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The Transmission of Anaerobic Periodontopathic Organisms
1 Department of Orthodontic and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor, MI 48109-1078, USA; Correspondence: * corresponding author, wloesche{at}umich.edu
The oral microbial flora is unique, and available evidence indicates that it is passed vertically from parents to children. In this investigation, we used a chairside assay for the N-benzoyl-DL-arginine-2-naphthylamide (BANA)-sensitive enzyme found in Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythensis, to determine the prevalence of these BANA-positive species in young children and their caregivers. We predicted that if the BANA enzyme was found in plaque samples of children, it would also be present in the plaque samples of the caregivers. Forty-four percent of 150 children had at least one plaque sample positive for the BANA enzyme. If the caregiver was BANA-positive, the odds of the child also being BANA-positive was 35 times more than for a child with a BANA-negative caregiver, after adjustment for the child’s age and papillary bleeding score (PBS). Other significant predictors were the PBS of children (p < 0.001), a history of periodontal disease, and the ages of the caregivers (p < 0.001).
Key Words: BANA test • children • transmission
Periodontal diseases are often neglected in childhood and adolescence. As evidence accumulates that adult forms of periodontal disease are opportunistic infections, due to certain indigenous bacterial species, there is interest as to when these periodontal pathogens colonize the oral surfaces. Some studies showed that if a child harbored a periodontal pathogen, then at least one of the parents will exhibit the same genotype of bacteria (Alaluusua et al., 1991; Watson et al., 1994). Kononen et al. (1992a,b) found that various anaerobic species colonize the edentulous mouths of infants, and that maternal saliva may act as a source of some Gram-negative anaerobes. Tests capable of detecting various oral species have been developed, but DNA probes, immunological reagents, and bacterial culturing are laboratory-based and are not appropriate for chair-side use. Toward this end, there is need for a test that could be used reliably in routine clinical examinations to identify the presence of bacteria associated with periodontal diseases. The BANA (N-benzoyl-DL-arginine-2-naphthylamide) test detects a trypsin-like enzyme that is present in Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythensis. The BANA test had 92% sensitivity and 70% specificity when compared with DNA probes and polyclonal immunological reagents (Loesche et al., 1992). Watson et al.(1991) showed that 56% of 157 children were positive for BANA-positive species in one or more of 4 samples of plaque, indicating that young children are colonized by P. gingivalis, T. denticola, and T. forsythensis. Children whose parents were colonized by BANA-positive bacteria were 9.8 times more likely to be colonized by BANA-positive species than were children whose parents were BANA-test-negative. Children whose parents had clinical evidence of periodontitis were 12 times more likely to be colonized by BANA-positive species. These data are compatible with the hypothesis that children may acquire the BANA-positive species from their parents, especially if the parent has periodontitis. The purpose of our study was to obtain information regarding the prevalence of BANA-positive species in young children and their parents, by seeking evidence of the potential transmission of periodontal pathogens between parents and their children.
Subjects Watson et al.(1991) found, with 34 caregivers, that it was possible to show a relationship between the presence of BANA-positive species in both the caregiver and the child. We sought to expand on that number by approaching caregivers who brought children to the pediatric clinic between September and December of 2003. After approval of the protocol by the University’s Institutional Review Board, informed consent was obtained from 140 caregivers (107 mothers, 30 fathers, three grandparents) responsible for 150 children. The 150 subjects, ages 3 to 10 yrs, were seen in Graduate (n = 57) and Undergraduate clinics (n = 93) at the University of Michigan School of Dentistry. There were 86 boys and 64 girls, distributed in five racial groups: Caucasian (46.7%), African-American (33.3%), Asian (4.0%), Hispanic (13.3%), and others (2.7%).
Experimental Protocol
BANA Test
Statistical Analysis
The 63 children with primary dentition had a mean dmft score of 6 (SD = 3.54). The 84 children with mixed dentition had a mean dmft score of 1.0 (SD = 1.47) and a mean DMFT score of 3.2 (SD = 2.04). The mean DMFT score for the three children with permanent dentition was 0.
Eighty-four (56%) of the children tested BANA-negative for all 4 plaque samples, and 66 (44%) tested positive and/or weakly positive in one or more of the samples (Table 1
There was no significant relationship between the number of BANA-positive samples and gender, race, PI, caries status, the history of dental visits, brushing habits, or the antibiotic history of the subject (p > 0.05). Children who had a mixed dentition had significantly more BANA-positive samples than did children with a primary dentition (p < 0.001) (Table 2  ). Twenty-four percent of the children aged 3–5 yrs had BANA-positive samples, compared with 56.5% of the children aged 6 to 10 yrs (p < 0.001) (Table 2).
There was no significant difference between the mean dmft, DMFT, and total DMF (dmft+DMFT) for BANA-positive compared with BANA-negative children. The BANA-positive children were significantly older than the BANA-negative children. The BANA-positive children had a significantly higher PBS score (Table 2  ).
Seventy of the 140 caregivers tested BANA-positive and/or weakly positive in one or more of the quadrants. Eighty-four percent of children whose caregivers were BANA-positive were also BANA-positive, whereas only 7% of children whose caregivers were BANA-negative were BANA-positive (p < 0.001). Sixty-three percent of the children aged 3–5 yrs and 92% of the children aged 6–10 yrs, whose caregivers were BANA-positive, were also BANA-positive (Table 3
If caregivers or family members had a history of periodontal disease, the children were significantly more likely to be BANA-positive (p < 0.001). Forty-seven children (62%) whose caregivers were  35 yrs old had BANA-positive scores, while only 26% of children who had younger caregivers had BANA-positive scores (p < 0.001).
We performed a stepwise logistic regression analysis to determine the association between various independent variables and BANA-positive results in the children. Each variable that was found to have a significant relationship to BANA-positive test results was included in the analysis. At each step, the most significant variables were entered into the model. At step one of the model, children with a BANA-positive caregiver had 69 times greater odds of a BANA-positive sample than did children with a BANA-negative caregiver. When the mean PBS and the age of the child were added to the model, they were also significant, and the model R2 increased to 0.85 (Table 4
The prevalence of aggressive (early onset) periodontitis in children in the United States is low (0.4–0.8%) (Löe et al., 1991; Albandar and Tineco, 2002). These studies, based on radiographic assessments and detection of pocket depths, were unable to show the process of an ongoing inflammatory response to periodontopathic bacteria. Three bacteria associated with aggressive periodontitis—P. gingivalis (Lopez et al., 1996), T. denticola (Albandar et al., 1997; Mullally et al., 2000), and T. forsythensis (Darby et al., 2000)—are BANA-positive. Since the BANA test can be used at chairside to look for these species, this could be a means of detecting children at risk for, or actually experiencing, aggressive periodontitis. The present study and that by Watson et al.(1991) showed that 44% and 56%, respectively, of the children had at least one BANA-positive plaque sample. BANA-positive plaque samples were more frequently encountered in older children with a mixed dentition, compared with younger children with a primary dentition. This could reflect that, with increasing age, there is more time for children’s mouths to be colonized from outside sources. Another explanation could be that the micro-environment at interproximal sites in the mixed dentition, such as bleeding during eruption, promotes colonization of BANA-positive species from sites such as the tongue and the primary dentition. In this regard, the BANA species have nutrient requirements for host molecules, such as hemin, progesterone, ceruloplasmin, and acetyl muramic acid, among others (Loesche, 1968; Kornman and Loesche, 1982; Suzuki and Loesche, 1989). The eruption of the permanent teeth increases the number of interproximal sites that provide an ideal environment for anaerobic bacteria.
There was no correlation between BANA scores and PI or brushing habits. The mean value of the PBS was significantly correlated with the presence of BANA-positive plaques (Table 2 The vertical transmission of periodontal microflora from mother to child has been reported (Könönen et al., 1992b; Matto et al., 1998). The present study found that children whose parents were colonized by BANA-positive bacteria were significantly more likely to have a positive BANA reaction. Also, children with BANA-positive plaques were more likely to have caregivers or family members who were older and had a history of periodontal disease (P < 0.001). It is possible that a multi-factor risk model could be designed, like the early childhood caries risk model, to provide some benefit in the recognition and management of aggressive periodontitis. A limitation with the present concept(s) of the etiology of periodontal disease is the difficulty in explaining to young patients or parents why they are more or less at risk based solely on their level of oral hygiene. But an aggressive periodontitis risk model could be used to explain how an anaerobic infection could cause periodontal disease in either the child or the parent (Albandar, 2000; Albandar and Tineco, 2002).
An anaerobic periodontal infection risk model can be proposed from the present study. The BANA reaction of caregivers was the strongest predictor of BANA-positive plaque samples in the children. If the caregiver was BANA-positive, the odds of the child also being BANA-positive was 35 times more than for a child with a BANA-negative caregiver, after adjustment for the child’s age and PBS. The R2 of the model indicated that 85% of the variability was accounted for (Table 4 Oral health risk assessment of this nature should focus efforts toward those children who have the greatest needs, thereby saving time and reducing expenditures. However, children in the present study were selected from patients with high caries scores and some behavioral issues. Therefore, a larger randomly selected population needs to be sampled for the results to be applicable to the general population. A long-term follow-up for those children who had the BANA reactions would be necessary to determine whether the risk indicators identified would predict which children are more likely to develop aggressive periodontitis. Longitudinal studies in adults showed that the presence of P. gingivalis, T. forsythensis, and BANA-positive plaque samples was a risk factor for periodontal disease (Beck et al., 1990; Grossi et al., 1994; Elter et al., 1999). An unexpected dividend from the present findings could be the observation that children who were BANA-positive always had a mother who was BANA-positive. Recent reports (Jeffcoat et al., 2001; Lopez et al., 2002) indicated a significant association between preterm and low-birthweight infants, and mothers with periodontal disease. Pediatric dentists who identify children with positive BANA results could ask the child’s mother about her periodontal and pregnancy status. If the particular mother was pregnant, the dentist could recommend a periodontal examination.
This research was performed in partial fulfillment of the requirements for the Master’s Thesis in Pediatric Dentistry (Kevin Lee). The Department of Pediatric Dentistry provided funds and access to clinic patients. The BANA tests and incubators were provided by BANAMet LLC of Ann Arbor, MI. The advice and guidance of Kevin Hale and Jan Hu are gratefully acknowledged. Received for publication January 13, 2005. Revision received August 17, 2005. Accepted for publication October 12, 2005.
Journal of Dental Research, Vol. 85, No. 2,
182-186 (2006) This article has been cited by other articles:
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