A Bad Taste in His Mouth: Salivary Testing for Periodontal Disease

Kimberly R. Miller, RDH; William M. Tudor, RDH, EMT

March 26, 2012

Halitosis and Bleeding Gums

A 31-year-old man reports a bad taste in his mouth, as well as bleeding gums a couple of times a week, especially when he brushes his teeth. His wife has told him that he has halitosis. He has no dental pain. He occasionally uses floss. He sees his dentist once a year; the last visit was about a year ago. The patient's third molars were extracted about 10 years ago, and it was a negative experience. He reports a family history of diabetes, myocardial infarction, and periodontal disease, which (along with bleeding gums) are risk factors for gingival disease. His own medical history is unremarkable except that his blood pressure is 135/90 mm Hg.

Patient Evaluation: A Collaborative Approach

The comprehensive oral evaluation includes a series of examinations and data collection and is a joint effort between dentist and dental hygienist. Following a dental examination by the dentist, data are collected and a treatment plan that is in the best interest of the patient is developed collaboratively by dentist and dental hygienist.

Dental Examination

Data collection for this patient included:

  • Full-mouth radiographs of all teeth, surrounding bone, and root tips;

  • Panorex/CT scan showing temporal mandibular joints, third molar region, sinus, and sphenoid bone;

  • Hard tooth examination to assess the presence of tooth decay, tooth fractures, abfractions, wear facets, bite relationship and interferences, missing teeth, and any tooth replacements (eg, bridges, implants, and partials or dentures); and

  • Periodontal evaluation, including charting of pocket depths (space between tooth and gum), gum recession, bleeding, pus, furcations (access to the space between the roots of molar teeth), and tooth mobility (Figure 1).

Figure 1. Periodontal chart showing degree of periodontal disease (> 5-mm pockets).

The comprehensive oral evaluation revealed the following:

  • Two areas of active decay that could easily be treated with composite and porcelain restorations; and

  • Active periodontal infection with pocket depths up to 6 mm with bleeding, indicating the need for periodontal therapy, especially when considering his risk factors.

Diagnostic Testing: Periodontal Disease

To plan this patient's treatment, additional information about his periodontal health was obtained. Salivary samples were sent to the laboratory for a DNA-polymerase chain reaction (PCR) test (My Perio Path®; OralDNA Labs; Brentwood, Tennessee) to test for the presence of high-risk pathogens and a periodontal susceptibility test (PST®, OralDNA Labs, Brentwood, Tennessee) for the probability of more severe periodontal disease. The DNA bacteria test identifies the type and concentration of pathogenic bacteria that are known to cause periodontal disease. The PST detects variations in the genes for interleukin 1A and 1B that suggest a predisposition for overexpression of inflammation and risk for periodontal disease. These tests permit appropriate treatment of the patient's periodontal disease, without overtreating or undertreating, and take the level of risk for future disease and complications into consideration.

This patient's DNA-PCR results indicate that he has high levels of the following pathogenic bacteria:

  • Aggregatibacter actinomycetemcomitans (Aa)

  • Treponema denticola

  • Eubacterium nodatum

  • Fusobacterium nucleatum/periodontium

  • Peptostreptococcus (Micromonas) micros

All of these pathogens are associated with periodontal disease. Aa leukotoxin kills white blood cells in a variety of ways, allowing pathogenic bacteria to survive the immune response and releasing compounds that are essential for bacteria survival and growth. Aa leukotoxin is involved in attachment loss in adolescents, indicating that it plays a role in the pathogenesis of aggressive periodontitis.[1]

Fortunately, the patient's genetic susceptibility test was negative, suggesting that he should respond very well to treatment. With his cooperation, compliance with a prescribed home care routine, and personalized periodontal therapy, we expected a very positive outcome.

Treatment

  • Periodontal therapy in each quadrant, with anesthesia as needed to keep the patient comfortable.

  • Root debridement of all hard and soft deposits, with a blended approach using both hand and micro-ultrasonic instrumentation (Figures 2-4).

Hand instrumentation is important to ensure that even the smallest deposit is removed. Ultrasonic instrumentation creates turbulence at 30,000 cycles/sec. When the bubbles burst, they deliver energy, breaking the cell wall of the pathogen and essentially killing the bacteria.

Figure 2. Lower anterior hand instrumentation.

Figure 3. Micro-ultrasonic instrumentation.

Figure 4. Posterior hand instrumentation.

  • Laser to remove necrotic tissue and attempt to kill bacteria.

  • Subgingival irrigation with povidone-iodine into the periodontal pockets.

  • Locally applied antibiotics in pockets >4 mm.

  • Specific home care instructions:

    • Use a power toothbrush

    • Use a water irrigator

    • Use antibacterial tooth paste

    • Use antibacterial mouth rinse

    • Eat a balanced diet high in antioxidants

    • Take high-quality nutritional supplementation

    • Get adequate rest and exercise

  • Oral antibiotic therapy. Published guidelines[1] suggest the following (subject to allergy, drug interaction, and other medical considerations) as a possible adjunct to treatment based on the patient's bacterial profile: amoxicillin 500 mg 3 times daily for 8 days and metronidazole 500 mg twice daily for 8 days beginning on the last day of periodontal therapy. All roots must be debrided before the systemic antibiotics are started to avoid recontamination of the tissue by pathogen invasion.

Therapeutic strategies targeting cellular and molecular inflammatory host responses might be an effective addition to the treatment plan when periodontal disease with the presence of Aa has been diagnosed.[2] One way to help cells fight disease or free-radical damage is to increase antioxidant levels. It is recommended that patients consume more vegetables and fruits, because foods high in antioxidants may promote good cellular function.

Food for Thought

This patient mentioned that he and his wife are planning to start a family. Taking into consideration the transmissible nature of Aa, the odds that his wife has a similar periodontal pathogen profile are substantial. The American Academy of Periodontology (AAP) states that "All infections are cause for concern among pregnant women because they pose a risk to the health of the baby. The Academy recommends that women considering pregnancy have a periodontal evaluation."[3] Based on this recommendation from the AAP, we suggested that she have a periodontal evaluation, and if signs of disease activity are present, a bacterial pathogen test. Research has indicated a potential relationship between prematurity and low birthweight in babies and maternal periodontal disease.[4] To minimize the risk for periodontal disease during pregnancy, we believe that if the wife needs periodontal treatment, she and her husband should be treated simultaneously to avoid the exchange of pathogens. She should be retested to ensure that the pathogens have been eliminated.

References

  1. Slots J; Research, Science and Therapy Committee. Systemic antibiotics in periodontics. J Periodontol. 2004,75:1553-1565.

  2. Johansson A. Aggregatibacter actinomycetemcomitans leukotoxin: A powerful tool with capacity to cause imbalance in the host inflammatory response. Toxins. 2011;3:242-259.

  3. American Academy of Periodontology. Gum disease and pregnancy problems. May 31, 2011. http://www.perio.org/consumer/mbc.baby.htm Accessed March 12, 2012.

  4. Jeffcoat M. Periodontitis in pregnancy. Medscape Dentistry and Oral Health. http://www.medscape.com/viewarticle/741656 Accessed February 28, 2012.