Periodontal lab results

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andrewm
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Joined: Tue Jan 10, 2017 10:28 am

Periodontal lab results

Post by andrewm » Sun Nov 12, 2017 2:47 pm

Hi!

A bit over 12 years ago my dentist back then couldn't figure out the cause for my inflammed caused. A test revealed that I had increased Aggregatibacter actinomycetemcomitans. Took antibiotics, gum inflammation resolved.

I randomly mentioned this to my current dentist, he said he's not really concerned, because in the 7 years I've been with him, I haven't mostly shown no gum inflammation at all or rarely a very minimal one that completely resolved with a dental cleaning. He nevertheless did a test. Results were:

A. actinomycetemcomitans: neg
P. gingivalis: neg
P: intermedia: neg
T. forsythia: ++ (increased)
T. denticola: + (minimally increased)

My dentist said that usually they only recommend antibiotics when lab findings like that exist together with clinical findings.. and since I don't have any gum problems, he thinks there is no point in my taking them... and that if I would take them, it's also likely that the results would look like above again in a year or two.

Do you think that's the best way to handle the situation?

Thank you!

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sbornfeld
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Re: Periodontal lab results

Post by sbornfeld » Sun Nov 12, 2017 3:51 pm

I'm not sure I'm understanding you correctly. Your dentist does not see any sign of gum disease. Nevertheless, he performed a culture. Was this because he felt it was necessary, or because you twisted his arm?
Although T. forsythia and T. denticola have been ASSOCIATED with periodontal disease, that does NOT mean that either of them is capable of CAUSING periodontal disease in every context. There are all kinds of POTENTIALLY pathogenic bugs which exist on the skin and mucosae without causing harm. How do we know this? Because these bacteria are found in HEALTHY PATIENTS like you. Furthermore, you say you have a 7-year history with this dentist, so unless the culture became contaminated it's highly likely that these, and many other bugs could have been cultured from your mouth at almost any time.
The other issue is that some patients will not only convince their doctors to do what are almost certainly unnecessary tests, but will also get their doctors to treat nonexistent bacterial infections with antibiotics. This is a small but definite contributor to the very serious issue of bacterial resistance which is leading us into what the CDC refers to as the "post-antibiotic era".
Don't treat a non-existent problem.
Steven Bornfeld, DDS
Brooklyn, NY

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mbornfeld
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Re: Periodontal lab results

Post by mbornfeld » Sun Nov 12, 2017 7:36 pm

This is a perfect example of how science can run far ahead of its practical utilization.

The identification of pathogenic oral bacteria has historically been somewhat problematic. First, it is difficult (if not impossible) to get a "clean" specimen for culturing or identifying the causative organisms of dental infection; there are just too many opportunities for non-pathogenic colonizers to contaminate the sample. Consequently, it is difficult to distinguish between the microbes that normally colonize the mouth from those causing clinical disease. Finally, some of the bacteria in the mouth are quite fastidious with regard to their environmental tolerance, and may not be detected under conventional culturing procedures.

Enter 16-s ribosomal RNA sequencing. This rather sophisticated method can more reliably detect and identify bacteria. Whether this fascinating technology currently has any application to real-world clinical dentistry hasn't prevented some labs from marketing their services to the dental profession. And despite its potential as a diagnostic tool, any information it provides does not in any substantive way inform the treatment your periodontist will be providing-- at least, at the state of the art of periodontal therapy today.

Although periodontitis can occasionally manifest with acute infection which might justify antibiotic therapy, it is fundamentally a chronic disease. And in the current healthcare climate where clinicians are becoming increasingly selective with regard to antibiotic use, the strategy of using these vital drugs for chronic disease makes less and less sense. Even short-term use can have unpredictable effects on the microbiome; prior colonizers can re-establish themselves, while new "dysbioses" can emerge.

So-- exactly what will your dentist do with this information? He's not going to use antibiotics. He's going to emphasize proper diet, oral hygiene, regular professional cleanings, control of any systemic conditions (e.g., diabetes)-- exactly what any competent dentist would have recommended without those fancy tests.
Mark Bornfeld DDS
Brooklyn, NY

andrewm
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Joined: Tue Jan 10, 2017 10:28 am

Re: Periodontal lab results

Post by andrewm » Mon Nov 13, 2017 12:39 pm

sbornfeld wrote:
Sun Nov 12, 2017 3:51 pm
I'm not sure I'm understanding you correctly. Your dentist does not see any sign of gum disease. Nevertheless, he performed a culture. Was this because he felt it was necessary, or because you twisted his arm?
He didn't seem all that worried. I told him that my previous dentist said AA is pretty bad and he replied that if I'm really concerned he can do the test. I wasn't aware that people can have an increased count for the mentioned bacteria and it not being of any concern. I assumed that an increased bacteria count, even if currently no gum disease is visible, will cause problems down the road and should be fixed. But what you wrote makes sense.

Thanks so much for your answers! Will definitely not use antibiotics in this case, just like you and my dentist recommended.

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sbornfeld
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Re: Periodontal lab results

Post by sbornfeld » Mon Nov 13, 2017 1:15 pm

By "AA", do you mean Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans)? I think your first dentist proved my brother's point--you stated that your gums were "inflamed", and you were treated (AFAIK) for a non-infection, and your dentist caused needless concern and worry. Periodontal disease has been historically diagnosed by clinical findings. By being able to culture bacteria, the dentist treated a condition that you almost certainly did not have. (We can't know this, because we don't have your x-rays or clinical findings).
There is almost never any real confusion about the cause of inflamed gums--it is dental plaque. In early stages, the treatment is meticulous scaling and good oral hygiene--not antibiotic therapy. That ain't sexy, but it's true.
Good luck!
Steven Bornfeld, DDS
Brooklyn, NY

andrewm
Posts: 4
Joined: Tue Jan 10, 2017 10:28 am

Re: Periodontal lab results

Post by andrewm » Mon Nov 13, 2017 2:48 pm

sbornfeld wrote:
Mon Nov 13, 2017 1:15 pm
By "AA", do you mean Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans)? I think your first dentist proved my brother's point--you stated that your gums were "inflamed", and you were treated (AFAIK) for a non-infection, and your dentist caused needless concern and worry. Periodontal disease has been historically diagnosed by clinical findings.
Yes, I meant Aggregatibacter actinomycetemcomitans.

I think there is a misunderstanding though. 12 years ago, when I was treated with antibiotics, I did have an extreme increased count of Aggregatibacter actinomycetemcomitans. I'm not sure about the exact details, since it's so long ago and I'm not a dentist, but I remember that there were gum problems (inflammation, tendency to bleed, deeper gum pockets, if I remember correctly).

At first my dentist back then assumed that it's due to bad oral hygiene, he checked how I brushed my teeth, told me to be extra diligent. But the gum issue would not resolve. Professional dental cleaning also didn't help. Only then he ordered the lab tests, which showed an extreme increased count of Aggregatibacter actinomycetemcomitans.

He prescribed antibiotics, after which the issues above resolved. So from my understanding, back then AA was the cause for the problems/disease. Now it seems to opposite, positive lab results without any problems/disease.

Thanks again :)

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