Perio Reports

Does perio therapy improve glycemic control in diabetics?

The link between periodontal disease and diabetes was first described in a study published in 1960 showing that patients with poorly controlled diabetes required less insulin after periodontal treatment, extractions and systemic antibiotics. More recently, six studies have confirmed these findings, while 10 studies were unable to demonstrate this effect. It is suggested that the increase in proinflammatory cytokines that occurs during periodontal disease is responsible for insulin resistance and poor glycemic control.

Researchers from Boston University and clinicians at four Department of Veterans Affairs facilities evaluated the effects of periodontal treatment on glycemic control of diabetics with glycated hemoglobin A1c levels of 8.5% (normal is 4-6%). The test group received scaling and root planning (SRP), doxycycline 100mg daily for two weeks, and twice daily rinsing with chlorhexidine (CHX). The control group received usual care – defined as whatever they had received in the past.

Both test and control groups demonstrated a similar likelihood for improved glycemic control. This may be due in part to the Hawthorne Effect or the fact that the physicians for all subjects were contacted and informed that the patients were poorly controlled. This information may have led to more aggressive medical treatment. Insulin was increased for twice as many in the control group compared to the treatment group.

The test subjects did show some improvement in their glycemic control, however it wasn’t considered statistically significant. Other studies have shown that periodontal healing may take up to 12 months. Thus, this study will continue for one year, to determine if periodontal treatment over one year will impact glycemic control for these veterans with diabetes.

Clinical Implications: Periodontal treatment may need to continue for several months and show clinical signs of healing in order to impact the glycemic control of veterans with diabetes.

Jones, J., Miller, D., Wehler, C., Rich, S., Krall-Kaye, E., McCoy, L., Christiansen, C., Rothendler, J., Garcia, R.: Does Periodontal Care Improve Glycemic Control? The Department of Veterans Affairs Dental Diabetes Study. J Clin Perio 34: 46-52, 2007.

Gingivitis remained stable over three years

Researchers in Sweden wanted to know the impact on gingivitis of a primary preventive program, stressing daily self-care plus visits with the dental hygienist every six months. A total of 126 subjects were followed for three years. Dental hygienists provided supragingival scaling, polishing and oral hygiene instructions twice yearly. Subjects were instructed to brush twice daily and to clean between their teeth with dental floss and/or toothpicks.

Plaque scores remained approximately 28% for the entire study. Bleeding upon probing showed a slight reduction from baseline to one year for 60% of the subjects, while 32% showed a slight increase. However, these changes were too small to be statistically significant. The average probing depth at baseline was 2.3 mm and decreased 0.1 mm each year. This was not a clinically significant change.

With no control group, it is difficult to claim the twice-yearly visits with the dental hygienist are responsible for the stability of gingival health. It makes sense that the care was helpful in maintaining health, but we need to see what would happen to this group of patients without regular dental hygiene care over a period of three years to come to that conclusion.

Clinical Implications: Patients with gingivitis and no loss of clinical attachment may not be at risk of further disease. It is not clear if regular dental hygiene visits are responsible for this stability or if those with gingivitis and no attachment loss are themselves resistant to further disease.

Bogren, A., Teles, R., Torresyap, G., Haffajee, A., Socransky, S., Lindhe, J., Wennström, J.: A Three-Year Prospective Study of Adult Subjects with Gingivitis. I: Clincal Priodontal Parameters. J Clin Perio 34: 1-6, 2007.

Laser detects and removes calculus

Determining the end point of subgingival instrumentation is at best subjective, being based on the tactile evaluation of a subgingival surface. Only endoscopy allows for visual evaluation of subgingival surfaces. Using only tactile evaluation, it is possible to over-instrument a surface, leading to excessive cementum removal or under-instrument a surface, leaving calculus.

An Er:YAG laser has been combined with laser florescence technology capable of detecting calculus. Red florescence is suggested to correlate with the presence of microorganisms. When the laser light detects calculus, the laser is activated to remove the deposits. When no calculus or microorganisms are detected, the laser is not activated.

Researchers in Germany tested the Key Laser III from KaVo on 20 single-rooted, extracted teeth. All teeth were extracted for periodontal reasons and exhibited calculus deposits. A 10mm section of each side of the root was evaluated, one as the test site and one as the control site. The teeth were stabilized, moistened with water and the laser was used at a 15-degree angle to the surface. Various laser florescence settings were tested and surfaces evaluated for calculus removal and damage to the cementum.

Contrary to other laser studies, no cracking or charring of the root surfaces were observed for any of the test teeth. When used at the manufacturer’s recommended florescence level of 5, it was determined that 11% of the calculus remained. At settings of 1 to 4, no calculus remained.

Clinical Implications: Hygienists may one day have a smart laser to use in the detection and removal of subgingival calculus without over-instrumentation or excessive removal of cementum.

Crause, F., Braun, A., Brede, O., Eberhard, J., Frentzen, M. Jepen, S.: Evaluation of Selective Calculus Removal by a Fluorescence Feedback-Controlled Er:YAG Laser In Vitro. J Clin Perio 34: 66-71, 2007.

Minimally invasive surgery preferred by patients

Less invasive surgery takes less time, is less demanding, results in better healing and is preferred by patients over traditional full flap surgery. Minimally invasive surgery or MIS was introduced in 1995 by Drs. Harrell and Ress. This study adds Emdogain to the MIS procedure and thus adds the word “technique” to the acronyn, making it MIST.

This clinical practice study was conducted in a periodontal practice in Florence, Italy, and included 13 patients, each with one intra-boney defect. Scaling and root planing and oral hygiene instructions were provided in the three months before beginning the study. If surgery other than regenerative surgery was needed, it was completed at this time. Thus, the patients began the study with good oral hygiene, and all necessary dental and periodontal work completed, except for the defects treatment planned for regenerative therapy.

Baseline data was collected prior to performing the MIST procedure. After papilla reflection, the intra-bony defects were debrided with a combination of Hu-Friedy Gracey curettes and the KaVo Soniflex sonic scaler. Root surfaces were treated with EDTA for two minutes, rinsed with saline and dried before the Emdogain was placed in the defect and the papilla repositioned and sutured. All the surgical procedures were performed with the aid of a microscope.

Following surgery, patients took 100mg of doxycycline twice daily for one week and rinsed three times daily with 0.12% chlorhexidine. They returned for weekly prophylaxis for the first few months and then for three month recalls during the remainder of the year-long study.

None of the patients reported post-operative pain, and only three reported limited discomfort for the first two days. Healing was excellent, with defect resolution of 90% overall, and 100% in seven sites. The gain in clinical attachment after one year was 5mm and probing depths were 4mm in three sites and 3mm or less in all other sites compared to an average baseline depth of 8mm.

Clinical Implications: This conservative surgical technique plus Emdogain results in both periodontal health and happier patients.

Cortellini, P., Tonetti, M.: A Minimally Invasive Surgical Technique with an Enamel Matrix Derivative in the Regenerative Treatment of Intra-Bony Defects: A Novel Approach to Limit Morbidity. J Clin Perio 34: 87-89, 2007.

Perio disease not a predictor of low birth weight

Adverse pregnancy outcomes can be expensive both financially and in terms of infant mortality. There is an observed increase in low birth weight around the world, prompting researchers to look for explanations. Periodontal disease is considered a risk factor for preterm, low birth weight, with studies both supporting and refuting this hypothesis. Women with periodontal disease may also have other risk factors such as alcohol consumption, tobacco use, infections, hypertension, preeclampsia, previous preterm and/or low-birth-weight deliveries, etc. These confounding factors may be the more likely risk factors influencing pregnancy outcomes.

Researchers from the University of Toronto, Canada and Brazil, designed a study to evaluate the influence of periodontal condition on low birth weight. Mothers at three hospitals in Porto Alege, Brazil, were invited to participate. More than 300 test and 600 controls were enrolled in the study. Interviews and periodontal exams were conducted after the women gave birth.

Periodontal conditions were similar for both the women whose babies were preterm and less than 2,500 grams and those with babies were full term and more than 2,500 grams. Other risk factors were more likely to predict preterm, low birth weight than periodontal condition.

Clinical Implications: Many risk factors have been identified for adverse pregnancy outcomes. Periodontal disease alone was not a predictor of low birth weight in this study, suggesting the need for further studies evaluating the potential for a link between severe periodontal disease and low birth weight.

Bassani, D., Olinto, M., Kreiger, N.: Periodontal Disease and Perinatal Outcomes: A Case-Control Study. J Clin Perio 34: 31-39, 2007.

Low folic acid levels in smokers

Smoking is considered the greatest risk factor for periodontal disease, contributing to greater attachment loss, increased bone loss, deeper pockets, more subgingival calculus, and more tooth loss compared to non-smokers. Smoking impairs the immune response and reduces the phagocytic ability of neutrophils. Secondhand smoke can lead to elevated leukocyte counts.

Cigarette smoking also affects vitamin B12 and folic acid or folate. The most common nutrient deficiency is suggested to be folic acid. Folic acid is important for cell division and new cell production and is an essential co-factor in DNA synthesis.

Researchers in Sweden and Turkey designed a study to measure vitamin B12 and folic acid in periodontal patients. The study included 88 patients (45 smokers and 43 non-smokers) at the Kirikkale University Faculty of Dentistry in Turkey. All had untreated periodontal disease. Clinical indices showed similar findings between groups for gingival index and bleeding upon probing. Smokers did show higher levels for plaque, probing depths and clinical attachment levels.

Blood tests showed no difference between groups for vitamin B12, however, the smokers had folic acid levels 28% lower than non-smokers. Smokers also had higher levels of neutrophils. Since this was a cross-sectional study, cause and effect can not be established. Longitudinal studies are needed to determine if the onset of periodontal disease resulted in the higher folic acid levels.

Clinical Implications: Smokers should be encouraged to increase their dietary intake of folic acid or consider a folic acid supplement.

Erdemir, E., Bergstron, J.: Relationship Between Smoking and Folic Acid, Vitamin B12 and Some Haematological Variables in Patients with Chronic Periodontal Disease. J Clin Perio 33: 878-884, 2006.