I am a periodontal specialist. I do not need a microbial test because I have the clinical signs to determine the periodontal problem.
Clinical signs like bleeding on probing and probing depths are indicators that the disease exists are a measurement of the past damage of the disease process. However, they do not show the actual cause which is often the presence of periodontal pathogens but may as well be a systemic disease or medication induced periodontal problems.
As a specialist you will certainly appreciate the problem, but many patients refuse periodontal care and deny the importance of maintaining periodontal health. Patient communication and case acceptance can be more readily achieved because the test elicit a persuasive "seeing is believing" attitude when reviewing test results with patients.
The treatment is always the same. I just give antibiotics.
While periodontitis observed in the context of systemic disease (see 1a) should be considered a manifestation of the systemic disease and does not require specific periodontal treatment.
So clearly there should be different treatment regimens for different types of periodontitis.
What do I do with the PerioPOC results?
The PerioPOC result tells you whether the periodontal problems are caused by bacteria. Moreover, the PerioPOC result also shows you which bacterial species are present.
Some bacterial species such as Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis penetrate periodontal tissues or dentin tubules. Therefore, the use of systemic antibiotics is recommended. Other periodontal pathogens such as Treponema denticola, Tannerella forsythia and Prevotella intermedia can successfully be removed by mechanical treatment.
Dentists should be aware of the increasing problem of antibiotics resistance in bacteria and carefully evaluate the use of broad band antibiotics. PerioPOC evaluation of the bacteria before the treatment start enables individual and targeted treatment, reduce unnecessary use of antibiotics and by that save money, save your patients form side effects and keep up the effectiveness of antimicrobial substances.
I doubt my patients will pay for this test. How can I sell it?
The easiest way to sell PerioPOC is to integrate the analysis in the treatment plan.
Most patients affected by periodontitis do not feel much pain and their own perception is that their teeth are fine. So, communicating the need for periodontal treatment might be difficult. However, almost all patients understand that the presence of bacteria is not a good sign and showing the results can be an excellent convincing argument. Even more so, when mentioning that the disease can be contagious to their spouses or other close family members.
Similarly, patients who have dental implants often feel there is no need to thoroughly clean their artificial teeth. Again, PerioPOC can help patients to understand that the presence of those bacteria can cause implant failure.
In all cases the follow up costs will be much higher than the initial check-up, treatment and maintenance of oral hygiene.
I do not have many periodontal patients. Is it worthwhile introducing PerioPOC in my office?
You probably have more potential clients for PerioPOC than you might think. Approximately 50 % of people above 45 years of age have some periodontal problem. Moreover, there are certain risk groups such as smokers, people whose immune system is somewhat compromised by certain medication such as chemotherapy (cancer patients) or systemic diseases (diabetics).
It has also been shown that periodontal disease may cause infertility in women or induce pre-term birth. So pregnant women and young women who wish to become pregnant should be in the focus of periodontal prophylaxis.
Peri-implantitis is caused by the same bacteria as periodontitis and often periodontitis is the reason for the use of an implant. The success of the dental implant is largely dependent on the maintenance of an inflammation-free oral environment. PerioPOC should be used both for pre-surgical evaluation as well as for regular check-up visits to prevent peri-implantitis.
I used a similar test before, and it was always positive even when the patient had already received a specific periodontal therapy. How can PerioPOC be any better?
PerioPOC was evaluated in a clinical study and has been in use by numerous clinicians across Europe and outside Europe. While the specificity is 100 % for each of the five pathogens the sensitivity is clinically relevant and lies at approx. 10 000 bacteria per test. Even though some bacteria (also pathogenic ones) might be present in healthy subjects PerioPOC does not give false positive results (see clinical study). Moreover, PerioPOC is an assay based on RNA and only detects living bacteria which makes it a perfect tool to monitor the treatment success or to show the maintenance of the periodontal status (no bacterial growth).
Almost all laboratory tests that investigate periodontal pathogens are based on the polymerase chain reaction (PCR) of bacterial DNA. DNA is a very stable molecule that can be detected decades or even centuries after the organism died. Therefore, the PCR methods tend to show positive results even in successfully treated patients.
In the past there were also some saliva tests for chair side testing available. To my knowledge most of them were withdrawn from the market due to bad performance.There is one saliva test for MMP-8 (matrix-metallo-proteinase- 8) which is an unspecific marker for inflammation. The test works quite well. However, it does not give any information on where the inflammation site is and what is causing the inflammation.
How often and in which patient group should I use PerioPOC?
PerioPOC was designed to help you as a dentist to detect periodontal problems at an early stage. Since periodontitis does not usually cause any pain and the shift from a healthy mixed oral microbiome to an overgrowth of pathogenic bacteria might go unnoticed it is important to define you risk group. Similar as in other prophylactic programs people from age 45 years and older should be checked by PerioPOC for their periodontal health on a regular basis (once a year).
I had a patient with very deep dental pockets and clinical attachment loss (CAL). Why did the PerioPOC test not detect any bacteria?
There are several reasons for this result:
If all the controls were valid (including the total germ load, TGL) the actual reason for the CAL might not be the presence of periodontal pathogens but rather a systemic disease or a medication induced condition (e.g. chemotherapy, blood pressure medication).
The bacterial load of the five periodontal pathogens in deep pockets may be below the limit of detection of PerioPOC. Try to sample a nearby site to evaluate the presence of those pathogens.
The paper points might not have reached the base of the dental pocket. Try to sample a less deep nearby site to evaluate the presence of those pathogens.
What are the sensitivities of PerioPOC for the individual bacterial species?
The sensitivities of PerioPOC for the individual species are as follows:
Treponema denticola (T.d.)
Prevotella intermedia (P.i.)
Tannerella forsythia (T.f.)
Aggregatibacter actinomycetemcomitans (A.a.)
Porphyromonas gigivalis (P.g.)
What is the meaning of “sensitivity”?
For in vitro diagnostic assays the term “sensitivity” is one of the most important characteristics of performance. The test sensitivity is the ability to correctly identify the requested parameter (e.g. bacteria or biochemical marker). This is called the true positive rate. From the value of true positives, we can also deduct the false negative rate.
In case of PerioPOC the test was shown to identify 100 % of Aggregatibacter actimomycetemcomtitans correctly. However, 83.8 % of Porphyromonas gingivalis were correctly identified. In other words, in 1.72 cases out of 10 the test would show negative although P.g. bacteria were present.
Essentially, there is no assay that will perform at 100 % for all cases and all parameters. There is always some uncertainty.
What is the difference between the PerioPOC tests and the laboratory tests?
a) Time and opportunity. There is no need to ship the samples to an external lab and wait for the results. You can show the patient their results at their first visit and set up a treatment plan at the same time.
b) Most laboratory tests are highly sensitive DNA-based assays that will detect even traces of periodontal pathogens. While this is generally a great tool it might lead to an “overkill” with inappropriate use of antibiotics, increased side effects due to overtreatment and finally loss of credibility.
c) PerioPOC is based on the detection of living (metabolic active) bacteria. Its higher limit of detection is clinically relevant (steady-state levels vs. infectious state) and prevents false positive results. The 3-level semi-quantitative results of PerioPOC Pro enables the monitoring of your treatment success.