journal of dental hygiene - american dental...

Vol. 85 No. 4 Fall 2011 The Journal of Dental Hygiene 239

Treating Aggressive PeriodontitisOralHealthLiteracyintheDentalOffice:TheUnrecognizedPatientRisk

FactorDentalDiagnostics:MolecularAnalysisofOralBiofilmsDiabetesandOralHealth:TheImportanceofOralHealthRelatedBehaviorUseofComplementaryandAlternativeMedicineforWorkRelatedPain

CorrelatesWithCareerSatisfactionAmongDentalHygienistsCaliforniaDentalHygienistsKnowledge,AttitudesandPracticesRegarding

HerbalandDietarySupplementsComparisonofDentalHygieneClinicalInstructorandStudentOpinionsof

ProfessionalPreparationforClinicalInstructionOralHygieneKnowledgeandPracticeAmongDinkaandNuerfromSudan

totheU.S.AssessmentoftheUniversityofMichigansDentalHygienePartnershipwith

theHuronValleyBoys&GirlsClub:AStudyofStudentsandStaffs PerceptionsandServiceLearningOutcomes

FactorsAffectingthePerformanceofOralCancerScreeningsbyTexas Dental Hygienists

PredictingNationalDentalHygieneBoardExaminationSuccessBasedon SpecificAdmissionFactors

FinancialManagementPracticesandAttitudesofDentalHygienists:A DescriptiveStudy

RepetitiveCoronalPolishingYieldsMinimalEnamelLoss

Journalof

DentalHygiene

The AmericAn DenTAl hygienisTs AssociATion

FAll 2011 Volume 85 number 4

240 The Journal of Dental Hygiene Vol. 85 No. 4 Fall 2011

Journal of Dental HygieneVOLUME85NUMBER4FALL2011

CelesteM.Abraham,DDS,MSCynthiaC.Amyot,BSDH,EdDJoannaAsadoorian,AAS,BScD,MScCarenM.Barnes,RDH,BS,MSPhyllisL.Beemsterboer,RDH,MS,EdDStephanieBossenberger,RDH,MSLindaD.Boyd,RDH,RD,LS,EdDKimberlyS.Bray,RDH,MSLorraineBrockmann,RDH,MSPatriciaRegenerCampbell,RDH,MSDanCaplan,DDS,PhDMarieCollins,RDH,EdDBarbaraH.Connolly,PT,EdD,FAPTAValerieJ.Cooke,RDH,MS,EdDMaryAnnCugini,RDH,MHPSusanJ.Daniel,AAS,BS,MSMicheleDarby,BSDH,MSCatherineDavis,RDH,PhD.FIDSAJaniceDeWald,BSDH,DDS,MSSusanDuley,BS,MS,EdS,EdD,LPC,CEDSJacquelynM.Dylla,DPT,PTKathyEklund,RDH,BS,MHPDeborahE.Fleming,RDH,MSJaneL.Forrest,BSDH,MS,EdD

JacquelynL.Fried,RDH,BA,MSMaryGeorge,RDH,BSDH,MEdKathyGeurink,RDH,BS,MAJoanGluch,RDH,PhDMariaPernoGoldie,RDH,BA,MSEllenGrimes,RDH,MA,MPA,EdDJoAnnR.Gurenlian,RDH,PhDLindaL.Hanlon,RDH,BS,MEd,PhDKittyHarkleroad,RDH,MSLisaF.HarperMallonee,BSDH,MPH,RD/LDHaroldA.Henson,RDH,MEdLauraJansenHowerton,RDH,MSOlgaA.C.Ibsen,RDH,MSMaryJacks,MS,RDHHeatherL.Jared,RDH,BS,MSWendyKerschbaum,RDH,MA,MPHSalmeLavigne,RDH,BA,MSDHJessicaY.Lee,DDS,MPH,PhDMadeleineLloyd,MS,FNPBC,MHNPBCDeborahLyle,RDH,BS,MSDeborahS.Manne,RDH,RN,MSN,OCNAnnL.McCann,RDH,BS,MS,PhDStacyMcCauley,RDH,MSGayleMcCombs,RDH,MS

TriciaMoore,RDH,BSDH,MA,EdDChristineNathe,RDH,MSKathleenJ.Newell,RDH,MA,PhDJohannaOdrich,RDH,MS,DrPhPamelaOverman,BSDH,MS,EdDVickieOverman,RDH,BS,MEdFotinosS.Panagakos,DMD,PhD,MEdM.ElaineParker,RDH,MS,PhDCeibPhillips,MPH,PhDMarjorieReveal,RDH,MS,MBAPamelaD.Ritzline,PT,EdDJudithSkeleton,RDH,BS,MEd,PhDAnnEshenaurSpolarich,RDH,PhDSherylL.ErnestSyme,RDH,MSTerriTilliss,RDH,BS,MS,MA,PhDLynnTolle,BSDH,MSMargaretWalsh,RDH,MS,MA,EdDDonnaWarrenMorris,RDH,MS,MEdCherylWestphal,RDH,MSKarenB.Williams,RDH,PhDCharlotteJ.Wyche,RDH,MSPamelaZarkowski,BSDH,MPH,JD

EDitorial rEviEw BoarD

The Journal of Dental Hygiene is the refereed, scientificpublicationoftheAmericanDentalHygienistsAssociation.Itpromotesthepublicationoforiginalresearchrelatedtotheprofession,theeducation,andthepracticeofdentalhygiene.The journal supports the development and disseminationof a dental hygiene body of knowledge through scientificinquiryinbasic,applied,andclinicalresearch.

StatEmEnt of PurPoSE

Please submit manuscripts for possible publication in theJournal of Dental [email protected].

SuBmiSSionS

The Journal of Dental Hygieneispublishedquarterlyonlineby the American Dental Hygienists Association, 444 N.Michigan Avenue, Chicago, IL 60611. Copyright 2010 bytheAmericanDentalHygienistsAssociation.Reproductioninwhole or partwithoutwritten permission is prohibited.Subscriptionratesfornonmembersareoneyear,$45;twoyears,$65;threeyears,$90;freeformembers.

SuBSCriPtionS

SandraBoucherBessent,RDH,BSJacquelineR.Carpenter,RDHMaryCooper,RDH,MSEdHeidiEmmerling,RDH,PhDMargaretJ.Fehrenbach,RDH,MSCathrynL.Frere,BSDH,MSEd

PatriciaA.Frese,RDH,BS,MEdJoanGibsonHowell,RDH,MSEd,EdDAnneGwozdek,RDH,BA,MACassandraHolderBallard,RDH,MPALynneCarolHunt,RDH,MSShannonMitchell,RDH,MS

KipRowland,RDH,MSLisaK.Shaw,RDH,MSMargaretSix,RDH,BS,MSDHRuthFearingTornwall,RDH,BS,MSSandraTuttle,RDH,BSDHJeanTyner,RDH,BS

BooK rEviEw BoarD

ExECutivE DirECtorAnnBattrell,RDH,BS,[email protected]

DirECtor of [email protected]

EDitor EmErituSMaryAliceGaston,RDH,MS

EDitorinCHiEfRebeccaS.Wilder,RDH,BS,[email protected]

Staff [email protected]

layout/DESignJoshSnyder

PrESiDEntPamelaQuinones,RDH,BS

PrESiDEntElECtSusanSavage,RDH,BSDH

viCE PrESiDEntDeniseBowers,RDH,MSEd

trEaSurErLouannM.Goodnough,RDH,BSDH

immEDiatE PaSt PrESiDEntCarynSolie,RDH

2010 2011 aDHa offiCErS


insideJournal of Dental HygieneVol.85No.4Fall2011

features

Departments 242 Editorial

Research

244 treating aggressive Periodontitis DeniseM.Bowen,RDH,MS

248 OralHealthLiteracyintheDentalOffice:TheUnrecognizedPatient risk factor JulieH.Schiavo,MLIS,AHIP

256 DentalDiagnostics:MolecularAnalysisofOralBiofilms SarahHiyari,MS;KatieM.Bennett,PhD

264 DiabetesandOralHealth:TheImportanceofOralHealthRelated Behavior PreethaP.Kanjirath,BDS,MDS,MS;SeungEunKim,DDS; MaritaRohrInglehart,Dr.phil.habil.273 use of Complementary and alternative medicine for workrelated Pain Correlates with Career Satisfaction among Dental Hygienists AubreChismark,RDH,MS;GaryAsher,MD,MPH;MargotStein,PhD; TabithaTavoc,RDH,PhD;AliceCurran,DMD,MS285 California Dental Hygienists Knowledge, attitudes and Practices regarding Herbal and Dietary Supplements MichelleHurlbutt,RDH,MSDH;KimberlyBray,RDH,MS; TanyaVillalpandoMitchell,RDH,MS;JoniStephens,EdS,RDH297 Comparison of Dental Hygiene Clinical instructor and Student opinions of Professional Preparation for Clinical instruction MarieR.Paulis,RDH,MSDH306 oral Hygiene Knowledge and Practice among Dinka and nuer from Sudan to the u.S. MaryS.Willis,PhD;RachelM.Bothun,BS316 assessment of the university of michigans Dental Hygiene PartnershipwiththeHuronValleyBoys&GirlsClub:AStudyof Students and Staffs Perceptions and Service learning outcomes SarahChristensenBrydges,RDH,BSDH;AnneE.Gwozdek,RDH,BA,MA326 factors affecting the Performance of oral Cancer Screenings by texas Dental Hygienists JaneC.Cotter,RDHBS;AnnL.McCann,RDH,PhD; EmetD.Schneiderman,PhD;JaniceP.DeWald,DDS; PatriciaR.Campbell,RDHMS335 Predicting national Dental Hygiene Board Examination Success BasedonSpecificAdmissionFactors LynnD.Austin,RDH,MPH,PhD340 FinancialManagementPracticesandAttitudesofDentalHygienists:A Descriptive Study KatherineRussell,RDH,MS;SandraStramoski,RDH,MSDH348 repetitive Coronal Polishing yields minimal Enamel loss SandraD.Pence,MS,RDH;DoyleA.Chambers,DMD; IanG.vanTets,PhD;RandallC.Wolf,DDS;DavidC.Pfeiffer,PhD

Critical Issues in Dental Hygiene

Review of the Literature

Linking Research to

Clinical Practice


Editorial

AlargenumberofindividualshavecontributedtomakingthispastyearalandmarkyearfortheJournalofDentalHygiene.Wesuccessfullymadethetransitiontoanonline-onlyformatand,onceagain, we have broken our previous record forthemostsubmissionsinasingleyear!Wehavealotofpeopletothankforthesuccesswehaveenjoyedthisyear.Ofcourse,noneofthiswouldbepossiblewithout theenergy,diligence, com-mitment and enthusiasm from a large numberof ADHAmembers and other professionalswhomakethepublicationpossible.

I wish to gratefully acknowledge the supportandvaluablecontributionsoftheAmericanDen-talHygienistsAssociationfortheircommitmentto the Journal and for recognizing the value ofscholarshiptothegrowthoftheprofession.Spe-cifically,IwishtothankourJournalStaffEditor,JoshSnyder forhisattention todetailandpro-

fessional manner. Also, thanks to Ann Battrell,ExecutiveDirector,andJeffMitchell,DirectorofCommunications, for their support and leader-shipattheADHA.

Weareproudofthepeerreviewprocessandthequalitypublicationsthatculminatefromtheeffortsoftheeditorialreviewboardandtheotheracademicianswhoassistuswithqualityreviews.These volunteers, whether regularmembers orguest reviewers,makeourpublicationone thatallofuscanbeproudofaswestrivetocontinu-ouslygrowourbodyofknowledge.

ThankYou!

Sincerely,

RebeccaWilder,RDH,BS,MSEditorinChief,JournalofDentalHygiene

ThankYou!RebeccaWilder,RDH,BS,MS

CelesteM.Abraham,DDS,MSCynthiaC.Amyot,MSDH,EdDJoannaAsadoorian,AAS,BScD,MScCarenM.Barnes,RDH,MSPhyllisL.Beemsterboer,RDH,MS,EdDStephanieBossenberger,RDH,MSLindaD.Boyd,RDH,RD,EdDKimberlyS.Bray,RDH,MSColleenBrickle,RDH,RF,EdDLorraineBrockmann,RDH,MSPatriciaRegenerCampbell,RDH,MSDanCaplan,DDS,PhDMarieCollins,RDH,EdDBarbaraH.Connonlly,DPT,EdD,FAPTAValerieJ.Cooke,RDH,MS,EdD,MEdMaryAnnCugini,RDH,MHPSusanJ.Daniel,BS,MSMicheleDarby,BSDH,MSDHJaniceDeWald,BSDH,DDS,MSSusanDuley,EdD,LPC,CEDS,RDH,EdSJacquelynM.Dylla,DPT,PTKathyEklund,RDH,MHPDeborahE.Fleming,RDH,MS

JournalofDentalHygieneEditorialReviewBoardJaneL.Forrest,BSDH,MS,EdDJacquelynL.Fried,RDH,MSMaryGeorge,RDH,BSDH,MEdKathyGeurink,RDH,MAJoanGluch,RDH,PhDMariaPernoGoldie,RDH,MSEllenB.Grimes,RDH,MA,MPA,EdDJoAnnR.Gurenlian,RDH,PhDLindaL.Hanlon,RDH,PhD,BS,MEdKittyHarkleroad,RDH,MSLisaF.HarperMallonee,BSDH,MPH,RD/LDHaroldA.Henson,RDH,MEdLauraJansenHowerton,RDH,MSOlgaA.C.Ibsen,RDH,MSMaryJacks,RDH,MSWendyKerschbaum,BS,MA,MPHSalmeLavigne,RDH,BA,MSDHJessicaY.Lee,DDS,MPH,PhDDeborahLyle,RDH,BS,MSDeborahS.Manne,RDH,RN,MSN,OCNAnnL.McCann,RDH,MS,PhDStacyMcCauley,RDH,MSGayleMcCombs,RDH,MS


TanyaVillalpandoMitchell,RDH,MSTriciaMoore,RDH,BSDH,MA,EdDChristineNathe,RDH,MSKathleenJ.Newell,RDH,PhDJohannaOdrich,RDH,MS,PhD,MPHPamelaOverman,BS,MS,EdDVickieOverman,RDH,MEdFotinosS.Panagakos,DMD,PhDM.ElaineParker,RDH,MS,PhDCeibPhillips,MPH,PhDMarjorieReveal,RDH,MS,MBAKathiR.Shepherd,RDH,MSDeanneShuman,BSDH,MSPhD

JudithSkeleton,RDH,BSDH,MEd,PhDAnnEshenaurSpolarich,RDH,PhDRebeccaStolberg,RDH,BS,MSDHSherylL.ErnestSyme,RDH,MSTerriTilliss,RDH,PhDLynnTolle,BSDH,MSMargaretWalsh,RDH,MS,MA,EdDDonnaWarren-Morris,RDH,MEdCherylWestphal,RDH,MSKarenB.Williams,RDH,MS,PhDNancyWilliams,RDH,EdDCharlotteJ.Wyche,RDH,MSPamelaZarkowski,BSDH,MPH,JD

GuestReviewers,2011RolandArnold,PhDJenniferBrame,RDH,MSCharlesCobb,DDSLouisG.Depaola,DDS,MSTerryDonovanDDSSalNares,DDS,PhDRicardoPadilla,DDS

DavidPaquette,DMD,PhDLaurenPatton,DDSRocioQuinonez,DMD,MPH,MSAndreRitter,DDS,MSMariaRyan,DMD,PhDRoseD.Sheats,DMD,MPHEdwardSwift,DDS,MS


LinkingResearchtoClinicalPractice

GriffithsGS,AyobR,GuerroroA,etal.Amox-icillin and metronidazole as an adjunctivetreatment in generalized aggressive perio-dontitis at initial therapy or retreatment:arandomizedcontrolledclinical trial.JClinPeriodontol.2011;38(1):4349.

Background: Previously, we showed that sys-temicmetronidazole and amoxicillin significantlyimprovedtheoutcomesofnonsurgicaldebride-ment ingeneralizedaggressiveperiodontitis pa-tients.Thisstudyaimedtoobservewhetherretreatment with adjunctive antimicrobials wouldgivetheplacebogroupbenefitscomparablewiththetestgroup.

Methods: Thirtyeight of 41 subjects, from theinitial6monthtrial,completedthesecondphase,theretreatmentofsiteswithremainingpocketsof5mm.Subjectsonplaceboinphase1receivedadjunctiveantibiotics for7days.Clinicalparam-eterswerecollectedat2monthsposttreatment(8monthsfrombaseline).

Results:Patientswhoreceivedantibioticsatini-tial therapy showed statistically significant im-provement inpocketdepth reductionand in thepercentage of sites improving above clinicallyrelevantthresholds,comparedwithpatientswhoreceived antibiotics at retreatment. In deeppockets (7 mm), the mean difference was 0.9mm(p=0.003)and inmoderatepockets(4to6mm)itwas0.4mm(p=0.036).Pocketsconvert-ingfrom5to4mmwas83%comparedwith67%(p=0.041), and pockets converting from 4 to 3mmwas63%comparedwith49%(p=0.297).

Treating Aggressive Periodontitis

DeniseM.Bowen,RDH,MS

the purpose of linking research to Clinical Practice is to present evidence based information to clinical dental hygienists so that they can make informed decisions regarding patient treatment and recommendations. Each issue will feature a different topic area of importance to clinical dental hygienists with a Bottom linE to translatetheresearchfindingsintoclinicalapplication.

Conclusion:At8months,patientswhohadan-tibioticsatinitialtherapyshowedstatisticallysig-nificant benefits compared with those who hadantibioticsatretreatment.

Commentary

Current classifications of periodontal diseasesweredevelopedatthe1999WorldWorkshopfortheClassificationofPeriodontalDiseasesandCon-ditions.1Aggressiveperiodontitis,formerlyknownas earlyonset periodontitis/rapidly progressiveperiodontitis/juvenile periodontitis, was definedasrapidattachmentlossandbonedestructioninotherwisehealthyindividuals,withafamilialpat-ternandmicrobialdepositsthatare inconsistentwithseverityof tissuedestruction.The localizedformoccurs around puberty and affects incisorsandfirstmolars. The generalized formoften af-fectspeopleunder30yearsofage,butpatientsmaybeolder.Ingeneralizedaggressiveperiodon-titis(GAgP),generalizedinterproximalattachmentlossaffectsatleast3permanentteethotherthantheincisorsandfirstmolars.Invasiveperiodontalpathogens, neutrophil abnormalities and a poorserumantibodyresponseto infectingagentsarefrequently identified. These characteristics pro-vide the impetus for consideration of adjunctiveantimicrobialsinthetreatmentofaggressiveperi-odontitis.2

In a previous study, these authors concludedthata7day regimenof systemicmetronidazoleandamoxicillin (500mgeach,3 timesperday)significantly improved clinical outcomes of nonsurgicaldebridementinsubjectswithGAgPwhenadministered in conjunction with initial therapy.


Thosefindingshavebeenreplicatedinotherstud-ies of initial therapy forGAgP. The focus of thisstudywastoassesswhethersystemicantibioticsin conjunctionwith fullmouth root surfacedeb-ridement (FMRSD) improve periodontal diseaseparameters better than FMRSD with a placeboinpatientswithGAgPwhenadministeredat retreatment.

Severalquestionsariseaboutthisdesign.Whywould the researcherswant to test theantibiot-icsatretreatmentiftheyknewthattheregimenwaseffectiveininitialtherapy?Whyareantibiot-ics considered in treatmentofGAgPandnot fortreatment of chronic periodontitis? How does aclinicianknowwhentoincludesystemicantibiot-icsinatreatmentplanfornonsurgicalperiodontaltherapy?

Research findings indicate that FMRSD forchronicperiodontitisiseffectivewithoutprescrib-ingantibioticsasadjuncts.Unnecessaryuseofan-tibiotics is also discouraged due to concerns about developmentofresistantstrainsofpathogensren-deringdrugs ineffective,risksandadversereac-tionsandcost.Asaresult,mostcliniciansattemptinitialtherapyforperiodontitiswithoutantibioticsandconsidertheiruseatreevaluationifitisde-terminedthatFMRSDwasineffective.

The researchers had previously treated onegroupofsubjectswithoutantibiotics.Theseindi-vidualscouldserveasthegroupreceivingantibi-oticsatretreatmentinphase2,andthosesubjectswhoreceivedantibioticsinthefirsttrialwouldre-ceiveFMRSDalone.Althoughtherewasimprove-ment inmost subjects after phase 1, siteswith5mmpocketsremained.Thefirstphaseofthestudyincludedinitialtherapywith2and6monthfollowups, and this study was implemented 2months later at reevaluation. Nineteen subjectsin each group entered the second phase of thestudy. The authors reported, based on a poweranalysis,that17subjectsineachgroupwouldbeanadequatesamplesizeforpowerneededtode-tectadifferenceof1mminpocketdepth(indeeppockets7mm),assuming1mmvariationisnor-mal.Thesamplesizeisonlyoneofseveralfactorsinassuringthereisenoughpowertodetectadif-ferenceinoutcomesifoneexists,andgenerallyalargersampleincreasesstatisticalpower.Currentguidelines for reportingclinical trials requireau-thorstoreportthisinformation.

Results indicated that antibiotics administeredatinitialtherapyweremoreeffectivethanadmin-istrationofthesameantibioticsatreevaluationbasedonpocketdepthreductionandpercentage

of sites that improved above clinically relevantthresholds. In periodontal therapy studies, it isimportanttodeterminewhetherresultsareclini-cally relevant or just statistically significant. Forexample, a statistically significant reduction of0.5mminpocketdepthsfrom7mmto6.5mmwouldnotprovideagoodprognosisforhealth.Aclinicianwouldnotwanttoadopttheinterventionfortheirpatients,eventhoughastudymayhavefoundasignificantdifference.Theseresearchersconducted an analysis to identify reductions in pocketsby2mmorreductionsinthenumberofpockets that would require additional treatment(5mmto4mmor4mmto3mm).Theseparameters represent criteria used in practiceto assess success of periodontal therapy at reevaluation. Findings from a comparison of bothgroups indicated that, in deep pockets (7mm),the mean difference in probing depth reductionwas0.9mm(p=0.003),andinmoderatepockets(4to6mm)itwas0.4mm(p=0.036).Forpock-etsconvertingfrom5mmto4mm,thegroupreceivingantibioticsatinitialtherapyhad83%ofsitesimprovedcomparedwith67%(p=0.041)atreevaluation.Forpocketsconvertingfrom4mmto 3 mm reduction, the percentage was 63%comparedwith49%(p=0.297).Theauthorsalsoreported a high incidence (42%) of adverse ef-fectsfromthemedicationwiththemajoritybeingminor such as mild nausea, vomiting, diarrhea,metallictasteorheadache.Theserisksneedtobeweighedagainsttheadvantagesofusingsystemicantibiotics in periodontal therapy, thereby rein-forcingtheirpotentialuseinGAgPcasesandnotinchronicperiodontitiscases.It is interestingtonotethatnoneofthepossiblesideeffectsof0.2%chlorhexidinemouthrinsewerereported,possiblybecausethesubjectsonlywererequiredtouseitfor2weeksfollowingthedebridement.

Although a statistically significant differencein pocket depth reduction was found from 0 to8months, itwas found inbothgroups,perhapsbecausebothgroupshadbeenexposed toanti-bioticsatsomepointintherapy.Themaineffectwasfoundinphase1(0to6months)whenan-tibiotics were administered with initial therapy.These findings would not support the commonapproachofdeliveringinitialtherapyandwaitingto see if itworkedbeforeprescribingantibioticsinpatientswithGAgP.Prescribingamoxicillinandmetronidazole(500mgeach,3timesaday)withFMSRDismoreeffectivewhenadministeredwithinitial therapy. A careful periodontal assessmentwith consideration of all criteria for an accurateperiodontal disease classification is indicated forappropriatecareplanning.


varela vm, Heller D, Silva mx, torres mC, Co-lombo aP, feresfilho EJ. Systemic antimicro-bialsadjunctivetoarepeatedmechanicalandantiseptic therapy for aggressive periodonti-tis:a6monthrandomizedcontrolledclinicaltrial.JPeriodontol.2011;82(8):11211130.

Background: The purpose of this study is tocomparetheadditionalbenefitofsystemicantimi-crobialsversusplacebostoarepeatedmechanicalinstrumentationcombinedwithcomprehensivelocalchemical plaque control for the periodontal treat-mentofGAgP.

Methods: This was a 6 month, randomized,doublemasked,placebocontrolledclinicaltrial.AllGAgPpatientsreceivedfullmouthdisinfectionfol-lowed by staged scaling and root planingwithout(placebogroup,n=17)orwith (test groupn=18)systemicantimicrobials(500mgamoxicillin[AMX]+250mgmetronidazole[MET],3timesadayfor10days).Clinicalparametersweremeasuredatbase-lineand3and6monthsposttherapy.SignificantdifferencesbetweengroupsatbaselineweresoughtbyusingtheMannWhitneyUtest,whereascom-parisonsovertimewereexaminedbyusingagen-erallinearmodelrepeatedmeasuresprocedure.

Results:Bothgroupsdemonstratedsimilar im-provements in most parameters over time. Thetestgrouppresentedagreatermeanprobingdepthreductionandclinicalattachment level (CAL)gainatsiteswith initiallymoderateprobingdepthat6months(p4mmat3months (p

Vol. 85 No. 4 Fall2011 TheJournalofDentalHygiene 247

the Bottom lineSummary

Each of these studies addressed the adjunctiveuse of antibiotics in patientswithGAgP. Althoughthis classification of periodontitis is less commonthanchronicperiodontitis,prevalencehasbeenes-timated to be 2% forGAgP and 4% for localizedaggressiveperiodontitisinindividualsbetweentheages of 18 and 30 years.3

Bothofthesestudiesprovidesupportforuseofsystemicantibioticsintheinitialnonsurgicaltreat-mentofGAgP.Bothauthorsalsoemphasizetheim-portanceofprudentuseofantibioticsinperiodon-taltherapybecauseofconcernsaboutsideeffects/adversereactions,developmentofresistantstrainsrenderingtheantibioticsineffectiveandcost.Basedonthefindingsofthesestudies,thefollowingcon-clusionscanbedrawn:

ForpatientswithGAgP,adjunctivetherapywithsystemic antibiotics (500 mg amoxicillin and500mgmetronidazole,3timesadayfor7or10days)withnonsurgicalperiodontaltherapy(fullmouth debridement, scaling and root planing)results in greater reduction of pocket depthsandclinicalattachmentgainsinmoderatepock-ets(4to6mm)whencomparedtononsurgicalperiodontaltherapyalone.Forpockets7mm,thisimprovementwasfoundat6monthsinonestudy,anddetectedonlyat3monthsinanother.Deeppocketsshouldbereferredforperiodontal

Evidencepresentedinthiscolumnindicatesthatadjunctiveantibioticsshouldbeconsideredintreat-mentplansforGAgP,despitethefactthattheyarenot recommended for initial treatment of chronicperiodontitis.Bothof these studieswerewellde-signedandprovidesupportfordentalhygieniststoalternormalcareplanningandtreatmentconsider-ationsforGAgPcases.

Denise M. Bowen, RDH, MS, is Professor Emerita in Dental Hygiene at Idaho State University. She has served as a consultant to dental industry, as well as numerous government, university and private organizations and presently is a member of the National Advisory Panel for the National Center for Dental Hygiene Research in the U.S.

any adverse effects. Several of the sideeffectsalsocouldbeattributedtothelongtermCHXusein thisstudyascomparedto the2weekregimenusedposttherapyintheformerstudy.Sideeffectsincludedoralulcerations,metallic taste,dizziness,nausea, diarrhea, tongue staining, teeth staining,taste alterations and mouth burning. The lowerdoseofMETwas intended to reduce sideeffects;however,theauthorsnotethatitispossiblethatthe250mgofMET3timesadayislesseffectivethanatahigherdosage,andcouldexplaintheminimaleffectinthetestgroupinthisstudy.

TheconclusiondrawnbytheauthorswasthattheuseofAMXandMETbroughtsomeadditionalclini-calbenefitstorepeatedSRPandantiseptictherapyforGAgPintheshortterm(3months),whichhadatendencytodisappearat6months.Thisconclusionisrelatedtotheauthorsidentifiedprimaryoutcomemeasureofdeeppockets(7mm)andtheclinicallyrelevantmeasureswhich included the percentageofsitesreducedby2mmorreducedto4mm.Itdoesnotdrawaconclusionaboutthemoderatepockets(4mmto6mm)whichdidmaintainsuc-cessfulreductionsat6months.

surgery. Systemic antibiotics added a benefit,especiallyinthemoderatecategoriesofprobingdepthandCAL.

Adjunctive systemic antibiotic therapy ismoreeffectivewhenadministeredwithinitialnonsur-gical periodontal therapy than when adminis-tered at reevaluation.

A thorough periodontal examinationwith con-sideration given to characteristics of aggressive periodontitisshouldbeperformedforallpatientsbetweentheagesof18and30years.Boneandattachmentlossinthemandibularincisorsandfirstmolars,aswellas3othersites,presenceofdepositsinconsistentwithdegreeofattachmentlossandafamilialpatternsuggestaclassifica-tionofGAgP.WhenGAgPisfound,consultationwiththedentistorperiodontistandtheadjunc-tive use of antibiotics should be considered in conjunctionwith initial nonsurgical periodontaltherapyratherthanwaitingtoseeifperiodontaldebridement/scaling/root planing alonewill beeffective at reevaluation.

references

Armitage GC. Development of a classification1. systemforperiodontaldiseasesandconditions.Ann Periodontol.1999;4(1):16.

Parameter on aggressive periodontitis. Ameri-2. canAcademy of Periodontology. J Periodontol. 2000;71(5Suppl):867869.

Demmer RT & Papapanou PN. Epidemiologic3. patternsofchronicandaggressiveperiodontitis.Periodontology 2000.2010;53:2844.

http://www.ingentaconnect.com/content/external-references?article=0022-3492(2000)71L.867[aid=8760943]http://www.ingentaconnect.com/content/external-references?article=0022-3492(2000)71L.867[aid=8760943]


introduction

Dental hygienists devote a large portionoftheirtimetoeducatingpa-tientsabouttheiroralhealth,dentalproceduresandpreventivemeasurestoencouragebetterhabits, increasetreatment success and assuage pa-tientfears.Clearcommunicationisavitalfactorinpatienteducation,butapatientshealthliteracyisalsoimpor-tantandoftenoverlookedbydentalhealth care professionals. Adequatehealth literacy enables patients tobecomeanactivepartof thedentalhealthcareprocessandtoactintheirownbestinterests.MillionsofAmeri-can adults, who are unable to readdentalpatienthealthorinsurancein-formation,areunableorunwillingtoadmit this deficit. A patients healthliteracy level can have farreachingand often surprising consequences.Researchhasshownthatliteracyskillspredict an individuals health statusmorestronglythanage,income,em-ploymentstatus,educationlevelandracial or ethnic group.1 Themodernhealth care system makes an unprecedented de-mandonpatientsliteracyskills.Tosuccessfullyne-gotiatethroughthesystem,patientsareexpectedtofindmoreinformationontheirown,understandandacceptnewrightsandresponsibilitiesandmakede-cisionsforthemselvesandothers.2 Dental hygienists areinauniquepositiontohelppatientswithloworalorgeneralhealthliteracy,thusempoweringthemtotakeanactiveroleintheiroralhealthcare.

Health literacy is not only the ability to read but includes the skills necessary to decipher dosagecharts, understand appointment slips, understanddoctorsdirectionsandcompletemedical,dentalorinsuranceforms.Improvedconsumerhealthliteracy

OralHealthLiteracyintheDentalOffice:TheUnrecognizedPatientRiskFactor

JulieH.Schiavo,MLIS,AHIP

abstractPurpose: According to the report Healthy People 2010, oralhealthliteracyisthedegreetowhichindividualshavetheca-pacity to obtain, process and understand basic health infor-mation and services needed tomake appropriate oral healthdecisions.Studieshave linkedapatientshealth literacy toavarietyofsignificanthealthbehaviors,statusesandoutcomes.ThisarticleprovidesanoverviewoftheliteratureconcerningthelevelsofhealthliteracyamongadultsintheU.S.,theeffectsofliteracylevelsontreatmentandpatientoutcomes,literacyas-sessmentinthepracticesettingandtheeffectsofapatientsliteracyon communicationwithadental healthprovider. Theimplications of inadequate patient oral health literacy on thepracticeofdentalhygienistsandcommunicationrecommenda-tionsarediscussed,asistheneedforfutureresearchspecifi-cally on oral health literacy.

Keywords:CommunicationBarriers,DentalHealthEducation,Health Knowledge, Attitude, and Practice, Health Promotion,LiteratureReview,OralHealth,OralHealthLiteracy,PatientAc-ceptanceofHealthCare,PatientParticipation,ProfessionalPa-tientRelations

ThisstudysupportstheNDHRApriorityarea,Health Promo-tion/DiseasePrevention:Assessstrategiesforeffectivecom-municationbetweenthedentalhygienistandclient.

CriticalIssuesinDental Hygiene

isdeemedso important that itwas includedasanobjectiveintheU.S.DepartmentofHealthandHu-manServicesHealthyPeople2010,andisapartoftheSurgeonGenerals 2000 report,OralHealth inAmerica.3,4Oralhealthliteracy,asdefinedbyHealthyPeople2010,isthedegreetowhichindividualshavethecapacitytoobtain,processandunderstandba-sichealthinformationandservicesneededtomakeappropriate oral health decisions.3,4 As a result of itsinclusioninHealthyPeople2010,healthliteracyresearch has greatly increased over the last decade. Researchersarestudyingtheeffectsoflowhealthlit-eracyonpatientsindifferentsettingsanddevelopinginstrumentstoaidintheidentificationofthosewhostrugglewithliteracy.


Patient health literacy is consid-ered to be an important aspect ofpatientcarebytheAmericanDentalHygienistsAssociation(ADHA).TheADHAhaspresentedtotheInstituteofMedicine(IOM)committeesonoralhealth, includingAnOralHealth Ini-tiative,a studyconvenedby IOM in2010.Thestudy,comprisedofdentalhygienists, dentists, nurses, physi-cians,epidemiologistsandhealthpro-motionexperts,examinedoralhealthliteracyfromabroadperspectivewitha goal to increase oral health literacy inAmericans.5,6 ADHA has concluded thatapatientsliteracyisafactortobeevaluatedtodetermineapatientslevelofgeneralororalhealthriskintheStandardsofClinicalDentalHy-giene Practice.7

In2008,theAmericanDentalAs-sociation(ADA)HouseofDelegatespassedthefol-lowing 3 resolutions to promote communication intheprofession:

Theneed fordental professionals to communi-1. cateinaclear,accurateandeffectivemannerContinuedfundingthroughNationalInstitutesof2. Health,includingtheNationalInstituteofDentalandCraniofacialResearch,toencourageresearchin health literacyStrategic plan development through the ADA3. Council on Access, Prevention and Interprofes-sionalRelationsandother agencies to improvetheoralhealthliteracyofthepublic8

In2009,ADAsCouncilonAccess,PreventionandInterprofessionalRelationshipspublishedHealthLit-eracyinDentistryStrategicActionPlan20102015toprovideguidancetotheADA,dentalprofessionalsandpolicymakerstoimprovepatienthealthlitera-cybydevelopingasetofprinciples,goalsandevensomespecificstrategies.9

Thisliteraturereviewdiscussesthelevelsofhealthliteracyamongadults in theU.S.andtheeffectofliteracylevelsondentaltreatmentandpatientout-comes. Suggestions for health literacy assessmentinthepracticesettingarediscussedasarerecom-mendationsforeffectivecommunicationbetweenthedentalteamandthepatientwhostruggleswithlit-eracy.

adult literacy in america

TheNationalCenterofEducationalStatisticscon-ducted the National Assessment of Adult Literacy

Proficient

BelowBasic

Basic

Intermediate

Figure1:AdultHealthLiteracyLevels:ResultsfromtheNationalAssessmentofAdultLiteracy,2003

(NAAL)in2003toassesstheliteracyofU.S.adults.10 TheNAALwasadministeredtoapproximately30,000adults:18,000adultslivinginhouseholdsand12,000prison inmates.The followingresultsarebasedonthehouseholdsample.ParticipantsintheNAALsur-vey were grouped in 1 of 4 literacy levels: belowbasic,basic,intermediateandproficient,dependingontheirresponsestothequestions.TheresultsoftheassessmentgiveanaccuratesnapshotofadulthealthliteracyinAmerica(Figure1).10

Effects of Health literacy on treatment

The linkbetweenapatientshealth literacy levelanddentalormedicalprognosishasbeendemon-stratedbycurrent research.Patientswhohave in-sufficienthealthliteracylevelshavelessknowledgeabouttheirchronicmedicalconditionsandare lessable to manage the conditions.1113 They are at ahigher riskofbeinghospitalizedand tend to re-maininthehospitallongerthanpatientswithhigherhealthliteracyrates.Patientswithlowhealthliteracylevelsaremorepronetomakemedicationerrorsduetomisinterpretationsofdruglabelinstructionsoralackof knowledgeof dosingmethodsormeasure-ments.14,15Researchershavealsoconcludedthatin-adequatehealthliteracyhasastrongassociationwithmortalityinelderlypersons.16 Parental health literacy canaffectthehealthofachild.Childrenwithparentsorcaregiverswhohavelowhealthliteracyscoresaremorelikelytobehospitalized,engageinmoreriskyhealth behaviors and have less desirable health out-comesbothindentalandmedicalsituations.Studieshaveshownthatwhenparentalliteracyisimproved,childrenbenefit.1719


Figure2:StrategiesforAssessingLiteracyLevelsbytheDentalTeam

Health professionals tend not torecognizethesignsoflowhealthlit-eracyandarenotawareoftheirpa-tients reading levels. Studies havefoundthatbothphysiciansandresi-dentsconsistentlyoverestimatetheirpatients literacy levels and fail torecognize patients at risk of low lit-eracy.20,21 A health professionalsoverestimationofapatients literacylevelcanpresentabarriertoeffectivecommunicationandbedetrimentaltoapositivetreatmentoutcome.

assessing literacy in thePractice Setting

Patientswithlimitedhealthliteracycanbedifficulttoidentify,astheprob-lemisspreadacrosssocial,racialandeconomicborders.In2007,Jonesetalconcludedthatasignificantnumberofdentalpatientshavelowhealthlit-eracy.Thesepatientsexhibitalowerlevelofdentalknowledge,lessrecentdentalcareandworseselfperceivedoral health status.22

Thedentalhygienistcanlookforsignsthatapa-tient has a low literacy level. Patients with a lowliteracy levelwilloftenshow littleorno interest inwrittendocumentation,suchaspamphletsorhealthhistory forms,andwill oftenexpress frustrationorimpatiencewhenencouragedtouseprintedmateri-als.Apatientwithlowhealthliteracywilltakealongtime filling out forms andwill return them incom-pletelyorincorrectlycompleted.Apatientmaymakeexcusestoavoidreadingorcompletingaform,say-ingIforgotmyglassesathome,orImtootiredtoreadrightnow,Illtakeithomeanddoitlater.Poorreadersmayshowsignsofnervousness,confusion,frustrationoreven indifferenceandwithdraw fromsituationswheretheirreadingdifficultiesmaybeno-ticed.Patientsmayalsogivethewronganswerstoquestionsaboutsomethingtheyhavejustbeengiventoread.Adentalhygienistcanoftenspotapatientwhoishavingproblemsreadingbysimplywatchingthepatientseyes. Ifapatientseyeswanderoverthepage,donotfocusononeareaandthenmoveon,heorsheismostlikelynotactuallyreading.Poorreadersmayalsoholdthepaperclosetotheireyesorfollowthewordswiththeirfingerwhilereading.Anothersignoflowliteracyiswhenthepatientlooksat the pills inside a bottle rather than reading thelabelwhendescribingthepurposeofthemedication.Suchapatienthasassociated thesize, shapeandcolorofthepillwithitsintendedpurposeratherthanactually reading the label.23,24

Thedentalhygienistcantakeaproactiveapproachtohealthliteracyassessment.Iflowliteracyissus-pected,acasualconversationonthesubjectcanof-ten reveal valuable insight into apatients level ofliteracy.SimplyaskingapatientWhatdoyou liketoread?Areyouhappywiththewayyouread?orHowoftendoyouread?canbeginaconversationonthesubject.AstudybyWallaceetalin2006de-terminedthatclinicianscanidentifypatientswithlowliteracy levelsbyaskingthemthesimplequestion,Howconfidentareyoufillingoutmedicalformsbyyourself?Theanswerspatientsgavetothisquestioncorrespondedwelltotheirperformanceonformallit-eracyassessments.25Approachingapatientwithlowreadingabilitywithasimple,nonjudgmentalques-tionmayallowthehygienisttooffertheassistanceapatientneedswithoutcausinganyshameordis-comfort.

Ifamoreformalassessmentofhealthliteracyisdesired,thereareseveraloptionsavailable,suchastheRapidEstimateofAdultLiteracyinDentistry(RE-ALD),theTestofFunctionalHealthLiteracyinAdultsor theOral Health Literacy Instrument (Figures 2,3).2632Althoughhealthliteracyassessmentscanbeanimportanttoolforthedentalteam,aformalas-sessment,howeverbrief,maynotbeidealinanof-ficepracticesetting.Thereisapossibilityofcausingthepatientdiscomfort,alienationandshamewhena literacyassessmentbecomesapartofanexam.Personswho livewith the daily struggles resulting


Figure3:PopularFormalHealthLiteracyAssessmentTools

Medical

REALM(RapidEstimateofAdultLiteracyinMedicine)

1991 Wordrecognitiontest 5min

REALM 1993 ShortenedversionofREALM 2min

Test of Functional Health Literacy in Adults

1995 Readingcomprehensionandnumericalability

22min

NVS(NewestVitalSign) 2005 Literacyandnumeracyskills 3min

Dental

REALD30 2007 Wordrecognitiontest 510min

REALD99 2007 LongerversionofREALD30 510min

Test of Functional Health Literacy in Dentistry

2007 Readingcomprehensionandnumericalability

30min

Oral Health LiteracyInstrument

2009 Comprehension,numericalability,andgeneraloralhealthknowledge

45min

fromaninabilitytoreadwell develop elaboratecopingskillstohidetheirdeficiency, even fromthosetowhomtheyareclosest.Ifa literacyas-sessment becomes aregularpartofadentalexam,patientswithlowliteracy skills may be-gintoavoidofficesthatadminister such testsand not receive need-ed treatment. Formalhealth literacy assess-mentscanbesafelyad-ministered in researchsettings in which thepatientsareinformedofthepurposeofthestudyand give consent but arenotcurrentlyrecommendedasregularscreeningtechniques.33

Communication

Manyfactorscanaffectapersonsabilitytoread,comprehendanduseinformation.Thisistrueforallpersons,regardlessoftheirliteracylevel,butalowliteracylevelcancompoundsimpleproblems.Condi-tionsthatareinherentindentaltreatmentcanoftenmakeapatientsliteracyabilitydecrease.Stressandillnessareoftenthelargestcontributorstoapatientsinabilitytoread,understandorrememberahealthprovidersadvice.Eventhosewithgoodgenerallit-eracyskillsmayfinddentalandgeneralhealthcareinformationdifficulttounderstand,andasaresult,be hesitant to ask questions.24 Patients with lowhealthliteracyscoresdonotaskasmanyquestionsasthosewithsufficienthealthliteracyscores.Theyarelesslikelytoaskahealthcareprovidertorepeataconcepttheydonotunderstand.Dentalhealthcareprovidersmustbeawareofthisandtakemeasurestomakethemselvescleartothepatient.34

Apatientsageandthenormalagingprocesscanaffecthealthliteracylevels.Amongthemanyfactorsarethegenerationalcultureofapatientandphysi-calormentalhealthconditions.Anelderlypatientsbackgroundcanaffectinteractionwithahealthpro-vider. Many elderly patients grew up in a culturewhereonedidnotquestiontherecommendationsofahealthcareprovider.Thepatientwastodoastoldregardlessoftheirunderstandingofthetreatment.Factorssuchasalossofvisual,auditoryormentalacuityintheagedpopulationalsochangeapatientshealthliteracylevels.Readingabilityscorestendtodeclinedramaticallyaftertheageof55.23

Languagebarrierscanbeacontributor toapa-tients low health literacy level. When a person isunder stress, comprehension and communicationareinherentlyeasierinapatientsnativelanguage.If that language is not the languageof thehealthprovider, communication will be hindered. Spokenlanguageskillsandreadingskillscanbedrasticallydifferentwithinthegeneralpopulation,andthesedif-ferencescanbegreatlymagnifiedinpersonswhoarecommunicating ina language that isnotnative tothem.

Culturaldifferencesmustalsobeconsideredunderthescopeofapatientshealthliteracy.Manyculturesgive the familypriorityover the individual, andasaresult,healthrelateddecisionmakingisdoneasa familyunit thepatientmaynotbe thepersonresponsibleformakingthedecisionsforthefamily.Apatientmaynotbecomfortableaskingquestionsofahealthprofessionalofadifferentgenderorsta-tus.Someculturesadvocateshowingdeferenceandpoliteness to thosewhoareperceivedasauthorityfigures,suchashealthcareproviders.Often,inanattempt tonot offendor appear confrontational, apatient fromsuchaculturewillnotaskquestions.Suchdifferences canmake communicationdifficultforthepatientandtheprovidermustinsurethepa-tientunderstandsthediagnosis,treatmentplanandramificationsofnotfollowingthetreatmentplan.35

Itisimportantforthedentalhygienisttousegoodcommunication skills when treating patients whohavelowhealthliteracy.Theamountofinformationinitiallygivenshouldbelimitedtowhatthepatientneedstoknowasopposedtowhatisgoodtoknow.Theprovidershouldfocuson3to5mainpointsthepatient should know to aid in comprehension. Re-


searchhasconcludedthatlessthan50%oftheinfor-mationconveyedtoapatientduringthecourseofanappointmentwillberetained.36Dentalofficesshouldstrivetomaintainashamefreeenvironment.Allpatientsshouldbeofferedassistanceandstaffshouldnevertrytosingleoutpatientstheybelievehavelowhealthliteracyskills.2,37

Usingplainlanguagethatissimple,easilyunder-stoodandjargonfree is important inensuringthepatientunderstands.Dentalhygienistsaresurround-ed by technical terms and jargon as part of theireducationanddailypracticethelanguageusedbyprovidersisoftennoteasilyunderstoodbythedentalpatientandtheirfamily.Usingeverydaylanguagetoconveymeaningismucheasieronboththeproviderandthepatient.Termssuchascavitiesasopposedtocaries,orgumdiseaseasopposedtoperiodontaldiseasecanimprovepatient/providercommunication(Figure4).

Dentalhygienistsshouldalwaysexplaintherea-

sonswhyatreatmenthasbeenrecommendedandemphasizethebenefitsofcomplyingwiththetreat-mentplan. It is important tobe clearandconcisewhenexplaininghowapatient should comply. Pa-tientscaneasilybecomeconfusedwithdentalcaredevices,oralrinsesormedicationiftheiruseisnotsufficientlyexplained.Drawingpictures,usingvisualaidsoractivedemonstrationswillaidinthecompre-hension of directions. Dental hygienists should also remembertospeakslowlyandallowforampletimeforthepatienttovoiceanyquestions.Althoughtheurgetorepeatdirectionsinaloudervoicewhennotunderstood is strong, research has shown it actu-ally distracts from the understanding of the mes-sage.Communicationismorelikelyifthehygienistrethinksthewordsandmannerusedtoconveythemessage.39

Patientswithlowliteracylevelsoftenhavehighlydevelopedcopingsystems thathaveallowed themtofunctioninsociety.Ifaskedbyahealthprovideriftheyunderstandtheinformationthattheyhavebeen

MedicalTerm Plain Language alternative

Halitosis Badbreath

Hypertension Highbloodpressure

Immediate Rightaway

Inflammation Pain,swelling,heat,redness

Intake Whatyoueatordrink

Migraine Very bad headache

Neglect Donttakecareof

NonPrescription Youcanbuyitwithoutaprescription

Occlusion Wayteethfittogetherwhenyoubite

Oral Mouth

Orthodontics Braces

Palate Roofofyourmouth

Periodontal disease Gumdisease

Permanent Lasting forever

Pulp Tooth nerves

Refrain Stayawayfrom;stopdoing

RootCanal Removalofdamagedtoothnerve

Severe Verybad;dangerous

Sideeffect Effectcausedbyamedicineyoutake

Symptoms Whatyouarefeeling;signs

Toxic Poisonous

Xerostoma Drymouth

TempromandibularJoint

Jointthatattachesjawtoskull

Figure4:MedicalTermsandPlainLanguageAlternatives

MedicalTerm Plain Language alternative

Abscess Pocketofinfection

Allergen Somethingyouareallergicto

Amalgam Fillingmaterial

Analgesic Painkiller

Antiinflammatory Lessensswelling,fever,orpain

Benign Not cancer

Bridge False teeth

Bruxism Grindingyourteeth

Carcinoma Cancer

Cardiacproblems Heartproblems

Caries Cavities;toothdecay

Chronic Constant;lifelongcondition

Confidential Private,secret

Crown Caporcoveroveryourtooth

Deciduous teeth Babyteeth;firstsetofteeth

Denture False teeth

Diagnosis Causeornameofyourillness

Drug interaction Onedrugseffectonanotherdrug

Enlarge Getbigger

Extraction Pull a tooth

Function Doesthejob;action

Gingivitis Gumdisease

Sealants Coatingpaintedonteethtopreventcavities

Adaptedfrom:ClearHealthCommunication:MediaWordstoWatch.38


ConclusionThroughawareness of oral health literacy, dental

hygienistscanenhancethepatientsroleintheirownhealthcare.MillionsofAmericanadultshavehealthliteracyproblemswhicharenotrelatedtointelligenceoreducationmanyfactorsplayaroleinhowapa-tientcanunderstandandprocesshealthinformationatanytime.Patientshealthliteracyrateshavebeenlinked toprognosis, complianceandevenmortality,yetmanydentalhealthprofessionalsmaynotevenbeawarethepatientishavingaproblem.Oralhealthliteracy canbedetermined inmanydifferentways.Formal assessments can be conducted or informal,conversational, questionsmay be asked of the pa-tient.Withthisinformation,adentalhygienistcantai-lororalhealthinformationtothepatientsneeds.Plainlanguageandassurancethatquestionsarewelcomedandassistance isavailablewillgiveapatientconfi-denceinthedentalhygienistandtheofficeorclinic.

Health literacy is a relatively new subject in themedical and dental literature. Research is growingrapidly, but hasbeendominatedby studiesheld inmedicalsettings.Althoughsomeresearchhasbeendoneontheimplicationsofinadequateoralhealthlit-eracyinspecificallythedentalsetting,moreresearchis needed.

Julie H. Schiavo, MLIS, AHIP, is an Instructor of Medical Bibliography and Dental Reference Librarian at the Louisiana State University Health Sciences Center New Orleans, School of Dentistry. She is a Distinguished member of the Academy of Health Information Specialists and has received a Level II Specialization in Consumer Health Information from the Medical Library Association in 2011. She is also currently pursuing a Certificate in Advanced Study in Health Science Librarianship from the University of Pittsburghs School of Information Sciences and Health Sciences Library System.

acknowledgments

IwouldliketoexpressmysinceregratitudetoMs.ElizabethStrotherMLS,MBA,AssociateDirector forDental Library Services, Louisiana State UniversityHealth Sciences Center New Orleans, for all hersupportandencouragementduringtheresearchandwritingofthismanuscriptandwhileIampursuingmyCertificateinAdvancedStudies.

giventoread,patientswillalmostalwaysreplyintheaffirmativeinanattempttonotadmittheirdeficien-cies.Ahealthprovidershouldseekthisinformationinanonjudgmentalandcasualmanner.Tellingpa-tients thatmanypeoplehaveproblemswith theseinstructionswillgivepatientsanopportunitytoadmittheirignoranceandstillkeeptheirpride.23

TheTeachBackTechniquecanbeausefultooltoensure that a patient understands the instructionsfromahealthcareprovider.Byusingthistechnique,theproviderasksthepatienttorepeattheinstruc-tionsintheirownwordsordemonstratetheconcept.Thiscanbeaccomplishedinseveralnonthreateningand nonjudgmental ways. Patients should not beaskedquestionsthatcanbeansweredwithayesornoresponselearningwillbereinforcedifpatientsareaskedtosupplyinformationordemonstrateandrestateconcepts.40AnothertoolistheAskMe3ed-ucation program developed by the Partnership forClearHealthCommunication.AskMe3isanofficephilosophythatseekstocommunicatetothepatientthatthedentalteaminthatofficewanttoanswer3mainquestions:Whatismymainproblem?WhatdoIneedtodo?Whyisitimportantformetodothis?Patientsareencouragedthroughposters,brochuresandflyersplacedthroughouttheofficeorclinictoaskthesequestions,writedowntheanswersandbringtheinformationhomewiththem.41

Patient education pamphlets, booklets or otherwrittenmaterialareusefulinprovidingpatientstheinformation theyneedaboutprivacy,dental condi-tions, procedures or treatment options. However,readinglevelmustbeconsideredwhenchoosingthematerial.Ifadentalhygienistprovidespatientswithpamphletsorotherhealthinformationinprintform,theyshouldbewritten innohigher thanafifthorsixthgradelevel.TheaverageAmericanreadsataseventhtoninthgradelevelhealthrelatedmateri-alsareoftenwrittenatamuchhigherlevel.42Ifpos-sible,writtenmaterialshouldbeillustratedwithcleargraphics.43Pamphletsshouldfocusonafewmainim-portantfactsstatedasclearlyaspossible.HealthIn-surance Portability and Accountability Act notices and informedconsentpaperworkareevenmoredifficultforapatientwithliteracyconcernsasthenatureofthedocumentsrequirethemtobewrittenatahigherreading level.42,44,45


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introductionSomeof thefirstmicroorganisms

studied in thedawnofmicrobiologyoriginatedfromdentalplaque.Dutchscientist Antonie van Leeuwenhoekperformedsomeofhisinitialexperi-ments on scrapings of plaque fromhis teeth, and these studies wouldestablishthefoundationsformodernmicrobiology. In one of his studies,hedescribedscrapingthewhitema-terial lodgedbetweenhisgumsandteeth,inwhichheobservedmovinganimalcules.1Atthetime,Leeuwen-hoek only had the aid of a micro-scopetoanalyzethemicroorganismsheobservedfromtheteethscrapingsamples.Someoftheorganismsde-scribedbyvanLeeuwenhoek,thoughunknownatthetime,werethemostabundantmicroorganismspresentinthe oral cavity.

W.D.Miller,apracticingdentist inthe1890s,spentmuchofhistimean-alyzingthemicrobesfoundintheoralcavity.He laterwroteabook calledMicroorganismsoftheHumanMouth,whichdiscussedthetheorythatmi-croorganisms present in the mouthwereagroupofbacteriaworkingto-gether.2 These initial studies on dental biofilmshaveinspiredfurtherstudiesoftheorganismsthatliveintheoralcavity.Today,dentalbiofilmsaredefinedasadiversecommunityofmicroorganisms living as a structural unit,withcomplex communication pathways between spe-cies.3Thesemicrobialcolonieshavealsobeenfoundtocausedentalcariesandperiodontaldisease.4

Dentalplaqueisawellorganizedbiofilmthatat-tachestothetoothsurface.Itslocationinthemouthallowsforaconstantsourceofmoisture,nutrients,warmth and surface, all ofwhich contribute to itsgrowth. The inhabitants of themouth are incred-iblydiverse,andmutualisticrelationshipsoftentakeplace.Whilesomemicrobesoccupythenichepro-

DentalDiagnostics:MolecularAnalysisofOralBiofilmsSarahHiyari,MS;KatieM.Bennett,PhD

abstractPurpose:Dentalbiofilmsarecomplex,multispeciesbacterialcommunitiesthatcolonizethemouthintheformofplaqueandareknowntocausedentalcariesandperiodontaldisease.Bio-filmsareuniquefromplanktonicbacteriainthattheyaremu-tualisticcommunitieswitha3dimensionalstructureandcom-plexnutritionalandcommunicationpathways.Thehomeostasiswithinthebiofilmcolonycanbedisrupted,causingashiftinthebacterialcompositionofthecolonyandresultinginproliferationofpathogenicspecies.Becauseofthisdynamiclifestyle,tradi-tionalmicrobiologicaltechniquesareinadequateforthestudyofbiofilms.Manyofthebacteriapresentintheoralcavityareviablebutnotculturable,whichseverelylimitslaboratoryanal-ysis.However,with theadventof newmolecular techniques,themicrobialmakeupoforalbiofilmscanbebetteridentified.SomeofthesetechniquesincludeDNADNAhybridization,16SrRNAgenesequencing,denaturinggradientgelelectrophoresis,terminalrestrictionfragmentlengthpolymorphism,denaturinghighperformanceliquidchromatographyandpyrosequencing.Thisreviewprovidesanoverviewofbiofilmformationandex-aminesthemajormoleculartechniquescurrentlyusedinoralbiofilmanalysis.Futureapplicationsofthemolecularanalysisoforalbiofilmsinthediagnosisandtreatmentofcariesandperi-odontal disease are also discussed.

Keywords:dentalbiofilm,dentalplaque,oralhealth,PCR,bac-teria,moleculartechniques,16SrRNA,sequencing

ThisstudysupportstheNDHRApriorityarea,Clinical Dental HygieneCare:Assesshowdentalhygienistsareusingemerg-ingsciencethroughoutthedentalhygieneprocessofcare.

videdbythehost,otherspeciesmayonlythriveinthepresenceoftheprimarycolonizers.Further,thedevelopingcolonymaypreventcompetingspeciesofbacteriafromcolonizingbymonopolizingspaceandresources.Thismutualisticrelationshipisanimpor-tantaspectinthedevelopmentofbiofilmsingener-al,andmodernresearchtechniqueshaveexpandedour understanding of the ecology of oral bacterial communities.

Dental plaque formation is unique from typicalbiofilmformationduetothenatureoftheoralen-vironment.Tartar,orcalculus,isacalcifieddepositontheteeththatisformedbythecontinuouspres-enceofplaque.Theroughsurfaceofthetartarpro-

ReviewoftheLiterature


videsan ideal place forplaque toaccumulate.Al-mostimmediately,asalivaryglycoproteinfilmcalledapelliclecoatsacleantooth.Thepellicleallowsfortheadherenceofgrampositiveprimarycolonizers,which include Streptococcus mutans, Streptococcus anguisandActinomycetespecies.5,6Thebiofilmmasscontinuestoincreaseduetothemultiplicationoftheprimarycolonizers,whichprovidesaplaceforotherorganismstosubsequentlyattach.Inaspanof1to3days,thesecondarycolonizersadheretothegrampositiveprimarycolonizers.Thesesecond-arycolonizersaregenerallygramnegativespeciesandtypicallyincludeFusibacteriumnucleatum,Pre-vatellaspeciesandCapnocytophagaspecies.6Inthefinalstageofdentalbiofilmformation,thetertiarycolonizersattach,andthereisanoverallshiftfromgrampositivefacultativemicrobestogramnegativeanaerobes.46

Thethrivingbiofilmmayresultincariogeniccon-ditionsthatcanleadtocaries,oraffecttheadjacentsofttissueandresultinperiodontaldisease.Further,chronic oral infections have also been associated withsystemicdiseases,suchasdiabetesandheartdisease,duetothespreadoforalmicrobesintothebloodstream,and tocertain lungdiseasesdue totheaspirationoftheplaqueintotherespiratorysys-tem.7,8Thus,oralbiofilmshavehealthconsequencesbeyondinfectionsofthemouth,andnovelmethodsfor eradication or control of these colonies are need-ed.

Intraditionalmicrobiology,theindividualcellunitis typically the focus.However, in thecaseofbio-filmsanddentalbiofilmsinparticular,thewholeor-ganism isworking togetherandeachbacterium isdependentontheotherspeciespresent.3Therefore,typicalmicrobiologicalapproachesmaynotbesuf-ficientfortheidentificationorstudyofbiofilmform-ingbacteria.Treatmentstrategiesmustincorporateamoreholistic,ecologicalapproach to thecontrolofthedentalbiofilm.Anunderstandingoftheetiol-ogyofdiseasescausedbyoralbiofilmsfirstrequiresidentificationofthebacterialspeciesinvolved,whichisbestaccomplishedusingmoleculargenetictech-niques.Thisreviewsummarizesmanyofthemolec-ulartechniquesthatmaybeutilizedinthedetectionofbacterialspeciesindentalbiofilmsanddiscussesthefutureofmoleculardiagnosticsindentalhygienepractice.

MethodsusedforStudyofBiofilmsDuetothecomplexmultispecieslifestyleofdental

biofilms,uniqueresearchmethodshavebeendevel-opedforthestudyoftheseorganisms.Traditionalculturingmethodsofbacteriaareofteninsufficientfortheanalysisofbiofilms,becausemanybacteria

thatarepresentintheoralcavityareconsideredvi-able but not culturable.9Ithasbeensuggestedthatlessthan1%ofmicroorganismscanbeculturedinthe laboratory,meaning that the vastmajority oforalbacteriaevadestandardmicrobiologicaldetec-tionmethods.9ThishasleadtothedevelopmentofalternativemethodstoassessdentalbiofilmsbasedonDNAanalysisorothermoleculartechniques.Bylearningmoreaboutthegeneticsandbiochemistryoftheorganism,wecanderivebetterstrategiesfortreating infection.Biofilmcolonyhomeostasis is adelicatebalance,andwhendisrupted,pathologicalspeciescanpredominate.5DNAanalysiscanallowidentificationofallofthespeciespresentinanoralbiofilm, ofwhich only 1 or 2 speciesmay be thepathological culprits.Byknowingwhichspeciesofbacteriaarepresent in theoral cavity,new treat-mentoptionscanbedevelopedthatwould,inturn,providebetterdentalcare.TableIsummarizeseachmoleculartechniquediscussedbelow.

CheckerboardDNADNAHybridization

DNADNA hybridization is considered the goldstandardoforalbiofilmanalysis.Itwasdevelopedby Socransky et al for the synchronized process-ingoflargenumbersofsamplesandtheprofilingofmultiplespecieswithinthesamesampleinasemiquantitativemanner.10 The technique relies on the bindingofDNA isolated frombacterialsamples toamembrane, followed by hybridization with DNAprobes specific to at least 40 different bacterialspecies.10Thismethodisveryusefulforanalyzingdentalplaquebecauseofthesimultaneousprocess-ingoflargenumbersofsamples.11 The technology hasbeenable todetectmicrobespresentonoralsurfaces,biofilmcompositioninperiodontaldiseaseandbacterialprevalenceinspecificoralcommuni-ties.1215Furthermore,thistechniquehasbeenusedtoassesstheoutcomeoftherapeutictreatment.16

Because of the use of whole genome probes,DNADNAhybridizationwasoriginally limitedonlytotheidentificationofspeciesthatcanbecultured.However,areversecapturecheckerboardhybridiza-tionmethodwasdeveloped.17Inthismodificationofthetraditionalmethod,PCRamplified16Sribosom-alRNAgenesofupto30knownbacterialspeciesarespottedontoblots.ThemembraneisthenhybridizedwithPCRamplified16SrRNAgenesfromunknownplaquesamples.Theprimersforthesetargetsarelabeledwithuniversalprobeswhicharedetectedbychemifluorescence.Thisreversecapturehybridiza-tionmethodallowsfor1,350hybridizationssimulta-neouslyon1membrane.17 A disadvantage of these slotblotmethodsisthattheyareratherlaborious,andnonhybridizationPCRmethodsarenowmorecommonlyused.


16S rrna gene Sequencing

The16SribosomalRNAgeneishighlyconservedandcanbeused in the formationofphylogenetictrees or genetic relationships.18,19 This discovery,alongwith the advent of PCR techniques, has al-lowedtheanalysisoforalbiofilmsonageneticlevel.16SRNAispresentinalmostallbacterialspecies,withuniquesequencedifferencesallowingdiscrimi-nation between species.20 Amplification methods,suchas16SrRNAsequencing,haveeliminatedtherequirement for culture based techniques, allow-ingtheidentificationofunculturablespecies.Iden-tification of the species present is determined bycomparing the 16S rRNA sequence derived fromtheunknown sample to databases of known spe-cies.Figure1summarizestheprocessof16SrRNAsequencing.

There is some disagreement on the similaritythresholdnecessarytoverifyaspecies.20 A reason-ablecriterionforgenusidentificationisa97%simi-larity score toa knowndatabase sequence,while99%similaritywasdeterminedsufficienttoidentifyatthespecieslevel.21Alimitationofthismethodislowresolutionindistinguishingbetweenbacteriaat

thespecieslevel.Speciesmayshareidentical16SrRNAsequencesorthedifferencesbetweenrelatedspeciesmaybeverysmall(lessthan0.5%).20 De-spite these limitations, 16S rRNA sequencing hasyielded awealth of new information about dentalbiofilms.16S rRNAanalysishasshown that thereareover300bacterial speciespresent in theoralcavitythatwerenotinitiallyidentifiedbytypicalcul-turingmethods.22,23Furthermore,itwasfoundthattherearedifferencesinbacterialflorapresentintheoral cavity of individualswith immunosuppressivediseasessuchasHIV.24Atotalofover700bacterialspecieshavebeenidentifiedintheoralcavity,manyofwhicharespecifictoaparticularoralsurface.25

Denaturing gradient gel electrophoresis

Denaturinggradientgel electrophoresis (DGGE)is a PCR and electrophoresisbased approach foranalysisofmicrobialcommunities.Variousmarkergenes,including16SrRNA,areamplifiedusingPCRandthenanalyzedonadenaturinggel.Abandingpatterndevelopsbasedonthedenaturationcharac-teristics determined by the sequence compositionof each amplifiedDNA. Eachbandobservedon aDGGEgeltheoreticallyrepresentsadifferentbacte-

MolecularMethod Pros Cons References

CheckerboardDNADNAHybridization

SimultaneousprofilingofmultiplespeciesLargenumberofplaquesamplescanbeprocessedsimultaneously

Traditionalmethodslimitedtoculturablespeciesof bacteriaLabor intensive

1017,37

16SrRNAGeneSe-quencing

HighthroughputIdentifiesunculturablespecies

LowresolutionatspecieslevelNostandardizedthresholdfordistinguishingnewspecies

1820

DGGE EachbandpatternrepresentsdifferentbacterialpopulationShowsrelativeabundanceofeachspeciescollected

DifficultymaintainingreproducibleresultsMultiplespeciessequencesmaycomigrate

26,27,30

TRFLP Quickdetectionofgeneticdiversity

HighcomputationalpowerneededNovelsoftwareanddatabase required

3133

DHPLC Detectpointmutations InitsinfancystageswithassessmentofdentalbiofilmsFairlynewtechnology,needsmoreoptimization

3638

Pyrosequencing RapidresultsIdentifymicrobesandde-termineantibioticresistancegenotype

Cannotsequencefulllength16SrRNAgene

3941

TableI:Summaryofmoleculartechniquesfordentalbiofilmanalysis


rial populationwithin a community.26 Thus,DGGEbandpatternscanillustratethecomplexityanddi-versityofabiofilmsample,andindividualbandscanbe subsequently excisedand sequenced todeter-minespecies identity.Figure2showsaschematicexampleofaDGGEgel.DGGEhasbeenappliedintheanalysisoforalmicrobialcommunities incon-ditionssuchasperiodontitisandseverechildhoodcaries.2729 A limitation of DGGE is that sequencedifferences greater than 1 base pair may fail toseparate on a denaturing gel because of similari-tiesinnucleotideproportionsthatresultinidenticaldenaturing characteristics of 2 different sequences. Therefore,excisionandsequencingisnecessarytoconfirmtheidentificationofspeciespresentwithinan individual band.30

terminal restriction fragmentlength Polymorphism

Terminal restriction fragment length polymor-phism (TRFLP) is another PCRbased techniquethat can be applied to the study of oral biofilms.Thistechniqueoriginatedfromthestudyofbacterialdiversity inenvironmental samples,andwas laterused for the analysis of oral microbial communi-ties.3134TRFLP issimilar toDGGE in thatcertaingenemarkers,including16SrRNA,areamplifiedbyPCRusinggenespecificprimerslabeledwithafluo-rescentprobe.Theamplifiedproductsarethendi-gestedwithrestrictionendonucleases,andthefrag-ments are separated by capillary electrophoresis.Thefragmentswiththeattachedfluorescentprobesaredetectedbytheinstrumentandanalyzedusingfragmentanalysissoftware.Whenthesamplesareanalyzed by gel electrophoresis, specific bandingpatternscanbeassessedwhichrepresentcomplexmicrobialcommunities.35 This technology has been usedtoassessdifferentmicrobialprofilesinhumansaliva,changesinmicrobialcommunitiesintheoralcavity after treatment and bacteria present in in-fected root canals.3234 The applications of TRFLParepromising,butthetechniqueisstillinitsinfancystages.TRFLPrequiresexpensiveinstrumentation,highcomputationalpowerandverylargedatabasestocomparethegeneticsequences.11

Emerging technologies

Anumberofrecentlydevelopedtechniqueshavebeenimplementedformicrobial identification,andthese methods show potential for future applica-tionsinthestudyoforalbiofilms.Denaturinghighperformance liquid chromatography (DHPLC) is aPCRbasedmethodwhichisfollowedbyseparationbasedonpartialdenaturationoftheamplifiedDNA.This technique can be used to detect DNA sequence changes, such as point mutations.36 DHPLC has

Figure1:16SrRNAGeneSequencingFlowchart

Thisfigureshowsageneralschematicoftheprocessof16SrRNAsequencing.DNAisfirstpurifiedfromthebiofilmsampleorbacterialisolate.The16SrRNAgeneisamplifiedfromthegenomicDNAusinggenespecificprimers.Eithertheentire16SrRNAgeneorasmallerhypervariableregionofthegenemaybeamplified.ThePCRproductisthensequenced,andthesequenceiscomparedagainstadata-baseofknownbacterialspecies.Exactornearlyexact(>99%)sequencealignmentbetweenknownandunknownsequencescanidentifyamicrobeatthespecieslevel.Bacteriamayonlybeidentifiableatthegenuslevel(>97%sequenceidentity).

beenpreviouslyutilizedinotherareasofresearch,suchasintestinalmicrobiota,andhasmorerecentlybeenappliedforanalysisofdentalbiofilmsandbac-teria.37,38Techniquesusedinchronicwoundbiofilmanalysismayalsobecomeusefulfororalbiofilmre-searchanddiagnosis.Pyrosequencing,arapidse-quencingmethod that can simultaneously identifymicrobesanddetectantibioticresistance,hasbeenappliedforthedeterminationofbacterialdiversityin chronicwoundbiofilmssuchas indiabetic foot


ulcers, venous leg ulcers and pressure ulcers.3940 Recently, thepyrosequencingmethodwasappliedto the analysis of saliva and supragingival plaquesamples,anditwasestimatedthat19,000differentmicrobialspeciesarepresentinthemouth.41Stud-ieswhichutilizethesenextgenerationmethodsarerevealingthatoriginalapproximationsoforalmicro-bialdiversitywerehighlyunderestimated.

Themainstreamapplicationofmolecularmethodsin both research and clinical settings has allowedfora rapidexpansionofourunderstandingof theoralmicrobialenvironment.Asinotherfields,suchaschronicwoundcare,thefuturemanagementoforaldiseasewillbenefitfromadoptionofmolecularbiofilm analysis methods. While the identificationofspeciespresentwithinaplaquebiofilmisessen-tialforfocusedtreatment,theunderstandingoftheunified communication and adaptive changes thatoccurwithin themicrobial community as awholeisequallyimportant.Somefuturedirectionsshouldinclude the assessment of gene expression levelsintheoralbiofilm.Theanalysisofgeneexpressionwithinabiofilmcanhelpaidintheidentificationofvirulencefactorsthatmightmakethebiofilmmoreresistant to antibiotics or other treatment, similartostudiesperformedonmethicillinresistantS.au-reus.42MethodssuchasrealtimePCRormicroar-raycananalyzethegeneexpressionpatternsthatmaymake a particular biofilm population inclinedtocausedisease.Expressiondataderivedbysuchmethods can be applied to analyze oral biofilmsunderconditionssuchas inflammationor immunesuppression,orcanbeusedtoevaluatedentalbac-teriabehaviorbeforeandafterantibiotictreatment.This can provide insight into how the oral biofilmcommunicatesandbehavesasawholeunit.

Asmoleculartechniquesbecomemainstreamandmorewidelyavailableinclinicallaboratories,theca-pabilitytoobtainindividualpatientbiofilmprofilesisbecomingattainable.Byidentifyingthepathogenicbacteriainapatient,treatmentcanbepersonalizedto the infection. A recently launched clinical diagnos-ticlaboratory(OralDNALabs)nowoffersmoleculartesting todentalpractitioners for thediagnosisofperiodontaldisease,usingPCRbasedteststoiden-tify pathogenic oral bacteria.43 Such servicesmayhelpavoidthegeneralizeduseofantibioticsthatareineffective or encourage antibiotic resistance. The traditional empiricalmethod of prescribing antibi-otics in dentistry has been questioned because of unnecessaryorinappropriateuseofantibioticsthatcanleadtoantibioticresistantorganisms.44,45

Thereareanumberofobstaclespreventingthe

Discussion

immediatemarriageofdentistryandmoleculardi-agnostics.Rapidtreatmentandreliefforthepatientisaprimaryconcern for thedentalpractitioner.Apatientwith a critical oral infection shouldnot bedeniedtreatmentforthe48hoursormorethatisrequired for traditional microbiological tests, thusempiricaltreatmenthasbeentraditionallyutilizedintheabsenceofabetteroption.However,therapidnature of most molecular assays provides a vastimprovement over lengthy culture methods, withmanymoleculartechniquesprovidingidentificationof organisms in amatter of a few hours. Even aturnaroundtimeof24hoursforreliableidentifica-tionofpathogenicbacteriacanallowforcustomizedmodificationoftheinitialempiricalantibiotictreat-mentofveryillpatients,particularlyforrefractoryformsoforaldisease.Thereisunderuseofdiagnos-ticmicrobiologylaboratoriesbydentalpractitioners,

Figure2:SchematicofaDGGEGel

Variousmarkergenes,suchas16SrRNA,areampli-fiedbyPCRandanalyzedbydenaturingelectropho-resis.Thepolyacrylamidegelconsistsofagradientofdenaturant,typicallyureaandformamide.PCRprod-uctswhicharesimilaroridenticalinmolecularweightareseparatedbasedondifferingdenaturingcharacter-isticsdeterminedbytheuniquenucleotidesequence.DistinctbandsrepresentdifferentsequencesofDNAfromdifferentbacteriapresentinthesample.Forexample,lanesA,BandCrepresentknownbacterialsamples.Lanes1and2arebiofilmsamplesofun-knownbacterialcomposition.Bandsthatmigratesimi-larlyintheunknownlanesarecomparedtotheknownbands.Thebiofilmsampleinlane1includesMicrobeAandMicrobeC,whilethesampleinlane2includesMicrobeA,MicrobeBandanunknownspecies.Theunknownband,indicatedwithanarrow,canbeex-cisedfromthegelandsequencedforidentification.


whichmaybemitigatedbyagreaterawarenessoftheservicesprovidedbysuchlaboratories.44

Otherconsiderations for implementationofmo-leculardiagnosticsindentalpracticearethatofprac-ticality and cost.46Someofthetechniquesdiscussedabovearecurrentlycostprohibitiveforroutineusein the diagnosis of oral infection. The reimburse-mentofmolecularassaysbythirdpartypayersisalsocomplicatedby lackingorambiguousCurrentProcedural Terminology codes for somemoleculartests.However,molecularassaysarerapidlybecom-inghigherthroughputandmorestandardized,andsomemolecular testsarekitbasedand relativelyinexpensive.Nonetheless,whilemoleculardiagnos-ticsarequicklybecomingafeasibleapproach,labo-ratorydiagnosisoforaldiseasewilllikelyremainre-servedforpatientswithsevereperiodontaldiseaseorthosewhohavebeenunresponsivetotraditionaltreatment.Althoughmoleculardiagnosticswillnottake the place of the primary clinicalmethods ofpreventionanddebridement,itdoesofferabenefi-cialcomplementtothepracticeofdentalhygiene.

ConclusionUnderstanding the complex interactions be-

tweenbacteriathatoccurwithinanoralbiofilmwillprovideinsightnecessaryforimprovingdiagnosis,treatment andprevention of periodontal disease.Dentalpractitionersshouldbeawareofemergingdiagnostictechniquesandshouldstrivetoworkinconcertwithresearcherstoharnessnewtechnolo-giesforimprovingbiofilmmanagement.Moleculardiagnosticsofdentalbiofilmswillallow for rapid,focused and personalized treatment, enhancingthetraditionalmethodsusedbydentalhygieniststocontrolandpreventperiodontaldisease.

Sarah Hiyari, MS, is currently a PhD student in Oral Biology at the University of California Los Angeles, School of Dentistry. Katie Bennett, PhD, is an assistant professor in the Molecular Pathology and Clinical Laboratory Science programs at the Texas Tech University Health Sciences Center, School of Allied Health, in Lubbock, Texas.


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