Dental Flossing and Interproximal Caries: a Systematic Review

Our aim was to assess, systematically, the effect of flossing on interproximal caries risk. Six trials involving 808 subjects, ages 4 to 13 years, were identified. There were significant study-to-study differences and a moderate to large potential for bias. Professional flossing performed on school days for 1.7 years on predominantly primary teeth in children was associated with a 40% caries risk reduction (relative risk, 0.60; 95% confidence interval, 0.48–0.76; p-value, < 0.001). Both three-monthly professional flossing for 3 years (relative risk, 0.93; 95% confidence interval, 0.73–1.19; p-value, 0.32) and self-performed flossing in young adolescents for 2 years (relative risk, 1.01; 95% confidence interval, 0.85–1.20; p-value, 0.93) did not reduce caries risk. No flossing trials in adults or under unsupervised conditions could be identified. Professional flossing in children with low fluoride exposures is highly effective in reducing interproximal caries risk. These findings should be extrapolated to more typical floss-users with care, since self-flossing has failed to show an effect.

The transmission of anaerobic periodontopathic organisms

The oral microbial flora is unique, and available evidence indicates that it is passed vertically from parents to children. In this investigation, we used a chairside assay for the N-benzoyl-DL-arginine-2-naphthylamide (BANA)-sensitive enzyme found in Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythensis, to determine the prevalence of these BANA-positive species in young children and their caregivers. We predicted that if the BANA enzyme was found in plaque samples of children, it would also be present in the plaque samples of the caregivers. Forty-four percent of 150 children had at least one plaque sample positive for the BANA enzyme. If the caregiver was BANA-positive, the odds of the child also being BANA-positive was 35 times more than for a child with a BANA-negative caregiver, after adjustment for the child's age and papillary bleeding score (PBS). Other significant predictors were the PBS of children (p < 0.001), a history of periodontal disease, and the ages of the caregivers (p < 0.001).

The Diagnosis of Periodontal Disease in Private Practice

BACKGROUND

Periodontal disease is an inflammatory reaction to the bacteria in dental plaque. The present study compared the prevalence of periodontal disease in patients using as a diagnostic either probing depth measurements, an inflammatory marker such as numbers of white blood cells in plaque samples, or microbiological markers such as the microscopic count and the benzoyl-DL-arginine naphthylamide (BANA) test.

METHODS

Teeth with the most inflammation and/or deepest pockets in each quadrant were probed and subgingival plaque was sampled from 1,043 consecutive new patients enrolled in a private practice. Multivariate "diagnostic" models were developed based upon the probing depth (general linear models), percentage of white blood cell-positive and percentage of BANA-positive plaques (logistic regression models) to determine the prevalence of patients with periodontal disease.

RESULTS

Plaque samples were removed from 3,694 sites. Fifty-two percent of sampled pockets were >4 mm; 49% of sites were inflamed, using the presence of white blood cells, and 28% were infected using the BANA test. Diagnostic models were highly significant at P<0.0001. The white blood cell model was the most parsimonious as demonstrated by the lowest Akaike information criteria statistic and had the highest receiver operator characteristic (ROC) curve relative to the probing depth and BANA models.

CONCLUSIONS

Periodontal disease can be diagnosed chairside by the presence of white blood cells in plaque samples, a finding that reflects the inflammatory nature of the disease process. This approach would reduce the misclassification of subjects as having periodontal disease (130 patients in the present study who had pockets) but minimal evidence of an inflammatory response.

Diversity of bacterial populations on the tongue dorsa of patients with halitosis and healthy patients

The primary purpose of the present study was to compare the microbial profiles of the tongue dorsa of healthy subjects and subjects with halitosis by using culture-independent molecular methods. Our overall goal was to determine the bacterial diversity on the surface of the tongue dorsum as part of our ongoing efforts to identify all cultivable and not-yet-cultivated species of the oral cavity. Tongue dorsum scrapings were analyzed from healthy subjects with no complaints of halitosis and subjects with halitosis, defined as an organoleptic score of 2 or more and volatile sulfur compound levels greater than 200 ppb. 16S rRNA genes from DNA isolated from tongue dorsum scrapings were amplified by PCR with universally conserved bacterial primers and cloned into Escherichia coli. Typically, 50 to 100 clones were analyzed from each subject. Fifty-one strains isolated from the tongue dorsa of healthy subjects were also analyzed. Partial sequences of approximately 500 bases of cloned inserts from the 16S rRNA genes of isolates were compared with sequences of known species or phylotypes to determine species identity or closest relatives. Nearly complete sequences of about 1,500 bases were obtained for potentially novel species or phylotypes. In an analysis of approximately 750 clones, 92 different bacterial species were identified. About half of the clones were identified as phylotypes, of which 29 were novel to the tongue microbiota. Fifty-one of the 92 species or phylotypes were detected in more than one subject. Those species most associated with healthy subjects were Streptococcus salivarius, Rothia mucilaginosa, and an uncharacterized species of Eubacterium (strain FTB41). Streptococcus salivarius was the predominant species in healthy subjects, as it represented 12 to 40% of the total clones analyzed from each healthy subject. Overall, the predominant microbiota on the tongue dorsa of healthy subjects was different from that on the tongue dorsa of subjects with halitosis. Those species most associated with halitosis were Atopobium parvulum, a phylotype (clone BS095) of Dialister, Eubacterium sulci, a phylotype (clone DR034) of the uncultivated phylum TM7, Solobacterium moorei, and a phylotype (clone BW009) of STREPTOCOCCUS: On the basis of our ongoing efforts to obtain full 16S rRNA sequences for all cultivable and not-yet-cultivated species that colonize the oral cavity, there are now over 600 species.

Periodontal disease as a specific, albeit chronic, infection: diagnosis and treatment

Periodontal disease is perhaps the most common chronic infection in adults. Evidence has been accumulating for the past 30 years which indicates that almost all forms of periodontal disease are chronic but specific bacterial infections due to the overgrowth in the dental plaque of a finite number of mostly anaerobic species such as Porphyromonas gingivalis, Bacteroides forsythus, and Treponema denticola. The success of traditional debridement procedures and/or antimicrobial agents in improving periodontal health can be associated with the reduction in levels of these anaerobes in the dental plaque. These findings suggest that patients and clinicians have a choice in the treatment of this overgrowth, either a debridement and surgery approach or a debridement and antimicrobial treatment approach. However, the antimicrobial approach, while supported by a wealth of scientific evidence, goes contrary to centuries of dental teaching that states that periodontal disease results from a "dirty mouth." If periodontal disease is demonstrated to be a risk factor for cardiovascular disease and stroke, it will be a modifiable risk factor since periodontal disease can be prevented and treated. Since the antimicrobial approach may be as effective as a surgical approach in the restoration and maintenance of a periodontally healthy dentition, this would give a cardiac or stroke patient and his or her physician a choice in the implementation of treatment seeking to improve the patient's periodontal condition so as to reduce and/or delay future cardiovascular events.

Aspiration pneumonia: dental and oral risk factors in an older veteran population

OBJECTIVES

To investigate the importance of medical and dental factors in aspiration pneumonia in an older veteran population.

DESIGN

Prospective enrollment of subjects with retrospective analysis of data.

SETTING

Department of Veterans Affairs outpatient clinic, inpatient ward, and nursing home.

PARTICIPANTS

358 veterans age 55 and older; 50 subjects with aspiration pneumonia.

MEASUREMENTS

Demographic and medical data; functional status; health-related behaviors; dental care utilization; personal oral hygiene; comprehensive dental examination; salivary assays including IgA antibodies; and cultures of saliva, throat, and dental plaques.

RESULTS

Two logistic regression models produced estimates of significant risk factors. One model using dentate patients included: requiring help with feeding (odds ratio (OR) = 13.9), chronic obstructive pulmonary disease (COPD) (OR = 4.7), diabetes mellitus (OR = 3.5), number of decayed teeth (OR = 1.2), number of functional dental units (OR = 1.2), presence of important organisms for decay, Streptococcus sobrinus in saliva (OR = 6.2), and periodontal disease, Porphyromonous gingivalis in dental plaque (OR = 4.2), and Staphylococcus aureus presence in saliva (OR = 7.4). The second model, containing both dentate and edentulous patients included: requiring help with feeding (OR = 4.7), COPD (OR = 2.5), diabetes mellitus (OR = 1.7), and presence of S. aureus in saliva (OR = 8.3).

CONCLUSION

This study supports the significance of oral and dental factors while controlling for established medical risk factors in aspiration pneumonia incidence.

Impact of oral diseases on systemic health in the elderly: diabetes mellitus and aspiration pneumonia

Evidence is increasing that oral health has important impacts on systemic health. This paper presents data from the third National Health and Nutrition Examination Survey (NHANES III) describing the prevalence of dental caries and periodontal diseases in the older adult population. It then evaluates published reports and presents data from clinical and epidemiologic studies on relationships among oral health status, chronic oral infections (of which caries and periodontitis predominate), and certain systemic diseases, specifically focusing on type 2 diabetes and aspiration pneumonia. Both of these diseases increase in occurrence and impact in older age groups. The NHANES III data demonstrate that dental caries and periodontal diseases occur with substantial frequency and represent a burden of unmet treatment need in older adults. Our review found clinical and epidemiologic evidence to support considering periodontal infection a risk factor for poor glycemic control in type 2 diabetes; however, there is limited representation of older adults in reports of this relationship. For aspiration pneumonia, several lines of evidence support oral health status as an important etiologic factor. Additional clinical studies designed specifically to evaluate the effects of treating periodontal infection on glycemic control and improving oral health status in reducing the risk of aspiration pneumonia are warranted. Although further establishing causal relationships among a set of increasingly more frequently demonstrated associations is indicated, there is evidence to support recommending oral care regimens in protocols for managing type 2 diabetes and preventing aspiration pneumonia.

Minor salivary gland secretion in the elderly

OBJECTIVE

Very little information exists on minor salivary gland output (MSGO) in health and disease. We investigated the minor salivary gland output of elderly subjects with different medical backgrounds and the relationship of that output with life practices, demographic variables, complaints of dry mouth, medication usage, functional status, medical treatments, and dental and medical variables.

STUDY DESIGN

MSGO was measured with a special moisture-detecting paper on the lip, cheek, and palate, which comprised the total MSGO. A parsimonious linear regression model was developed to determine which of the many measured variables influenced the MSGO.

RESULTS

There were significant differences in MSGO between the recruitment sites, with the non-Veteran Affairs (VA) Independent Living participants having significantly lower MSGO than the VA groups. A secretion rate for MSGO based on median values from all subjects of <4.6 microL/min was categorized as being low, whereas a secretion rate for MSGO >/=4.6 microL/min was categorized as high. A regression model was used to examine variables that could be associated with MSGO variability. The results show that being older, a woman, a current smoker, and having a complaint of dry mouth were associated with lower MSGO rates.

CONCLUSIONS

An association between subjective complaints of dry mouth and a decrease in MSGO measured objectively was demonstrated in this elderly population. Furthermore, age and sex effects on MSGO were also demonstrated.

Periodontal disease: link to cardiovascular disease

Poor oral hygiene that leads to dental infections could contribute to adverse medical outcomes such as cardiovascular disease. Twelve studies of varying degrees of design rigor have associated dental conditions, such as periodontal disease, missing teeth, and edentulousness, with either coronary heart disease or a cerebral vascular accident. Six of the studies were longitudinal so that the demonstration of the oral health parameters as significant predictors of the cardiovascular event would elevate the dental parameter to the status of a risk factor. Because dental diseases (especially periodontal disease) are treatable, the dental component is a modifiable risk factor; therefore, maintaining good oral health should receive the highest priority for a healthy life.

The antimicrobial treatment of periodontal disease: changing the treatment paradigm

Over the last 100 years, methods of surgical periodontal treatment have enjoyed a history of success in improving oral health. The paradigm of care is based on the "non-specific plaque hypothesis"--that is, the overgrowth of bacterial plaques cause periodontal disease, and the suppression of this overgrowth reduces disease risk. The central feature of this approach to care is the removal of inflamed gingival tissue around the teeth to reduce periodontal pocket depth, thereby facilitating plaque removal by the dentist and by the patient at home. Over the last 30 years, with the recognition that periodontal disease(s) is caused by specific bacteria and that specific antimicrobial agents can reduce or eliminate the infection, a second paradigm has developed. This new paradigm, the "specific plaque hypothesis", focuses on reducing the specific bacteria that cause periodontal attachment loss. The contrast between the two paradigms can be succinctly stated as follows: The antimicrobial therapy reduces the cause, while the surgical therapy reduces the result of the periodontal infection. The specific plaque hypothesis has two important implications. First, with the increasing attention to evidence-based models for prevention, treatment, outcome assessment, and reimbursement of care, increasing attention and financial effort will be channeled into effective preventive and treatment methods. Second, the recent observations that periodontal infections increase the risk of specific systemic health problems, such as cardiovascular disease, argue for the prevention and elimination of these periodontal infections. This review highlights some of the evidence for the specific plaque hypothesis, and the questions that should be addressed if antimicrobial agents are to be used responsively and effectively.

The prevalence of BANA-hydrolyzing periodontopathic bacteria in smokers

Smoking has been identified as a risk factor for development of periodontal disease and a strong indicator for treatment failure in periodontal patients. This study examined 172 patients categorized as current smokers (n=55), previous smokers (n=38) or individuals that had never smoked (n=79). A total of 670 interproximal plaques collected with a wooden toothpick were analyzed for hydrolysis of the synthetic trypsin substrate benzoyl-DL-arginine naphthylamide (BANA). About 95% of the BANA hydrolysis by plaque is due to the presence of one or more of the periodontopathogens, P. gingivalis, T. denticola or B. forsythus. Gingival health was measured using the papillary bleeding score (PBS). Current smokers had less gingival bleeding than previous smokers or those who had never smoked (20% versus 41% and 25%, respectively). Plaque removed from non-bleeding sites in current smokers were 11x more likely to have a positive BANA reaction when compared to plaque removed from non-bleeding sites in individuals who never smoked. A significant positive relationship exists between smoking and colonization by the BANA periodontopathogens. Smoking may select for these periodontopathic species in the plaque and may be one reason why smoking is a risk factor in periodontal disease development.

Factors which are associated with dental decay in the older individual

OBJECTIVES

To improve reliability of salivary bacterial cultures as a surrogate for plaque levels of cariogenic bacterial species by reporting the salivary CFUs of these organisms as a function of the number of teeth.

DESIGN

Cross-sectional collection of data in a convenience sample of adults over 60 years of age.

SETTING

Hospital Dental clinic, University bacteriology laboratory.

SUBJECTS

523 older dentate subjects, average age 70, including 412 subjects who were in an independent living status and 111 in a dependent-living situation.

MAIN OUTCOME MEASURES

Subjects were examined for decay and the presence of salivary factors including the levels of S. mutans, lactobacilli, yeast and other bacteria. The salivary levels of the bacteria were adjusted for the number of teeth in the mouth, and the resultant values were entered into multivariable logistic regression models along with clinical and other salivary parameters.

RESULTS

Mutans streptococci levels reported as CFUs/ml saliva per tooth were significantly associated with coronal surface decay, and lactobacilli, reported in a similar way, were significantly associated with root surface decay. Salivary levels of yeasts, which had previously been associated with decay in this population, were no longer significant using this construct.

CONCLUSIONS

This construct of reporting salivary bacteriological data as a function of tooth number and per ml saliva could improve the reliability of bacteriological data obtained in epidemiological studies investigating the role of bacteria in dental decay in the elderly.

Effect of chlorhexidine varnish mouthguards on the levels of selected oral microorganisms in pediatric patients

PURPOSE

The effect of a chlorhexidine varnish delivery system on the levels of selected oral microorganisms was evaluated in caries active pediatric patients, ages 4 to 12 years old.

METHODS

Forty-six patients were enrolled into the study when they had multiple carious surfaces and salivary mutans streptococci (MS) levels higher than 10(4) colony forming units (CFUs) per milliliter. This study incorporated a double-blind design and patients were randomly assigned to either the chlorhexidine treatment group or the placebo group. Complete-arch, vacuum-adapted mouthguards (0.02 in. polypropylene coping material) were custom fabricated and coated internally with either a 3.0% chlorhexidine varnish or a placebo varnish. Two pretreatment paraffin-stimulated saliva samples were obtained for culturing prior to varnish treatment. Saliva samples were also obtained immediately after treatment and once a month for up to three months after wearing the mouthguard appliances. Dental restorations were placed at most of these saliva collection visits. Mouthguards were reportedly worn for an average of 9.7 hours per night for approximately seven nights by 40 subjects (87%).

RESULTS

After two months, and after three months, there was a significant reduction in MS levels immediately after the chlorhexidine varnish treatment. Total anaerobic and total facultative bacteria levels were not significantly affected.

CONCLUSION

One week of nightly use of the chlorhexidine varnish mouthguard system is effective at reducing the number of MS in caries-active pediatric patients in the mixed and primary dentition for at least three months.

The effects of antimicrobial mouthrinses on oral malodor and their status relative to US Food and Drug Administration regulations

This study was undertaken to review the rationale behind the usage of antibacterial mouthrinses to control oral malodor and to evaluate the claims made for antibacterial mouthrinses against the statements of US Food and Drug Administration regulations. The literature from 1960 to August 1997, found in a MEDLINE search on oral malodor, halitosis, and tongue microbiology, was examined. Clinical trials that were double blind and had selected subjects who exhibited a detectable level of oral malodor were evaluated. Individuals who experience oral malodor resulting from the overgrowth of proteolytic, anaerobic bacteria on their tongue surfaces can be successfully treated by a regimen that includes tongue brushing and toothbrushing, often in combination with use of a mouthrinse containing an antibacterial agent. Several candidate mouthrinses containing essential oils, zinc chloride, or an oil-water-cetylpyridinium chloride mouthrinse have reduced the organoleptic scores of individuals with moderate levels of oral malodor in the absence of tongue brushing. Very little long-term data beyond 6 weeks of usage are available. These mouthrinses should be marketed as oral deodorants that are analogous in purpose to the usage of deodorant soaps to control and/or eliminate body malodors.

Anaerobic Periodontal Infections as Risk Factors for Medical Diseases

Advanced forms of periodontal disease are associated with the overgrowth of a limited number of gram-negative anaerobic species in plaques found in periodontal pockets. Double-blind clinical trials of metronidazole and doxycycline, combined with debriding of the tooth surfaces, have significantly reduced the need for periodontal surgery. Epidemiologic studies have indicated that untreated periodontal disease could be a risk factor for preterm delivery of low birth weight infants, coronary heart disease, and cerebral vascular accidents. This is because gram-negative anaerobic species implicated in periodontal disease, eg, Bacteroides forsythus, Porphyromonas gingivalis, and Treponema denticola, could introduce lipopolysaccharides, heat-shock proteins, and proinflammatory cytokines into the blood stream. If periodontal disease is a risk factor for cardiovascular disease, then it is a modifiable risk factor, as periodontal disease is treatable.

Association of the oral flora with important medical diseases

Recently, there have been case-control and epidemiologic investigations that strongly associate poor dental health with cardiovascular disease, preterm low birth weight infants, and early death from any cause. In a 7-year prospective study, dental disease was a significant predictor of coronary events leading to death after controlling for known coronary disease risk factors. Missing teeth displaces smoking as a risk factor for ischemic heart disease in another study. Periodontal disease was seven times more likely to be associated with a preterm delivery of a low birth weight infant than mother's age, race, number of live births, and use of tobacco or alcohol. This review examines the role of asymptomatic bacteremia as possibly explaining these associations, focusing on the bacterial load on the teeth as mediated via oral hygiene.

The relationship between dental disease and cerebral vascular accident in elderly United States veterans

We report here information obtained from a cross-sectional study of 401 veterans, who were at least 60 years of age, which showed that several dental/oral conditions can be significantly associated with the diagnosis of a cerebral vascular accident (CVA), when included in a multivariate logistic regression model with and without many of the known risk factors for a CVA. The dental findings relative to the prevalence of dental caries and periodontal disease were not distinctly different between the subjects with and without a CVA in the bivariate analysis. A higher stimulated salivary flow was negatively associated with a CVA in the multivariate models. The plaque index and oral hygiene habits relating to brushing, flossing, and frequency of having teeth cleaned by a dentist/hygienist were significantly associated with a CVA in the bivariate analysis. Among these oral hygiene parameters, *needing help in brushing one's teeth" and the reported annual visit to the dentist/hygienist for teeth cleaning remained significant in the multivariate models involving the dependent-living subjects. The need for help in brushing one's teeth could reflect the fact that many subjects had reduced manual dexterity as a result of the CVA and required this extra care. However, the finding that those dependent-living individuals who reported that they did not have their teeth cleaned at least once a year were 4.76 times more likely to have had a CVA, suggests that a pattern of oral neglect might be associated with developing a CVA. The implications of this in terms of an intervention strategy for CVA warrants further consideration. However, caution is recommended because the data were obtained from a convenience sampling of older veterans and may not be generalizable to other populations.

Predictors of aspiration pneumonia: how important is dysphagia?

Aspiration pneumonia is a major cause of morbidity and mortality among the elderly who are hospitalized or in nursing homes. Multiple risk factors for pneumonia have been identified, but no study has effectively compared the relative risk of factors in several different categories, including dysphagia. In this prospective outcomes study, 189 elderly subjects were recruited from the outpatient clinics, inpatient acute care wards, and the nursing home care center at the VA Medical Center in Ann Arbor, Michigan. They were given a variety of assessments to determine oropharyngeal and esophageal swallowing and feeding status, functional status, medical status, and oral/dental status. The subjects were followed for up to 4 years for an outcome of verified aspiration pneumonia. Bivariate analyses identified several factors as significantly associated with pneumonia. Logistic regression analyses then identified the significant predictors of aspiration pneumonia. The best predictors, in one or more groups of subjects, were dependent for feeding, dependent for oral care, number of decayed teeth, tube feeding, more than one medical diagnosis, number of medications, and smoking. The role that each of the significant predictors might play was described in relation to the pathogenesis of aspiration pneumonia. Dysphagia was concluded to be an important risk for aspiration pneumonia, but generally not sufficient to cause pneumonia unless other risk factors are present as well. A dependency upon others for feeding emerged as the dominant risk factor, with an odds ratio of 19.98 in a logistic regression model that excluded tube-fed patients.

Assessing the relationship between dental disease and coronary heart disease in elderly U.S. veterans

Several recent studies have shown a link between dental disease and coronary heart disease. The authors studied 320 U.S. veterans in a convenience sample to assess the relationship between oral health and systemic diseases among older people. They present cross-sectional data confirming that a statistically significant association exists between a diagnosis of coronary heart disease and certain oral health parameters, such as the number of missing teeth, plaque benzoyl-DL-arginine-naphthylamide test scores, salivary levels of Streptococcus sanguis and complaints of xerostomia. The oral parameters in these subjects were independent of and more strongly associated with coronary heart disease than were recognized risk factors, such as serum cholesterol levels, body mass index, diabetes and smoking status. However, because of the convenience sample studied, these findings cannot be generalized to other populations.

Clinical use of antibiotics in dental practice

Inappropriate use of antibiotics by clinicians leads to development of antibiotic resistance. For the most part, antibiotics are prescribed in dental practice for prophylactic and therapeutic reasons. Prophylactic antibiotics are prescribed to prevent diseases caused by members of the oral flora introduced to distant sites in a host at risk or introduced to a local compromised site in a host at risk. In most cases, prophylaxis is used for prevention of endocarditis. Therapeutic antibiotics are prescribed, in most cases, to treat diseases of hard and soft tissues in the oral cavity after local debridement has failed. Antibiotics used for prophylaxis must: (1) be active against the major pathogens; and (2) achieve a tissue loading dose before the bacteria are introduced. Antibiotics used for therapy are required in cases where the infection is already present and thus the agent must reach the site of infection at a high enough level for a long enough time to produce the desired effect. For an exogenous agent the goal is to eliminate the agent from the site of infection. In the case of an endogenous agent the antibiotic must suppress the organism at the site of infection. Recent evidence underscores the important role of antibiotics in the treatment and prevention of diseases initiated in the oral cavity that have the potential to spread to distant organs in the body.

The optimization of the BANA test as a screening instrument for gingivitis among subjects seeking dental treatment

Porphyromonas gingivalis, Treponema denticola and Bacteroides forsythus have been implicated in periodontal disease and each possesses an enzyme capable of hydrolyzing the synthetic trypsin substrate, BANA. We have used a chairside test for BANA hydrolysis to diagnose an anaerobic periodontal infection in patients with advanced forms of clinical disease using a 15-min/55 degrees C incubation protocol. However, the BANA test performance is dependent upon the length and temperature of incubation. In the present study, we have evaluated a 5-min/35 degrees C, a 5-min/55 degrees C and a 15-min/55 degrees C incubation protocol to determine whether the performance of the BANA test could be optimized using plaque samples obtained from subjects seeking dental treatment. Logistic regression models were tested with age, smoking status, and gingivitis scores as covariates. The best fitting model obtained with the 5-min/35 degrees C protocol had a sensitivity of 71%, a specificity of 68%, a false-positive proportion of 9%, a false-negative proportion of 65%, and an overall accuracy of 80%. When maximum likelihood estimates were obtained in this model, plaques from individuals who reported that they currently smoked were 9.57x, and those who quit smoking were 4.73x more likely to have a positive BANA score than someone who never smoked. Plaques were 4.55x more likely to be BANA-positive if they were removed from sites with gingivitis. These findings indicate that the performance of the BANA test is best using the 5-min/35 degrees C incubation protocol.

Functional units, chewing, swallowing, and food avoidance among the elderly

PURPOSE

The number of teeth in the dentition was compared with the number and types of dental functional units (opposing tooth pairs) to correlate the number of functional units with complaints about chewing and swallowing in the elderly.

MATERIAL AND METHODS

Complaints of oral pharyngeal function and food avoidance practices were compared with the number and types of functional units. A convenience sample of 602 elderly subjects (468 men, 134 women, mean age 70 years) were interviewed and examined dentally.

RESULTS

Functional unit measures, which included functional arrangement of the teeth and the number and type of teeth present, were found to be more discriminatory and descriptive of masticatory potential than the more number of teeth. Elderly persons (> or = 60 years of age) with reduced numbers of functional units tended to report difficulty chewing, avoidance of stringy foods (including meat), crunchy foods (including vegetables), and dry solid foods (including breads), and difficulty in swallowing. Removable prostheses did not appear to prevent these consequences and, at least in this elderly population, did not appear to be equivalent to natural teeth in terms of masticatory potential.

CONCLUSIONS

It is possible that compromised dental function results in the swallowing of poorly chewed food, food avoidance patterns, dietary inadequacies, and systemic changes favoring illness, reduced vigor, debilitation, and shortened life expectancy. Emphasis should be placed on maintaining natural teeth whenever possible.

Treatment paradigms in periodontal disease

The prevailing treatment paradigm in periodontal disease relies on debriding the tooth surfaces to keep the bacterial load below the level that triggers tissue loss. When debridement cannot be easily accomplished because of deep pocketing, access surgery is recommended. The debridement approach that involves access surgery is successful in 80% to 85% of patients. Patients who do not respond are often treated with systemic antibiotics. This paradigm, which is based on the nonspecific plaque hypothesis, is labor-intensive and relies on antibiotics only as a last resort. This nonspecific treatment paradigm is in contrast with the specific plaque hypothesis, which states that a limited number of bacterial species are specifically involved in most forms of periodontal disease. Some studies have significantly associated anaerobic bacteria with advanced forms of periodontal disease. These observations led us to hypothesize that most forms of periodontal disease are anaerobic infections, which can be treated by antimicrobials such as metronidazole or clindamycin. Three double-blind studies have shown that 1 to 2 weeks of unsupervised use of metronidazole-plus-debridement was significantly better than placebo-plus-debridement in reducing the need for periodontal surgery. These findings suggest that treatments based on the specific plaque hypothesis give clinicians and patients a choice regarding treatment options in periodontal disease.

A logistic regression model for the decision to perform access surgery

Access surgery may be recommended to about 80% of patients who present with advanced forms of periodontal disease. In this report, a multivariate logistic regression analysis which incorporated several clinical parameters for each tooth examined, i.e., tooth type, furcation involvement, bleeding on probing, attachment level, probing depth, mobility and BANA test score, was conducted using generalized estimating equations (GEE). This approach identified parameters that were significantly associated at p < 0.05 level with the need for access surgery or extraction for periodontal purposes. The estimated probabilities derived from the GEE model were plotted over the complete spectrum of operating conditions to obtain a receiver-operator characteristic (ROC) curve. At a probability cutpoint of 0.8, the decision threshold for surgery/extraction at the pretreatment examination would have a sensitivity of 76.1% and a specificity of 75.3%. We have taken this 0.8 cut point to look at specific clinical decisions made by our examiners after the patients had received scaling and root planing plus 2 weeks unsupervised usage of systemic antimicrobials. The clinicians' decision was taken as the primary reference standard. The model's estimated decision agreed with the clinicians' decision in 226 of the 284 teeth, for an accuracy of 80%. The specificity was 90% and the sensitivity was 43%.

Nonsurgical treatment of patients with periodontal disease

OBJECTIVE

To determine whether the short-term use of systemic antimicrobials (metronidazole or doxycycline) and locally delivered antimicrobials (metronidazole, chlorhexidine) in patients with advanced forms of periodontal disease could prevent the normally necessary access surgery.

STUDY DESIGN

Ninety-four patients were randomly assigned with the use of a double-blind protocol.

RESULTS

There was a 93% reduction in the need for periodontal surgery about individual teeth and an 81% reduction in the need for tooth extractions. Only 93 teeth of an initial total of 783 teeth actually needed surgery or extractions. Eighty-one percent of the patients entered into the maintenance phase of treatment without needing surgical treatments.

CONCLUSION

These findings indicate that a treatment paradigm based on the diagnosis and treatment of anaerobic infections is likely to be successful in those patients for whom access surgery is recommended.

Factors which influence levels of selected organisms in saliva of older individuals

The most commonly measured bacterial parameters in saliva are the levels of the mutans group streptococci and lactobacilli, which have diagnostic implications for the incidence of dental decay. Diagnostic guidelines which are applicable to children and young adults in whom most, if not all, teeth are present and in whom the rate of stimulated saliva is almost always greater than 0.5 ml/min have been developed. Dental decay is a potential health problem of considerable magnitude among elderly individuals. In elderly individuals, missing teeth, the presence of dentures, and a reduced salivary flow could confound the interpretation of salivary levels of cariogenic bacteria. In the present study, in which saliva was collected from more than 560 elderly individuals (average age, 70 +/- 8 years), there was a significant positive relationship between the salivary levels of Streptococcus mutans and increased numbers of teeth. There was a positive association between the salivary levels of S. mutans and decay when the data were stratified for the presence of a complaint of xerostomia and the presence of dentures. However, a similar analysis indicated that lactobacilli and yeasts were more likely to be associated with decay. The various variables which could influence the bacterial counts per milliliter of saliva, e.g., independent or dependent living status, complaint of xerostomia, stimulated salivary flow, salivary pH, the presence of dentures, number of teeth, and decay, were analyzed simultaneously by using a multivariable linear model. In that analysis the number of decayed teeth was significantly associated with the presence of lactobacilli (P = 0.0001) and yeasts (P = 0.025) but not with the presence of S. mutans. Our findings indicate that salivary levels of lactobacilli and yeasts, as well as the salivary levels of S. mutans, should be monitored when seeking microbial indicators that might predict the incidence of caries in elderly individuals.

Assessing the contribution of anaerobic microflora of the tongue to oral malodor

Research suggests that the tongue plays an important role in the production of oral malodor. To investigate the role of tongue surface characteristics and oral bacteria in halitosis development, the authors tested associations between odor measurements, volatile sulfur compound levels, periodontal parameters, tongue surface characteristics, presence of trypsinlike activity of organisms on the tongue and teeth and bacteriological parameters in 16 participants with complaints of oral malodor. The data indicate that the proteolytic, anaerobic flora residing on the tongue plays an essential role in the development of halitosis.

Dental findings in geriatric populations with diverse medical backgrounds

OBJECTIVE

To determine whether there is a difference in the oral/dental health in older persons with different life styles and medical status.

STUDY DESIGN

Survey (cross-sectional study) included four groups: (1) subjects (n = 123) living in a residential retirement home or community dwelling; (2) subjects (n = 218) seeking dental treatment at a Veterans Affairs Dental Outpatient Clinic; (3) subjects (n = 132) resident in a VA long-term care facility; and (4) subjects (n = 81) recently admitted to a VA acute care ward with a diagnosis of cerebral vascular accident or other neurologic problem. Each subject answered questions on medical and dental health and dietary preferences in a comprehensive interview. They were given a comprehensive dental examination that included measurements of stimulated salivary flow and minor salivary gland output.

RESULTS

The data from groups 2 and 3 confirmed previous reports that independent living subjects have better oral/dental health than dependent living subjects. The data from groups 1 and 4, obtained from geriatric populations on the opposite ends of the medical health/disease continuum provide new information that suggests that good medical health and good oral/dental health are linked. The subjects in group 1 were very healthy as judged by their longevity; 54% were > or = 80 years and they had low reported prevalence of medical disease. Only 6% were edentulous and the dentate persons were missing 4.5 teeth. In contrast, over 50% of the patients in group 4 were < 70 years; they had an edentulous rate of 49% and among the dentate persons had an average 12 missing and 5 decayed teeth.

CONCLUSIONS

The medically healthy persons had excellent dental health whereas the sickest persons were either edentulous or had many missing teeth.

Xerostomia, xerogenic medications and food avoidances in selected geriatric groups

OBJECTIVE

To study the relationship between complaints of xerostomia and salivary performance and food avoidances in four geriatric groups chosen to reflect a broad spectrum of individuals along the health-disease continuum. To determine whether xerogenic medications taken by these individuals could be associated with either complaints of xerostomia or with food avoidances.

DESIGN

Cross-sectional survey. Clinical examinations and interview.

SETTING

A VA dental clinic and a retirement home.

PATIENTS AND OTHER PARTICIPANTS

Subjects were 529 individuals older than 56 years of age, living both in institutions and in the community (average age 70 years). Two hundred eight persons were recruited from a VA Dental Clinic, 114 from a residential retirement home, and 132 from a nursing/long-term-care facility; 75 were from an acute care ward and had a diagnosis of a cerebral vascular accident or other neurological condition.

OUTCOME MEASURES

Prevalence of xerostomia, dental morbidity, salivary flow, and food avoidances.

RESULTS

About 72% of the subjects experienced xerostomia sometime during the day. Stimulated salivary flow was found to be significantly lower in individuals who complained of xerostomia than in those who did not. Fifty-five percent of participants reported using one or more xerogenic medications, with an 86% prevalence in the nursing/long-term-care facility. Individuals with xerostomia had difficulty in chewing and in starting a swallow and were significantly more likely to avoid crunchy foods such as vegetables, dry foods such as bread, and sticky foods such as peanut butter in their diets. Specific medications such as the inhalants ipratropium and triamcinolone and the systemic agents oxybutynin and triazolam could be statistically associated with xerostomia and/or low salivary flow, and/or specific food avoidances.

CONCLUSION

Xerostomia apparently affects the ability to chew and start a swallow. This leads to avoidance of certain foods, which raises the possibility that xerostomia could contribute to undernutrition in older persons. The topically applied ipratropium and triamcinolone and the systemic agents amitriptyline, oxybutynin and triazolam could be statistically associated with one or more complaints of xerostomia.

Comparison of the number and type of dental functional units in geriatric populations with diverse medical backgrounds

Elderly subjects (N 430) from four convenience populations that represented different levels of medical health--independent living (Veterans Affairs and non-Veterans Affairs), nursing home, and hospitalized acute care--were given dental examinations. The independent living groups had significantly higher numbers of functional units (opposing natural or prosthetic tooth pairs) and of contiguous functional units compared with the nursing home and hospitalized groups. There was a shift from functional units that consisted of natural teeth to functional units that consisted of prosthetic teeth in the nursing home and hospitalized groups. Numbers of functional units were negatively correlated to plaque index, papillary bleeding scores, and minor salivary gland output. This study suggests a strong relationship between functional integrity of the dentition and general health.

Purification and general properties of an oligopeptidase from Treponema denticola ATCC 35405--a human oral spirochete

An endo-acting oligopeptidase (OPase) was purified to homogeneity from the cells of Treponema denticola ATCC 35405--a human oral spirochete--by a procedure that comprised a mild Triton X-100 extraction (which disintegrates the outer membrane but leaves the cells morphologically intact) and four successive fast protein liquid chromatographic steps of the extract. The activity of this oligopeptidase (formerly named "trypsin-like" enzyme and "BANA-peptidase") together with the proteinase activities of T. denticola and Porphyromonas gingivalis is utilized in a diagnostic test for human periodontal infections, but the enzyme's chemical nature has not been studied. The enzyme is a cell-associated 78-kDa protein with an isoelectric point of 6.1, and its estimated minimum peptide length was 688 amino acid residues. The OPase does not hydrolyze proteins, but hydrolyzes -X-Arg-p-nitroaniline peptides between arginine and the chromogen, the optimum pH of hydrolysis covering a broad pH range (7 to 9). The OPase is not a metalloenzyme, although 1.0 mmol/liter Ca(II) increases the rate of the hydrolysis of all substrates. Ca(II) did not affect the values of the Michaelis constant. The OPase activity is not dependent on reactive SH-groups, but is suggested to depend on the catalytic triad COOH. . .His. . .Ser. The N-terminal sequence for the first 29 amino acid residues is MKQSDFEKPPIAEIKETRFEKFGKTRIDN. The purified enzyme is very sensitive to chlorhexidine acetate (mixed inhibition; Ki = 0.85 microM) and somewhat less sensitive to bacitracin (Ki(app) = 27.5 microM). The present OPase is considered to belong to the serine peptidases, functionally resembling trypsin except that the OPase does not hydrolyze proteins. The OPase may be regarded as an oligopeptidase, the substrate specificity profile of which resembles to a certain extent that of some members of the coagulation cascade.

Presence of Treponema denticola and Porphyromonas gingivalis in children correlated with periodontal disease of their parents

Considerable evidence exists suggesting that periodontal disease is due to the overgrowth of a finite number of specific bacteria such as Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, Treponema denticola, Bacteroides forsythus, and Prevotella intermedia, among others. Three of these organisms-P. gingivalis, T. denticola, and B. forsythus-can be easily detected in plaque samples by the hydrolysis of the synthetic trypsin substrate benzoyl-DL-arginine-naphthylamide (BANA). The aim of the present study was to determine if a relationship could be found between the presence of either these organisms of periodontitis in the parent and the presence of BANA-positive species in the child. Thirty-four mothers or fathers and 34 children were examined for plaque scores, papillary bleeding scores, and the presence of P. gingivalis and T. denticola in four subgingival or marginal gingival plaque samples as assayed by the BANA test or specific polyclonal antibodies using an ELISA. Children whose parents were colonized by BANA-positive bacteria were 9.8 times more likely to be colonized by these BANA-positive species. Children whose parents had clinical evidence of periodontitis were 12 times more likely to be colonized by these BANA-positive species. These data are compatible with the hypothesis that children may acquire the BANA-positive species from their parents, especially if the parent has periodontitis.

Metronidazole in periodontitis V: debridement should precede medication

Two previous double-blind studies have shown that 1 week of metronidazole, plus scaling and root planing, can significantly reduce the number of teeth per patient that require periodontal surgery, when compared to a positive-control treatment that consisted of 1 week of placebo treatment plus scaling and root planing. The only difference between the two studies was that in one, metronidazole or placebo tablets were taken at the beginning of the debridement procedures, while in the other, the tablets were taken after all debridement was completed. This article describes the results obtained by combining the data from both studies and using an analysis of variance to identify the effects of medication and those of the study protocol. There was an average reduction in surgical needs of about 7.1 teeth per patient using metronidazole compared to 2.4 teeth in the positive-control group (P = 0.004). In the deep pockets, there was a significant protocol effect because there were additional improvements associated with using the medications after the debridement was completed.

Periodontal disease as a risk factor for heart disease

Many individuals with cardiovascular disease appear from epidemiologic studies to have either periodontal disease or to be edentulous. A Finnish group has provided evidence that after conventional risk factors for stroke and heart attacks have been accounted for, there still remains a significant relationship between dental disease and cardiovascular disease. A preliminary analysis of our own investigation of the interrelationship of medical and dental health shows that individuals with a high dental morbidity (ie, edentulous or with many missing teeth) have a high prevalence of coronary heart disease and stroke. A model based on how smoking can predispose to periodontal disease is used to explain how periodontal disease could be a potential risk factor for heart disease.

Correlation between the BANA test and oral malodor parameters

The purpose of the present investigation was to test the association between the BANA test (Perioscan, Oral-B), and oral malodor parameters. The subject population consisted of 52 Israeli adults, 43 of whom complained of oral malodor. Oral malodor measurements consisted of peak and steady-state volatile sulphide measurement by a portable sulphide monitor (Interscan Corp., model 1170), as well as organoleptic measurements of malodor from whole mouth, tongue, and saliva. Samples for the BANA test were obtained from four loci (shallow pocket, deep pocket, tongue dorsum, saliva); results were scored as negative (0), weak (1), or strong (2). BANA scores were significantly associated with odor-judge ratings, with the highest association obtained when BANA saliva scores and odor-judge saliva assessment were compared (r = 0.500; p < 0.001). BANA tests from the different loci were not significantly associated with sulphide monitor levels. Stepwise multiple-regression analysis of odor-judge measurements in terms of sulphide levels and average BANA scores showed that both log peak sulphide levels as well as BANA scores were significantly factored into the equations, yielding, in all cases, highly significant correlations (multiple r = 0.57, 0.50, and 0.59, respectively, with significance levels of 0.0001, 0.001, and < 0.0001, for whole mouth, tongue, and saliva malodor, respectively). The results suggest that the BANA scores are associated with a component of oral malodor which is independent of volatile sulphide measurements and suggest its use as an adjunct test to volatile sulphide measurement.

The use of a rapid enzymatic assay in the field for the detection of infections associated with adult periodontitis

There are few objective assays for studies of the epidemiology of periodontal diseases. The PerioScan is an assay capable of detecting three periodontal pathogens, namely T. denticola, P. gingivalis, and B. forsythus, which have been associated with adult periodontitis. The PerioScan was tested in a sample of 301 Brazilians. Clinical indices--bleeding, probing depth, gingival index, and periodontal index--were recorded from four sites in each subject. Subgingival plaque samples were collected from those sites and placed on the PerioScan card. Color results were scored in the field after 15 minutes. The plaque samples were screened with polyclonal antibodies for the three species by an ELISA system. The PerioScan, when compared with the ELISA system, yields a sensitivity of 91 percent, specificity of 89 percent, and an accuracy of 90 percent. When the PerioScan was compared to clinical indices, there was a high sensitivity (at least 93%) and a low specificity (no less than 47%), with an accuracy of at least 61 percent.

The effects of incubation length and temperature on the specificity and sensitivity of the BANA (N-benzoyl-DL-arginine-naphthylamide) test

A previous multi-center study examining patients diagnosed as having at least four periodontally diseased teeth showed that when BANA (N-Benzoyl-DL-Arginine-Naphthylamide) hydrolysis by periodontal pathogens such as Treponema denticola, Porphyromonas gingivalis, and Bacteroides forsythus was evaluated versus clinical parameters such as clinical judgment of disease, bleeding on probing, and pocket depth, the sensitivity of the test was 84%, 82%, and 87%, respectively, while the specificity was only 42%, 41%, and 32%, respectively. The purpose of the present investigation was to improve the specificity of the test while retaining a high level of sensitivity in both gingivally healthy and periodontally diseased groups. One hundred forty-nine patients participated in this study providing 3,497 interproximal plaque samples. Gingival health was measured using the papillary bleeding score and this was compared with the presence or absence of detectable trypsin-like activity, as determined by the BANA hydrolysis of interproximal plaque samples, using a commercially-available test. Sensitivity and specificity were measured by varying the incubation time and temperature of the enzymatic assay. Using the correlated binomial model to analyze site-specific data within a patient, the specificity was highest at 35 degrees C and 5 minutes incubation (94%), and lowest at 45 degrees C and 15 minutes incubation (33%). Sensitivity was highest at 45 degrees C or 55 degrees C and 15 minutes incubation (90%) and lowest at 35 degrees C and 5 minutes incubation (47%).(ABSTRACT TRUNCATED AT 250 WORDS)

Bacterial mediators in periodontal disease

Periodontal disease is the general description given to the inflammatory response of the gingiva and underlying connective tissue to bacterial accumulations (dental plaque) on the teeth. A limited number of cultivable species are usually associated with periodontal disease. The majority of putative periodontal pathogens are gram-negative anaerobic rods. Some of the characteristics of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Treponema denticola will be discussed, given their prominence in the literature. These organisms share the ability to penetrate the gingival epithelium, such that their endotoxins, immunologically active compounds, and cytotoxic enzymes and molecules are presented directly to the host's inflammatory cells. This ability may be what distinguishes these gram-negative species from the plethora of other gram-negative species that inhabit the subgingival plaque. In addition, these organisms tend to be selected for in disease-associated plaques, suggesting that their nutritional needs are met when the gingival crevicular fluid contains a variety of inflammatory mediators and products of tissue breakdown. A. actinomycetemcomitans produces a leukotoxin, and the immunologic response of the host to this antigen may explain the unique pattern of tooth involvement in localized juvenile periodontitis. Both P. gingivalis and T. denticola have a trypsin-like enzyme that could be a virulence factor, primarily because this enzyme(s) may allow these organisms to grow in the presence of the inflammatory response of the host.

Metronidazole in periodontitis (IV). The effect of patient compliance on treatment parameters

Patient compliance with the unsupervised usage of prescription medication can be poor. In the treatment of periodontal infections with systemic antimicrobial agents, in situations where the efficacy of the antimicrobial agent is being evaluated, non-compliance could underestimate the true efficacy of the agent. Metronidazole is an agent with reported success in the treatment of anaerobic periodontal infections. Metronidazole is particularly effective in vitro against spirochetes, and this efficacy was investigated as a means of measuring patient compliance with metronidazole usage. Patients who had high proportions of spirochetes, i.e., > 20%, in plaques removed from diseased periodontal sites, were given metronidazole (500 mg bid) under supervision. In all individuals who received the metronidazole, there was a significant and rapid decline and/or disappearance of spirochetes from the plaque during the time interval that metronidazole was detectable in the saliva. This observed decline in spirochetes was then used to determine which patients had been compliant in a double-blind clinical trial involving the unsupervised usage of metronidazole. Only 10 of 18 patients (56%) were considered compliant in their usage of metronidazole. These 10 patients experienced a significantly greater benefit from the metronidazole than did the 8 patients who were considered noncompliant, i.e., a reduction of surgical needs of 8.3 teeth per compliant patient versus 3.6 teeth per non-compliant patient. A test for the hydrolysis of the synthetic peptide (BANA) was also able to identify most non-compliant patients. Clinical trials involving the unsupervised usage of systemic medication need to take into account patient non-compliance.

The effect of incubation temperature on the specificity of the BANA (N-benzoyl-DL-arginine-naphthylamide) test

The hydrolysis of BANA by subgingival plaque samples is associated with the presence of either Treponema denticola, Porphyromonas gingivalis, and/or Bacteroides forsythus. A protocol in which pure cultures were incubated for 15 min at 55 degrees C detected about 5 x 10(5) CFU of P. gingivalis and 1 x 10(6) CFU of T. denticola. Clinical studies indicated that the BANA test in this configuration will detect about 10(4) organisms in vivo as compared with the 10(5) to 10(6) organisms found with in vitro grown cells. The BANA test can be made less sensitive by decreasing the time and/or temperature of incubation, which could improve the specificity of the test. In the present study we determined the incubation parameters that would give optimal specificity when the plaque samples were removed from sites of gingival health. Twenty-six approximal plaque samples were taken from each of 90 clinically healthy subjects and incubated with the BANA substrate on PerioScan cards (Oral-B Laboratories) for 5 and 15 min at 35 degrees, 45 degrees, and 55 degrees C. Subjects were randomly assigned to the various temperatures. Wooden toothpicks were inserted interproximally in all sites anterior to distal of the first molars and then each side of the toothpick was wiped onto the PerioScan card. The specificity of the BANA test relative to clinical health was 96% when the cards were incubated for 5 min at 35 degrees C, but decreased to 50-70% when the cards were incubated for 15 min at 35 degrees C or for 5 and 15 min at 45 degrees C and 55 degrees C.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of fluoxetine on the oral environment of bulimics

The purpose of this study was to evaluate in a double-blind placebo-based study the effects of fluoxetine over a period of 16 weeks on the frequency of binging and purging and on fluctuations in the levels of cariogenic organisms and saliva secretion rate of patients (n = 30) with bulima nervosa. Profile analysis suggested that, over the course of the study, binging and purging frequency and Streptococcus sobrinus salivary levels decreased significantly in the fluoxetine group as compared with the placebo group. Our finding that S. sobrinus levels decreased 16 weeks after subjects were on medication suggests that the salivary levels of these organisms could serve as an objectively measured indicator of patient compliance with antibulimic therapy.

DNA probe and enzyme analysis in periodontal diagnostics

Recent research in periodontology has indicated that a finite number of bacterial species are associated with periodontal disease. This has generated the hypothesis that periodontal disease is essentially an infection due to one or more of the putative periodontopathogens; i.e., the specific plaque hypothesis (SPH). This microbial specificity paradigm has already changed the way researchers and some clinicians view periodontal disease. The clinician must heed several cautions signs, however, if he is to use the SPH to provide treatment options that could enhance the delivery of care. There are several diagnostic technologies that can be used to detect and semi-quantitate those bacterial species that have been identified as periodontopathogens. This paper discusses diagnostic tests based upon the detection in plaque of DNA segments or enzyme activity(ies) that are unique for one or more of the suspected periodontopathogens.

Relationship of microbial and salivary parameters with dental caries in Brazilian pre-school children

Caries examination and collection of paraffin wax-stimulated saliva samples were performed in 37 children, 3-6 years old, in a child-care facility at the Vidigal slum, Rio de Janeiro, Brazil. The levels of mutans streptococci and lactobacilli in saliva were estimated by the Cariescreen and by the Dentocult tests and the saliva secretion rate was determined. Statistical analysis was performed on surface-based and patient-based caries prevalence rates (SBCPR and PBCPR), and related to bacterial and salivary parameters. The results show that 31 of the 37 children were caries active. The SBCPR for the primary dentition was 6.7% +/- 1.0%. Occlusal surfaces were the most affected by decay. Regression analysis revealed that mutans streptococci salivary levels were significantly associated with the SBCPR (P = 0.0001). Similarly, lactobacilli salivary levels were significantly associated with the SBCPR (P = 0.0001). No significant association could be found between the saliva secretion rate and the SBCPR. When regression analysis was used to model dependence of the SBCPR on both organisms, the mutans streptococci and lactobacilli salivary levels were significantly associated with the SBCPRs (P = 0.0021 and 0.0118, respectively), and salivary levels of these organisms accounted for 57% of the SBCPR variability. These findings indicate that the levels of mutans streptococci and lactobacilli in saliva are significantly related to the SBCPRs on the primary dentition of these children.

Comparison of the benzoyl-DL-arginine-naphthylamide (BANA) test, DNA probes, and immunological reagents for ability to detect anaerobic periodontal infections due to Porphyromonas gingivalis, Treponema denticola, and Bacteroides forsythus

Most forms of periodontal disease are associated with the presence or overgrowth of anaerobic species that could include Treponema denticola, Porphyromonas gingivalis, and Bacteroides forsythus among others. These three organisms are among the few cultivable plaque species that can hydrolyze the synthetic trypsin substrate benzoyl-DL-arginine-naphthylamide (BANA). In turn, BANA hydrolysis by the plaque can be associated with periodontal morbidity and with the presence of these three BANA-positive organisms in the plaque. In this investigation, the results of the BANA test, which simultaneously detects one or more of these organisms, were compared with the detection of these organisms by (i) highly specific antibodies to P. gingivalis, T. denticola, and B. forsythus; (ii) whole genomic DNA probes to P. gingivalis and T. denticola; and (iii) culturing or microscopic procedures. The BANA test, the DNA probes, and an enzyme-linked immunosorbent assay or an indirect immunofluorescence assay procedure exhibited high sensitivities, i.e., 90 ot 96%, and high accuracies, i.e., 83 to 92%, in their ability to detect combinations of these organisms in over 200 subgingival plaque samples taken from the most periodontally diseased sites in 67 patients. This indicated that if P. gingivalis, T. denticola, and B. forsythus are appropriate marker organisms for an anaerobic periodontal infection, then the three detection methods are equally accurate in their ability to diagnose this infection. The same statement could not be made for the culturing approach, where accuracies of 50 to 62% were observed.