Biofilm infections in urinary tract suggest better dental diagnosis
by Patti DiGangi, RDH, BS
A 56-year-old female with autoimmune thyroid dysfunction, multiple allergies, and sensitivities presented to her gynecologist with the signs and symptoms typical of a recurrent urinary tract infection (UTI). UTIs are the second most common type of infection in the body1 and, like periodontal disease, are frequently treated based on symptoms alone, with antibiotic therapy started before testing is complete.
This particular physician treated many UTIs, so autopilot took control and he ignored the patient's history of multiple allergies, just as oral health professionals can also forget a patient's history when treating periodontal disease. Treating this woman for a UTI without testing could have led to inadequate or inappropriate care. As a proactive, involved patient, this woman questioned the physician's therapeutic recommendations, and this was enough to shock him out of autopilot. He reevaluated the case and altered the course of therapy, making it specific to the patient.
The correct treatment - a specific antibiotic regimen determined by the culture tests and allergy profile - resolved the UTI without creating further problems. Due to the recurrent nature of the infection and the inherent risks of UTIs, the patient returned for follow-up evaluation AND testing. The physician designed the successful, patient-centered strategy (sidebar) through patient input, a full history, and examination, coupled with proper diagnostic and follow-up testing. The same type of treatment strategy is necessary for your patients with periodontal disease. All too often oral health clinicians don't perform diagnostic testing, don't pay enough attention to genetic factors, and don't measure the effectiveness of the treatment. If infection continues or worsens, the patient is blamed.
Other links between UTIs and perio
Like periodontal disease, the UTI is a common, yet serious, health problem that is not limited to any particular age group. A UTI's clinical manifestation depends on the patient's ability to mount an immune response. Physicians treat UTIs with antibacterial drugs, with specific treatment determined by the patient's history and urine tests that identify the offending planktonic bacteria. Sensitivity tests are especially useful in helping physicians select the most effective drug or therapy. This is prudent with the emergence of antibiotic resistance from unnecessary or overused antibiotics.
For example, many people carry or are colonized by staph infection bacteria, yet have no symptoms, and only suffer an infection when they have another illness or wound. Antibiotics were effective against staph for many years, but now methicillin-resistant Staphylococcus aureus has emerged (MRSA)2. There are no widespread findings of resistant bacterial strains in the subgingival microfloral, but that could be just a matter of time. Similar to what almost happened in the example above, oral health-care professionals tend to treat periodontal disease on autopilot without performing appropriate diagnostics.
Diagnostics play a key role
Extensive research and testing systems that use saliva to diagnose systemic diseases - including cancer, cardiovascular, metabolic, and neurological diseases - as well as indicators, markers, and risk indicators of oral disease, are being developed (see sidebar The Diabetic Patient.) But dentistry doesn't have to wait. Dental professionals can resurrect the time-honored basics of saliva diagnosis in products such as Ivoclar Vivadent's saliva agar incubator (ivoclarvivadent.com).
New chairside saliva-based diagnostics also are available, such as GC America's (gcamerica.com) Saliva-Check. Saliva-Check assesses caries risk based on a patient's saliva condition, measuring hydration, resting, stimulated saliva pH, and more. The Saliva-Check Mutans Kit is a rapid detection test for higher levels of Streptococcus mutans that places patients at high risk for caries breakdown. Oral BioTech's CariFree (carifree.com) developed a handheld reader to determine the risk based on a quick, noninvasive swab test indicating the shift in pH that creates the environment for caries.
Risk assessment and genetics
Research indicates many recurrent urinary tract infections3 are biofilm infections, which may explain why the body's defenses and antibiotics don't always cure them. There is extensive research on diagnosing and managing UTIs, yet until recently genetic risk factors haven't received much attention. Just as with the UTI, testing for pathogenic bacteria and genetic risk is appropriate prior to treating a patient's periodontal disease. OralDNA Labs (oraldna.com) offers two saliva-based molecular tests to help identify patients with or at risk for periodontal disease. These molecular tests help professionals diagnose periodontal infections and design tailored treatment plans for each patient, as well as have a mechanism to reassess the treatment's effectiveness. MyPerioPath detects pathogenic species and then determines bacterial load, while MyPerioID PST is a one-time test that determines genetic susceptibility traits: mutations or polymorphisms. It's a good idea to follow up with a second MyPerioPath test after treatment to evaluate therapeutic success.
Chairside salivary testing and laboratory testing should be part of every oral health professional's armamentarium. These are exciting times in the field with a wealth of opportunities for professionals to deliver an enhanced model of true patient-centered care, whether the treatment is for a UTI, caries, or periodontal disease.
Patti DiGangi, RDH, BS, is a vision-driven person who finds strength and direction from her inner convictions. As a life-long learner, her energetic, thought provoking, and successful program development and mind-bending view of what can be shines a bright light for others to preview the future and find their place in it. She is a member of the National Speaker's Association, working toward her Certified Speaking Professional (CSP) credential. She can be reached through her Web site at www.pdigangi.com.What it means to be a patient-centered practice
Patient-centered dental care is the standard of clinical education and part of the standards of clinical practice as defined by both the American Dental Association Commission on Dental Accreditation Standards of Dental Education Programs,4 and the Standards of Clinical Dental Hygiene Practice:5 Patient-centered care that is respectful of and responsive to individual patient preferences, needs, and values can improve clinical outcomes, yet many patients do not feel as though they receive this kind of care. And while many clinicians feel like they pay attention to their patients, they may not be doing enough. It's time to make the shift from treating individual teeth to treating each patient who presents with a problem.6The Diabetic Patient
The diabetes-periodontal connection is well documented. When treating patients with diabetes or at risk for diabetes, a Hemoglobin A1c (also known as glycated hemoglobin or HbA1c) test gives a picture of the patient's average blood glucose control for the previous three months. It is the standard self-monitoring test, and the results give a good idea of how well the patient's treatment plan is working and how well the diabetes is controlled.
Healthy Heart Dentistry (healthyheartdentistry.com) offers in-office diabetes risk assessment tests cleared by the FDA as being substantially equivalent to tests performed in physician's offices and clinical reference laboratories.
With the increase in childhood obesity rates9, Type 2 prediabetic or diabetic conditions10 are common. According to a 2005 Journal of the American Academy of Pediatrics, "Health care professionals are advised to perform the appropriate screening in children at risk for T2DM, diagnose the condition as early as possible, and provide rigorous management of the disease." Healthy Heart Dentistry tests are suitable for pediatric patients.References
- Urinary Tract Infections in Adults. 2005. National Kidney and Urologic Diseases Information Clearinghouse National Institutes of Health of the U.S. Department of Health and Human Services. Available at http://kidney.niddk.nih.gov/Kudiseases/pubs/utiadult/.
- Community Associated MRSA Information for the Public. June 30, 2008. Division of Healthcare Quality Promotion (DHQP) National Center for Preparedness, Detection, and Control of Infectious Diseases. Available at http://www.cdc.gov/ncidod/dhqp/ar_MRSA_ca_public.html.
- Biofilms Inside Bladder Cells May Cause Recurrent Urinary Tract Infections. 2003. Biofilms Online: Montana State University for Biofilm Engineering. Available at http://www.biofilmsonline.com/cgi-bin/biofilmsonline/00159.html.
- American Dental Association Commission on Dental Accreditation Standards of Dental Education Programs. Goals. Revised February 1, 2008. Available at http://www.ada.org/prof/ed/accred/standards/predoc.pdf.
- Standards of Clinical Dental Hygiene Practice. 2007. American Dental Hygienists' Association. Available at http://www.adha.org/downloads/adha_standards08.pdf.
- New Opportunities for Dentistry in Diagnosis and Primary Health Care. 2008 American Dental Education Association. J Dent Educ. 72(2_suppl): 66-72 2008.
- Offenbacher S, Barros SP, Paquette DW, et al. Gingival transcriptome patterns during induction and resolution of experimental gingivitis in humans. J Periodontol. 2009 Dec;80(12):1963-82.
- Wong DT. Salivary diagnostics powered by nanotechnologies, proteomics and genomics. J Am Dent Assoc. 2006 Mar;137(3):313-21. Available at http://jada.ada.org/cgi/reprint/137/3/313.
- Childhood Overweight and Obesity. October 20, 2009. Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion. Available at http://www.cdc.gov/obesity/childhood/index.html.
- Hannon T, Rao G, Arslanian S. Childhood Obesity and Type 2 Diabetes Mellitus. August 1, 2005. PEDIATRICS Vol. 116 No. 2 August 2005, pp. 473-480 (doi:10.1542/peds.2004-2536) Available at http://pediatrics.aappublications.org/cgi/content/full/116/2/473.