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Perio Reports

Perio Reports  Vol. 17 No. 1
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.

For 16 years, Perio Reports has provided a valuable scientific resource for clinicians. Until this year it was a paid subscription of $59 per year. Our 2005 partnership with Farran Media now provides these research summaries to you free of charge each month.

At this time of change, sincere appreciation goes out to the Perio Reports Associate Editors: Cynthia A. Chillock, Jean E. Suvan, and Regina Dreyer Thomas. The Editorial Review Board also deserves a debt of gratitude: Phebe Blitz, Karen Boulton, Dr. Larry Burnett, Davine B. Daniels, Dr. Albert Frydman, Sharen Leigh, Tricia Moore, Dr. Gerrarda O'Beirne, and Margaret Perry. Thank you all for your many years of dedicated service to Perio Reports.

Trisha E. O'Hehir, Editor of Perio Reports
Photodynamic Therapy for Perio Bacteria
* Dye plus light kills bacteria

In 1900 German researchers reported death of single cell organisms when exposed to fluorescent agents and light. The Photodynamic Therapy (PDT) has more recently been used to eliminate tumor cells. A photosensitive dye is injected into the tumor, light is focused on the tumor and the combination produces free radicals that produce a toxic effect on tumor cells. The same seems to be true with bacteria.

For several years, researchers have been investigating this approach for periodontal pathogens. A recent laboratory study tested several photosensitizers plus laser light. The bacteria were grown in culture and then a diode laser was applied to the bottom of each culture dish. Various concentrations of the photosensitizers were tested along with various laser light settings.

Previous studies revealed that the photosensitizers used alone had no effect on the bacteria and the laser light used alone did not kill the bacteria. However, this study showed that the combination of the two successfully killed the periodontal pathogens being tested. The increasing problem of bacterial resistance to antibiotics has prompted this research to find alternative antimicrobial approaches that reach the subgingival bacteria.

Clinical Implications: In the future you may be injecting a photosensitive substance into periodontal pockets, followed by laser light to kill subgingival bacteria. The laboratory tests look promising. Animal tests are underway and human testing will follow.

Pfitzner, A., Sigusch, B., Albrecht, V., Glockmann, E.: Killing of Periodontopathogenic Bacteria by Photodynamic Therapy. J Perio 75: 1343-1349, 2004.
Chlorhexidine Improves Healing
* Suggest very soft brush to apply CHX gel following surgery

Heavy plaque levels following surgery can actually result in more periodontal damage than the patient presented with before surgery. Healing is better in a plaque free environment and so special attention must be given to plaque control in the first days and weeks following surgery. However, healing involves inflammation, which promotes bacterial plaque biofilm formation and increased gingival crevicular fluid flow provides nutrition for bacterial growth. Several approaches are used to control bacterial growth. Several approaches are used to control bacterial growth following surgery including professional plaque control, chlorhexidine (CHX) rinses, CHX packing material, and systemic antibiotics. CHX rinses twice daily for six months produced the same results as dental hygiene visits every two weeks for six months. Based on the overwhelming research demonstrating the overuse of systemic antibiotics, they should not be used as a substitute for mechanical oral hygiene as some research findings may suggest.

Researchers in Switzerland added a 0.2% CHX gel to the post-op instructions of 30 patients undergoing either single stage implant placement or flap surgery. All 60 patients were instructed to refrain from using toothpaste for four weeks. Instead, they dipped their regular toothbrush in CHX rinse and brushed all non-treated teeth, followed by rinsing with 0.1% CHX for one minute. This routine was followed twice daily. Interdental cleaning was also stressed.

The 30 test subjects also used a very soft post-surgical toothbrush to apply CHX gel to the surgical sites using vertical stokes. This was done from day three following surgery until day 14. For the next two weeks, they used a slightly firmer, yet still very soft brush with CHX gel. At the end of four weeks, both groups showed comparable healing with very low plaque and bleeding levels. In the test group, fewer sites showed recession of 2 millimeters or more. In the control group, six out of 30 sites showed recession. Use of a very soft brush on the surgical sites can be recommended.

Clinical Implications: Post-operative oral hygiene instructions for those undergoing implant placement or flap surgery should suggest CHX rinsing and the use of a very soft toothbrush beginning on day three to apply 1% CHX gel, available in some countries. In the US, dipping a very soft brush in CHX rinse and applying it with vertical stokes to the treated teeth or implants may provide added benefit, although that was not tested in this study.

Heitz, F., Heitz-Mayfield, L., Lang, N.: Effects of Post-Surgical Cleansing Protocols on Early Plaque Control in Periodontal and/or Periimplant Wound Healing. J Clin Perio 31: 1012-1018, 2004.
Desensitizing Gel After SRP
* Potassium oxalate gel reduced hypersensitivity after instrumentation


Dentinal hypersensitivity is due to open dentinal tubules. The hydrodynamic theory suggests that various stimuli to the root surface can trigger movement of dentinal fluid leading to pain. Desensitizing agents work by closing off the open tubules. Desensitizing agents that have been tested include: sodium fluoride, cyanoacrylate, calcium hydroxide, potassium nitrate, and ferric oxalate.

Oxa-Gel‚ is a potassium oxalate available in Brazil. Researchers there tested this gel following scaling and root planing using local anesthesia. The 15 test patients all had bilateral dentinal hypersensitivity in cuspid-premolar areas and were scheduled for non-surgical periodontal therapy.

Following instrumentation, Oxa-Gel was applied to the CEJ of all treated teeth on one side of the mouth and a color and texture matched placebo on the other side. Both test and control gels were provided in identical bottles so neither clinician nor patient knew which product was the Oxa-Gel.

Patients were asked to rate their pain and discomfort on a visual analog scale. The scale was a straight line with one end representing no pain and the other end representing the worst pain imaginable. Patients were asked to rate pain 7, 14, and 21 days after treatment.

The percent reduction in pain on day 7 was 30% for Oxa-Gel and 13% for the placebo. On day 14 the reductions were 65% and 21% and on day 21 the reductions were 81% and 35%. Post treatment pain often reduces over time with no treatment, as is seen with the placebo subjects. However, reducing the subject's experience of pain 80% by day 21 is significant.

Clinical Implications: I'm not aware of a potassium oxalate gel available here in the US, but the concept of applying a desensitizing agent following root instrumentation makes good sense.

Pillon, F., Romani, I., Schmidt, ….: Effect of a 3% Potassium Oxalate Topical Application on Dentinal Hypersensitivity After Subgingival Scaling and Root Planing. J Perio 75: 1461-1464, 2004
Finger-Toothbrush Compared to Butler Gum 311®
* Finger toothbrush provides oral hygiene option

According to the research, toothbrushing generally removes about 50% of plaque, even with two minutes of brushing. Ideally, a toothbrush should be designed to allow the average person to remove almost all plaque. "As yet, such a toothbrush has not been developed." A new finger-toothbrush was recently introduced in Germany, the I-Brush®. Picture an elastic stocking that fits over the index finger and has a tuft of bristles on the end. The finger-toothbrush is then used to brush all the teeth as usual. Researchers compared this finger-brush to a Butler Gum 311 toothbrush.

Thirty-seven men and women volunteered for the comparison study. Each subject was given both the I-Brush and the Butler Gum 311 and asked to brush with each brush on alternate days for three weeks. To keep track of this unusual brushing schedule, subjects were given a brushing calendar.

To evaluate brushing, subjects were instructed to come in for the next visit without brushing for 48 hours. A baseline plaque score was taken and then subjects were assigned to brush two contralateral quadrants with one brush and the remaining quadrants with the other brush. Subjects were timed and told to change quadrants after 30 seconds and also reminded at 15 seconds to change from buccal to lingual.

The manual toothbrush was more effective on all surfaces compared to the finger-brush. Overall, the finger-brush removed 62% of plaque and the manual brush removed 79%, both well above the 50% average. The finger-brush was least effective on lingual interproximal surfaces, removing 50% compared to 70% reduction with the manual brush.

Clinical Implications: These findings remind us how important interproximal plaque control really is for complete plaque removal. We should encourage oral hygiene product manufacturers to design a tool that effectively removes 100% of visible plaque.

Graveland, M., Rosema, N., Timmerman, M., Van der Weijden, F.: The Plaque-Removing Efficacy of a Finger Brush (I-Brush®). J Clin Perio 31: 1084-1087, 2004.
Dentin Removal with Power Scalers
* A Greater root surface loss with larger power scaler tips

Power scalers are being used more these days for both debridement (scaling and root planing) and for maintenance therapy. Research published to date suggests that hand instruments remove more tooth structure than power scalers. Some studies report less surface alteration with magnetostrictive, while others report less with the piezoelectric scalers. This is the first comparison between the magnetostrictive and piezoelectric scalers to determine dentin loss.

Twenty teeth extracted for orthodontics were used in this study. Only root surfaces were used, and all cementum was removed from these root surfaces to expose the underlying dentin. A stand was used for the root surface specimens and a constant force arm for the EMS Piezon® Master 400 and the Cavi-Med 200, 30K. The tips tested include the Cavitron® TFI-10, the Cavitron Slimline®, the EMS Type A, and the EMS Perioprobe.

Instrumentation was done with two different pressure settings for each tip. Each tip was activated with water for three forward and backward strokes at a constant speed of 2.5 millimeters/second.

Microscopic evaluations revealed both the least and most change with the Cavitron tips. The Slimline tip removed the least dentin and the TFI-10 removed the most. The EMS Perioprobe tip was close to the Slimline and the Type A tip was not quite as aggressive as the TFI-10.

Clinical Implications: It is likely that larger power scaler tips will result in more root surface loss than smaller tips, based on these laboratory results. Clinical studies are now needed to see if these differences influence clinical outcomes

Jepsen, S., Ayna, M., Hedderich, J., Eberhard, J.: Significant Influence of Scaler Tip Design on Root Substance Loss Resulting from Ultrasonic Scaling: A Laserprofilometric In Vitro Study. J Clin Perio 31: 1003-1006, 2004.
Two Sonicare® Toothbrushes Compared
* Sonicare Elite better than the first Sonicare

By the time a new toothbrush hits the market, research is completed, the manuscript written and finally published nine months later, another version of that toothbrush may be introduced. That's what happened here. Although Philips has introduced the IntelliClean, brush plus paste, research is just being published comparing the original Sonicare Advance and the Sonicare Elite.

Researchers in the UK compared the Sonicare Advance and the Sonicare Elite in a group of 45 volunteers. They were asked to come to the first visit without brushing for 24 hours, to determine who was a good plaque former. The second visit was for ultrasonic scaling, polishing and toothbrushing instructions with the randomly assigned toothbrush. The third visit was two weeks later, again without brushing for 24 hours prior to the visit. The teeth were disclosed, a plaque score taken on molars and premolars and then subjects were allowed to brush for two minutes with their assigned brush. A post-brushing plaque score was taken and then the teeth were polished and flossed to bring the plaque score to zero. Twenty-four hours later they returned, again without brushing. This time the examiners wanted to see the effect of the brush on new plaque as compared to the first evaluation on mature plaque. Pre- and post-brushing plaque scores on molars and premolars were again taken.

At this point in the study, subjects were given the other Sonicare brush and the study was repeated. This cross-over design allowed all patients to be tested with both brushes. Both brushes removed significant amounts of posterior plaque, removing more 24-hour plaque than mature plaque. The Sonicare Elite removed 56–60% of posterior plaque and the Sonicare Advance slightly less. It is still surprising that toothbrushing doesn't remove more than 60% of visible plaque.

Clinical Implications: When deciding which Sonicare toothbrush to recommend, the Elite is more effective in removing posterior plaque than the Advance. Despite this fact, the Advance will still provide an effective power toothbrush option.

McCracken, G., Preshaw, P., Heasman, L., Stacey, F., Steen, N., Heasman, P.: Efficacy of Plaque Removal of the Sonciare Elite Versus the Sonicare Advance from Hard-to-Reach Sites. J Clin Perio 31: 1007-1077, 2004.
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