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Perio Reports

Perio Reports Vol. 19 No. 9

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

Salivary proteins provide valuable information

The protein picture or proteome of saliva is complex and susceptible to many physiologic and biochemical changes. Protein biosynthesis begins in the salivary glands, and changes to the proteins take place in the mouth after secretion until leaving the oral cavity by swallowing. Changes are observed on four levels, beginning in the salivary glands with basic biosysthesis from the genetic blueprint. Second, there are changes within the protein cells prior to secretion into the mouth. Third, changes occur during secretion and transit through the ductal tree. The final stage of modifications happens after the proteins enter the non-sterile oral cavity and mix with gingival crevicular fluid, bacteria, desquamated epithelial cells and neutrophils.

Several changes take place prior to secretion of saliva from the salivary glands, including glycosylation (the addition of a carbohydrate molecule), phosphorylation (adding a phosphate group) and proteolysis (breakdown of proteins into simpler molecules). These changes produce closely related families of molecules. These changes influence the predisposition of some individuals for colonization of specific bacterial species that will be helpful as a diagnostic tool. Phosphorylation is important to the balance of minerals and the precipitation of substances onto enamel surfaces.

Saliva leaves the salivary glands under neurological control, depending on a stimulus. The amount and type of proteins contained in saliva will depend on the neurological stimulus provided.

Clinical Implications: Salivary proteins play an important role in the identification of biomarkers for oral and systemic diseases. Learning more about them will provide diagnostic information for the future.

Helmerhorst, E., Oppenheim, F.: Saliva: A Dynamic Proteome. J Dent Research 86: 680-693, 2007.

Photodynamic options for treating periodontitis

Use of a photoactive dye activated by a cold laser of a specific light spectrum in the presence of oxygen is called photodynamic therapy (PDT). This technology has been used for many years to treat and control oral lesions, head and neck cancer, and other malignancies. It is used to treat macular degeneration, bladder cancer, and gynecologic tumors. It is also used to treat periodontal disease (PerioWave available in Canada and soon in the United States). Studies underway currently include treatments for cancers of the brain, breast, skin, prostate, cervix, pancreas, and other organs.

PDT works by damaging cells, cell membranes and cell contents. Illumination of the photoactive dye leads to changes in the calcium and lipid metabolism within cells, producing cytokines and stress hormones. The diode laser is easy to use, portable and cost-effective. In the past, a variety of light sources have been used: argon, Nd/YAG, and gold and copper vapor pumps. To treat larger areas, tungsten filament, quartz halogen, xenon arc, metal halide and phosphor-coated sodium lamps have been used. More recently, light-emitting diodes (LED) have been used for this treatment, as they are less expensive, small, lightweight and flexible.

Besides the bacteria and other organisms, the polysaccharides that make up the slime surrounding bacteria in a biofilm are susceptible to the photodamage. This makes PDT therapy more desirable than antibiotics for control of biofilms around teeth, implants and associated with endodontically involved teeth. PDT is also effective against opportunistic infections like candidiasis and oral cancer.

Clinical Implications: Photodynamic therapy provides a new opportunity to treat periodontal disease and other oral lesions with a non-invasive, non-antibiotic approach.

Konopka, K., Goslinski, T: Photodynamic Therapy in Dentistry. J Dent Research 86: 694-707, 2007.

Tissue damage due to white blood cells

In periodontitis, the immune system sends neutrophils to the sulcus to phagocytize the bacteria. As the white blood cells move from the blood vessels in the healthy tissue to reach the sulcus, connective tissue is destroyed. People with chronic periodontitis are predisposed to having an abnormal immune response to the bacteria of periodontitis, which results in significantly higher levels of oxygen-free radical generation. These free radicals are responsible for tissue damage.

Researchers at the University of Birmingham in the UK evaluated blood samples from 19 patients before, and three months after, undergoing scaling and root planing. For each periodontal patient there was an age-matched patient who was periodontally healthy. Crevicular fluid samples were collected one week after baseline from the teeth with the deepest pockets. Non-surgical therapy was completed by quadrants scheduled one week apart. Both an ultrasonic scaler and hand instruments were used. Clinical indices all demonstrated improvement three months following non-surgical therapy.

Blood samples at baseline showed higher levels of oxygen-free radicals in the periodontitis patients compared to the controls. At three months, the levels in the periodontitits patients were still higher than the controls, however, the differences between groups was no longer statistically significant.

Clinical Implications: Hyper-responsiveness of neutrophils will increase the damage associated with periodontitis and can also be used as an important etiological risk factor for periodontal disease.

Matthews, J., Wright, H., Roberts, A., Ling-Mountford, N., Cooper, P., Chapple, I., Neutropil Hyper-responsiveness in Periodontitis. J of Dent Research. 86: 718-722, 2007.
Toothbrushing may help gingival tissue architecture

When cells are wounded it can be a lethal injury, therefore cell adaptations are in place to protect, prevent and repair the damage when necessary. To determine if toothbrushing causes cell wounding and what local cell response occurs, researchers at the Medical College of Georgia evaluated the effects of toothbrushing on 10-week-old rats in the laboratory. Toothbrushing was done with an Oral-B Plak Control battery operated toothbrush with bristles trimmed to fit in the tiny mouths of the rats. The rats were deeply anesthetized and injected with a dye-labeled solution that will be trapped inside damaged cells.

Brushing was done for two minutes. To determine disruptions to the gingival and tongue tissues, a dye was brushed into the tissues to determine how far into the tissues of the gingiva and tongue it penetrated.

Following sacrifice of the rats, microscopic evaluations of tissue samples revealed the dye-labeled solution marked damaged cells in both the tongue and on gingival tissues, especially tissue around mandibular teeth. Skeletal muscles of the tongue were damaged.

Despite injury to cells on many levels, there did not appear to be any damage done to disrupt the epithelial barrier function of the epithelium. Gene expression was evident that signaled beneficial adaptive changes in the architecture of the tissues. Other studies have shown that brushing induces cell proliferation by epithelial, endothelial and fibroblast cells and stimulates collagen to be synthesized in connective tissue.

Clinical Implications: This laboratory study helps clinicians understand the cell level benefits toothbrushing may have on gingival tissues.

Amano, K, Miyake, K., Borke, J., McNeil, P.: Breaking Biological Barriers with a Toothbrush. J Dent Research, 86: 769-774, 2007.

Malodor linked to alcohol intake and weight

Bad breath is estimated to affect 20-40 percent of the population, yet it is difficult to evaluate for both the individual and the clinician. Smelling one’s own breath is often difficult and unreliable. Those concerned that they have bad breath are embarrassed to ask others for feedback and those with bad breath are not usually told the truth by those around them.

The gold standard for measuring bad breath is an odor judge – a person who smells the breath and assigns a score of 0-5 based on intensity of the odor. The Halimeter measures the volatile sulphur compound levels and a new test called “OK to Kiss” from a company in Israel measures Beta-galactosidase levels in saliva based on color change when mixed with a test pellet.

Researchers in Isreal tested 88 adults (46 males, 42 females) with a Halimeter, odor judge and the OK to Kiss test. Subjects also completed a 38-item questionnaire. Testing was done after a 12-hour overnight fast. Subjects were allowed to perform regular oral hygiene on the morning of the exam.

Odor judge scores indicated that 26 people had bad breath and the OK to Kiss test correctly identified 23 of these people. Of the 26 with bad breath, 17 reported thinking they had bad breath. Conversely, 19 people thought they had bad breath, but did not according to the odor judge.

Of the nine questions correlated with bad breath, the top two were alcohol and weight.

Clinical Implications: Alcohol intake and body mass index may be predictors of bad breath, giving clinicians risk factors to consider when assessing oral malodor in patients.

Rosenberg, M., Knaan, T., Cohen, D.: Association among Bad Breath, Body Mass Index, and Alcohol Intake. J Dent Research 86: 997-1000, 2007.

Factors influencing periodontal healing

To determine the factors influencing healing after periodontal therapy, a team of researchers from Sweden, the UK and Italy evaluated outcomes after two different approaches to non-surgical therapy. A total of 41 patients were seen in clinics in Sweden and Italy. Half were treated with a single one-hour session of full-mouth ultrasonic scaling using an EMS piezoelectric scaler. The other half of the subjects received four visits for quadrant treatment using hand instruments. The study began with 1,447 sites measuring 5mm or more around 771 teeth. Treatment success was defined as pocket closure measured at three months to be 4mm or less.

Using statistics, a prediction table was constructed to estimate healing. Results showed differences influenced by smoking, plaque levels and tooth type rather than the type of treatment received. An 8mm pocket on a single rooted tooth with good oral hygiene in a non-smoker was 4.7mm at three months compared to an 8mm pocket on a molar tooth with plaque in a smoker that was reduced to 7mm.

Smoking influenced both the probability of pocket closure and the magnitude of healing. The overall full-mouth plaque scores were not as important as the plaque scores at the treated 5mm or deeper sites. It appears that a combination of factors influences healing: posterior teeth, plaque levels at those sites and smoking.

Clinical Implications: Smoking is the greatest risk factor for periodontal disease and compromises healing. Plaque around teeth, especially multi-rooted teeth following treatment prevents healing. Smoking cessation and oral hygiene coaching are essential for pocket closure after periodontal therapy.

Tomasi, C., Leyland,, A., Wenström, J: Factors Influencing the Outcome off Non-Surgical Periodontal Treatment: A Multilevel Approach. J Clin Perio 34: 682-690, 2007.
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