Perio Reports provides easy-to-read research summaries on topics of specific interest to clinicians. Perio Reports research summaries will be included each month to keep you on the cutting edge of dental hygiene science.

Classic Study
Periodontal surgery without maintenance can be destructive

What happens if a patient has periodontal surgery but does not receive regular maintenance therapy? Is the surgery beneficial or actually harmful to the periodontal condition of the patient? Should surgery be done without reassurance of follow-up care?

Researchers in Sweden compared five surgical procedures without maintenance care. The 25 patients were divided among five surgical groups. The surgical procedures included an apically repositioned flap with and without osseous recontouring, a Widman flap with and without osseous recontouring, and a gingivectomy.

Detailed case presentations were made to the patients stressing the importance of their plaque control efforts. During this appointment they received oral hygiene instructions including toothbrushing, and interdental cleaning with floss, toothpicks, and interdental brushes. No review of oral hygiene or maintenance therapy was provided after surgery. However, clinical data was collected at 6, 12, and 24 months.

A temporary improvement in oral hygiene was measured following plaque control instructions. Plaque accumulation increased significantly following surgery, leading to recurrence of destructive periodontal disease. Significant bone loss and loss of attachment resulted. Patients were able to keep the facial surfaces of the teeth relatively free from plaque accumulations, but lingual and interproximal surfaces showed significant accumulations. During the two-year test period, attachment levels showed a loss of 1 mm on lingual surfaces and 2 mm interproximally. That figure is significantly higher than loss measured in untreated periodontitis, which is documented to be an average loss of .1 to .3 mm per year.

Clinical Implications: Without effective plaque control or maintenance therapy, periodontal surgery can be more detrimental than doing nothing.

Nyman, S., Lindhe, J., Rosling, B.: Periodontal Surgery in Plaque-Infected Dentitions. J of Clin Perio 4: 240, 1977.

Waterpik more effective than string floss

Researchers at the University of Nebraska compared traditional manual brushing and flossing to either manual or power brushing plus oral irrigation using 105 subjects assigned to one of three groups. The control group used the Oral-B 35 manual toothbrush and Johnson & Johnson REACH floss. Subjects were instructed to brush twice daily and floss once per day.

The second group used the Oral-B 35 manual toothbrush twice daily and used the Waterpik once daily. The third group used the Waterpik Sensonic Toothbrush twice daily and the oral irrigator once daily. All subjects received both written and oral instructions on their assigned oral hygiene aids.

Bleeding, plaque and gingivitis scores were recorded at baseline, day 14 and day 28 on facial and lingual surfaces. Measurements at the interproximal sites were not included in the study design.

Throughout the study, all groups showed reductions in bleeding, plaque and gingivitis scores. Differences on the lingual surfaces did not vary significantly between groups. On day 14, lingual gingivitis scores were reduced from baseline scores by 12-14%; bleeding by 31-41% and plaque by 7-10%. On day 28, reductions in facial bleeding and gingivitis scores were greater for the two oral irrigation groups than the flossing group. The bleeding reduction for the flossing group was 31% and for the manual brush plus the Waterpik it was 59%. This difference of 28 percentage points between groups is nearly the reduction experienced by the control group. This reduction can be interpreted to mean the Waterpik is 93% better in reducing facial bleeding than floss.

No differences in lingual plaque levels were found between groups. The Sensonic toothbrush showed greater plaque reduction on facial surfaces than both manual toothbrushing groups.

Clinical Implications: For patients who aren’t effective with floss, oral irrigation is an effective alternative for reducing facial bleeding and gingivitis.

Barnes, C., Russell, C., Reinhardt, R., Payne, J., Lyle, D.: Comparison of Irrigation to Floss as an Adjunct to Toothbrushing: Effect on Bleeding, Gingivitis, and Supragingival Plaque. J Clin Dent 16: 71-77, 2005.

Children of edentulous mothers are more prone to caries

Edentulism and caries are two significant health problems in Quebec, Canada. In 1993, 14% of 35-44 year olds had lost all their teeth. Tooth loss before the age of 50 is generally due to caries and not periodontal disease. Past research suggests that oral health correlations are higher for mother-child than for father-child. We also know from studies of twins raised apart that there is a genetic component to dental caries, which may be passed from mother to child.

A team of researchers from the University of Montreal and the Montreal Public Health Department evaluated over 6,000 mother-child couples to determine if school children of edentulous mothers experienced more caries. Two groups of children were targeted: 5-6 year olds and 7-8 year olds.

Children interviewed by dentist/hygienist teams were asked about toothbrushing, snacks before bed and visits to the dentist. They were examined clinically, but no radiographs were used in the examination. Demographic, socio-economic data, and the mother’s current dentition was determined through a written questionnaire.

There were 264 edentulous mothers whose children were primarily in the 7-8 year old group. These children were twice as likely to have caries in their deciduous teeth and one and a half times more likely to have caries in their permanent teeth. At every age group, the percentage of caries-free children was lower for the children of edentulous mothers.

Several theories were suggested to explain these findings. Modeling of oral hygiene behaviors is the way children learn and edentulous mothers are not modeling proper oral hygiene behavior. In general, denture wearers eat a diet high in sugar snacks and low in vegetables and fibrous foods. These dietary choices my influence fetal growth and may dictate snack choices offered to children.

Clinical Implications: Encourage edentulous mothers of young children to instill good oral hygiene habits in their children, including brushing, nutrition, and visiting the dentist.

Bedos, C., Brodeur, J., Arpin, S., Nicolau, B.: Dental Caries Experience: A Two-Generation Study. J Dent Research 84: 931-936, 2005.

Dentin loss related to combination of abrasive and detergent

Toothpaste abrasiveness is generally associated with the level of the abrasive used and not the other ingredients. Researchers at the Dental School in Bristol, England wanted to know if the combination of abrasive and detergent changed the wear pattern.

Four abrasives and four detergents were tested individually and in combination on dentin blocks from extracted wisdom teeth. Test areas of dentin measured 2 mm by 2 mm. Tape was used to cover half of the tiny square when testing samples in a toothbrushing machine. Slurries of the detergents and abrasives were prepared and all the detergent/abrasive combinations were prepared with 2.5% abrasive and 1% detergent. Six dentin specimens were brushed at once for 10,000 strokes or 83 minutes. The slurry was manually agitated every 10 minutes and replaced after 5,000 brush strokes. Dentin loss was measured at baseline and after 10,000 brush strokes. At this time, the toothbrush was replaced with a new one and the dentin specimen brushed for another 10,000 strokes. A control group of dentin specimens was brushed with water.

The water control showed negligible dentin loss. In contrast, very little dentin loss was measured with the detergents, and more dentin loss was shown with abrasives only. The detergent/abrasive combinations generally showed an enhanced loss of dentin, while one actually reduced the potential for dentin loss. Some combinations of abrasive and detergent resulted in dentin loss two to four times greater than that produced with the abrasive alone.

Thickeners or humectants used in toothpaste are also responsible for dentin loss. The combinations of humectants, abrasives and detergent need to be tested further on dentin samples to determine abrasive potentials of various toothpastes.

Clinical Implications: It’s no longer just about the abrasive in a toothpaste. The detergent/abrasive interaction is an important aspect of tooth surface wear.

Moore, C., Addy, M.: Wear of Dentine In Vitro by Toothpaste Abrasives and Detergents Alone and Combined. J Clin Perio 32: 1242-1246, 2005.

Number of blood vessels similar in smokers and non-smokers

Smoking is directly related to medical problems such as skin disease, lung disease, cancer, macular degeneration and cardiovascular disease. Smoking is also associated with oral tissue changes, but the exact mechanism is still unclear. Nicotine as well as many toxic chemicals contact oral tissues during smoking. Conflicting reports suggest that nicotine is responsible for vasoconstriction of oral vessels.

Researchers in the Netherlands used new, non-invasive technology to measure the number of blood vessels in gingival tissue in the right maxillary premolar region of 20 male smokers and non-smokers. Orthogonal polarization spectral imaging was used to measure and record capillary density. Light directed 1 mm, into the mucosa produced high contrast reflected light images that were recorded on digital video. During a 2-minute exposure, still images were captured at intervals of 20 seconds, providing six images per subject. Magnification of 325x resulted in images with visible dots for each blood vessel. Computer analysis counted and compared the number of vessels in each image.

The average density of vessels per image was 70 for non-smokers and 61 for smokers. Despite this difference, the numbers were not statistically significant.

Clinical Implications: This information adds to your understanding of the effects of smoking on oral tissues. Vascular changes observed in smokers are more likely due to change in capillary flow or diameter, as this study showed no difference in the number of blood vessels in buccal gingival tissue between young male smokers and non-smokers.

Lindeboom, J., Mathura, K., Harkisoen, S., van den Akker, H., Ince, C.: Effect of Smoking on the Gingival Capillary Density: Assessment of Gingival Capillary Density with Orthogonal Polarizaiton Spectral Imaging. J Clin Perio 32: 1208-1212, 2005.

Sonic toothbrushes found safe and effective

To test toothbrushing effectiveness, researchers at the Academic Medical Centre in the Netherlands used the experimental gingivitis model on lower teeth. Each of the 34 subjects used both the Sonicare Elite and the Oral-B Sonic Complete sonic toothbrushes. Twice daily for a period of four weeks, subjects used the brushes on alternating days, to familiarize themselves with each brush. They received both verbal and written instructions when given the brushes and again one week later. Subjects recorded daily brush-ing times on a brushing calendar. Subjects were also instructed to use wooden interdental sticks once per day.

After the familiarization period, subjects began the 21-day experimental gingivitis phase of the study. They were asked to refrain from all oral hygiene on the lower arch for this period. All subjects received a prophylaxis at the start of this phase so they all stared with equally clean teeth.

On day 21 it was determined that all subjects had a gingival bleeding scores of 40% or more. Subjects were instructed to resume brushing, using one sonic toothbrush on the right side and the other on the left side, as assigned so equal numbers used the brushes on right and left sides. No other oral hygiene aids were allowed during this period.

Bleeding and plaque scores were monitored weekly for four weeks. Bleeding scores were reduced similarly for both brushes. Plaque scores were lower for the Sonicare Elite at week one, but by week four scores for both groups were similar.

This study was funded by Braun Oral-B.

Clinical Implications: Both the Sonicare Elite and the Oral-B Sonic Complete toothbrushes reduced gingival inflammation associated with experimental gingivitis. The Sonicare Elite was preferred over the Sonic Complete by 62% of subjects.

Versteeg, P., Timmerman, M., Rosema, N., Warren, P., Van der Velden, U., Van der Weijden, G.: Sonic-Powered Toothbrushes and Reversal of Experimental Gingivitis. J Clin Perio 32: 1236-1241, 2005.