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Refractory Patients and DNA Bacteriologic Analysis

How may times have you seen a patient who simply never appears periodontally healthy in spite of all your efforts?  It’s far too easy to just dismiss this type of patient by rationalizing that this is simply their normal appearance.   After all, that is how they always appear: boggy, edematous gingiva with a reddish hue, generalized light to moderate bleeding upon probing, and pockets in the 4-7 mm range.  You may have root planed them quadrant by quadrant, tried some antibiotic therapy, put them on a chlorhexidine rinse, and had them return every three months for a prophylaxis.  Yet in spite of those efforts, they still appear unhealthy.   Welcome to the world of the refractory patient.   

The term, defined in the AAP’s “Parameter on Refractory Periodontitis,” published in The Journal of Periodontology May Supplement 2000 (Volume 71, No. 71), “refers to destructive periodontal diseases in patients who, when longitudinally monitored, demonstrate additional attachment loss at one or more sites, despite well-executed therapeutic and patient efforts to stop the progression of disease. These diseases may occur in situations where conventional therapy has failed to eliminate microbial reservoirs of infection, or has resulted in the emergence or superinfection of opportunistic pathogens. They may also occur as the result of a complexity of unknown factors which may compromise the host's response to conventional periodontal therapy.”

When faced with a patient like this I always “exit” them from my standard, three month alternating supportive periodontal maintenance regimen.  Their prior periodontal care is critically reviewed.

First, are there identifiable systemic conditions that may increase their susceptibility to periodontal infections such as allergies, diabetes mellitus, immunosuppressive disorders, certain blood dyscrasias, hormonal imbalances, pregnancy or stress?  If so, are they being properly addressed?  If the patient has not been diagnosed previously with a systemic concern,  at this point consultation with an appropriate physician is advisable.  This is an instance when dental professionals can be the first to uncover an underlying medical problem.

Next, I rule out localized areas of rapid attachment loss, which are related to factors such as root fracture, retrograde pulpal diseases, foreign body impaction, and various root anomalies. These types of problems are site-specific and although they need correction, they do not fall within the scope of the refractory patient.

Finally, I look for evidence of incomplete or inadequate conventional therapy. Have we in some way failed to fully debride this patient? If so, I will perform another extremely definitive round of root planing, often with the aid of our Perioscope (the dental endoscope described in our last news letter).  At this stage, additionally I employ  bacteriologic testing. 

The DNA probe test is an excellent method for identifying known periodontal pathogenic bacteria.  The test identifies the presence and concentrations of the eight most notorious periodontally destructive bacteria; Porphyromonas gingivalis, Prevotella intermedia, Bacteroides forcythus, Fusobacterium nucleatum, Eikenella corrodens, Campylobacter rectus, Treponema denticola, and Actinobacillus actinomycetumcomitans. The test relies on a pooled sample taken from various teeth you select. Proper site selection is critical for accurate test results.  A paper point is inserted into the pocket for 15 seconds.  Care is taken so that the paper point does not contact any other surfaces harboring bacteria to guard against contamination. The paper points are inserted into a vial, which is identified with a bar-coded label.  The laboratory slip has the same bar code on it for proper specimen identification.  Sample sites are listed on the lab slip and the test is packaged, and then mailed to the laboratory.

The lab procedures identify the species specific DNA from the dead bacteria on the paper points.  About two weeks later, a report is sent by mail that documents the specific bacteria present in the sample and their approximate concentrations.  I use this information to determine which antibiotic regimen would be most effective.

After the root planing and antibiotic regimen are complete, I place the patient on an intensified maintenance schedule, which can vary in frequency but usually involves supportive periodontal maintenance every 6 to 8 weeks. I will often re-test the patient with another DNA probe test three months later to make sure the pathogens have been eradicated or significantly reduced.  The patient may then receive a long course of a collagenase inhibiting drug, such as Periostat.

My goal in treating patients with refractory periodontitis is simply to arrest or control the disease.  Remember, the refractory periodontitis patient has a complex disease state, which includes many factors that are still unidentified.  It may not be possible to fully arrest this disease process.  In some cases, only a slowing of the rate of attachment loss is seen.  However, for the patient interested in preserving their dentition for as long as possible, this is a very much-appreciated result. 

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