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31 Jul 2017 | Australasian Dental Practice

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New tool for microbial analysis of periodontitis and peri-implantitis

A great number of periodontal disease cases can be treated and maintained under control for many years by dental professionals through traditional mechanical methods, such as radicular surfacing along with good oral hygiene regime and in some cases, antibiotics. The choice of the therapy depends on the composition of the sub-gingival microflora.


However, in the presence of aggressive, anaerobic pathogenic bacteria, these methods are not enough to eliminate them from the sulcus. Consequently, some bacterial strains are responsible for fast decomposition of alveolar bone. In these circumstances, personalised antibiotic therapy can be prescribed following bacterial identification using a new diagnostic test - Perio-Analyse® - in combination with meticulous cleaning of the pockets. Certain aggressive, anaerobic pathogenic bacteria are intracellular and require surgical removal of contaminated soft and /or hard tissue, along with specific antibiotics.

Two particular pathogenic bacteria strains known to be high risk for rapid bone destruction and that need specific treatment are Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis (if present at a certain quantity).

Aggregatibacter actinomycetemcomitans

A.a is sensitive to new Quinolone, Penicillin and Tetracycline, but is practically insensitive to Metronidazol. There is a strong relation with youthful periodontitis (very high). Bone lost could be more than 3 mm in 2 months with only 105 bacteria into the pocket (Haffajee 1994). Antibiotics are always necessary and gingiplasty could be recommended in some cases to eliminate soft tissue. Aggregatibacter actinomycetemcomitans is also transmissible between parents and children.

Porphyromonas gingivalis (if present at a certain quantity)

P.g. is sensitive to Tetracycline and Penicillin. Bone lost could be more than 2mm in 2 months with only 105 bacteria in the pocket (Haffajee 1994). Pg is transmissible between parents and children and between partners.

Periodontal disease antibiotic therapy is recommended with a microbiological analysis1,2 to identify and quantify the exact bacteria present in the sulcus and decide the efficient antibiotic, reduce antibiotic resistance and prevent treatment failure.

The success of the long-term treatment is assured only if the patient practices good oral hygiene and follows a monitoring program with regular Perio-Analyse® controls, facilitated by the dental professional.

There is a strong need for dental professionals to be involved in monitoring and maintaining good oral hygiene practices of patients requiring dental implants. During the last decade, dental implants have become an alternative treatment to removable prostheses. However, patients suffering from periodontal disease are at risk of new bacterial infections, such as peri-implantitis, around the dental implants, potentially reducing the life cycle3 of the implant. Peri-implantitis (osseous loss is ≥1.8 mm after one year and associated with bleeding and/or a suppuration) occurs in around 16% of patients and around 6.6% of implants.4,5

The microbial colonisation associated with peri-implantitis is like bacteria identified in periodontal disease,6-11 however high levels of some bacteria seems more associated with peri-implantitis.11,12

Periodontal disease bacterial translocation could be highlighted as the source of peri-implantitis. Indeed, gingival pockets of adjacent teeth, as well as surrounding soft tissue, such as the back of the tongue and mucous membranes are bacterial tanks able to provide bacterial sources that can colonize the dental implant surface.

Antecedents of periodontal diseases must be regarded as a risk factor11,13-16 and patients presenting with untreated or refractory periodontal disease present an increasing risk of complications.

Moreover, some fungus, like Candida albicans, have been recovered from periodontal pockets in 7.1 to 19.6% of patients with chronic periodontal disease17 and are a cause of resistance to treatment. Candida albicans has also been isolated from periodontal pockets in HIV-positive and diabetic patients. Candida albicans can also be associated with peri-implantitis infections.18,19 Candida albicans yeast is a regular inhabitant of human mucosal surfaces and a part of its microbiota. Oral mucosal surfaces are the primary oral reservoirs of these yeasts, followed by removal of both supra and subgingival biofilm. Antibiotics are not efficient against fungus and local treatment needs to be proposed. Antifungal treatment could be Nystatin, Amphothericin, Miconazol or Fluconazole, having local effects.

Considering the difficulties of decontamination related to the design of the implants, which aim to optimise bone-integration, a preventive approach, together with specific brushes and strict maintenance protocols, is far more effective.

Mucositis systematically makes the bed of periodontal infection whereas the passage of the gingivitis to periodontal disease is not in all clinical cases.

Patients having periodontal disease treatment history and smokers appear more likely to develop peri-implantitis.

Dental professionals must be conscious of the risks of contamination pre-operative and post-operative and should be able to anticipate the late infectious risk to limit the risk of implant infection and failure.

It is considered important in daily clinical practice to evaluate the biological risk before placing the implants, and supervising the patients after treatment to detect early signs of peri-implantitis infection. The early detection of signs of bacterial risk, the reinforcement of measurements of oral hygiene and the treatments will be able to reduce the bacterial loads and prevent peri-implantitis.

Objectives and Technical recommendations

It is advised to carry out an analysis in the following situations:

  • Patient with periodontal disease risk or gingivitis;
  • Patients who smoke;
  • Diabetic patients;
  • Periodontal disease with pocket depths > 4mm (despite very good oral hygiene);
  • Aggressive or progressive periodontal disease;
  • Refractory periodontal disease resistant to therapy;
  • Periodontal disease evolving/moving quickly;
  • Peri-implantitis risk patient;
  • 3 months after periodontal treatment start date; and
  • Every 6 months for high risk patients.

The objectives of the analysis:

  • Choice of a suitable antibiotic and treatment in relation with bacterial strain identity;
  • Follow-up of treatment and evaluation success or failure;
  • Early detection of secondary infection; and
  • Motivation of patient to maintain their treatment and their oral hygiene in the long run.

Pathogenic threshold

Periodontal pathogens are presented schematically within microbiological complexes (Socransky et al., 1998) with different colours as shown in Table 1.



Table 1. Periodontal pathogens presented schematically within microbiological complexes


Complex of Socransky Bacteria strains Abbreviation Threshold*

Aa Aggregatibacter actinomycetemcomitans Aa >103 CFU

Red complex Porphymonas gingivalis
Tannerella forsythensis
Treponema denticola
Pg
Tf
Td
>105 CFU
>105 CFU
>105 CFU

Orange complex Prevotella intermedia
Peptostreptococcus micro
Pi
Pm
>105 CFU
>106 CFU

Complex Orange Associated Campylobacter rectus Cr >106 CFU

* Threshold of pathogenicity requiring the use of a antibiotic adapted in addition to one mechanical action.


The PCR microbiological analysis gives a value of quantification (equivalent CFU by sample) of each periodontopathogen as well as the percentage of each bacterial type compared to the total flora.

Using Perio-Analyse

Institut Clinident's Perio-Analyse test identifies and quantifies periodontal-pathogenic species by real-time PCR based on microbial DNA extracted from a paper point inserted into the patient's sulcus by the treating clinician. Perio-Analyse Platinum Test quantifies the presence of Aggregatibacter actinomycetemcomitans; Candida Albicans; Porphyromonas gingivalis; Tannerella forsythensis; Treponema denticola; Prevotella intermedia; Pepostreptococcus micros; Fusobacterium nucleatum; Campilobacter rectus; and Eikenella corrodens as well as total flora.

References

  1. Antimicrobial susceptibility variation of 50 anaerobic periopathogens in aggressive periodontitis: an interindividual variability study. Lakhssassi N1, Elhajoui N, Lodter JP, Pineill JL, Sixou M. Oral Microbiol Immunol. 2005 Aug.
  2. Efficient antimicrobial treatment in periodontal maintenance care. Slots J, Jorgensen MG. J Am Dent Assoc. 2000 Sep.
  3. Long time follow up of implant therapy and treatment of peri-implantitis. Roos-Jansåker AM. Swed Dent J Suppl. 2007.
  4. Nine- to 14-year follow-up of implant treatment. Part III: factors associated with peri-implant lesions. Roos-Jansåker AM, Renvert H, Lindahl C, Renvert S. J Clin Periodontol. 2006 Apr.
  5. Prevalence progressive bone loss at implants. Fransson C, Lekholm U, Jemt T, Berglundh T. Clin Oral Implants Res. 2005.
  6. Microbiota around root-form endosseous implants: a review of the literature. Heydenrijk K1, Meijer HJ, van der Reijden WA, Raghoebar GM, Vissink A, Stegenga B. Int J Oral Maxillofac Implants. 2002 Nov-Dec.
  7. Subgingival microbiome in patients with healthy and ailing dental implants. Zheng H, Xu L, Wang Z, Li L, Zhang J, Zhang Q, Chen T, Lin J, Chen F. Sci Rep. 2015 Jun 16;5:10948.
  8. Clinical and microbiological determinants of ailing dental implants. Tabanella G, Nowzari H, Slots J. Clin Implant Dent Relat Res. 2009 Mar;11(1):24-3.
  9. Bacterial colonization of oral implants from nondental sources. Emrani J, Chee W, Slots J. Clin Implant Dent Relat Res. 2009 Jun;11(2):106-12.
  10. Microbial aspects of failing osseointegrated dental implants in humans. Alcoforado GA, Rams TE, Feik D, Slots J. J Parodontol. 1991 Feb;10(1):11-8.
  11. Periodontal and peri-implant microbiota in patient with healthy and inflamed periodontal and peri-implant tissue. Zhuang LF, Watt RM, Mattheos N, Si MS, Lai HC, Lang NP. Clin Oral Implants Res. 2014 Nov 14.
  12. Clinical and microbiological findings in patients with peri-implantitis: a cross-sectional study. Canullo L, Peñarrocha-Oltra D, Covani U, Botticelli D, Serino G, Penarrocha M. Clin Oral Implants Res. 2015 Jan 26.
  13. Peri-implant disease in subjects with and without preventive maintenance: a 5-year follow-up. Costa FO1, Takenaka-Martinez S, Cota LO, Ferreira SD, Silva GL, Costa JE. J Clin Periodontol. 2012 Feb;39(2):173-81.
  14. Cross-sectional study on the prevalence and risk indicators of peri-implant diseases. Konstantinidis IK, Kotsakis GA, Gerdes S, Walter MH. Eur J Oral Implantol. 2015.
  15. Prevalence and Possible Risk Factors of Peri-implantitis: A Concept Review. Marcantonio C, Nicoli LG, Junior EM, Zandim-Barcelos DL. J Contemp Dent Pract. 2015 Sep.
  16. Implant therapy in partially edentulous, periodontally compromised patients: a review. Van der Weijden GA, van Bemmel KM, Renvert S. J Clin Periodontol. 2005 May.
  17. Candida spp. in periodontal disease: a brief review. Sardi JC, Duque C, Mariano FS, Peixoto IT, Höfling JF, Gonçalves RB. J Oral Sci. 2010 Jun.
  18. Microbial aspects of failing osseointegrated dental implants in humans. Alcoforado GA, Rams TE, Feik D, Slots J. J Parodontol. 1991 Feb.
  19. Microbial findings at failing implants. Leonhardt A, Renvert S, Dahlén G. Clin Oral Implants Res. 1999 Oct.

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