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.

Bacteremia more likely for those with periodontitis

Bacteria in the mouth can travel to other parts of the body following dental and dental hygiene procedures. More recent research shows that even chewing, toothbrushing and flossing can lead to bacteremia. Bacteria entering the blood stream from the oral cavity may trigger infection at distant sites. Some of the periodontal pathogens have been found in carotid and abdominal aortic arthromas. Previously published research that found oral bacteria in the blood stream after dental treatment did not evaluate the periodontal health of the test subjects to see if it related to the bacteremia.

Researchers at the University of Copenhagen in Denmark measured bacteremia following chewing, toothbrushing and subgingival instrumentation in patients with good periodontal health, gingivitis or chronic periodontitis. Patients received an oral exam and were classified one week prior to the start of the study. Each subject was monitored for bacteremia following chewing three pieces of gum for 10 minutes, supervised toothbrushing for two minutes, and full-mouth instrumentation using both KaVo SonicFlex and hand instruments. Tests were performed one week apart. Blood was drawn at 0.5 minutes, 10 minutes and 30 minutes after each procedure. These time intervals were selected based on past research findings.

Following chewing, four of the periodontitis patients had evidence of bacteremia while none of the healthy or gingivitis patients did. Following toothbrushing one of the periodontitis patients was bacteremic. None in the other groups.

After instrumentation, two of the healthy, four of the gingivitis patients and 15 of the periodontitis patients had detectable bacteria in their bloodstream. This means that 75% of the periodontitis patients experienced bacteremia after instrumentation.

There are more than 600 bacterial species in the oral cavity and half of them haven’t been grown in laboratory cultures yet. Bacteremia studies evaluate the bacteria that can be grown in culture from a blood sample. It’s clear that only a fraction of the bacteria present in blood after chewing, toothbrushing and instrumentating have been idenitified.

Clinical Implications: People with periodontitis are more likely to trigger bacteremia following chewing, toothbrushing or subgingival instrumentation.

Forner, L., Larsen, T., Kilian, M., Holmstrup, P.: Incidence of Bacteremia After Chewing, Tooth Brushing and Scaling in Individuals with Periodontal Inflammation. J Clin Perio 33: 401-407, 2006.

Arestin used for periimplantitis

Periimplantitis is a bacterial infection, similar to periodontitis and therefore antibacterial agents are investigated to determine effectiveness in controlling the infection. Researchers at the Kristianstad University in Sweden compared chlorhexidine (CHX) gel to Arestin around infected implants. Study implants all had at least 4 mm pockets and radiographic bone loss. A total of 32 patients began the study, but two people in the CHX group took antibiotics for other reasons and were dropped from the study, leaving 14 in the CHX group and 16 in the Arestin group.

Subjects all received oral hygiene instructions and supra- and subgingival instrumentation and polishing around the infected implants. Then they were randomly assigned to receive Arestin at four sites per implant or CHX gel at four sites per implant. All subjects were told to avoid brushing the implant for 12 hours and to refrain from interproximal oral hygiene for 10 days. Follow-up visits were scheduled at 10 days, one month, two months, three months, six months, nine months and 12 months. Follow-up visits were to gather clinical data, but no maintenance therapy was provided. Oral hygiene instructions were given only if the patient asked for advice.

No control group was included in the study, to determine the effects of mechanical instrumentation alone. Bacterial sampling showed no significant differences between the two groups. Plaque levels were also similar. Probing depths were 3.9 mm for both groups at baseline and 3.6 mm for the Arestin group at 12 months. No reduction was noted for the CHX group. Probing scores for the deepest sites were 5.1 mm for the CHX group and 5.0 mm for the Arestin group. At 12 months, these scores were 4.9 mm for CHX and 4.4 mm for Arestin, a difference of 0.2 mm for CHX and 0.6 mm for Arestin or a difference between groups of 0.4 mm.

Clinical Implications: Arestin may be helpful for treating periimplantitis. CHX may be helpful for treating periimplantitis for people allergic to tetracycline.

Renvert, S., Lessem, J., Dahlén, G., Lindahl, C., Svensson, M.: Topical Minocycline Microspheres Versus Topical Chlorhexidine Gel as an Adjunct to Mechanical Debridement of Incipient Perio-Implant Infections: A Randomized Clinical Trial. J Clin Perio 33: 362-369, 2006.

Controlling pain during periodontal instrumentation

Non-surgical instrumentation is often associated with pain. Local and topical anesthesics are used frequently for this procedure, but not without some unpleasant side effects. The long-lasting effects of local anesthesia, the bad taste of topicals and the potential for adherence problems with anesthetic patches suggests the need for an alternative.

Researchers at the University of Zurich in Switzerland tested the effects of ibuprofen in a group of 60 private-practice patients undergoing scaling and root planing by a board certified periodontist. They used a single dose of 800 mg of ibuprofen arginine, sold in Switzerland as Spedifen. The addition of arginine enhances uptake and duration of the drug.

Test subjects in the private-practice had all experienced scaling and root planing in the past. On the day of their treatment, one quadrant was treated as a “rehearsal” to give them a chance to get used to the forms they were to complete about their pain experience, both during and after the instrumentation. After this “rehearsal” quadrant, patients were given either the test or placebo drug and 30 minutes later, treatment resumed. At any time during the treatment, patients could request local anesthesia. Following instrumentation of the other quadrant in that arch, they completed a visual analog scale with scores from 1 to 100. They recorded pain levels during treatment, 15 and 30 minutes after treatment. They also recorded pain for the next 24 hours, at regular intervals.

The Spedifen group experienced 72% less pain than the placebo group during the scaling and root planing. Scores for average pain were 16 for the placebo group and 4.5 for the Spedifen group. After treatment scores were 0-1 for the Spedifen group and 0-5 for the placebo group. No difference in side effects was reported between groups.

Clinical Implications: When not using topical or injectable anesthetics for scaling and root planing, you may want to consider a single 800mg dose of ibuprofen-arginine 30 minutes prior to instrumentation to reduce pain.

Ettlin, D., Ettlin, A., Bless, K., Puhan, M., Bernasconi, C., Tillmann, H., Palla, S., Gallo, L.: Ibuprofen Arginine for Pain Control During Scaling and Root Planing: A Randomized, Triple-Blind Trial. J Clin Perio 33: 345-350, 2006.