Perio Reports Vol. 26, No. 12 |
Perio Reports provides easy-to-read research summaries on topics of specific
interest to clinicians. Perio Reports research summaries will be included in each
issue to keep you on the cutting edge of dental hygiene science.
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Hospitalization Increases Plaque and Gingivitis
A person’s daily routine changes significantly when hospitalized,
even for a short time. Stress, anxiety and the fear of
pain and discomfort may make the body more fragile. Physical
limitation of the patient or even the hospital environment can
impact otherwise regular healthy oral habits.
Researchers at the Federal University of Piau in Brazil
observed patients in two hospitals for changes in their plaque
and gingivitis levels during a short stay. Patients were in one
private and one public hospital and no subjects were in intensive
care. Both demographic and socioeconomic data were
collected from each of the 162 patients. One dentist with an
assistant holding a flashlight carried out all the exams. Patients
were not told of their oral health status and no oral hygiene
instructions were given. Data was collected from four sites per
tooth for plaque and gingivitis.
There were four observation periods based on the number of
days in the hospital: three, seven, 14 and 21 days. Sixteen patients
were observed throughout the four observation times. Neither
hospital had an oral health protocol for patients to follow. Daily
toothbrushing was reduced by 72 percent of the patients, despite
83 percent reporting no barrier to daily oral hygiene.
Plaque levels increased at each time point, compared to
baseline. Gingivitis scores increased significantly at days 7 and
21. There may have been pre-existing systemic conditions that
contributed to the increases in plaque and gingivitis.
These findings suggest the need for oral health care
protocols for hospital patients.
Clinical Implications: Hospitalized patients need advice and
coaching to maintain their regular daily oral hygiene habits.
Sousa, L., Filho, W., Mendes, R., Neto, J., Prado, R.: Oral Health of Patients Under
Short Hospitalization Period: Observational Study. J Clin Perio 41:558-563, 2014.
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Smokers Cancel Their Hygiene Visits More Often
Than Non-Smokers
Periodontal disease is still a significant problem, with nearly
half the population suffering with chronic periodontitis. Periodontal
therapy, both scaling and root planing and surgical procedures
can stop the progression of disease. Patients are encouraged to
maintain good daily oral hygiene and return to their dental professional
for regular Supportive Periodontal Therapy (SPT) visits.
Despite these efforts on the part of dental professionals, patient
compliance with SPT is generally poor. Depending on the study,
compliance rates show approximately one-third of perio patients
are completely compliant with recommended SPT. Many things
influence compliance, including age, severity of the disease, financial
costs, attitude, anxiety, stress, depression and smoking.
Researchers at the University of Bern in Bern, Switzerland
evaluated a group of 1,336 patient charts for those being seen by
dental hygienists in the periodontal clinic of the dental school.
Of this group, 32 percent were smokers, 23 percent were former-
smokers and 45 percent were non-smokers. The patients
had been seen over a period of 26 years, from 1985-2011. Of this
group, 74 percent returned to see the dental hygienist and 26
percent never returned. Some were referred back to their general
dentist, but others simply never returned.
Overall compliance of those returning was 70 percent. Of
the smokers, 67 percent complied compared to non-smokers
who complied at a level of 72 percent. A total of 66 patients
presented with 100 percent compliance with the recommended
interval, which amounts to about seven percent.
Clinical Implications: Compliance with SPT is low, and those who smoke are slightly less likely to comply.
Ramseier, C., Kobrehel, S., Staub, P., Sculean, A., Lang, N., Salvi, G.: Compliance of Cigarette Smokers with Scheduled Visits for Supportive Periodontal Therapy. J Clin Perio 41:473-480, 2014.
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Air Polishing with Erythritol and
Chlorhexidine
Maintenance therapy for periodontal
patients focuses on removal of subgingival bacterial
biofilm. Stainless steel curettes and power
scalers are the most popular tools for this task.
Recent research shows the benefit of subgingival
air polishing for subgingival biofi lm disruption
rather than hand or power scalers.
Researchers at the University of Geneva in
Switzerland compared two approaches to subgingival
biofilm removal. One side of the mouth was
treated with an air polisher using erythritol powder
containing 0.3 percent chlorhexidine and the
other side with a piezoelectric power scaler.
A total of 49 patients completed the 12
month study. Subjects all received baseline data
collection, collection of subgingival plaque samples,
calculus removal with hand instruments
and oral hygiene instructions. Random assignment
was then made for one side of the dentition
to be air polished with erythritol powder and the
other side to be treated with a power scaler. Sites
over 4mm were treated subgingivally. Patients
were seen every three months for one year, with
the assigned treatment repeated for any remaining
pockets 4mm or deeper. The time necessary
for the treatment and the patient’s comfort level
were also recorded.
At the end of one year, both the groups
showed improved probing depths and reduced
bleeding scores. The air polishing group demonstrated
lower levels of Aggregatibacter actinomycetemcomitans
than the power scaling group.
Treatment time was similar for both groups. The
perception of pain and discomfort was significantly lower for the air polished sites compared
to the power scaler treated sites.
Clinical Implications: Because of patient comfort and effectiveness,
subgingival air polishing with erythritol powder
may one day replace power scaling for periodontal maintenance
visits.
Müller, N., Moëne, R., Cancela, J., Mombelli, A.: Subgingival Air-Polishing
with Erythritol During Periodontal Maintenance. J Clin Perio 41(9):875-882, 2014.
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Xylitol Interferes with Periodontal Pathogens
The destruction of healthy connective tissue and bone in periodontal
disease is caused in part by proteinases secreted by the
bacteria. Subgingival bacteria release endotoxins that trigger an
infection in the tissues and an inflammatory response. The greatest
destruction is due to the cytokines released by white blood cells
in a reaction to the lipopolysaccharide released by the bacteria that
triggers the body’s immune response. Two of the cytokines associated
with periodontal destruction are interleukin-1 (IL-1) and
tumor necrosis factor alpha (TNF-). Xylitol inhibits the growth
and acid production by Streptococcus mutans, but little is known
of the effects on periodontal pathogens.
Researchers in the Department of Oral Microbiology at
Pusan National University in Korea evaluated the laboratory
effects of xylitol on cytokine expression by Porphyromonas gingivalis
(Pg). The bacteria were grown in anaerobic conditions
and lipopolysaccharide was extracted and added to macrophage
cultures. Expression of
IL-1 and TNF- were
then measured at two
and four hours.
To test the impact of
xylitol, the macrophages
were pre-treated with a
variety of xylitol concentrations
(1, 2, 4 or 8 percent) before being
exposed to lipopolysaccharide
from Pg. Xylitol pretreatment reduced the production of
IL-1 and TNF- at a dose dependent rate. Four and 8 percent significantly inhibited cytokine production without killing the cells.
Xylitol also showed an inhibitory effect on the growth of Pg.
These findings suggest that xylitol, a natural sugar, may provide
good clinical effects for controlling periodontal disease by
preventing bacterial proliferation and cytokine expression.
Clinical Implications: Daily xylitol use may provide preventive benefits for
periodontal disease as well as caries.
Han, S., Jeong, S., Chung, J.: Xylitol Inhibits Infl ammatory Cytokine Expression Induced by Lipopolysaccharide
from Porphyromonas Gingivalis. Clin Diagn Lab Immunol 11: 1285-1291, 2005.
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Oral Probiotics Reduce Levels of Strep Mutans
Dental caries is a preventable disease that affects people
of all ages. Biofilm containing Streptococcus mutans (Strep
mutans) together with a susceptible host and fermentable
nutrients leads to demineralization of tooth structure. Current
preventive measures focus primarily on topical fluorides,
diet and oral hygiene. Recently oral probiotics have been
introduced for caries prevention. Probiotics are living microorganisms
that confer a health benefit to the host. Probiotics
produce substances harmful to Strep mutans, they stimulate
immune response, modulate inflammation, compete with oral
bacteria for nutrients and binding sites on the teeth.
Research has shown beneficial effects to the gastrointestinal
tract from probiotics. Oral probiotics are designed to be dissolved
in the mouth to compete with the common oral microflora.
Researchers in Belgium and The Netherlands reviewed the
research on oral probiotics. They began with 725 research articles, narrowing it down to 19 that measured Strep mutans levels and
of these, 12 studies that were included in a meta-analysis - combining
data from the similarly designed studies.
Test subjects who were given probiotics had lower Strep
mutans levels than those given a placebo or nothing. Lactobacillus
counts did not show significant differences between
control and probiotic groups.
Three studies were long term and could measure the
impact of oral probiotics on caries incidence. Young children
drinking milk containing Lactobacillus rhammous did
experience a significant reduction in caries incidence. Milk
containing both probiotics and fluoride was beneficial in the
prevention of root caries in older individuals.
Clinical Implications: These findings suggest that oral probiotics may be an effective approach to preventing dental caries.
Laleman, I., Detailleur, V., Slot, D., Slomka, V., Quirynen, M., Teugels, W.: Probiotics Reduce Mutans Streptococci Counts in Humans: A Systematic Review and Meta-Analysis. J Clin Invest 18:1539-1552, 2014.
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Review of Xylitol Research and Update on Ongoing Efforts
This review article reported on xylitol research from 2008.
Xylitol is a safe natural sugar that effectively prevents transmission
of Streptococcus mutans from mother to baby when
used by the mother several times each day after the child’s
birth. Children receiving xylitol lozenges several times daily
experienced significantly less dental caries than control children.
School children receiving xylitol several times daily in
a gummy bear confection
showed reduced levels of
Streptococcus mutans. Once
daily use of xylitol containing
toothpaste was not effective.
Xylitol provides an added benefit to chewing gum beyond
the increase in salivary flow.
Evidenced-based reviews
often include only a few studies
following the same clinical
study design. Field studies are
more difficult to conduct than in-house clinical trials as many
factors influence the process.
Recently, the American Academy of Pediatric Dentistry
strengthened its recommendation of xylitol use stating that
“AAPD supports the use of xylitol as part of a preventive strategy
aimed specifically at long term caries pathogen suppression
and caries reduction in higher risk populations.”
Studies confirm the benefits of xylitol use in children to elevate
salivary pH and prevent dental caries. Other studies provide
new evidence of how xylitol reduces numbers of Streptococcus
mutans, not by growth inhibition, but rather by prevention of
bacterial adhesion to tooth surfaces exposed to xylitol.
Despite a multitude of studies published, information
about the clinical benefits of xylitol is not reaching clinicians.
Future studies are needed to determine the best ways to address
the global dental caries problem.
Clinical Implications: Xylitol provides significant preventive benefits for
those at risk for caries and for long term caries prevention.
Milgrom, P., Söderling, E., Nelson, S., Chi, D., Nakai, Y.: Clinical Evidence for Polyol Efficacy. Adv
Dent Res 24(2): 112-116, 2012.
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