Periodontal Disease and SalivaScore Testing (aMMP-8) 

What Is SalivaScore? As we enter the “molecular era of dentistry,” we have the unique opportunity to consider a significant change in basic assumptions where rather than looking backward (looking in the rearview mirror), we can look forward. Utilizing a point-of-care chairside testing of the aMMP-8 cellular biomarker, SalivaScore, we can identify pre-clinical inflammation and real-time collagen breakdown, which cannot be otherwise detected with an examination. A report can be generated in 5 minutes using a simple mouth rinse approach.  

Introduction: To properly utilize aMMP-8 testing, we must first enhance our understanding of periodontal disease. Periodontal conditions are chronic, multifactorial infectious and inflammatory diseases resulting from an “imbalance between one’s immune system and the bacterial challenge.” 

What does this mean for my patient? Stress levels, age, and other factors affect an immunological response's effectiveness. Accordingly, our resistance is episodic in nature. In addition, as disease entities; gingivitis, periodontitis, and even peri-implant diseases are characterized by periods of quiescence and exacerbation, which is why a single patient can present with both periods of health and breakdown over many years.  

Don’t I already know how to diagnose disease?  As clinicians, we have traditionally been trained to evaluate periodontal disease with radiographs, periodontal measurements, and bleeding on probing. This classical methodology determines a diagnosis of a patient’s current state or the destruction that has previously occurred. We contend that this is “no longer enough.” 

Can I use SalivaScore as a Diagnosis?  aMMP-8 testing does not provide a diagnosis. Instead, it provides important additional information to the patient and clinician to prevent and predict disease. 

What benefit will SalivaScore Provide?   aMMP-8 cellular biomarker analysis with a patented technology called SalivaScore makes the “invisible, visible,” where testing can produce an actual number. The production of a visible quantitative value is a “game changer” which can be used to improve patient communication, case acceptance, and a patient’s overall health. It represents a considerable advancement in dentistry as we move from subjective observational evaluation to objective findings. Like medicine and the treatment of diabetes mellitus, where patients can understand their HbA1c values (and what they need to do to stay healthy), patients can now better understand their periodontal status with SalivaScore testing values. Additionally, Quantitative values will provide “intrinsic motivation” and empower patients to be more involved in their dental health care process!  

The take home message is that clinical collagen breakdown can PRECEDE the appearance of observed pathology and accurately predict a pathological state before significant damage has occurred. 

 
How Do I present SalivaScore before Administering the Test?:  “We will ask you to take a simple saliva test to evaluate your dental health. It is just like taking blood pressure in your physician’s office. There is no fee; it is part of our standard-of-care wellness screening process.” 

Who is eligible for Testing?   

- All new patients 25 years or older. 

-Recare patients 38 years and older 

-Any recare patient with a history of periodontal treatment (not in active treatment) 

-Any recare patient with type 2 Diabetes or Rheumatoid arthritis 

Who should NOT be tested? 

Patients in active periodontal therapy such as scaling, laser therapy or surgical intervention. 

Patients who have brushed, rinsed, or smoked within an hour of the appointment. 

Who Administers the Test? 

The dental assistant will administer the test for all new patients before the start of treatment, and the dental hygienist will administer the test for hygiene patients before the start of treatment and for follow-ups. For hygiene patients, the hygienist can pass the patient sample along to the dental assistants (who can run the tests) and then bring the printout back to the hygienist. 

What Instructions are Given to Patient? 

“Please rinse (swish) vigorously for 30 seconds and then expectorate into this cup. Do not gargle.” 

What happens after the Test is Complete? 

Auxiliary personnel should deliver the patient report to the health care provider as soon as possible and before the start of any treatment. 

It is essential to deliver messaging in a succinct fashion and avoid a lengthy conversation in the middle of a busy day. If a patient is “pressing for additional information,” one of the following scripts should be helpful. If that is still insufficient, a more detailed response should be expected from the dentist, the hygienist or by visiting our website so that the patient receives the information they need. 

Accordingly, the hygienist should review the purpose of this analysis before the start of treatment. The clinician can choose one or more of the following scripts that “fit best.”
 

The following patient scripts can be utilized as follows:  

a) “This test is amazing because it can let us know if your body is breaking down the gum and bone that supports your teeth before significant damage occurs. This means it gives us an opportunity to both prevent and predict disease.” 

b) “By knowing what the future might be, clinicians can provide earlier, more cost-effective treatment options to prevent full-blown periodontal disease, tooth loss, and failed dental implants.” 

c) We have evidence to show that chronic oral inflammation (periodontal disease) is associated with: Heart disease, Diabetes, pre-term pregnancies and Alzheimer’s disease to name a few. Diabetes and chronic periodontitis are bi-directional. That means that oral inflammation makes diabetes mellitus worse (higher HbA1c), and higher HbA1c worsens your periodontal condition.” In terms of Alzheimer's disease, bacteria specific to the mouth has been found in the brain of these patients!” 

d) “We also know that if we can control inflammation in your mouth, we have a better chance of preventing these diseases and keeping you healthy. It is a real change in thinking where we now understand that seeing your dentist could impact your general health.” 

e) “An infection and inflammation control program are the key to successful periodontal treatment. The reason we are recommending a 3-month re-care program is that it takes 90 days (about three months) for the bad bacteria to repopulate, so if the bioburden is less, it is easier for the immune system to manage health.” 

What is “The Mouth-Body Connection?” 

Just like the skin, the purpose of the oral epithelium is that it is a protective barrier separating the outside world from the inside world. Once the barrier in the mouth is “breached” by the inflammatory process, a pathway is created whereby bacteria and bacterial byproducts can enter the bloodstream creating bacteremia. This is the basis of the spreading of the bacteria associated with chronic periodontitis and its effect on other diseases.”  

What do the SalivaScore Testing Values Mean? 

1. Highly Elevated SalivaScore-Grade C-(>30ng/ml (+)): Rapid disease progression/potential very poor oral health. Further diagnostic evaluation and definitive periodontal treatment are recommended. If the patient has any indication of periodontal disease on physical exam, please refer this high-risk patient to our partner periodontists. 

2. Elevated SalivaScore-Grade B- (≥20-29ng/ml): Predicts active disease progression/potential poor oral health. Intervention and periodontal treatment are recommended. For patients with obvious signs of periodontal disease, consider a referral to one of our periodontal partners.  

3. Normal SalivaScore Levels (0-19ng/ml): Indicates minimal disease progression/tendency towards good oral health. Less than 10ng/ml equates to no disease progression. 

Upon completion of periodontal treatment, patients need a specific re-care schedule (more frequent hygiene sessions), an improvement in oral hygiene, and retesting no sooner than three months. Depending on the result of several retest numbers, a visit to a primary care physician may be recommended, particularly for patients with other chronic diseases such as rheumatoid arthritis, diabetes, or heart disease. 

Therapeutic Goals 

aMMP-8 is a significant mediator of periodontitis and peri-implantitis tissue destruction. More importantly, from a clinical perspective, the scientific evidence demonstrates that a decrease in aMMP-8 was shown after treatment to reduce periodontitis and peri-implantitis.  

Although it is essential to understand the range of elevated and normal aMMP-8 levels, we need to identify our treatment goals. Our specific treatment objective is to have patients who have received periodontal treatment achieve levels of approximately 19ng/ml or less after retesting. This number represents an acceptable and attainable level of    aMMP-8 to control the disease process.