Reviewing case studies with Dr. Thomas Nabors

April 8, 2010

Editor's Note: The article below was written in conjunction with an article that appeared in the March issue of Dental Economics. It was an interview conducted by Dr. Joe Blaes with Dr. Thomas Nabors, who was instrumental in establishing OralDNA® Labs, Inc. You can read the entire article by clicking here.

Dr. Joe Blaes:
Can you describe some cases in which DNA testing impacted treatment decisions and favorable treatment outcomes?
Dr. Thomas Nabors: There are a number of patients that come to mind. I will make the stories brief even though some were very serious and complicated cases.

Case No. 1: A 12-year-old female in braces
Can 12-year-olds develop periodontal disease? We typically do not think this to be the case. So what do we always do when we see inflammation and bleeding? “Brush and floss.” This 12-year-old had bleeding tissues every time she came into the office. Of course she’s 12, going through major hormonal changes and ortho treatment: that’s the answer, right? Well, that’s only marginally correct.

The fact is that she was infected with a number of different pathogenic species and was genotype positive. As a result, her parents and siblings were also examined and tested. The result — all family members had varying degrees of periodontal disease. All were treated appropriately based on their state of disease. All infections were resolved, including the 12-year-old in braces. The point: periodontal infections can be transmitted horizontally and vertically through normal family interactivity. This young lady now knows that she is genetically susceptible to a serious infection and we see her every three months just to make sure that her inflammation is controlled. Her mouth is beautiful, healthy, and free of infection three years later.

Point: Even gingivitis should be examined closely. If clinical signs do not resolve with excellent home care, be suspicious and test. You may save a patient from a lifelong battle with periodontal disease, and their family as well.

Case No. 2: A nice lady drove four hours each way to come to my practice. Her local periodontist informed her that all of her teeth (28) would need to be extracted. We tested her for both pathogen load and genetic traits. Through the test report results, we were able to understand why her disease was so serious and what direction our treatment should be directed. As a result, we were able to save all but four of her teeth. We resolved her infection and were able to work with our local periodontist for him to place four implants, which we later restored. Most importantly, we diagnosed her problem more precisely, formed a treatment plan that was specific for her infection, saved her teeth, gave her confidence, and restored her oral health.

Case No. 3: This patient had periodontal surgery on three different occasions. She came to see me because she was told that four more teeth would need removal and more periodontal surgery. Her faith in the dental profession was at low ebb. She was angry and wondered why our profession “seemed so far behind other health professions.” We tested her for both the cause of her infection (inflammatory response), discovered the cause of her infection, treated her nonsurgically, discovered that she was positive for the genetic trait, and easily resolved her infection. More importantly, we restored her health and her confidence in the dental health profession. By the way, we also saved all four of her teeth and she has remained infection-free for a number of years.

Case No. 4: This patient also drove long distances to be seen by our office team. She had heard that we were “doing something different.” She was a nurse and had been told that all six of her implants that had been placed several years earlier would need surgical removal. She was not a smoker and took good care of her oral health, including seeing her dentist and periodontist every three months. My first procedure after taking her histories, both dental and medical, was to run both tests. Due to her nursing background, this made perfect sense to her. She had some remaining teeth but none with greater than 4 mm of pocketing. The genetic test revealed that she was genotype positive for the genetic variation, plus, the pathogen test revealed that her mouth was populated with large quantities of the periodontal pathogens. In this case, we were able to tell her why she was losing her implants but we were unable to save them due to the severity of the infection. However, we kept her in our practice, had the infected implants removed, were able to eventually graft the previously infected sites, place eight new implants, and restore her entire maxillary arch with a fixed/removable prosthesis. More importantly, we restored her health and saved the rest of her teeth. Again, from her perspective as a nurse, she understood very well the genetic factors and causative factors. Plus, we were able to restore her faith in the profession.

Case No. 5: The final case history is one that perhaps saved a life. This patient had a heart transplant one year earlier and had done exceptionally well. However, one day I received a call from the head of the hospital transplant team. The conversation went something like this: “Dr. Nabors, I am the transplant surgeon and am concerned with our patient. Upon his visit today, I noticed that his mouth appeared to be inflamed and the tissues enlarged. This patient is taking cyclosporine. My question to you is … is this inflammation, edema, and tissue change due to the cyclosporine or is it due to an infection within his mouth?” How would you react to that question? How would you know for sure, without a doubt?

My first reaction was to say, “Send him in immediately and I will be able to tell you if this is a true infection or not. We can rule on two important factors — the specific pathogens and the bacterial load (inflammatory burden). Plus, we can determine if he is genotype positive.” “This is exactly what we need to know,” was the doctor’s reply.

Both tests were negative. The patient was not infected and was genotype negative. He was able to continue to take his cyclosporine and we were able to build a treatment plan that was specific for him and his medical needs. We ultimately performed a gingivectomy (a result of medication, not infection) so that he could clean better, and we were able to resolve all of the inflammation and tissue problems. Needless to say, the heart surgeon was sent a copy of the lab reports and they became a permanent part of the patient’s record. The patient is now eight years post-heart transplant and seven years post-gingivectomy. This one case changed the way that I communicate with physicians.

Dr. Thomas W. Nabors practiced general dentistry for 38 years. He is a life member of the ADA, a member of many professional organizations, and is a frequent lecturer. His knowledge and application of oral microbiology and genetics as they pertain to oral medicine makes him unique as a teacher. Upon his retirement from practice, he was instrumental in establishing OralDNA® Labs, Inc. where he now serves as Chief Dental Officer. Dr. Nabors can be reached at [email protected].