chairside diagnostic aids

1. CHAIR SIDE DIAGNOSTIC
AIDS IN PERIODONTAL
EXAMINATION
Moderator :- Dr.Shivjot Chhina
Perceptor :- Dr.Kumar Saurav
Presented by:- Dr.Fatima Gilani
MDS- (2018-21)
SEMINAR-7

2. 1. Introduction
2. Conventional diagnostic aids and its limitations
3. Advanced diagnostic aids
4. Rationale of chair side diagnostic test
5. Microbiological CST
6. Biochemical CST
7. Genetic CST
8. Diagnostic tests under development.
9. Other CST
10. Conclusion.
CONTENTS

3. INTRODUCTION
 Periodontal diseases are conventionally diagnosed by
clinical evaluation of signs of inflammation &
periodontal tissue destruction.
Traditional methods of diagnosis
CLINICAL
RADIOGRAPHIC
Both attempts to identify & quantify
current clinical signs of inflammation
as well as historic evidence of damage
with its extent & severity

4. Limitations of traditional methods of diagnosis
1. Cannot reliably identify sites with ongoing periodontal
destruction.
2. Does not provide information on the cause of the condition
on the patient’s susceptibility to disease, whether the
disease is progressing, its remission & its response to
therapy.
3. Any force >0.25 N may evoke bleeding in healthy sites
(Lang et al)
4. Tobacco smoking masks inflammatory signs in gingivitis
and periodontitis.
5. Substantial volumes of alveolar bone must be destroyed
before the loss is detectable in radiographs. (Goodson,
Haffajee, Socransky 1984)

5. ADVANCES IN DIAGNOSIS
Thermal probes for
measuring early
inflammatory changes
(Kung et al)
Example- Periotemp
probe (Abiodent)
Diagnostic Subtraction
Radiography, CADIA
Advances in bacterial
culturing e.g-ELISA,
Flow cytometry etc

6. CHAIRSIDE KIT MEANS SIMPLIFIED TEST
KIT INVOLVES NO
SPECIALIZED
EQUIPMENT &
EASY TO READ
S
H
O
U
L
D
PROVIDE IMMEDIATE
REPORTS OF THE
MICROFLORAASSOCIATED
WITH THE DISEASE
COMPARED TO TIME
CONSUMING TRADITIONAL
LABORATORY METHODS

7. CHAIRSIDE
DIAGNOSTIC KIT
MICROBIOLOGICAL
GENETIC
BIOCHEMICAL
KITS UNDER
DEVELOPMENT

8. Microbiology
 Subgingival microenvironment has 300+ species
 The main bacteria associated with periodontal disease are
Actinomycetemcomitans (Aa), Porphyromonas gingivalis
(Pg), Prevotella intermedia (Pi) and Tannerella forsythia (Tf).
(Slots, Bragd, Wikstrom, 1986)
 Other organisms that are thought to have etiologic role are
Camphylobacter rectus, Eubacterium nodatum,
Fusobacterium nucleatum, Peptostreptococcus micros, and
Prevotella nigrescens, Trepenoma denticola.2,3

9. Method of collection of microbiological
samples
International Journal of Recent Scientific Research Vol. 7, Issue, 8, pp.
12963-12969, August, 2016

10. 1. Bana
2. Evalusite
3. Omnigene
4. Perio-2000
5. Perioscan
6. Meridol periodiagnostics
MICROBIOLOGIC TEST KITS

11. BANA4
 N-Benzoyl-DL-Arginine-2-Napthylamide
 Rapid and reliable CST
 Can perform test in 15 minutes
 Pg, Td, Tf have unique ability of hydrolysing
trypsin substrate.
Presence of negative result means:-
 Improper sample collection
 Disease is associated with the presence of
non-BANA organism.

12. http://www.jisponline.com/viewimage.asp?img=JIndianSocPeriodontol_2015_19_4_401_154167_f4.jpg
BANA -ZymeTM reagent strip with subgingival plaque sample

13. Evalusite4
1. Evalusite is a diagnostic kit that
is based on a novel membrane-
based enzyme immunoassay for
the detection of three putative
periodontopathogens: Aa, Pg and
Pi.
2. A paper point subgingival plaque
sample is collected and added to
a sample tube.
3. The sample is placed within the
kit, which employs a sandwich-
type ELISA (enzyme-linked
immunosorbent)and a pink spot
is displayed if the test organism
is present.

14. `

15. Omnigene4
(Backman,Van, Arsdal,1996)
 DNA Probe for subgingival bacteria.
 Subgingival plaque is obtained on a paper and placed it in
the container and assayed.
 Available for the detection of P.gingivalis, P.intermedia,
A.acinomycetemcomitans, F.nucleatum, E.corrodens,
T.denticola, T.pectinovorum and C.recta.

16. Perio 20005
 Consist of diamond probe which determines sulphide levels
digitally at each site.
 Td, Pg, Pi, Tf – produce sulfates
 These VSC degrade periodontal structure aggravating
periodontitis.
 It is intended to measure probing depths, to evaluate the
presence or absence of bleeding or probing, as well as to
detect the presence of sulfides in periodontal pockets.

17. Technique
Probe tip should be hydrated using sterile wash solution provided
by the manufacturer & then inserted subgingivally at peak or hold
operational mode, after a positive reading, the tip is washed &
reinserted in other subgingival sites.

18. Perioscan6
 PERIOSCAN is a chair side test kit system which uses the
BANA test for bacterial trypsin-like proteases.
 mainly produced by P.gingivalis, but lesser amounts are also
produced by T.forsythia and T.denticola.
 The PERIOSCAN works by detecting the activity of this
enzyme and it can be measured with the hydrolysis of the
colourless substrate N-benzoyl-dL arginine-2-naphthylamide.
 When the hydrolysis takes place, it releases the chromophore β
-naphthylamide, which turns orange red when a drop of Fast
Garnet added to the solution.
 The system is particularly simple to use. This method has
recently been made more sensitive.(Ishihara et al. 1992)

19. Meridol Periodiagnostics7
Jervoe-storm et al (2005)
 Real time PCR for quantitative determination of 6
important marker organisms of periodontitis and peri-
implantitis (Aa, Pg, Td, Fn, Tf, Pi)
 It combines high specificity with high sensitivity and a
precise quantification.

20. Biochemical cst
1. Periogard
2. Pocketwatch
3. Periocheck
4. Prognostick

21. Gingival crevicular fluid
 Collected with paper strips, micro papillary
tubes, micropipettes, microsyringes, plastic
strips.
Saliva
• It is the next most used after GCF -easily collected
Collected from parotid, sub-mand or sub lingual or as ‘Whole
saliva’ (secretions of major and minor salivary glands,No
diagnostic test available in the market although lot of research is
in progress.
Markers to look for in saliva: proteins and enzymes from host,
phenotypic markers, host cells, hormones, bacteria, bacterial
products, volatile compounds, and ions.

22. Different enzymes involved in both the intracellular &
extracellular pathway of tissue destruction.
Intracellular destruction enzyme:-
1. Aspartate aminotransferase
2. Alkaline phosphate
3. Beta glucoronidase
4. Elastase
Released from dead & dying cells of
PDL Mostly from PMNs ,neutrophils.
• Extracellular destruction enzyme
Matrix metalloproteinases- produced
by inflammatory epithelial &
connective tissue cells at affected
sites.

23. Aspartate aminotransferase (AST)
 Released from dead cells
 Elevated in GCF in periodontal disease.
 Periogard and Pocket watch commercially available
colorimetric test.

24. Periogard
 Detect AST
 GCF sample is obtained on a strip and placed into a suitable
test well with two drops of each reagent, positive & negative,
control wells are prepared using strips provided.8
 The test results can be visually appreciated by comparing the
test well colour to the colour of the positive control.
 A colour of greater intensity to that of the negative control is
scored as positive and one of lesser or equal intensity as a
negative result

25. Pocket watch6
 Sample paper strip is placed in a well on the reagent coated test
tray that is a part of pocket watch kit & 1 drop of AST positive
control solution is added to another non-sample well.
 The tray is incubated for 10 minutes at room temperature for color
development.
 If the GCF sample after incubation shows the same color or lighter
color than AST positive control it is given a score of 2.
 A sample is given a score of 1 if its color is same as or lighter than
AST standard sample.
 A score of 0 is given if it is darker than AST standard sample.

26. Periocheck (Actechinc.usa)10
 The connective tissue of periodontium is
composed of fibrous (collagen & elastin)&non
fibrous (glycoproteins),water etc.
 In periodontitis ,elevated level of
hydroxyproline from collagen breakdown &
glycosaminoglycans from matrix degradation.
Checks neutral
proteases in GCF
such as Elastase,
Proteinases &
Collagenases by
releasing a blue
colour dye
intensity of which
is proportional to
the amount of
enzyme present in
the sample

27. Prognostik (Dentsply)12
 Checks levels of serine proteinase,elastase in GCF (which
may be indicative of active disease sites).
 Simple, painless can be performed in 7 minutes.
 Intensity of blue colour produced is directly proportional to
the amount of total proteins present in GCF.
TECHNIQUE
 GCF collected on a special filter paper strips which have
been impregnated with the appropriate peptidyl derivative of
7-amino trifluoromethycoumarin (AFC).
 If elastase is present the sample reacts with the substrate in
4-8 minutes releasing the fluorescent leaving group.
 AFC produces green fluorescence in the strip which can be
seen under UV light using UV light box.

29. TOPAS Tm (toxicity pre-screening assay)
 A new TOPAS TM test kit has been introduced to
detect elevated levels of bacterial toxins and increased levels of
human and bacterial inflammatory proteins.
 The first generation TOPAS was a manual test and the latest
Second generation TOPAS TM is an automated one.
 It detects the indirect presence of bacteria by two markers of
gingival infection which are bacterial toxins and bacterial
proteins. This test can be associated with the severity of
inflammation and with the evolution of destructive process. It
makes the difference between an active and an inactive
periodontal disease.
Mani, et al: Chairside kits

30. o It is a simple, painless test which can be performed by any
medical professional in only 7 minutes.
o The intensity of the blue colour produced by the assay is
proportional to the amount of total proteins present in the
GCF.(Puocaou and Dumitriu 2005)

31. GENETIC Chair
side test kit

32. Kornman et al 1997
 Found an association between the polymorphism in the
genes encoding IL-1 & increase in severity of periodontitis.10

33. Periodontal susceptibility test/genetic
susceptibility test
 First and only genetic test that analyses two interleukins
(IL-1α & IL-1β) genes for variations.
 Differentiate between IL-1 genotypes associated with
diverse inflammatory responses with diverse inflammatory
responses to identify subjects at risk for severe periodontitis
even before 60 years of age.

34. Nucleic acid probe 11
(Zambon 1995)
 Developed by microprobe corporation
 Semiquantitative detection of periopathogen
TECHNIQUE
Plaque sample taken
Bacterial cells in sample are lysed by heating in the presence of detergent
DNA is extracted & then placed into the first well of a multiwell cassette &
then placed into a machine with a programmable robotic arm which gives
digital display of current bacterial load.

35. DIAGNOSTIC
KITS UNDER
DEVELOPMENT

36. Beta-glucuronidase
• β-glucuronidase (b-GD) is a lysosomal
enzyme found in the primary granules of
neutrophils.
• Relationship between β-Glucoronidase
to probing depths and attachment loss
has been studied by Lamster et al in
1995.
• The enzyme concentration was found to
be positively correlated with the mean
percentage of bone loss.
• Test stick kit is used
ABBOT
LABORATORIES
(USA)
Chemical substrate for the enzyme,
coupled to a colour detection
system which is released if the
enzyme attacks the substrate.

37. Cysteine & serine proteinases
 Enzyme System Products/Prototek of Dublin, California
(USA).
 GCF is collected with chromatography filter paper strips.
 Detect proteases in GCF.
 Green fluorescent is produced which can be detected by
UV light.
 Amount of enzyme present is proportional to the intensity
of fluorescence & requires no special apparatus.

38. Advantage of diagnostic test based on proteolytic
& hydrolytic enzymes
 Convenient
 Can be read within short times.
 Can be shown to the patient.
 Markers are predictors of disease activity.
Disadvantage
 Difficulty in choosing an appropriate biomarker due to insufficient
studies.
 Difficulty in sampling of the sites & the time period of the sample.
 False positive result in Cases of association of a disease with
inflammation
 No account of biological control mechanism which are taken.
 Cost factor

39. Other diagnostic
aid

40. TANITA Breath Alert + HALITOX
• A small hand-held breath checking
device, detects VSC’s & hydrocarbons
in mouth air.
• Quick, simple colorimetric device.
• It contains Halitox reagent which has
chemicals which react with anaerobic
bacterial products (toxins) to produce
yellow colored reaction products.
• Mild yellow color indicates moderate
toxin & Bright yellow color indicates
high toxin levels.

41. My Perio ID13
This test uses saliva to determine a patient’s genetic susceptibility
to periodontal diseases. It assesses patients which are at higher
risk of more serious periodontal infections. This test requires the
transportation of saliva samples to a laboratory for results.
 Detects (from human DNA) genetic variation/polymorphism
within the IL-1 gene
 IL-1 positive individuals tend to have more aggressive and
more severe infections
 Determines patients that are most susceptible to severe disease,
especially if the patients smoke
 This genetic variation can increase risk for severe disease or
tooth loss by 2–7 times when present.

42. Electronic Taste Chips14
 They are chemically sensitized bead microreactors within the
lab-on-a-chip system and were applied for measurement of C
reactive protein and other biomarkers of inflammation in saliva.
 The electronic taste chips methodology was compared with the
standard laboratory technology (ELISA) for measuring C
reactive protein in saliva and displayed a 20-fold lower limit of
detection than the ELISA.
 With this technique, it is possible to differentiate in C-reactive
protein levels between healthy individuals and patients with
periodontal diseases quantitatively and can simultaneously
monitor several biomarkers.

43. Dip Stick Test15
 The matrix metalloproteinase-8 (MMP-8) test stick is based on the
immunochromatography principle that uses two monoclonal antibodies
specific for different epitopes of MMP-8.
 The test stick results can be detected in 5 min.
 The antibody detects both neutrophils and non-PMN-type MMP-8
isoforms.
 The GCF sample collected will be placed in a test tube containing 0.5 ml
of a buffer at pH 7.4.
 When the dip area of dipstick is placed in the extracted sample
the dipstick absorbs liquid, which starts to flow up the dipstick.
 When the sample contains MMP-8, it binds to the antibody attached to the
latex particles. The particles are carried by the liquid flow if MMP-8 is
bound to them; they bind to the catching antibody.
 If the concentration of MMP-8 in the sample exceeds the cutoff value for
the test,a positive line will appear in the result area.

44. Conclusion
 These recent advances are leading to the development of more
powerful diagnostic tools for practitioners to optimize their
treatment predictability. If a reliable predictive test is developed
then it can be used to predict future periodontal activity & thus
enable administration of the treatments tailored to specific sites
before irreversible damage has occurred. These will provide
practitioners with more effective means of prevention, detection,
& treatment of periodontitis.

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