Microbial and Genetic Testing in the Treatment of Periodontal Disease
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1 Microbial and Genetic Testing in the Treatment of Periodontal Disease Mr P.Renton-Harper Specialist in Periodontics Periodontal Disease A bacterial infection in a susceptible host Genetic Testing PST Test Microbial Anaylsis Culture & Sensitivity Molecular Microbiology Enzyme Analysis PST Genetic Test Simple Swab from buccal mucosa Measures production of : Pro-inflammatory Interleukin-1 (IL-1) Anti-inflammatory Interleukin-1 receptor antagonist (IL-1-RN)
2 Categorise Patient into one of four groups: Both IL-1 and IL-1-RN production normal IL-1 normal, IL-1-RN IL-1, IL-1-RN normal IL-1, IL-1-RN Risk increased further for smokers Susan Petersen Dr. Paul Renton-Harper (Litfield Periodontics) 1 Litfield Place Bristol, BS8 3LS, 08/28/1946 ANA /25/ /06/2008 The analysis of the individual periodontitis susceptibility for Susan Petersen resulted in risk type C. Patients diagnosed with risk type C show an overproduction of the proinflammatory Interleukin-1 opposed to a normal, healthy production of the infection inhibiting Interleukin-1 receptor antagonist. This means that Susan Petersen shows a genetically predisposed hypersensibility to infections. There is an increased genetic susceptibility to progressive periodontitis as well as for periodontitis-related implant complications. It is therefore recommended to take Susan Petersen on a strict recall-schedule to enable the dentist to monitor the clinical progression. Avoiding additional risk factors such as smoking, stress, etc. and regularly controlling subgingival pathogen bacterial load are also recommended It was not specified if Susan Petersen was tested for the presence of periodontopathogenic bacteria. Please be aware that patients with risk type C or D are likely to show a strongly increased immune response to infection with periodontopathogenic bacteria. Here, bacteria testing with micro-ident or micro-ident plus and reducing the bacterial load is highly recommended. Please note that tobacco use has a negative impact on both the immune reaction and the microbiological status of the patient and may lead to a reduced beneficial effect of the treatment.if patients are risk type C or D and smokers, they have an eight times higher risk of developing periodontitis. In addition, there is a significantly higher risk on complications or even loss of implants due to synergistic effects. Susan Petersen has polymorphisms in the genes for the inflammatory interleukin-1 (IL-1A/B). However, no polymorphisms were detected in the gene for the inhibiting Interleukin-1 receptor antagonist. This corresponds to risk type C. Indications for Testing (As recommended by Interleukin Genetics) New periodontal patients to assist in developing treatment plans Patients requiring extensive periodontal and/or implant therapy to determine prognosis, improve patient acceptance and optimise treatment outcomes. Smoking patients as an additional incentive for smoking cessation. Maintenance patients to set recall intervals and improve compliance Patients with early signs of disease to help determine the need for referral to a specialist.
3 Patients who have periodontal disease are known to be susceptible! Future Study... The University of Michigan is examining 15 years of patient clinical outcome data from an insurance company and will then recruit 4000 of those patients and establish their PST status. They will combine this genetic information with two other risk factors (Smoking & Diabetes) and measure tooth survival rates. Microbial Analysis Culture & Sensitivity Needs to be a local perio aware service Transport & Timing Difficulties Culturing Difficulties Mixed infection Other colonising organisms Commercial service only in USA Less accurate than other methods Microbial Analysis Molecular Microbiology Technically simple sampling Results in 3 weeks from USA Interpretation often demanding
4 Select 5 sites (Pooled analysis) >5mm with BOP (not suppurating) Clear gingival margin of plaque Insert paper point to base of pocket Hold in place for 10 seconds Guide with probe if necessary Place paper points in vial Complete lab form and mail Results in 3 weeks Do not sample patients who: Have had antibiotics in last 4-5 weeks Have had debridement in last 4-5 weeks Have used mouthrinse in last 12 hours......
5 Dr. Paul Renton-Harper (Litfield Periodontics) 1 Litfield Place Bristol, BS8 3LS, England 01/05/1965 Multi-site sample 08/19/2009 Initial analysis ANA /03/2009 3dp / 6d / 8m / 18d / 31d 10+mm Microbiological analysis for patient Alison Paton resulted in a bacterial concentration requiring periodontal treatment due to the following complexes:red Complex (Tf,Td). Depending on the severity of clinical findings, anti-infective measures should include periodontal debridement (SRP) and may include topical antiseptics, topical or systemic antibiotics. An adjunctive antibiotic administration (scenario 2, metronidazole: 2 x 500 mg/day, 8 days) may also be considered based upon clinical findings and patient's medical history. For evaluating therapy success a control analysis is recommended approx. 8 weeks after treatment. Non-smoker. As stated on the order form, no antibiotic hypersensitivities are known. Please note that the clarification of potential antibiotic hypersensitivities is mandatory prior to any antibiotic intake. No statement on the order form. Microbial Analysis Enzyme Analysis Technically simple sampling Results in 5-10 minutes Equipment USA only Red Complex Species Only Porphyromonas gingivalis Tannerella forsythia Treponema denticola Enzymic Microbial Analysis Of 60 subgingival plaque species tested only those in the Red complex possess an enzyme capable of hydrolyzing benzoyl-dl-argininenaphthylamide (BANA). This produces Bnaphthylamide which then reacts with a diazo dye to produce a blue colour. (Socransky, Haffajee, Cuglini. J Dent Res 1997) The result for those three species is as accurate as using molecular techniques and more accurate than culturing. (Loesche et al. J.Clin.Micro 1992) 3dp / 6d / 8m / 18d / 31d
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Materials and Methods: Literature review and Authors opinion.
Haffajee AD, Bogren A, Hasturk H et al. Subgingival microbiota of chronic periodontitis subjects from different geographic locations. J Clin Periodontol 2004; 31:996-1002. Purpose: To compare the subgingival
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