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Refractory Periodontitis

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Parameters and Microbiology of Refractory Periodontitis

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Refractory Periodontitis

  1. 1. Refractory Periodontitis
  2. 2. Parameter on “Refractory” Periodontitis American Academy of Periodontology, J Periodontol. May 2000
  3. 3. Clinical examination Photos from: pocketdentistry.com
  4. 4. Photos from: pocketdentistry.com
  5. 5. Photos from:; makeagif.com, bestanimations.com; gifhell.com; gifsoup.com; beverlyheights.comtoothclub.gov.hk,arestin.com
  6. 6. Refractory Periodontitis Photos from:; beverlyheights.comtoothclub.gov.hk,arestin.com; comfortdental4me.com
  7. 7. • A destructive periodontal disease in patients who, when longitudinally monitored, demonstrates additional attachment loss at one or more sites despite well-executed therapeutic and patient efforts to stop the progression of disease Refractory Periodontitis
  8. 8. Etiology: • conventional therapy failed to eliminate microbial reservoirs of infection • Emergence or superinfection of opportunistic pathogen • Unknown factors Refractory Periodontitis Photos from:; kohaladental.com; photos.com
  9. 9. Refractory Periodontitis Photos from: premier34.ru; dentalcompare.com; youtube.com; dentoplant.hu
  10. 10. Refractory Periodontitis Not applicable to patients who: 1. Have received incomplete or inadequate conventional therapy 2. Have identifiable systemic condition that increases susceptibility to infections 3. Have localized areas of rapid attachment loss related to local factors 4. Have recurrence of progressive periodontitis of many years of successful maintenance
  11. 11. Photos from:; www.behance.com; colorbox.com; presentermedia.com
  12. 12. Clinical and microbiological features of refractory periodontitis subjects Colombo et al. (1998)
  13. 13. Clinical and microbiological features of refractory periodontitis subjects • Aim: to compare clinical parameters and the site prevalence and levels of 40 subgingival species in successfully treated and refractory periodontitis subjects
  14. 14. methodology Photos from:clicker.com; tokeyclub.com; christianberdy.com; Colgate.com; clipartlord.com 94 subjects CLINICAL EXAM •Gingival redness •Suppuration •BOP •PI •PD •CAL Baseline Every 3 mo Scaling and Root planing Modified Widman + Tetracycline 250mg QID for 28 days
  15. 15. methodology 66 successful tx 14 28 refractory pt CAL > 3 sites, >2.5mm in 1 year Photos from:clicker.com; tokeyclub.com; www.scielo.cl;pinterest.com Checkerboard DNA- DNA hybridization Bacterial culture in blood agar plate PCR 1 2
  16. 16. Results < < < < < <
  17. 17. Mean PD and CAL in subjects with refractory and successfully treated  both show great variations  refractory > successfully treated Results
  18. 18. Results Baseline BOP and gingival redness:  both show great variations and overlap
  19. 19. Fig 3. % of sites colonized at baseline by different levels of the 40 subgingival taxa -Reject the hypothesis that periodontal pathogens were higher or more prevalent in refractory -Streptococcus constellatus: -12.6±3.6 for refractory -3.7±1.1 for successfully Results * * * * *
  20. 20. Odds Ratio: 8.6 Results
  21. 21. Results 4 3 3 4 • Great heterogeneity in subgigival microflora of refractory subjects
  22. 22. Results • Great heterogeneity in subgigival microflora of refractory subjects
  23. 23. Conclusion • Refractory subjects CANNOT BE distinguished through clinical features prior to therapy. • Refractory subjects had lower prevalence and levels of the 40 test species in their sites than subjects in the successfully treated group. • Putative perio pathogens were found in more sites of successfully treated than in refractory subjects prior to therapy. • Higher frequency of Streptococcus species in refractory.  S. constellatus in refractory
  24. 24. Subgingival microbial profiles in refractory periodontal disease • Socransky et al. (2002)
  25. 25. Aim: to examine subgingival microbial profiles associated with refractory periodontitis and to seek such profiles in periodontally healthy, periodontally well- maintained elder and untreated periodontitis subjects Subgingival microbial profiles in refractory periodontal disease
  26. 26. Methodology REFRACTORY N=36 PERIODONTALLY HEALTHY N=27 WELL- MAINTAINED N=35 UNTREATED PERIO N=115 •TX = SRP + MWF + Tetracycline •Showed full mouth mean CAL or >3 sites w/ >2.5mm after therapy •No PPD or CAL > 4mm •≥ 66 yrs old •Regular perio maintenance q 3-6 mo for an average of 14.2 years after perio therapy •Atleast 4 sites w/ PD >4mm and / or CAL >4mm
  27. 27. Demographics of 4 groups
  28. 28. results Mean prevalence and level of taxa differed sig. for 4 groups
  29. 29. results • Perio & refractory –  red and orange complex;  purple and actinomyces
  30. 30. Results •ratio of counts of actinoymces sp and counts of red complex between groups. •Proportions of taxa of actinomyces and red complex
  31. 31. results • Clustered analysis showed heterogeneity in the 4 clusters of refractory group with 8 outlier subjects
  32. 32. results I -  streptococcus species of yellow complex II – low prevalence of all taxa;  orange III – wider distribution;  A. naeslundii and V. parvula IV-  red and orange complex;  B. forysthus strep constellatus in all group
  33. 33. results Clusters seen in refractory can also be seen in other groups
  34. 34. Conclusion • Refractory perio, on average, have similar microbiota to that seen in untreated perio • Refractory perio have heterogenous subgingival microbiota • Microbial profiles of refractory is seen in perio subjects as well as some healthy and some well maintained
  35. 35. Conclusion •  prevalence of Streptococcus species is not seen in refractory groups • Detection of different microbial profiles  design individual treatment for each patient
  36. 36. Comparison of subgingival microbial profiles of refractory periodontitis, severe periodontitis, and Periodontal Health using the Human Oral Microbe Identification Microarray• Colombo et al. (2009)
  37. 37. Comparison of subgingival microbial profiles of RP, GRs,PH using the HOMIM • Aim: to compare subgingival microbiota of subjects with refractory (RP), treatable periodontitis (GRs= good responders) or periodontal health (PH) using the human oral microbe identification microarray
  38. 38. methodology Photos from:clicker.com; tokeyclub.com; christianberdy.com; Colgate.com; clipartlord.com CLINICAL EXAM •Gingival redness •Suppuration •BOP •PI •PD •CAL Baseline Every 3 mo Scaling and Root planing Modified Widman + Amox 500mg + Metro 250mg TID for 14 days PERIODONTALLY HEALTHY N=20 •No PPD > 3mm or CAL > 2mm PERIO N=47 •Atleast 5 sites with PD and CAL ≥6mm
  39. 39. methodology Photos from:clicker.com; tokeyclub.com; christianberdy.com; Colgate.com; clipartlord.com PERIODONTALLY HEALTHY N=20 PERIO N=47 Good Responders N= 30 Refractory Perio N=17 •Show mean attachment loss and/or > 3 sites w/ ≥ 2.5mm HOMIM
  40. 40. HUMAN ORAL MICROBE IDENTIFICATION MICROARRAY
  41. 41. RESULTS •All clinical parameters (except suppuration) were sig.  in perio group vs control •RP showed  mean CAL than GRs
  42. 42. Microbiologic profiles of 3 groups at baseline: Prevalence of Streptococcus species Most species were seen in perio pt 28% of all species/genera/ clones is not seen in PH  perio pathogen in RP
  43. 43. Results Species detected higher in periodontally healthy subjects
  44. 44. Comparison of microbiota in sites that lost attachment vs healthy/gained attachment • S. intermedius/ constellatus, S. anginosus, P. micra, Selenomonas spp, etc are higher in sites losing attachment
  45. 45. Conclusion • Role of species that play in the initiation and /or progression of RP, the effect of periodontal therapy on this unusual microbiota and the interaction between these species and oral microorganism are unknown
  46. 46. Conclusion • Abx may be effective against pathogenic bacteria but may not be effective against unusual species  overgrowth  continuous perio destruction • More studies are needed
  47. 47. DETECTION OF ENTEROCOCCUS FAECALIS IN SUBGINGVIVAL BIOFILM OF PATIENT WITH CHRONIC REFRACTORY PERIODONTITIS • Gajan et al. (2010)
  48. 48. DETECTION OF ENTEROCOCCUS FAECALIS IN SUBGINGVIVAL BIOFILM OF PATIENT WITH CHRONIC REFRACTORY PERIODONTITIS • Aim: to investigate the presence of E. faecalis in subgingival biofilm of patients with chronic refractory periodontal diseases
  49. 49. Enterococcus Faecalis Photo from: microbiologyinpictures.com
  50. 50. Enterococcus Faecalis • Normal human commensals adapted to nutrient- rich, oxygen-depleted and ecologically complex environments • 1 of the top 3 nosocomial bacterial pathogen • strain resistant to antibiotics • Found in 60% of school children with high caries and 75% of pt w/ endodontic infection • Most commonly isolated or detected species from oral infection
  51. 51. methodology Photos from:clicker.com; tokeyclub.com; christianberdy.com; Colgate.com; clipartlord.com 100 non-smoking Chronic periodontitis subjects CLINICAL EXAM •Gingival redness •Suppuration •BOP •PI •PD •CAL Baseline Every 3 mo Scaling and Root planing Modified Widman + Tetracycline 250mg QID for 28 days
  52. 52. methodology Photos from:clicker.com; tokeyclub.com; christianberdy.com; Colgate.com; clipartlord.com 100 non-smoking Chronic periodontitis subjects 73 successful 27 Refractory
  53. 53. methodology Photos from:clicker.com; tokeyclub.com; christianberdy.com; Colgate.com; clipartlord.com 73 successful  get 27 27 Refractory •Mean attachment level gain •No sites w/ CAL >2.5mm after 1 yr of perio therapy •Mean attachment loss and/or >3 sites w/ CAL > 2.5mm after perio therapy culture in blood agar plate to determine presence of E. faecalis
  54. 54. Result Successfully Treated Refractory Periodontitis Age 41.25±1.7 42.45±2.9 Presence of E. faecalis * 11.1% 51.8% * p<0.05
  55. 55. Conclusion • Within the limitations of this study, detection of E. faecalis in refractory sites seem to have a role in pathogenesis of refractory periodontitis • Sound knowledge of pathogen can help develop effective treatment strategies • Patients with refractory are candidates for bacterial culturing
  56. 56. How do We Proceed with Treatment? Photos from: picgif.com
  57. 57. 1. Arrest the disease 2. Slow the progression of disease • Control may not be possible in all instances  just slow the progression Therapeutic Goals
  58. 58. 1. Collection of subgingival microbial samples 2. Selection and administration of an appropriate antibiotic regimen 3. antimicrobial regimen + conventional therapies may be used Treatment Considerations
  59. 59. 4. Re-evaluation with microbiological testing as indicated 5. Identification and attempt to control risk factors (ex. Smoking) 6. Intensified periodontal maintenance program  shorter intervals between appointment with microbiologic testing if indicated Treatment Considerations
  60. 60. 1. Desired outcome is to arrest or control the disease 2. If control is not possible, the treatment objective is to slow the progression of the disease Outcome Assessment
  61. 61. THANK YOU 

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