Re: [ACEsthetics] What's a crenated RBC?

This is REALLY good stuff for those of us who use PCM! Explains alot.

BTW, we ALWAYS take our samples via the 'Oratec/Bill Landers/Paul Keyes/ Dan Watt' protocol (at the beginning of the appointment, before ANYThing is done).

And this patient WAS on Cipro for a few weeks prior to this appointment for a bladder infection.

Hmm.

Ray

----- Original Message -----

From: William Domb

To: gnr

Sent: Wednesday, May 29, 2013 6:10 PM

Subject: Fw: [ACEsthetics] What's a crenated RBC?

Bill Landers from Oratec shares his multiple insights on Ray Voller's microscope video.

 

regards

bill domb

 

 

 

Thanks for forwarding the video. One can deduce a lot from it.

 

The rightmost RBC is highly crenated, but the other two RBC's are only very slightly crenated. That rules out a hypertonic mounting medium as the cause. If that were the case, all of the RBC's would exhibit similar crenation. The healthy appearance of the other two cells also argues against disease as the cause. One would expect more uniformity.

The most likely explanation is routine senescence. RBC's have a lifespan of ~120 days. Interestingly and germane to the video, RBC's do not degrade gradually over the 120 days. They appear normal microscopically until just before the end, when they crenate rather suddenly. While there is a complex web of factors that influence the aging process, microvesiculation is the final stage. It's thought that it exposes proteins and senescence marks on the RBC membrane that WBC's use to target RBC's for phagocytosis and removal. If a crevicular sample has a fair number of RBC's, one can usually find some that are crenated in the population.

 

BTW, (normal, physiologic) saline is hypertonic to crevicular RBC's and causes widespread crenation. That's because saline is isotonic to blood, not crevicular fluid, which is considerably more dilute. Back in the 80's, we used to see a lot of crenation in samples until we performed serial dilution studies and found the optimum tonicity. The tonicity of OraTec's mounting solution, OraPrep is identical to crevicular fluid.   

 

Lastly, there's an anomaly regarding the spirochetes in the sample. There are only a few, but they're fairly large and rigid. Those species aren't initial colonizers. They're typically found in more mature, more anaerobic biofilms in large numbers in conjunction with other spirochete species and motile rods. Four possibilities come to mind:

1.      We're only seeing the periphery of the sample. The concentration is denser than seen here.

2.      Atypical sample:  possibly taken more toward the CEJ and not from the apical 1/3 of the pocket where mature biofilms typically exist or perhaps the site was mechanically disrupted prior to sampling. Scaled prior to sampling?

3.      The patient performed heroic hygiene earlier knowing they had a dental appointment. That could also explain the increased presence of the RBC's (recent mechanical trauma). It's not uncommon to see patients trying to catch up on their hygiene the night before.

4.      Systemic antibiotics:  If not from the dentist, perhaps the patient's MD? That might explain the disparity between morphotypes and numbers. Also, if the patient just finished a course of antibiotics, they either weren't compliant or the antibiotic wasn't effective against Gram negative anaerobes. There are only a few spirochetes in the video, but they're vigorous. If the right antibiotic and compliant, there should be no spirochetes, alive or dead in the sample. They should have completely died off over the course of the drug. In addition to risk assessment, lots of clinicians are now using their microscopes to check antibiotic compliance by sampling the patient just after the course completion.    

 

Bill Landers
President, OraTec
Columnist, RDH

 

From: William Domb [mailto:wmdomb@verizon.net]
Sent: Wednesday, May 29, 2013 11:53 AM
To: Bill Landers
Subject: Fw: [ACEsthetics] What's a crenated RBC?

 

??

 

Could his suspensory saline be drying out and getting more concentrated?

 

Just an old red cell?

 

regards

bill domb

 

From: Dr. Ray Voller

Sent: Wednesday, May 29, 2013 8:38 AM

To: acesthetics@googlegroups.com

Subject: [ACEsthetics] What's a crenated RBC?

 

My hygienist saw this 'thing' on the PCM/slide yesterday (what looks like a ball with projectiles on it). She said, "What kind of bacteria is THAT!?

I informed her that it is a 'crenated RBC' caused by either a disease process, or it could be just an anomoly. This is also caused by the plaque sample placed in a 'hypertonic' or hyperosmotic solution, which is possible, because we do apply saline to the samples we take to help suspend them and allow better viewing of the samples.. They are 'virgin' basically, but these little projections on an RBC can be also caused by the 'manhandling' of the sample, and shrinkage of the RBC. We occasionally but rarely see these types of 'echinocytes' in our samples, however. They CAN signify a 'disease process' going on also, (this patient has moderate perio and you can see some evidence of spirochetes in this sample also.) The spirochetes are the squiggly pig tail shaped bugs faintly seen in this video.

I find this type of additional data as very valuable adjunct to 'making a case' for patients to be rigorously treated to arrest this perio, particularly with the presence of spirochetes in her sample. Her boyfriend just came in yesterday too and we also found a similar sample from him.
Treatment is 4 quads of S/RP, ozonation, home ozone (oil) applications, 3 month recare appointment, home irrigation with Therasol, and if spirochetes are in sample in 3 months, hit em with Flaygl. She HAD been on Cipro for a bladder infection recently (wonder if the bladder infection had the primary etiology as a spirochete?? hmm..?)

The other thing is a possible 'superinfection' from the Cipro.  ?

Ray

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