Management Equipment Home Care OraTec, has been providing anti-infective periodontal products and information since 1986. They introduced the first Phase Contrast Microscope, designed by Paul Keyes as well as the BANA enzymatic test. Recently they have taken a leap forward in technology by being appointed the US distributor for the DNA testing of Hain Life Sciences including the Genetic analysis called the Geno Type Periodontitis Susceptibility Test, and the PRC based Micro-IDent bacterial test. Bacterial Testing As we well know, periodontal disease is connected with eleven anaerobic gram negative bacteria that we call “the periodontal pathogens”. Particularly Aggregatibacter actinomycetemcomitans and the “Red Bacteria T. forsythensis, P. gingivalis and T. denticola. We know that periodontal disease is transmissible, and that it is in fact correct to say that periodontal disease is an inflammation resulting from a microbial infection. An excellent discussion of the total subject is found in J. Appl. Oral Sci. vol.12 no.4 Bauru Oct./Dec. 2004 Microbiological basis for periodontal therapy - www.scielo.br. The Oral Systemic Connection has focused new importance on the pathogenic bactera. Genco (1,2) has reported that the success in reducing both C-Reactive Protein and HbA1c depends on the reduction of bacteria during treatment, with anti-microbial treatment more effective than SRP alone. (3) Hisayama reported the level of P.Gingivalis due to deep pockets as being responsible for an individual developing diabetes. Ford (4) has noted that maintenance of inflammation (elsewhere in the body-ed) may be enhanced by the presence of periodontopathic bacteria', which contributed to inflammation of arteries, but may explain the increased risk of cancer noted with individuals (5). While it is clear that the pathogenic bacteria should play a central role in the diagnosis and treatment of periodontal disease, they have been dealt with only indirectly while the direct “diagnostic” measurements including inflammation, pocket depth and bleeding are actually only symptoms of the disease. The treatment may or may not include anti-microbial treatment according to the philosophy of the practitioner, not patient based criteria such as the amount and type of bacteria present. Failure in treatment is dismissed for unknown causes. The reason that this is the case, has been the lack of a convenient, cost and time effective accurate assessment of the number and types of pathogens present. The Micro-Ident Test Previously the methods of bacterial diagnosis have been the phase contrast microscope and live cultures. The phase microscope while being excellent for patient understanding and co-discovery, has been more qualitative than quantitative. Since the Centers for Dental Medicine started, we recommended that patients not responding well to treatment should be referred to an Oral Micribiology testing service for a culture. However because of the complications of the process- having to send a live culture overnight it has been rarely used by our Centers. Even more importantly the result gives only a “Percent of Cultivatible Microbiota” rather than an absolute number (which is necessary for assigning a degree of infection), and it is not known how many died along the way. The micro-IDent process, in dealing with the DNA of the dead sample, does not deal with the live bacteria and is able to identify the absolute number and type of the pathogens. Additionally one merely places some sterile paper points in the 5 deepest pockets, places these in a collector and mails them off. The kits are free. The results come back in about 5-10 days. As can be seen from the report above the micro-IDent Test gives A quantitative assessment of the level of each of the 11 periodontal pathogens A danger threshold for each pathogen, defined as the level at which the person with average immune system would not be able to counteract the infection without developing periodontal disease. If treatment has been attempted, and pathogen levels are still above threshold, the service recommends a specific systemic antibiotic regimen appropriate for the pathogens in question The cost is $89 plus mail which is significantly less than the OMBTS service plus overnight delivery. J Clin Periodontol 2002: 29: 638-644, Sigrun Eick, Wolfgang Pfister Comparison of microbial cultivation and a commercial PCR based method for detection of periodontopathogenic species in subgingival plaque samples Conclusion: Nucleic acid techniques should replace cultivation methods as gold standard in microbiological diagnosis of progressive periodontitis. The micro-IDent™ kit can be recommended for microbiological laboratories analysing subgingival plaque samples. Learn the technique for placing the Advanced Diagnostics Micro-iDent Paper Points View presentation The BANA Test While the micro-iDent test has been for our program the ultimate bacterial assessment and is recommended to be included in every Class II and Class III periodontal treatment, it is too expensive at $89 to be used as a screening device everywhere that it might be useful. Enter the BANA enzymatic Test BANA stands for benzoyl-DL-arginine-naphthylamide and is a modification of the hydrolysis test developed originally by Walter Loesche at the U of Mich.. It rests on the principle that the “Red” periodontal pathogens- Treponema denticola, Porphyromonas gingivalis and Bacteroides forsythus, uniquely among subgingival species, possess an enzyme capable of hydrolyzing the BANA test strip and turning it blue. While being more of a qualitative test (shades of blue) rather than quantitative like the Micro Ident test, and being limited to these three species or bacteria (compared to the 11 of the micro-iDent Test) it has the distinct advantages of giving immediate feedback and costing only $6.00 making it practical as a screening device! It is done by applying subgingival plaque to a small test strip, and placing it in the incubator (shown below) for 5 minutes. The incubator is a one-time cost of $300-$400 depending on the model. Because of it’s effectiveness and low cost we recommend that a BANA test be included as part of the diagnostic process with every Wellness Center Visit. GenoType PST Wouldn’t it be wonderful if you could tell your patient if they are in the 30% of the population most susceptible to periodontal disease, arthritis and heart disease? Those people so identified could: Initiate an effective home care regimen prior to developing clinical symptoms to avoid getting the disease. Be motivated to initiate active periodontal treatment if they have the disease. Keep up their home care religiously after treatment. It turns out that people differ genetically in their inflammatory response to attack which has tremendous correlation with all three diseases mentioned above and any disease correlated with C Reactive Protein. Interleukin-1 (IL-1) is one of the first cytokines ever described. Its initial discovery was as a factor that could induce fever, control lymphocytes, increase the number of bone marrow cells and cause degeneration of bone joints. At that time, IL-1 was known under several other names including endogenous pyrogen, lymphocyte activating factor, haemopoetin-1 and mononuclear cell factor, amongst others. It was around 1984-1985 when scientists confirmed that IL-1 was actually composed of two distinct proteins, now called IL-1a and IL-1ß.[1] These belong to a family of cytokines known as the interleukin-1 superfamily. http://en.wikipedia.org/wiki/IL-1 IL-1RA The IL-1 receptor antagonist (IL-1RA) was initially called the IL-1 inhibitor and was discovered separately in 1984 by two independent laboratories.[1] IL-1RA, is an agent which binds to the same receptor on the cell surface as IL-1, and thus prevents IL-1 from sending a signal to that cell. It is used in the treatment of rheumatoid arthritis, an autoimmune disease in which IL-1 plays a key role. There are two genes that determine our processing of IL-1 Gene: Interleukin-1 beta Chromosome location: 2q14 Gene product/function: IL-B is a cytokine which mediates inflammatory response. Gene: Interleukin-1 receptor antagonist Chromosome location: 2q14.2 Gene product/function: IL-1Ra is a cytokine which mediates inflammatory response. Variations in genes are called gene polymorphisms. Socransky( S.S. et al., 2000: Microbiological parameters associated with IL-1 gene polymorphismus in periodontitis patients) • “The proportion of IL-1 genotype positive subjects that exhibited mean counts of specific subgingival species above selected thresholds was significantly higher than the proportion of genotype negative subjects”.• “Prominent among species that were detected at higher levels in genotype positive subjects were members of the red and orange complexes and included: Bacteroides forsythus, Treponema denticola, the Fusobacterium nucleatum subspecies,Fusobacterium periodonticum, Campylobacter gracilis, Campylobacter showae and Streptococcus constellatus”. Essentially Il-1 gentotype positive people exhibit a more inflammatory reaction to stimulus, which is more likely to result in periodontal disease. Other research shows relationship of IL-1 genes to arthritis. CRP production, Cardiovascular disease, risk of complications in diabetes and osteoporosis. http://www.ilgenetics.com/content/development-pipeline/publications.jsp Therefore identifying a patient’s genotype may be a tremendously valuable contribution to their health management. In Summary we find the testing provided by OraTec to be an indispensible part of the Centers for Dental Medicine Protocol. References 1) ADA News Periodontal therapy lowers levels of heart disease inflammation markers 2) Treatment of Periodontal Disease in Diabetics Reduces Glycated Hemoglobin (HbA1c) 3) The Severity of Periodontal Disease is Associated with the Development of Glucose Intolerance in Non-diabetics: The Hisayama Study T. Saito1,*, Y. Shimazaki1, Y. Kiyohara2, I. Kato2, M. Kubo2, M. Iida2, and T. Koga1,3 2 Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan 4) Inflammation, heat shock proteins and periodontal pathogens in atherosclerosis: An Immunohistologic Study Oral Microbiology and Immunology, Vol. 21, pp. 206 - 211 Ford, P., 5) Periodontal Disease Increases Cancer Risk By Michael Smith, North American Correspondent, MedPage Today Published: May 27, 2008 6) Bill Landers on Theory of Bacteriological Diagnosis for Periodontal Disease (1 Hour) 7) Bill Landers on Options for Bacteriological Measurement (45 Minutes) 8) Detailed instructions on taking samples for BANA, MicroIDent and PST Testing (15 Minutes)