Identification and Laser Eradication of Oral Cavity Spirochetes. Case Study

Originally published April 2018 in the Journal of the American Laser Study Club. Pages 4-13. Download/Print as PDF

About the Author

Ben A. Sutter, DMD, FAGD, FICCMO, LVIF

Dr. Sutter graduated from Rutgers School of Dental Medicine in 2005.  Prior to dental school, Dr. Sutter had research experience in viral genomics and bioinformatics at UNLV in Dr. McClure’s Lab, where he studied the Order Mononegavirales, which includes Ebola, measles, mumps, and rabies among others. At Columbia University, College of Physicians and Surgeons, Microbiology Department, he examined PhoP-PhoQ, a well-studied two-component system that regulates virulence and stress response in Salmonella typhimurium under Dr. Waldburger.

Abstract

Microbial infections represent a substantial health risk worldwide.  Recently, more emphasis has been placed on the role of spirochetes in the etiology of Alzheimer’s disease.  Periodontal treponemas have been implicated in playing a co-infectious role in the disease process. Eliminating the co-infecting pathogens could interrupt or slow down the disease progression. This is a clinical case review, where a patient was confirmed to have an oral spirochetal infection via Phase Contrast Microscopy (PCM), was treated using a 10,600 nm CO₂ laser, and followed for a year. At post op intervals, subgingival plaque samples were examined with PCM.  No return of the infection was observed.  The author is also publishing the protocol used in the eradication of the oral infection.

Keywords:  Spirochetes, CO₂ Laser, Phase Contrast Microscope, Periodontal Infection, Alzheimer’s disease, dementia, periodontal pathogen, Treponema, laser periodontal therapy, Lyme disease.

Introduction

The significance of biofilms in the oral cavity has been well established and accepted. Loss of attachment and alveolar bone are associated with an increased proportion of Gram-negative organisms in subgingival plaque.  Socransky’s “red complex” is of specific interest because of its association with bleeding on probing and contains B. forsythus, P. gingivalis, and T. denticola.¹These organisms are known to be particularly pathogenic and virulent.  Unfortunately, the mouth is not the only place in the body where biofilms can wreak havoc.

The oral microflora, specifically periodontal pathogens, have been named as cofactors in adverse pregnancy outcomes and in systemic disease states such as cardiovascular disease, diabetes and.^2-4 There is a growing body of evidence that points to microbial involvement in Alzheimer’s Disease (AD).^5-8 Specifically, spirochetes working in mature biofilms have been found in amyloid plaques of post mortem brain samples from AD patients.  Miklossy’s review of the literature found spirochetes in 91.1% of AD cases (451/495) and the 185 control samples showed the absence of spirochetes.⁶ It is critical to note, that these biofilms exist as co-infections where multiple spirochetes are present and not just a single species.  This includes known periodontal pathogen Treponemas such as T. denticola, T. pectinovorum, T. amylovorum, T. lecithinolyticum, T. maltophilum, T. medium, T. socranskii.⁷ Miklossy’s analysis shows a probable causal relationship between neurospirochetosis and AD, following Koch’s and Hill’s postulates.⁶  Others have speculated that it is not the actual spirochete infection that causes the amyloid plaques, but rather the body’s immune response to the infection that causes the plaque formation.⁹  Regardless of the actual mechanism, if the spirochetes are not present it would stand to reason amyloid plaque formation could be minimized.

AD is a chronic neurodegenerative disease and is the most frequent cause of dementia. It is characterized symptomatically by a slowly progressive decline of thinking, behavior and memory. AD is confirmed histologically by progressive brain atrophy and the accumulation of amyloid plaques and neurofibrillary tangles.⁶

Spirochetes are gram-negative, anaerobic, motile, and coiled bacteria. They are able to avoid destruction by host immune reactions and initiate chronic infections. They have been linked both to AD and periodontal disease,⁶ and an association between AD and periodontal diseases has been demonstrated.¹⁰ As neurotropic microorganisms, spirochetes can enter the brain and generate a dormant, persistent infection.^11,12 This infection occurs years or decades before manifestation of dementia.⁶ Given that the frequency of periodontal pathogen spirochetes in the amyloid plaques is higher compared to that of B. burgdorferi, which is present in less than one third of the AD cases analyzed.⁶  It would make sense to target the periodontal spirochetes in an attempt to disrupt co-infectivity.  It stands to reason that disrupting the formation of a mature biofilm type could delay or decrease the incidence of AD. 

The use of phase contrast microscopy (PCM) in dentistry for rapid identification of therapeutic targets is not a new concept.¹³ Phase contrast microscopy offers the earliest stage risk assessment possible and spirochetes have a very unique morphology making them easy to identify.  Phase contrast microscopy is performed chair side and offers real-time evaluation of the periodontal risk.  Other technologies such as DNA sequencing require time for shipping and sample processing. Despite the advantage of specificity that DNA sequencing offers, the known sequenced pathogens are but a small portion of the 500-700 oral pathogens known to infect the oral cavity.  For the purposes of this case review, the detection and confirmation of elimination of spirochetes, were fulfilled by PCM.

CO₂ Laser Eradication of Oral Cavity Spirochetes

Photo-thermal laser ablation of spirochete-carrying tissues¹⁴ and bacterial biofilms¹⁵ has been proven effective with infrared (IR) 10,600 nm CO₂ laser and is utilized in the Case Study reported here. CO₂ laser advantages over near-IR 800-1,100 nm diode and Nd:YAG lasers and mid-IR 2,780/2,940 nm Erbium lasers are best understood through the Absorption Spectra (see Figure 1) for the strongest chromophores (at their histologically relevant concentrations) in biofilms (water), epithelium (water and melanin), and sub-epithelium (water, hemoglobin, oxyhemoglobin).^16-19 First, low absorption coefficient in near-IR range of the spectrum renders near-IR lasers inapplicable.¹⁸ Second, unlike the Erbium lasers, the CO₂ laser minimizes the introduction of Spirochetes into the blood stream during laser ablation, due to CO₂ laser’s coagulation depth being 5-15 times thicker than Erbium lasers’ coagulation depth.¹⁹ Also the absorption spectra defines the necessary CO₂ laser pulse (SuperPulse specifications under 1.5 msec duration) ^15,18,19 and fluence (over 3 J/cm²)^15,18,19 for safe and efficient ablation inside the sulcus (laser sulcular debridement).

Materials and Methods

Laser treatments were performed with the LightScalpel LS-1005 Surgical/Dental SuperPulse 10,600 nm CO₂ Laser (LightScalpel, LLC, Bothell, WA, USA).

CO₂ Laser Perio Tip Geometry and Treatment Settings

Laser treatments were performed with the LightScalpel LS-1005 Surgical/Dental SuperPulse 10,600 nm CO₂ laser (LightScalpel LLC, Bothell, WA). Two different SuperPulse settings were configured at 1,500 and 2,000 mWatts of average power (20 and 26.7 mJ pulse energy at 150 Hz further gated with 50% Duty Cycle at 20 Hz). Laser fluence during each individual SuperPulse is 40-54 J/cm², which greatly exceeds the required ablation threshold of 3 J/cm² for water-rich soft tissue and bacterial biofilms. LightScalpel dental angled laser hand piece PN LS9010-02 was used together with 0.25 mm small aperture “Perio Tip” PN LS9005-05 with >90% optical transmission and a miniature distal end design suitable for the intra-sulcus procedures. Perio Tip’s distal end OD is approximately 0.5 mm, and its tapered design allows for easy insertion into the deep pockets of up to 9 mm. The CO₂ laser beam out of the perio tip diverges at approximately 14^O, which is important for delivering laser energy to the walls of the sulcus. Constant air-flow through the hollow core of the Perio Tip pushes the sulcular debris and fluids (blood, saliva, irrigation) out of the way of the laser beam, and prevents tip clogging.

Case Study

The patient, a 55-year-old female, was seen by a dental hygienist in a general dentistry practice for her regular prophylaxis cleaning.  The patient’s gum tissue appeared normal and healthy.  Full-mouth periodontal probing was completed, revealing most pockets were 1 to 3 mm deep, a couple were 4 mm deep, and only one pocket was 5 mm deep, located in the lower right quadrant.

Visit 1: Prophy and Scaling and Root Planing (SRP) with PCM

Medical history was reviewed, and the patient reported a history of heart murmur, skin rashes, and obstructive sleep apnea, which was being treated with CPAP therapy.  The patient reported taking multivitamins and progesterone/estrogen replacement therapy.  Samples of subgingival plaque were obtained from the mesio-lingual aspect of teeth #30 and #31 and visualized under phase contrast microscopy at 400x and 1000x magnification using a Nikon Eclipse Ci-S research-grade phase-contrast microscope (OraTec, Manassas, VA). It was confirmed that the patient was infected with spirochetes (shown in Figure 2 along with some rods and cocci) and trichomonads.

The presence of leukocytes indicates the presence of infection (Figure 3). Limited SRP 1-3 was completed on the lower right quadrant, and a prophylaxis was completed in the rest of the mouth based on the presence of high-risk periodontal pathogens. The patient requested a trial of non-surgical treatment and recommitted to more consistent home care and observing better oral hygiene.

The cleaning was performed using ultrasonic USI 25 MPLC with E⁺ insert at 25 Hz (USI, Houston, TX), and hand instruments.  Oral hygiene instructions were given as well as post op instructions.  Post cleaning samples were difficult to obtain immediately following her cleaning, but neither spirochetes nor trichomonads were identified. This is due to the fact that an ultrasonic was used in the cleaning and plaque was disturbed, diluted and removed all in the same process. The author suspected the infection was still present although nothing was observed under PCM.

Laser periodontal therapy was advised as part of her treatment, but the patient decided to try to control the infection herself by implementing a more consistent homecare oral hygiene program. In an attempt to improve the oral environment, she utilized an Oral-B electric toothbrush (Proctor and Gamble, Cincinnati, OH), brushing only with baking soda (Bob’s Red Mill, Milwaukee, OR), and used a water irrigator (Hydro Floss®, Bessemer, AL).

At this first visit, the patient’s husband accompanied her and multiple subgingival plaque samples were obtained from him.  Interestingly, no spirochetes or trichomonads were found in any of his samples despite being married for over twenty years.

Visit 2: Follow-up with PCM

Patient returned after two weeks to have another plaque sample taken and evaluated under the microscope.  In this plaque sample neither spirochetes nor trichomonads were detected; however, white blood cells — tri-lobed polymorphonuclear leukocytes (PMN) — were observed and were too numerous to count.  This is an indication that the infection persisted even though no spirochetes could be seen (Figures 4A and 4B).

Due to the lack of observed spirochetes, the patient thought the infection was gone and decided to resume brushing with her regular toothpaste against medical advice.  She was advised to return within 24 hours for another plaque sample.  Plaque sample #3 (Figure 5A) revealed that the spirochetes had returned in less than 24 hours.

Spirochetes are unique and opportunistic — they can be found in one of two forms, i.e., an active form when movement can be observed, or a cystic/granular form (Figure 5B).  They can assume a cystic form and go dormant until the environment changes in their favor.  In this example cystic forms were found in epithelium cells (not shown) which traditional dental cleanings do not address. 

         These observations are consistent with the findings of others.²⁰ When the conditions are right, the spirochete reactivates and the infection continues.  At this point the patient wanted one last opportunity to rid herself of the infection on her own; patient was asked to keep track of what she was doing at home.

Visit 3: Follow up with PCM and Home Care Evaluation

The patient incorporated alternative home treatments into her oral hygiene regimen for one week. She added oil pulling, alternating between tea tree and coconut oil.  PerioScience rinse (PerioSciences LLC, Dallas, TX) was added twice a day, and baking soda paste was used with an electric toothbrush and water irrigator. At the conclusion of that week, a subgingival plaque sample (#4) was evaluated and indicated the presence of both the spirochetes and trichomonads (Figures 6A and 6B). The unique thing observed in this plaque sample was that the spirochetes had much more activity, such as spinning faster and with higher motility. At this point, the patient decided to undergo laser-assisted periodontal therapy.

Laser Periodontal Therapy

Four weeks after scaling and root planing and after exhausting other home care methods, the patient agreed to undergo CO₂ laser-assisted periodontal therapy through perio-pocket de-epithelization and closed-flap sulcular debridement. Subgingival plaque samples were obtained pre-treatment and confirmed the presence of spirochetes and trichomonads. Patient’s tissues appear healthy (Figure 7A). A consent form was signed and procedures, alternatives, risks, benefits were discussed and all questions were answered. 

Anesthesia

Anesthesia for the procedure was achieved by buccal infiltrations on the maxilla with 2 carpules, one carpule (1.7cc) on each side, of 4% Septocaine with 1:100k epinephrine.  The mandible was anesthetized with bilateral inferior alveolar nerve blocks of 4% Septocaine with 1:100k epinephrine (one carpule on each side).  No palatal or long buccal nerve injections were given.

Laser Procedure

The crest of the sulcus was de-epithelialized with the laser set at 3 Watts SuperPulse gated at 20 Hz with 50% Duty Cycle (average power to the tissue 1,500 mWatt). A 2 to 3 mm strip of epithelium around the neck of each tooth was treated to ensure that bacteria embedded into this tissue area were evaporated.  Laser energy was applied in small overlapping concentric (circular) movements at the crest of the sulcus in 1 to 2 mm circles from the distal interproximal aspect toward the mesial interproximal aspect and then moving to the next tooth (Figure 7B).  As this tissue heals, it brings in fresh new tissue and delays the epithelial downgrowth into the sulcus.  First, laser treatment was completed on all of the buccal surfaces of the arch; then the procedure was performed on lingual surfaces in the same manner.

Sulcular debridement was performed with the laser set to 4 Watts SuperPulse gated at 20Hz with 50% Duty Cycle (average power to the tissue 2,000 mWatt) for the posterior (molars and premolars) and 3 Watts SuperPulse gated at 20 Hz with 50% Duty Cycle (average power to the tissue 1,500 m Watt) for the anterior (canine to canine). The laser periodontal tip was inserted into the patient’s sulcus at the distal and moved slowly towards the mesial and into the proximal area at a rate of 2 to 3 mm/sec. The tip was kept approximately 1 mm away from the depth of the pocket (Figure 7C). The tip was slowly moved around the entire circumference of the tooth, all of the buccal surfaces were done first then the lingual surfaces were completed. Excess tissue was removed from the tip in order to prevent clogging.

Immediately following the laser therapy, a Cavitron prophy jet (Cavitron, Dentsply Sirona, York, PA) with 65 µm sodium bicarbonate powder (Air Flow, Nyon, Switzerland) was utilized to flush debris out of the sulcus — this was a full mouth procedure, just like with the laser where the application nozzle was walked around the neck of the tooth. It was performed with medium auto cycles, with the medium powder flow rate.  Oral hygiene instructions were given as well as post op instructions.

After periodontal therapy was completed, the results were verified with a slide on phase-contrast microscope. No spirochetes or trichomonads were detected (Figure 8). The day of treatment, soft cold food and beverages were advised, i.e., ice cream, smoothies, shakes. The patient was instructed to observe dietary restrictions for 4 to 5 days following the treatment of no caustic or spicy foods/beverages. For the same time period the patient was advised to brush her teeth with nothing on the brush and hydrofloss with the irrigator.  Following the initial healing time, the patient was to return to brushing with her electric toothbrush and baking soda after using the hydrofloss irrigator.

2 Week Follow-Up

The patient was seen two weeks postoperatively. A biofilm slide was taken and examined with PCM and the results were very minimalistic (Figures 9A). The oral environment as a whole was changed. Only one slow tumbling spirochete was observed (Figure 9A). At this visit a periodontal maintenance cleaning was completed.  The patent’s gingival tissues were healing well. Areas above teeth #9 and #10 were still granulating, but appeared healthy overall (Figure 9B). The patient was instructed that good oral habits are required to maintain the results.  Oral hygiene instructions were reviewed and encouraged.

Plaque samples of the mesio-lingual aspect of teeth 30 and 31 were taken and examined with the PCM at both visits. There was no re-colonization of spirochetes or trichomonads noted at the 6 week, 6 month (Figure 10A), and 1 year follow up visits (Figure 10B).  This indicates that the treatment was effective at eliminating bacteria, and that the patient was following her home-care instructions. The absence of spirochetes for a one year period was encouraging and suggests a stable oral environment that was not recolonized.

Discussion

Dr. Samuel Cohen of Cambridge University cautions, “For most of the last 114 years, everyone including scientists, mistakenly confused Alzheimer’s with aging.” ²¹ This is not the case.  One only needs to complete an age comparison between healthy brains and those ravaged by AD to see the difference. 40 million people are currently affected by AD; and by 2050 that number is expected to increase to 150 million.²¹ Statistically, if one plans on living to the age of 85, one’s probability of contracting AD will be almost one in two.²¹ The United States will spend 259 billion dollars in 2017 for Alzheimer’s care.²²  Costs are expected to increase 500% by the year 2050 as the baby boomer generation ages.²¹ AD is poised to be one of the biggest medical challenges of our generation²¹ and, like with many diseases, prevention and education are cheaper than treatments and cures.   

Proposed laser therapy offers an effective preventative treatment, which, if combined with adequate home care, may provide an efficient technique to maintain a spirochete-free oral environment. Many factors could contribute to the effectiveness of this therapy in other treated patients. This includes laser settings, medications, oral hygiene, sharing food practices, sexual and kissing partners and behaviors, genetics and host immune response.  Even allowing pets licking one’s face could reintroduce pathogenic bacteria into a treated mouth.  Differences in these factors between the patient in this case study and her husband may explain why she was infected, and he was not, despite being married over 20 years.

It is worth noting that no bleeding occurred during the laser therapy, minimizing the introduction of spirochetes into the bloodstream.  This is especially important if the goal is to minimize the number of bacteria released into the bloodstream and, ultimately, the brain and other organs. Absence of bleeding is attributed to highly efficient hemostatic and coagulative properties of the 10,600 nm CO₂ laser.¹⁹

Of particular note is that the patient treated in this case study was a Registered Dental Hygienist with 30 years of experience.  The infection in this case, being due to a lack of suitable home care, seems very remote and illustrates the point that the only way to know if more pathogenic bacteria are hosted in the mouth of our patients is to seek more data beyond periodontal probing and radiographic imaging.  In this case, conventional periodontal cleanings coupled with adjunctive therapies such as baking soda, oral irrigators, and oil pulling did nothing to definitively remove a spirochetal infection.  It was only when the 10,600 nm CO₂ laser was used that the infection was eliminated.

There are a few limitations about this case that need to be addressed.  No DNA sequencing was undertaken, as it is expensive and takes additional time in shipping. Observed eradication of spirochetes in this study does not mean other pathogens were not able to recolonize the mouth. Another limitation of this review is that the number of subjects is low (N=1, and it is hard to extrapolate results of a single case to broader populations.

Summary

Early intervention for a chronic oral spirochete infection could prove to be a realistic and effective prevention of spirochete infections. Phase-contrast microscopy, uniquely suitable for spirochete imaging, has shown that a 10,600 nm CO₂ laser can definitively eliminate spirochetal infections in the oral cavity. There was no detectable re-colonization of spirochetes for up to 1 year. More research is needed to verify the consistency of the results across a larger patient population.

Acknowledgement

The author is grateful to Peter Vitruk, PhD, for help in providing Figure 1, and to Anya Glazkova, PhD, for assistance in organizing this material for publication.

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