-
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
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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
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Vol. 85 No. 4 Fall 2011 The Journal of Dental Hygiene 241
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
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242 The Journal of Dental Hygiene Vol. 85 No. 4 Fall 2011
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
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Vol. 85 No. 4 Fall 2011 The Journal of Dental Hygiene 243
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
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244 The Journal of Dental Hygiene Vol. 85 No. 4 Fall 2011
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.
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Vol. 85 No. 4 Fall 2011 The Journal of Dental Hygiene 245
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.
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246 The Journal of Dental Hygiene Vol. 85 No. 4 Fall 2011
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
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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.
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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]
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248 The Journal of Dental Hygiene Vol. 85 No. 4 Fall 2011
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.
-
Vol. 85 No. 4 Fall 2011 The Journal of Dental Hygiene 249
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
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250 The Journal of Dental Hygiene Vol. 85 No. 4 Fall 2011
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
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Vol. 85 No. 4 Fall 2011 The Journal of Dental Hygiene 251
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-
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252 The Journal of Dental Hygiene Vol. 85 No. 4 Fall 2011
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
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Vol. 85 No. 4 Fall 2011 The Journal of Dental Hygiene 253
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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254 The Journal of Dental Hygiene Vol. 85 No. 4 Fall 2011
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256 The Journal of Dental Hygiene Vol. 85 No. 4 Fall 2011
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
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Vol. 85 No. 4 Fall2011 TheJournalofDentalHygiene 257
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.
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258 The Journal of Dental Hygiene Vol. 85 No. 4 Fall 2011
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
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Vol. 85 No. 4 Fall 2011 The Journal of Dental Hygiene 259
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
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260 The Journal of Dental Hygiene Vol. 85 No. 4 Fall 2011
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.
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Vol. 85 No. 4 Fall2011 TheJournalofDentalHygiene 261
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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