Out of the mouths of apes

There are many advantages to living in the Atlanta, Georgia area, despite the hot and humid summers.

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There are many advantages to living in the Atlanta, Georgia area, despite the hot and humid summers. Atlantans are a welcoming and very friendly people, and traditions here abound. Take, for example, our tradition of drive-in fast food. In 1928, The Varsity was founded in downtown Atlanta, and it still welcomes college students in the state with greetings like: “What’ll ya ha-ave?” and a menu consisting of items such as a naked dog (a plain hot dog in a bun) or a bag of rags (potato chips).

We are also home to the Margaret Mitchell Home and Museum where Ms. Mitchell wrote her Pulitzer Prize winning novel, “Gone With The Wind.” Did you know that in her early drafts of the book, the main character, Scarlett, was actually called “Pansy O’Hara?”

In addition to Atlanta’s many wonderful tourist attractions, the city is home to some really unique animal habitats. I’d like to tell you a little bit about one of them. Willie B., a silverback gorilla from Cameroon, Western Africa, arrived in the United States in 1961 and was eventually placed in a natural habitat at the Atlanta Zoo. It took more than 25 years to fund and develop a natural habitat for poor Willie, who had lived for many years in a small cage with a black-and-white TV set.

When Willie entered his new home, he briefly looked it over, then walked to the top of a small hill and claimed it as his own. He was often photographed sitting on top of that hill in solitude. Willie B. died in 2002 at the age of 41 from pneumonia but, while he was alive, he captured the hearts of many Atlantans with his typical gorilla behavior. Read the excerpt below and you will chuckle after reading this funny account:

“Willie B., the darkly handsome bachelor gorilla of Zoo Atlanta, had the pot-bellied, spindly-legged enchantress next door up to his room Tuesday and the result was not exactly a lover’s tryst.

“She (the gorilla next door) chased him a few laps around the room, pummeled him vigorously, and generally put the nation’s most eligible anthropoid to rout. Before the first date was much more than an hour old, the mighty Willie B. was so exhausted from the henpecking that he had to lie down.

“His keepers, however, were delighted that no one was hurt, and the age-old question of where a 400-pound gorilla sits was finally answered scientifically: he sits where his old lady tells him.” (Atlanta Journal Constitution, May 3, 1989)

What I haven’t yet told you about Willie B. is this: (Be prepared for a bit of a shock.) Willie B. had localized aggressive periodontitis! How do I know this bit of trivia (although for us, it’s definitely not trivial!)? I recently had the pleasure of speaking to Dr. Laura Braswell, a periodontist with a thriving practice in the Atlanta area. While Dr. Braswell was a faculty member at Emory University, School of Dentistry, she began conducting periodontal research trials on rhesus monkeys at the Yerkes Regional Primate Research Center, which is affiliated with Emory University.

Eventually, Dr. Braswell began working as a dentist in the Atlanta Zoo, where she treated apes with localized aggressive periodontitis. Even now, she diagnoses severe aggressive periodontitis in apes, which includes chimps, orangutans, and gorillas. When I questioned her on this subject, she indicated that the disease appears to be genetic in nature, very much like it is in humans. Not only did Willie B. have it but, according to Dr. Braswell, some of his children have it, too. She is also looking forward to meeting Willie B.’s grandchildren and, in fact, it has been reported that there are two confirmed pregnancies!

I then asked Dr. Braswell about when she begins to see destruction of the periodontium in apes, and she said that she starts to see some clinical signs of localized aggressive periodontitis around puberty. It presents as vertical alveolar bone defects on the mesial surface of first molars, which is reminiscent of localized or generalized aggressive periodontitis (formerly designated as juvenile periodontitis) in humans.1 According to Dr. Braswell, Willie B., when cultured, had the highest count of Actinobacillus actinomycetemcomitans (A.a) that Emory University School of Dentistry had ever seen!

A.a bacteria is still considered to be strongly associated with locally aggressive periodontitis.1 Since 1999, however, an accumulation of new data has revealed that:

• Other types of bacteria such as P. gingivalis, C. rectus, E. corrodens, and others in the orange and red complex are more strongly associated with aggressive periodontitis than A.a.

• There seems to be little difference in the types of bacteria that are associated with different forms of periodontitis.

• Deep, bleeding pockets (greater than or equal to 6 mm) in patients with periodontitis contain higher counts of bacteria in the orange and red complexes and A.a is not among them.2

Since I had no experience with apes (other than watching Tarzan movies), I also wanted to know if they cleaned their teeth with some type of implement. Dr. Braswell assured me that they picked at their teeth with twigs and with their own fingers.

The aggressive periodontitis that Dr. Braswell has diagnosed in the ape population is associated with rapid attachment loss and bone destruction and minimal visible plaque and calculus. According to the American Academy of Periodontology (AAP), we now know that the presence of visible plaque and calculus does not predict future disease to any useful extent.3 We also know, based on an accumulation of research data, that bacteria are essential but insufficient to cause periodontal disease, whatever the type.4

OK, I’ll explain what I am trying to say in another way. The subgingival microbiota (let’s call them pocket gumbugs) are different in healthy and periodontitis patients. We also know that a periodontal disease such as localized aggressive periodontitis is initiated by the invading pocket gumbugs, but it is not clear whether the disease progresses because of some change in the types of bugs that live in the pocket, or by a change in the gumbugs’ habitat or dwelling place. Just think of the many changes that could take place in a gumbug’s habitat, e.g., the dumb human being starts smoking (where is the smoke alarm when you need it?), or the unlucky host develops diabetes. Perhaps the human inherited lousy periodontal disease-related genes and is a sloppy housekeeper (poor oral hygiene). In the case of locally aggressive periodontitis, which sometimes begins at puberty, perhaps the young human’s immune system, for whatever reason, cannot fight the invading organisms and provides the ideal habitat for the invading gumbugs. The interplay of genetic, host, and various environmental factors go on and on.

Once my curiosity with gorillas was satisfied, I decided to ask Dr. Braswell about her nonsurgical treatment approach to humans with localized aggressive periodontitis. In treating humans, she emphasizes immaculate plaque control, and she especially likes interdental brushes. In the ape population, she commonly prescribes a 20-mg tablet form of doxycycline hyclate along with a local antimicrobial agent such as minocycline microspheres or doxycycline hyclate.

She joked with me about placing a local antimicrobial agent during initial scaling and root planing in apes because, as she says, “We know that they (apes) won’t floss, just like many of our patients!” She strongly believes in thoroughly cleaning and disinfecting the periodontal pockets and making sure that they are stable before considering any type of periodontal surgery.


Pearlee White tries to convince Willie B. that picking with sticks and leaves is just not enough. She is sure he could floss if he tried, after all he does have opposable thumbs!
Click here to enlarge image

Dr. Braswell and I also discussed the need for early referral for cases of localized or aggressive periodontitis. She believes that it is very important to culture these patients’ pockets, too, which she does routinely and sends bacterial cultures to Temple University for testing.

Dr. Braswell selects a systemic antibiotic based on culture results to maximize the effectiveness of the antibiotic regimen. In addition, she wants to develop an ongoing relationship with a client who presents with aggressive periodontitis and likes to coordinate treatment with the referring hygienist and dentist.

Kudos to Dr. Laura Braswell whose fascination with and devotion to exotic animals led her to treating gorillas with aggressive periodontitis. Dr. Braswell keeps up with her apes in interesting ways and even has a file drawer with various files on gorilla babies, their birthdays, and other ape trivia. I’ll bet there are hygienists out there who treat apes or other exotic animals like Dr. Braswell does. If so, please e-mail me or Mark Hartley, the magazine’s editor, so that you, too, can tell your unique story to RDH readers.

References

1. American Academy of Periodontology. Annals of Periodontology. 1999 International Workshop for a Classification of Periodontal Diseases and Conditions. December 1999. p. 53.

2. Microbiology of periodontal diseases: pathogens, virulence and ecology. Periodontology 2000 2005; 38: 9-182.

3. American Academy of Periodontology. Academy Report. Epidemiology of periodontal diseases; 76(8): 1406-1413.

4. American Academy of Periodontology. Academy Report. Implications of genetic technology for the management of periodontal diseases; 76(5): 850-857.

Lynne H. Slim, RDH, BSDH, MSDH, is a practicing hygienist/periodontal therapist who has more than 20 years experience in both clinical and educational settings. She is also President of Perio C Dent Inc. (Perio-Centered Dentistry), a practice management consulting firm that specializes in creating outstanding dental hygiene teams. Lynne is a member of the Speaking and Consulting Network (SCN) that was founded by Linda Miles and has won two first place journalism awards from ADHA. Lynne is also owner/moderator of a periodontal therapist yahoo group: http://yahoogroups.com/group/periotherapist. She can be contacted at periocdent@mindspring.com.

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