Periodontal Disease P3
2013
So, taking plaque, then, from the deepest periodontal pocket, I use a number six straight ended probe, and it’s moved around from the medial lingual to the medial. The plaque is lifted out and immediately deposited into the fixative, and the instrument is agitated rapidly to detach the plaque. I’ll take plaque from all quadrants of the mouth, from the worst areas, and then, the container is tightly resealed. When the form is filled out, it must be marked “dental plaque”, otherwise, at the lab, it might be mistaken for an empty container and simply thrown away.
If one is fortunate enough to have a phase contrast microscope, and in my opinion, all dental offices should have a phase contrast microscope and personnel adept at using it, then the situation becomes somewhat easier. What one needs to do is take a drop of the patient’s own saliva, not sterile bruff [31:12], not artificial saliva, not normal saline. These fluids will not provide reliable results. We must have homeogenic liquid which will not cause any distortion of the parasites.
Then, again, take drop of the saliva, put it on the slide. Take plaque from the deepest periodontal pocket, and from the base of it, deposit it down on the slide into the saliva, that is. Drop on a cover slip, and then press that cover slip down in order to squash the plaque out into the thinnest possible film. I use a double pipe cleaner, and I press it really, really hard. Sometimes, when I got too much saliva or too much plaque, it will come oozing out of the edges of the cover slip, and I just wipe it off.
Then, I make my lower power search. Now, when I do my low power search, instead of using the phase contrast condenser, which is matched to the low power phase contrast objective lens, I use the condenser which is actually matched to the high power phase contrast objective. So, on my microscope, I have 100 times low power, 1000 times high power, and that addition of one additional zero from 100 to 1000 times is important. It could be 125 to 1250, but it must be a 10 times factor. Then, you can use the high power phase contrast condenser with both the low power and the high power objective lenses. Then, on the low power, using that setup, you’ll get an apparent dark field illumination, which makes the Entamoeba easier to see, and on the high power, you’ll get a bright field phase contrast, which will make the positive identification possible.
The protoplasm is clear and non-granular. The movement is typically ameboid. Sometimes, it will be sluggish, just putting out a pseudopodium and retracting it, and at other times, it would be moving rapidly across the slide. Occasionally, they would be dormant, just sitting there and not moving. There would be a number of occlusions within the endoplasm, which are wound and look like nuclei. They are the nuclei of leukocytes, and then, the identifying factor is the Entamoeba nucleus. The Entamoeba nucleus is smaller than an erythrocyte. It’s about 4 microns across, to my recollection. It has an outer chromatin ring on which one can sometimes see the thickening of the three or four chromosomes. It has a central karyosome so that the whole thing looks like a bicycle rim with a halve, and the halve is sometimes a dark spot. Sometimes, it’s another second circle inside this outer circle.
Sometimes, one can see strands of chromatin material, which join the outer ring to the central karyosome, and it’s the identification of the nucleus of the parasite, which is diagnostic.
Host: Now, how are we going to treat this disease if the phase contrast microscope result is positive or if they report, “Yes, we found parasites in your specimen”?
Dr. Lyons: Well, here we just take a leaf out of the book of gastroenterologists and gynecologists, and parasite infection of both these body cavities are treated in basically the same way. The organism is considered to have invaded the wall of the body lumen and also to be present in the lumen itself. So, if one gives medication, which is entirely parenteral, the systemic medication will eliminate the parasites from within the tissue but will not affect the parasites within the lumen, and if one uses a local antiseptic, it will eliminate parasites within the lumen but not within the tissues. So, we need to use both.
I have used, with most success, metronidazole, and a metronidazole-based paste. The unfortunate thing about the paste is the taste. Sorry about the alliteration. So, the routine treatment that we follow is metronidazole times 30, and to minimize the side effect of the medication, the following should be employed: On the first evening, with food, one metronidazole. On the second day, again, one with breakfast and one with the evening meal. Now, the reason for bringing up the dosage to the third day, which is the full dosage, which is one of the 250 mg pills every 8 hours, is that as the parasites are destroyed by the medication, the disintegrating parasites seem to release a lot of antigenic material, which can cause quite a severe system reaction to the patient. We try to minimize these side effects.
It’s important for the patient to realize that most of their side effects are due to the destruction of the pathogenic parasites, and we’re fortunate, with Entamoeba gingivalis, that the release of antigenic material during treatment does not cause as severe are reaction as occurs with some of the treatment regimes for some of the other parasites.
The patient should be instructed that if they do become very ill, they should decease medication. They should also be instructed that they should phone in if they get any side effects. There’s two side effects that we see due to the medication alone: One is slight and transient headache, and the other one is an altered state of taste. These both disappear when the medication is discontinued.
One drug interaction which must be avoided is metronidazole and alcoholic beverages. They interact very badly. The patients don’t die if they take them both at the same time, but they’ll sure wish that they could.
Host: Could your treatment be for very bad periodontal condition and perhaps describe a case history that you’ve done, and then we’ll talk about a mild case.
Dr. Lyons: Sure. Before we do that, I think I’d better finish the pace that we use. What we have taken is 1 ounce of metronidazole vaginal cream. Then, we take 6 Mexiform tablets, which is an intestinal antiseptic and also antiparasitic, and both a drugs are antibacterial.
The Mexiform tablets are finely crushed and mixed in with the paste in order to stiffen it up, and due to the extreme bitter taste of the paste, we’ve disguised the taste by using a very strong anise flavoring. The patient will still have a bitter aftertaste, but at least it’s tolerable. The paste is applied to the gingival margin with a toothbrush, finger, pipe cleaner, but preferably with a toothbrush at least twice a day. This is done at the same time that the medication is taken. When the paste is applied, it should only be applied very sparingly. The excess can be spat out, and then, the patient does not eat or drink or rinse, of course, for the next 55 minutes. The important thing is if too much paste is used, it can be nauseating. The patient salivates excessively, and all the good which you’re trying to do is undone.
So, we can come on to sever cases. That’s how we treat a severe case, and we sit back and wait and see, how many pockets heal and at what depth they remain. After approximately 6 weeks and during the 6 weeks, they would continue with the paste and they will also have been using adjunctively, modified Torren’s powder, which is basically 6 parts baking soda to 1 part salt. Again, it has to be finely ground, and an ordinary house blender will do this.
A patient will take about a teaspoonful of this, and just pass it on the gingival margin with a saliva-wetted finger. This ideally should be done once a day. Patients on a salt-free diet should use baking soda by itself. The effect of the powder will help to keep the teeth looking with, help tooth keep the members of bacteria down, and help tissue to respond normally. Also, it will act as a partial preventive because when oral parasites come in contact with the power, they’re destroyed by reverse osmosis.
What do we do now if we’ve treated the patient and they’re back in 6 or 8 weeks later and they still have deep pockets? Well, the first thing that we do is go back again and check for parasites. If there’s parasites, they’ll then go back to medication, and before they finish the medication, they come back in and they have all the subgingival calculus removed. When I remove this, I use very fine curettes, and I always dip the instrument in the metronidazole-Mexiform paste prior to each movement with the scaler or curette. This will minimize the chances of any post-operative infection or soreness. At the end of the appointment, I’ll carefully apply a little of the metronidazole-Mexiform paste into dental areas to give us a sterile wound, which would then heal.
Now, having done all those things, one will still find that there’s a very deep periodontal pocket. They’re still on a five or a six, a triplication involvement or something like that, and it’s still wound. Take a 5 cc syringe with a 20 or 18 gauge needle, blunt the needle, and put it through at about 110 degrees. Then, fill it with metronidazole-Mexiform paste. Instruct the patient on how to inject the paste to the depth of the periodontal pocket, slowly pulling the syringe out as they fill the pocket. They should do this for a period of time until the pocket is healed, and they should do this at least twice a day and continue, during this period of time, in using the paste.
Sometimes, during this period of time, the patient will recontract the disease. The disease is contagious. It is spread by mouth to mouth contact which can be direct, which needs no explanation and indirection which can include any object which goes into the patient’s mouth which may have been contaminated with someone else’s saliva.