Page 27 - GP Fall Final 2017

Improving Outcomes for Periodontal Patients:

The Role of Oral Microbiology Testing

What you can do in office when a patient’s periodontal challenge persists.

By Lorna Flamer-Caldera, DDS, FAGD, FACD

Periodontal care is a mainstay of the general likely to produce a favorable outcome. As clinicians, we can decide to repeat
dental practice. Each new patient receives a Phase I treatment, change the adjunctive
“workup” – basic assessments and hygiene The microbiology of periodontal disease therapies such as oral rinses that provide
care. It is expected that they will comply became known in the 1800s through Ameri- chemical support, or refer to a specialist.
with homecare instructions and adhere to a can microbiologist W.D Miller and German Ideally, we aim to avoid clinical failure and
recall schedule. Of course, there are some dentist Adolph Witzel. For many decades prevent advancement to Phase II surgical
3
instances, where the degree of care needed dentistry promulgated Miller’s non-specif- therapy. 7
is best addressed by referral to a periodon- ic plaque hypothesis of oral disease arising
tist. The expected outcome for those who from the normal oral flora. Current adher- Case selection for oral microbiology sam-
remain in the practice is improvement in ence to the ecological plaque hypothesis pling is based on evaluating for signs of
periodontal status, reduction in inflamma- and more recent keystone-pathogen hy- active disease after all appropriate thera-
tion, and an improved clinical appearance. pothesis has placed consideration of the pies have been applied. Measurable and
Generally, these patients fall within the microbial nature of periodontal disease at non-measurable indicators of alteration in
American Association of Periodontology the forefront of treatment. 4,5 the oral flora and periodontal complex have
(AAP) case Type I, II, and, with caution, already been noted, such as radiographic
Type III. This outcome expectation sup- Therefore, the standard for treatment suc- osseous changes, bleeding, plaque index,
ports the general dentist’s decision that the cess should reflect a microbial distinction. tissue tone and consistency, mouth odor,
patient’s periodontal needs are within the Improvements in clinical assessments al- and pocket depths. Patients who exhibit
scope of care of their practice. But some ways reflect a change in the oral microflora. persistent low level inflammation, con-
patients don’t respond well over time and Clinical assessment improvements reflect tinued bone loss, and prolonged bleeding
their oral health status continues to indicate microbial changes. upon probing, are candidates for bacterial
active disease, when viewed according to culture and antibiotic susceptibility testing.
the determinants of periodontal status such With our standard procedure for establish- It at this point that OMT proves its benefits
as pocket depths, bleeding and tissue tone. ing periodontal status, we can assess and in advancing patients to health.
What has been missed? The answer can diagnose our patient to identify the thera-
lie within the microbiology of the patient’s peutic treatment we will prescribe. In addi- What OMT provides in these situations is
periodontium. tion to medical history, we use established both an unprecedented level of specificity
assessment markers such as pocket depth, about the periodontal microflora of each
Developments in Oral Microbiology bleeding (in all its parameters), tissue ede- patient and the antibiotic sensitivity profile
Testing (OMT) have made it possible to ma, sulcular exudate, oral habits, plaque that enables us to prescribe appropriately.
achieve highly beneficial outcomes for index, occlusion, and presence of caries When antibiotic therapy is utilized without
stubborn periodontal types and to con- to arrive at a treatment plan that we hope the benefit of OMT, it risks being imprecise
firm the presence of pathogens in early offers a predictable outcome. That plan and, thus, impotent. Knowing exactly
6
periodontal cases where few determinant routinely includes in-office and at-home which pathogenic bacteria are causing the
markers of disease are evident. Since the components designed to synergistically re- condition allows us to treat in an effective
1
Centers for Disease Control and Prevention solve the periodontal assessment concerns. and lasting way.
have determined that the incidence of adult At the end of Phase I therapy, we reassess
periodontitis in the United States is higher to determine the degree to which the condi- Periodontal infection is not a surface dis-
than 47%, the ability to change the course tion has been resolved. This re-evaluation ease and its proper management lies in
of disease development by identifying the process can range from simple for cases of treatment that goes beyond surface repair.
early culprits in oral microflora changes is gingivitis to complex for cases of periodon- One should not overlook or forget the ef-
significant. A fair number of people with tal disease. Both would include evaluation fect of microbial penetration of tissue at the
2
periodontally involved dentitions will not for complete mechanical debridement of site. While it is appropriate for treatment
8
seek dental care and will not understand the root surfaces (and its inherent disruption of goals to involve halting the progression of
disease process beyond the risk of pain or biofilm) along with the “hope” that the mi- disease, they should also clearly address
eventual tooth loss. For this group, an op- crobial ecology of disease has been elim- the restoration of normal oral microflora.
portunity to discuss the systemic impact of inated. But too often we find that despite The ultimate goal of antimicrobial therapy
periodontal disease will not present itself. our best clinical efforts and the patient’s is to change, on a sustained basis, the mi-
But for those who do seek care, we should diligent implementation of homecare rec- crobiological profile of subgingival biofilm
look to provide service which results in ommendations, the expected reduction of to one which is found in periodontal health.
long-term success. By being able to iden- bleeding and periodontal pocket depth has
tify the specific microflora, we can provide not occurred. Another important reason a sustained
a clear direction for treatment that is more solution is desirable arises from the

www.nysagd.org l Fall 2017 l GP 23