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Perio Reports

Perio Reports Vol. 19 No. 8

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

Subantimicrobial dose doxycycline improves clinical healing

According to the research, chronic inflammatory diseases like periodontitis might accelerate vascular disease and promote thrombosis. Both periodontal bacteria and the cytokines produced from periodontal inflammation can enter the blood stream and trigger changes associated with heart disease. For example, cytokines can breakdown the thin collagen cap covering cholesterol-rich plaques lining blood vessels, causing them to rupture, resulting in thrombosis.

Researchers at Gazi University in Ankara, Turkey, designed the first study to evaluate the effects of scaling and root planing (SRP) and subantimicrobial dose doxycycline (SDD) on a group of 36 subjects all having both chronic periodontitis and coronary artery disease. All of them were taking statin drugs. All subjects received SRP once a week for two weeks with both hand- and power-instruments. Half the group took a 20mg. SDD, and the other half took an identical appearing placebo twice daily for six weeks.

Blood and crevicular fluid samples taken at baseline and six weeks compared levels of cytokines and cholesterol, showing similar reductions for both test and control groups. Proteins of collagenase and gelatinase were measured rather than direct enzyme activity, therefore the proportion of active to inactive enzymes in these samples is unknown. In other studies measuring enzyme activity, SDD added to SRP results in greater reductions than measure in this study.

Clinical indices showed improvement for both groups but greater improvement was measured for those receiving SDD, especially for probing depths and gingivitis.

Clinical Implications: Preliminary findings suggest that taking subantimicrobial dose doxycycline along with scaling and root planing results in better periodontal healing and reduced cholesterol levels in patients with heart disease. Larger studies are needed to confirm these findings.

Tüter, G., Kurtis, B., Serdar, M., Aykan, T., Okyay, K., Yücel, A., Toyman, U., Pinar, S., Cemri, M., Cengel, A., Walker, S., Golub, L.: Effects of Scaling and Root Planing and Sub-Antimicrobial Dose Doxyclycline on Oral and Systemic Biomarkers of Disease in Patients with both Chronic Periodontitis and Coronary Artery Disease. J Clin Perio 34: 673-681, 2007.

Chlorhexidine toothpaste tested

Since toothbrushing is the most common oral hygiene method, toothpaste seems to be the best way to deliver a chemical to the oral cavity for controlling plaque and gingivitis. Chlorhexidine was not added to toothpaste for fear of interactions with sodium lauryl suphate (SLS) and competition for oral retention sites. Case studies have been published showing the effectiveness of a new formulation available in Germany called Lacalut. After just a few days, this toothpaste has been reported to reduce clinical signs of acute and chronic gingivitis.

Researchers at Albert-Ludwigs University in Freiburg, Germany, designed a six-month study to compare this chlorhexidine, aluminum lactate containing toothpaste to a similar formulation without these ingredients. Both formulations contained aluminum fluoride.

Subjects were evaluated at baseline, one, three and six months. Gingivitis scores were recorded on the six Ramfjord teeth, calculus scores on the lingual surfaces of the mandibular anterior teeth, and stain scores for the buccal surfaces of the maxillary and mandibular anterior teeth. A total of 60 patients began the study and only one dropped out of the study.

Plaque and gingivitis scores were similar at three months, probably due to the Hawthorne Effect. Between three and six months, a greater reduction in the gingival index was observed for the chlorhexidine toothpaste group. This might be due to the astringent effect of the aluminum lactate on the tissues, since plaque levels were not reduced. Minimal stain and calculus were noted for both groups at the end of the study.

The researchers speculated that the chlorhexidine might have been inactivated by the SLS. The low calculus and stain scores would support this conclusion.

Clinical Implications: This chlorhexidine toothpaste formulation provided no added benefit for reducing plaque and gingivitis, but we might see other formulations in the future that overcome the effects of SLS.

Rathe, F., Auschill, T., Sculean, A., Gaudszuhn, C., Arweiler, N.: The Plaque and Gingivitis Reducing Effect of a Chlorhexidine and Aluminium Lactate Containing Dentifice (Laculut Aktiv®) Over a Period of 6 Months. J Clin Perio 34: 646-651, 2007.

Listerine and Crest Pro-Health mouthrinses compared

According to the research, approximately 50 percent of the U.S. population has gingivitis. Effective plaque control can prevent gingivitis, but depends on dexterity, thoroughness and compliance. Because of the difficulty people have with effectively removing plaque from areas between the teeth and under the gingival margin, researchers suggest that chemical products such as toothpastes and mouthrinses may be beneficial.

Researchers at the University of Bern in Switzerland, with a grant from the Procter & Gamble Company, compared Crest Pro-Health (cetylpyridinium chloride) mouthrinse and Listerine (essential oil) in a group of 150 subjects. All study participants received a prophylaxis at baseline and instructions to brush twice daily for one-minute followed by a 30-second rinse with their randomly assigned mouthrinse. Every six weeks, subjects were given a new toothbrush, toothpaste and their assigned mouth-rinse. Mouthrinses were packaged in identical bottles. Plaque, bleeding and gingivitis scores were recorded at baseline, three months and six months. Subgingival bacterial samples were taken from the mesial-buccal surfaces of all molars.

Fifteen percent of study subjects dropped out of the study, probably due to the taste of the rinses. Similar numbers dropped out of both mouthrinse groups. No significant differences were observed in gingivitis scores or plaque scores between the groups. The percentage of bleeding sites was 10 percent lower in the Crest Pro-Health group, but this was not considered clinically significant. Subgingival bacterial samples were not reduced significantly for either mouthrinse group at the end of the study. For example, 49 percent of sites at baseline were positive for Porphyromonas gingivalis and 44 percent were positive at the end of the study.

Clinical Implications: Listerine and Crest Pro-Health mouth-rinses showed similar anti-gingivitis and antiplaque benefits. These two mouthrinses do not significantly reduce subgingival bacterial levels.

This study was funded by Procter & Gamble, makers of Crest Pro-Health.

Albert-Kiszely, A., Pjetursson, B., Salvi, G., Witt, J., Hamilton, A., Persson, G., Lang, N.: Comparison of the Effects of Cetylpyridinium Chloride with an Essential Oil Mouth Rinse on Dental Plaque and Gingivitis – A Six-Month Randomized Controlled Clinical Trial. J Clin Perio 34: 658-667, 3007.
Subgingival plaque reduced

According to the research, Listerine mouthrinse used twice daily reduces supragingival plaque and gingivitis. Most mouth-rinse studies evaluate gross plaque levels and not specific bacteria. Researchers at the New Jersey Dental School in Newark, and researchers from Johnson & Johnson (current owners of Listerine) evaluated the effect of daily Listerine use on specific subgingival bacteria.

In this crossover study, the 15 subjects rinsed with Listerine for two weeks and with a negative control rinse for two weeks with a one-week washout period between tests. Statistical analysis determined that 14 subjects completing the trial would be sufficient to determine differences.

Subgingival plaque samples were taken after an overnight of no oral hygiene or rinsing. Baseline samples were taken from the mesial surfaces of the maxillary left second bicuspid and second molar. Two weeks later, after using the assigned rinse twice daily, subgingival plaque samples were taken from the mesial surfaces of the maxillary left first bicuspid and first molar.

Researchers measured three bacteria that are found in both supra and subgingival plaque: Capnocytophaga, Veillonella, and F. nucleatum. Reductions in supragingival plaque due to rinsing resulted in small fractional yet statistically significant reductions in subgingival bacterial counts as well as the total count of subgingival anerobes.

Clinical Implications: After two weeks, reductions in supragingival bacterial plaque led to reduced bacterial counts of specific bugs in subgingival samples. The clinical significance of these reductions was not discussed.

This study was funded by the makers of Listerine.

Fine, D., Markowitz, K., Furgang, D., Goldsmith, D., Charles, C., Lisante, T., Lynch, M.: Effect of an Essential Oil-Containing Antimicrobial Mouthrinse on Specific Plaque Bacteria In Vivo. J Clin Perio 34: 652-657, 2007.

Thin tips reduce pain but require more time

Calculus provides an environment for bacterial biofilm to adhere, so it should be removed to prevent recolonization of bacteria. Removal can be done with hand instruments or power scalers. There are several benefits to using power scalers, including reduced time, less tooth surface removal, and fluid lavage to flush toxins from the pocket.

According to research published in 2005, patients experience pain with the removal of supragingival calculus. Other researchers suggest that the size and shape of the power scaler tip may influence the pain experienced by the patient.

Researchers at the University of Bonn in Germany compared standard and thin ultrasonic tips for the removal of supragingival calculus on the lingual of lower anterior teeth. Pain and time needed for calculus removal were recorded. The Sirona piezoelectric Sirosonic L power scaler was used for this study. All test subjects had probing depths no deeper than 4mm.

Both the standard and the slim tips were used for each of the 20 patients. Half of the lingual surfaces of the mandibular anterior teeth were treated with the slim tips and the other half with the standard tips. During the instrumentation, subjects held the bulb of a manometer in their hand and were instructed to increase or decrease the pressure to represent the pain they were experiencing. Readings were transmitted to a computer. The more pain, the tighter their grasp. Following the use of each ultrasonic tip, they were asked to complete a visual analog scale with zero representing no pain and 10 representing maximum pain.

The patients reported less pain with the slim tip compared to the standard tip. This was confirmed with both the computer measurements and the visual analog scale. Calculus removal took more time with the slim tips, 96 seconds (range: 64-164 seconds) compared to the standard tips 76 seconds (range: 54-127 seconds).

Clinical Implications: Thin Sirosonic ultrasonic tips reduce pain, but require more time to remove the deposits.

Braun, A., Jepsen, S., Krause, F.: Subjective Intensity of Pain During Ultrasonic Supra-gingival Calculus Removal. J Clin Perio 34: 668-672, 2007.

Preeclampsia linked to periodontal disease

Preeclampsia is the development of elevated blood pressure during pregnancy. Hypertension is a serious condition affecting seven to 10 percent of pregnant women and is one of two common causes of maternal mortality. Preeclampsia is characterized by new onset hypertension and protein in the urine (proteinuria).

Researchers at Atatürk University in Erzurum, Turkey, evaluated 59 pregnant women for clinical signs of dental disease and serum and GCF levels of inflammatory cytokines. The group was divided into three subgroups: 20 with mild preeclampsia, 18 with severe preeclampsia and 21 healthy pregnant woman. None of the women drank alcohol, however smoking was reported for two in each of the preeclampsia groups and six in the healthy group.

Dental disease was higher in the preeclampsia groups than the healthy group despite similar plaque levels in all groups. The average number of decayed teeth in the severe preeclampsia group was six, compared to three in the healthy group. Clinical signs of periodontal disease were much higher in the preeclampsia groups than the healthy group and higher in the severe pre-eclampsia group compared to the mild preeclampsia group. Similar findings were also reported for inflammatory cytokines measured in both GCF and blood. These cytokines are increased due to periodontal inflammation and may also be increased due to the higher blood pressure of preeclampsia.

Terms of pregnancy and birthweight followed the same pattern, higher in the healthy group and lower in both preeclampsia groups.

Clinical Implications: Periodontal therapy might soon be considered a vital part of prenatal care for women, especially those with preeclampsia.

Canakci, V., Canakci, C., Yildirim, A., Ingec, M., Eltas, A., Erturk, A.: Periodontal Disease Increases the Risk of Severe Pre-Eclampsia Among Pregnant Women. J Clin Perio 34: 639-645, 2007.
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