it. This is done in a one to two week period in a special chamber that replicates the conditions of the area of the mouth in which the bacteria grows.

After the culture is grown , it is examined by microbiologists and  the types of bacteria are identified. Then an antibiotic sensitivity test is performed on all the species of bacteria that were found. The pathogens were divided into groups depending on their known associations with periodontal disease. An acceptable critical % threshold level was given for each species of bacteria. The % of cultivable microbiota for each species from the sample was then compared against the given markers. For example if the acceptable threshold level for a certain species was 2.5% but the level found in this sample was 5.6% then the conclusion would be that there were elevated proportions of that species.

Antibiotic sensitivity tests were performed for 4 major antibiotics commonly used to treat periodontal pathogens. This bodes well for the patient because specific antibiotic therapy can be given to the patient in addition to dental treatment.

Clinical Scenario:
A patient presented to Dr. Dorfman’s office recently with severe periodontal disease and acute necrotizing ulcerative gingivitis (ANUG) on the lingual aspect of #27,28. The patient was treatment planned for 4 quadrant scaling and root planning,

The patient was previously treated with amoxicillin and metrodiazanole, two commonly prescribed antibiotics for periodontal pathogens. However, the lab results showed that many of the periodontal pathogens found were resistant to both antibiotics. The head of the lab at the OMTS suggested the use of Cipro to target the gram-negative bacteria that were found to be in significantly higher levels than expected.

R.A., Columbia University School of Dental Medicine

Our New York City dental practice has considered the whole body relationship of dental disease for 24 years. We obtain periodontal cultures of patients with advanced gum disease, based upon the early work of Dr. Max Listgarten. The recent discovery of diabetes in a patient based initially on periodontal (gum) diagnosis is a case in point. The Center for Special Dentistry (www.NYCdentist.com) is proud to work with Dr. Keith Berkowitz at the Center for Balanced Health (www.CenterForBalancedHealth.com) in mid-town NYC. The fasting glucose tolerance test they performed to diagnose the patient’s diabetes will contribute to the overall health of this 42 year young woman. This should be considered the standard of care in dentistry particularly with the present Administration’s push to expand healthcare for all. It will improve health, save lives and is cost-effective. For microbiology results from Temple University’s Oral Microbiologic Testing Lab visit:
http://www.nycdentist.com/?fuseaction=atlas.displayImage&im_id=2249&at_id=243&at_parent_id=242

Read the Wall Street Journal article.

Reply:

Please re-read my comments:  I said our dental practice screened the patient for diabetes but worked with Dr. Keith Berkowitz (M.D.) at The Center for Balanced Health for diagnosis and treatment.  Dentists should not diagnose and treat diabetes but they can be invaluable in screening patients.

Separately, most physicians do not have any understanding of dentistry nor how it relates to systemic health.  It should be part of medical school.  Just 15 minutes ago we had to reschedule a patient who underwent AV Nodal Reentrant Tachycardia (AVNRT) in March at a prominent Long Island heart hospital but was not given instructions to premedicate for dental procedures for the first six months post-op.

This afternoon I viewed a patient who was in for an implant placement on #9. The 25 year old female had the tooth extracted over 10 years ago because the tooth would not erupt and was not able to be orthodontically erupted. Prior to the implant surgery a bacterial culture was taken because of a few severe localized pockets on select molars and premolars, which may be indicative of post-juvenile periodontitis. (See Image #1) The bacterial culture was taken by placing paper points into the facial and lingual sites of each deep pocket location for a few seconds, and then placed into the culture solution. The culture will be sent to an oral microbiology lab for testing and further treatment will be decided on then.

The patient received profound anesthesia prior to the implant placement. The size and location of the edentulous area indicated the use of a 3.5mm x 12mm implant in the area of #9. (See Image #2 and #3) Radiographs were taken to verify the placement and seating of the implant and healing abutment and sutures were placed to reapproximate the tissues for successful healing. The patient has been wearing a flipper for approximately 8 years and therefore the seating of the flipper post-surgery was confirmed and no adjustments were necessary.

N.S., New York University College of Dentistry

Dr. Max Listgarten, now retired and living near his children in San Francisco, led the University of Pennsylvania Department of Periodontics for a generation.
At Penn he created the Microbiological Testing Lab (MTL) which received and analysed bacterial samples taken from perio patients. MTL offered appropriate chemotherapeutic agents (antibiotics) to referring dentists that were most likely to succeed in treating a given type of periodontal infection.
The Oral Cavity is a major gatekeeper for the billions of viruses and bacteria that infiltrate our body each day. These microorganisms could have a much more central role in our daily lives than anyone can now contemplate.
Dr. Listgarten laid a foundation in researching and understanding the relationship between the oral cavity, periodontium and systemic disease. Max also worked with Dr. Jan Lindhe, another periodontist and former Dean at both University of Pennsylvania and University Goteborg.
Anyone seeking to know where dentistry will be in thirty years should study what these geniuses were doing thirty years ago. Their work may not be easily accessible online but it is worth the trip to a dental school library and dust off a hardcopy journal on a rack.