Eliminating Infection

Oral infections can present primarily in the teeth, gums (periodontal) and bone of the jaws and occasionally saliva glands. Infections of the mouth are serious and can potentially be life threatening due to microorganisms spreading via the blood supply from oral tissues to the rest of the body. This creates increased risk to a host of health complications, both long-term and short-term. Dental infections have been implicated as a likely cause in multiple cases of brain abscesses, heart and lung infections and infections of orthopaedic joint prosthetic implants.1 , 2 , 3

Due to the complex nature of oral infections this page is broken down into the following sections:

What is broadly recognized by the scientific community is that most root filled teeth have residual root infection which may allow the systemic spread of bacteria and/or their byproducts to other sites of the body.

Understanding Oral Infection
The cluster of common oral infections seen everyday by dentists include dental caries (decay), gingivitis, periodontal disease, dental abscess, pericoronitis (usually wisdom teeth), bone cysts (cavitations), viral infections (HSV and HPV) such as cold sores and oral warts. The profession of dentistry is essentially founded on treating the complications of the two most prevalent infections of the world, that is – tooth decay and gum disease. Despite access to dental services, antibiotics and fluoridation, the burden of oral diseases remains – even in developed countries.4

The presentation of teeth, gum and bone infections is usually slowly progressive with pain being a symptom when the infections are quite advanced and needing intervention by a professional. Early diagnostic intervention by having regular checkups and radiographs is recommended, and of course, prevention of these infections from the outset by integrating a healthy diet and daily oral hygiene practices is the best course of action. Having a bad taste, smelly breath, bleeding gums and “pimples/boil” on the gums are signs of chronic oral infections and should be further investigated. Sometimes a blood test to evaluate the inflammatory marker C-reactive protein (CRP) can be used to determine the extent of the chronic infection and also to assess the success of targeted treatment. One study showed that young healthy men who had root filled teeth recorded an elevated CRP which puts them at greater risk of developing cardiovascular disease.5 , 6

Another study demonstrated the highest elevation in CRP was found in people who had periodontal disease and heart disease. Scientists were able to demonstrate that the treatment of the periodontal disease caused a 65% reduction in the level of CRP which remained low for 6 months.7

Results like these support the practice of regular professional oral hygiene cleaning sessions. The persistent presence of chronic oral infections has been associated with the onset of other diseases and is subject to ongoing research. Recently, it has been recognized that oral infection, especially periodontitis, may affect the course and pathogenesis of a number of systemic diseases, such as cardiovascular disease, bacterial pneumonia, diabetes mellitus, and low birth weight.8
Root Canals
Procedures such as root canals have been linked with various chronic conditions, attributed to residual infection spreading to other parts of the body.9
There are also reports in the scientific literature of patients who have had relief from suffering their health conditions and obtaining normal serology following extraction of their root filled teeth.10The possible mechanism of transmission of infections originating in the mouth causing systemic disease was put forward last century by eminent dental teachers led by Dr Weston A Price. The mechanism was described as “Dental Foci of Infection”.11Today modern researchers using DNA typing of microorganisms are able to verify that microorganisms from root canal filled teeth seed to other body sites and especially to sites that have had some form of prosthetic implant such as joint replacements and stents.12 The phenotypic and genetic methods used today appear valuable for tracing microorganisms in the blood back to their origin.13 It is hoped that the availability of molecular and genomic tests will help to demystify the connection between odontogenic bacteremia and end organ infections in the not too distant future. Hopefully we will see this issue become a research priority by the Universities soon.What is broadly recognized by the scientific community is that most root filled teeth have residual root infection which may allow the systemic spread of bacteria and/or their byproducts to other sites of the body. Histologic observation of root apices with surrounding bone removed from either patients or human cadavers has demonstrated that post-treatment apical periodontitis is associated with 50–90% of root filled human teeth.14 The types of microorganisms identified from root filled teeth include fungi, viruses, archaea (methane producing “hybrid” bacteria), and a host of bacteria. Enterococcus faecalis seems to be present in at least 90% of root filled teeth.15E. faecalis is often resistant to antibiotics and seems to remain unaffected by the conventional root canal therapy methods such as chlorhexidine, bleach and calcium hydroxide.16 This microorganism is responsible for potentially life-threatening infections such as meningitis, endocarditis, and kidney infections. These conditions can be difficult to treat due to the acquired antibiotic resistance of the bacteria.

A few bacteria survive in the circulation after a bacteremic challenge from the oral cavity. The role of these bacteria and how they survive host defenses need to be evaluated further, as they may well be the ones that evade the initial host immune burst and have the propensity to seed target organs and cause systemic and distant infections. 17It also seems that certain oral microorganisms have the ability to become dormant and before being triggered. This may stimulate the production of broad range growth stimulation factors that cause the “community/biofilm” of bacteria to undergo rapid growth, causing damage to the affected tooth and pain to the patient.
18

Cavitation – Bone Cysts
Another form of “hidden”/ residual infections are some types of bone cysts of the jaws. These are also known as radicular, residual cysts, “cavitation” and/or NICO lesions (neuralgia-inducing cavitational osteonecrosis). These bony lesions of the jaw are best detected by 3D low dose radiation digitally imaging, CBCT scans and are usually located in a former tooth extraction site including wisdom teeth – arising from the epithelium remnants of the periodontal ligament.19Features of bone cysts include a type of necrosis of the alveolar bone, “osteomyelitis” developing in the site of a previously extracted abscessed or root filled tooth. Bone biopsies of these lesions reveal that the bone marrow has poor blood supply (ischemia) and many autoimmune antibodies were detected that are associated with bloodclotting disorders, strokes, deep vein thrombosis, and neuropathies.20 , 21 , 22The associated microorganisms cultured from these bony lesions include: Streptococci, Staphylococci, Cornybacterium, yeasts, Spirochetes, Nesseria, Bacteroids, fusobacterium, pseudomonas, Actinomyces, and other microorganisms that prefer low oxygen environments.23
Abscesses from Actinomyces can spread easily from one part of the body to another. Complications may occur when the disease extends from the original site of the infection to other organs such as lungs, pelvis and stomach.
Periodontal Disease
Contrary to popular opinion, periodontal disease is the greatest cause of tooth loss – not tooth decay. Periodontal disease is the infection of gum tissue and the associated loss of bone and fibrous ligament anchoring the tooth into the jaw. Conventional therapies use antibiotics, ultrasonics and sharp instruments for mechanical debridement (scaling and root planing) of the biofilm attached to the tooth/root surface.The advent of laser assisted periodontal therapy supports a non surgical approach that simultaneously ablates the calcified biofilm, microorganisms, endotoxins, lipopolysaccharides and granulomatous tissue of the infected periodontal pocket.24The post treatment microenvironment provides a an excellent surface for the regeneration of the periodontal fibres to attach to the tooth root surface.
Eliminating Oral Infection
A recent technological development is Photon Induced Photoacoustic Streaming (PIPS). This is a revolutionary invention uses specialised lasers to address the common problem of oral infections especially periodontal disease and abscessed teeth. PIPS is defined as “laser activated irrigation system with an energy transfer at subablative levels, inducing a photomechanical effect rather than thermal.”25 PIPS has a profound antimicrobial effect with an average kill rate of 99.5% of bacteria, with another study publishing results of 100% elimination of Enterococcus faecalis in PIPS root canal treated teeth.26

PIPS assisted root canal therapy becomes an ideal solution for people who have concerns about the health impacts of conventional root canal therapy yet do not want to have an extraction of their abscessed tooth.

Pulsing the precise laser energy throughout the oral tissues not only targets the pathological microorganisms but biostimulates the surrounding area. PIPS assisted root canal therapy becomes an ideal solution for people who have concerns about the health impacts of conventional root canal therapy yet do not want to have an extraction of their abscessed tooth. Having an understanding of the multiple factors that lead to oral infections, an integrated approach must to be taken to eliminate these infections in a comprehensive manner. At Laser + Holistic Dental, a combination of pharmaceutical and surgical intervention is recommended utilising supportive technologies that deliver broad spectrum antimicrobial results such as lasers, medical grade ozone and antimicrobial photodynamic therapy.

Dental lasers on the appropriate settings and wavelengths will decontaminate the tooth, gum and bone surfaces where microorganisms have penetrated beyond the reach of conventional dental instruments. The use of the Er-YAG laser for treating decayed teeth as well as in preparing the enamel for preventative fissure seals, offers many advantages. Firstly the sensitive pulp tissue of the tooth is not overheated compared to the standard dental drill. This wavelength also has an antimicrobial decontamination effect on the treated tissue, which destroys both aerobic and anaerobic bacteria .The Er:YAG laser beam/spot size is smaller than a dental bur therefore more sound dental tissue is preserved whilst simultaneously creating a surface with increased bond strength of the adhesive dental filling material. These factors all contribute to reduced microleakage and prevention of reinfection of the tooth at the filling-tooth interface.27 , 28

For those who elect to have their infected teeth extracted or the residual bone cysts/cavitations treated, Laser + Holistic Dental developed a protocol designed to eliminate the infection in the jaw bone, oxygenate and improve the blood flow to the diseased bony site promoting regeneration for a potential dental implant at a later stage. Firstly thorough removal of all periodontal ligament epithelium is undertaken using both mechanical and laser curettage of the extraction site sealing the blood vessels and nerves. Medical ozone gas is applied to the wound which also destroys the anaerobic microorganisms and helps oxygenate the developing blood clot.

Laser + Holistic Dental highly recommends the placement of a blood graft membrane which is harvested from your own blood combined with calcium phosphate and hydroxyapatite crystals to alkalize and stimulate bone development. This has regenerative potential because of the fibrin, concentrated growth factors, CD34 stem cells and plasma enriched proteins. This method also accelerates the healing response with minimal pain and swelling following the procedure. Swift simple recovery follows with minimal surgical complications.

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References
1. Brain Abscess Secondary to a Dental Infection in an 11 Year Old Child: Case Report
2. Bacterial Endocarditis: The Disease, Treatment, and Prevention
3. Geriatric Oral Health and Pneumonia Risk
4. World Health Organisation: What is the burden of oral disease?
5. How does the periapical inflammatory process compromise general health?
7. Overview of risk factors for periodontal disease and implications for diabetes and cardiovascular disease.
8. Systemic Diseases Caused by Oral Infection
9. Serious complications of endodontic infections: Some cautionary tales
10. 16-year remission of rheumatoid arthritis after unusually vigorous treatment of closed dental foci
11. Dental Foci of infection
12. Detection of bacterial virulence genes associated with infective endocarditis in infected root canals
13. Anaerobic bacteremia and fungemia in patients undergoing endodontic therapy: an overview.
14. Consequences of and strategies to deal with residual post-treatment root canal infection
15. Distinctive features of the microbiota associated with different forms of apical periodontitis
16. Bacteriologic investigation of the effects of sodium hypochlorite and chlorhexidine during the endodontic treatment of teeth with apical periodontitis.
17. Microbiology of Odontogenic Bacteremia: beyond Endocarditis
18. Endodontic Microbiology
19. Localization of a Peripheral Residual Cyst: Diagnostic Role of CT Scan
20. Thrombophilia, hypofibrinolysis, and alveolar osteonecrosis of the jaws.
21. The pathophysiology of alveolar osteonecrosis of the jaw: anticardiolipin antibodies, thrombophilia, and hypofibrinolysis.
22. Elevated antimyelin antibodies in patients with maxillofacial osteonecrosis (NICO)
23. The predominant bacteria isolated from radicular cysts
24. Histopathologic Examination to Confirm Diagnosis of Periapical Lesions
25. Bactericidal effect of erbium YAG laser on periodontopathic bacteria
26. Er:YAG and adhesion in conservative dentistry : clinical overview
27. The TwinLight™ Concept in Dentistry
28. ER:YAG Laser for 3-Dimensional Debridement of Canal Systems
29. Disinfection of root canals with photon-initiated photoacoustic streaming
30. Efficacy of photon induced photoacoustic streaming (PIPS) on root canals infected with Enterococcus faecalis: A pilot study