by Thomas W. Nabors, DDS, FACD
I. Introduction:
The American College of Physicians recently published an article on the care of the chronically ill, and suggested the following: “Usual care is not doing the job; dozens of surveys and audits have revealed that sizable proportions of chronically ill patients are not receiving effective therapy ... and have poor disease control ...”
These statements “Usual care is not doing the job … patients are not receiving effective therapy and have poor disease control …” have significant meaning when we consider the incidence of periodontal disease in the population, and perhaps even in our patient bases. Data shows that periodontal disease is both underdiagnosed and undertreated in dental offices today.
Also, as more people choose dental implants to restore dental esthetics and function, post implant complications, such as peri-implant infections, are increasing. The significance of diagnosing and treating these infections is stressful for both the patient and clinician. And, when certain criteria are at play, the treatment success rate for failing implants is less than 50%.
Follow-up studies have shown that the prevalence of peri-implantitis currently ranges from 12% to 43% for most implant systems. Etiology and risk factors for this disease have been identified in experiments and clinical studies performed in recent years and examining implants over time. Not surprisingly, smoking is a major risk factor for peri-implantitis. However, it may surprise you that the same “high risk” bacteria that cause periodontitis are also considered to be “high risk” for implant failure.
Not surprisingly, however, is that molecular diagnostic methods from periodontology have been adapted and recommended to the implant setting. Literature reviews recommend the use of bacterial and genetic testing using saliva samples to determine potential microbial levels of risk prior to implant placement, as well as at the first sign of mucositis prior to bone loss around the implant. Even more effective is the practice of bacteria testing to determine bacterial loads and identification of specific high risk bacterial species as a prerequisite to the placement of dental implants. Thus, when “high-risk” species are discovered, appropriate treatment is rendered before the surgical procedure on implant placement.
As in the treatment of the chronically ill, “usual care for periodontal disease is not doing the job.” Effective therapy cannot be determined by just looking at clinical signs. The simple addition of a saliva rinse sample with the result report will define risk more completely for both periodontitis and peri-implantitis. Ideally, this biological approach can prevent early disease from becoming more serious disease.
II. The Medical Model
The Medical Model, by definition, “requires that the physician focus on the defect, or dysfunction, within the patient, using a problem-solving approach. The medical history, physical examination, and diagnostic tests provide the basis for the identification and treatment of a specific illness.” Modern medical examinations include both the clinical evaluation and appropriate lab tests. To put the value of lab tests in perspective, laboratory findings affect 60% to 70% of all clinical decisions in medicine. Both routine and advanced medical evaluations require specific laboratory information prior to a definitive diagnosis and treatment planning.
Clinical lab tests and lab values have become the cornerstone of the medical exam and record. They represent the majority of clinical data of each patient. Physicians rely heavily on this information and its interpretations to make critical decisions that govern patient diagnosis and treatment.
Clinical signs are by themselves too subjective for predictable treatment decision-making in both general medicine and oral medicine. Moving from “usual care” to state-of-the-art requires knowledge of the patient on a personal basis — biological information attainable only from saliva. Applying the medical model to oral medicine requires tests that target diseases, and new technology to accurately deliver information that personalizes each disease. Saliva provides that information, and the clinical lab science provides the new technology to achieve new goals for redefining periodontitis and peri-implant disease.
With the development of molecular genetics technology, dentists can take a saliva sample, send it to a lab, and receive an accurate report of both the bacterial burden as well as specific genetic susceptibility traits. This information adds great insight into risk assessment, etiology of disease, and genetic traits of each patient. Thus, the general practitioner and team now have the ability to prevent periodontitis, detect disease at the earliest moment, make sure that the oral environment is healthy prior to implant surgery, and make important treatment decisions on an individual basis.
Just as general medicine uses lab tests for clinical decisions, the practice of oral medicine requires the same degree of specificity and dedication to health. “Usual care” has served us for approximately 60 years, but it does not satisfy those that are receiving poor disease control. Saliva and the laboratory results provide a degree of accuracy and treatment success in a predictable manner in today’s modern dental practice. The medical model has arrived for oral medicine.
III. Saliva And The Medical Model
In 2008, The American Dental Association Council on Scientific Affairs stated: “Saliva has long been considered a ‘mirror of the body’ that generally reflects the state of a patient’s overall health.” Saliva has multiple resources that can reflect health and disease.
The following points were identified from the ADA statement for the clinical application of saliva as an important analyte for the everyday use in the modern dental practice.
- The Council recognizes the importance of oral fluid diagnostics, and welcomes the development of tests that provide accurate measurements of clinically validated biomarkers.
- A wide range of systemic diseases have oral manifestations that dentists encounter in patients at various stages of development.
- Oral samples are readily accessible as whole saliva or by sampling secretions from specific glands, mucosal tansudate, or gingival crevicular fluid.
- Sampling oral fluids provides an attractive medium for detecting a range of candidate biomarkers such as proteins, electrolytes, hormones, antibodies, and DNA/RNA.
Today, saliva tests achieve many of these goals as set forth by the ADA. Important information obtained through a lab report from a saliva sample includes:
- Specific oral pathogens that are well documented to be causative agents of periodontal diseases and peri-implant diseases.
- Specific genetic traits that increase risk for more severe implant and teeth infections.
- Specific types of the human papilloma virus (HPV) that increase risk for orapharyngeal cancer.
IV. Saliva And Lab Reports
As with other body fluids, saliva is setting new goals and standards in evidence-based medicine by the very nature of the information that it contains. Multiple blind studies clearly show the value of targeting specific pathogens found in the unique “DNA fingerprint” of each patient. When lab reports are used, those pathogens that present risk can be targeted with appropriate therapy. When reduced or eliminated, the patient’s health responds more favorably and for longer periods of time than with “usual care.” Studies clearly show that patients that achieve the most effective therapy are those that present with a strikingly reduced pathogen burden or eliminated pathogens after therapy. These positive clinical values of absence of bleeding, reduced pocket depth, and remodeled anatomy help patients remain healthier for longer periods of time.
V. Saliva Testing And Therapy
Without saliva testing, patients receive basically “usual care” with typically unpredictable results.
With saliva testing, etiology is defined, risk for more progressive disease is defined, and treatment can be tailored for each specific need. Treatment may require biofilm removal, local antiseptics, site-specific antibiotics, host modifying meds, and systemic antimicrobials. Rather than guess as in the case of “usual care,” saliva testing helps doctors make these important decisions. When needed, the specific antibiotic can be suggested based on the type of infection, the virulence of the infection, and the duration that is published in numerous studies. Double-blinded placebo-based studies have clearly shown that systemic antibiotics are very helpful in these biofilm infections. However, the clinician must use them appropriately and responsibly. Furthermore, using the same antibiotic for each patient with periodontitis or implant disease is not appropriate based on multiple studies. Saliva test results will recognize the need for more specific prescription needs.
With saliva tests, a “third, nonbiased” party exists — the clinical lab. The lab informs the clinician and patient of the risk for progressive disease, bone loss, implant loss, and more. Thus, the test becomes the instrument that defines risk and disease. As in general medicine, the clinical exam is also used in conjunction with the lab tests appropriate for each patient. But it is the test that moves both the doctor and patient into appropriate action.
IV: Conclusions
Saliva testing has become an important asset in oral medicine. Diagnosis and disease management of both periodontitis and peri-implant diseases are important issues. The ability to determine those at risk for bone loss before it occurs, the ability to effectively treat early diseases, and the ability to know when comanagement of disease is needed are being defined by salivary diagnostics. It is truly revolutionizing oral medicine and the treatment needs for these two diseases.
Thomas W. Nabors, DDS, FACD, is a frequent lecturer for both dental and medical groups on the subject of molecular genetics in the field of oral medicine. He has published numerous articles in a variety of peer reviewed publications. He is a Life Member of the American Dental Association, an associate member of the AAP, a Fellow of the American College of Dentists, and a member of the Pierre Fauchard Honorary Society. He can be reached at [email protected].
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