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.

Subgingival calculus found more often near CEJ

Researchers at Ankara University in Turkey evaluated mesial and distal surfaces on 90 extracted teeth to determine distribution patterns and morphology of subgingival calculus deposits. Prior to extraction 2-3 mm vertical grooves were cut into the teeth with a bur on all four line angles, crossing the cemento-enamel junction (CEJ). From these grooves, pocket depths and attachment levels were measured. A sterile pencil was used to mark the location of the gingival margin on proximal, facial and lingual surfaces. As the teeth were extracted, a bur was used to notch the clinical attachment level (CAL) on four surfaces. All teeth were single rooted: 66 incisors, 9 cuspids, and 15 premolars. More than half of the incisors were mandibular teeth.

Following extraction, the teeth were rinsed with tap water and dried before examination with 7x magnification. Pocket depths and attachment levels were slightly higher on mesial surfaces compared to distal surfaces. The distance between the most apical calculus deposit and remnants of soft tissue was 1.7 mm for both mesial and distal surfaces. More deposits were found on the coronal third than the middle third of the root. The four most prominent types of calculus found were:

1. thin smooth veneers––most often both mesial and distal surfaces
2. individual calculus islands or spots--slightly higher percentage on distals
3. crusty, spiny or nodular deposits--slightly higher percentage on mesials
4. ledge or ring formation--less than the other forms

Clinical Implications: These findings confirm what clinicians routinely encounter, that mesial and distal surfaces accumulate calculus equally. Deposits are heavier and found more often near the CEJ rather than at the base of the pocket, as the more coronal surfaces have been exposed longer. Other research shows that calculus is most often missed at the CEJ.

Gürgan, C., Bilgin, E.: Distribution of Different Morphologic Types of Subgingival Calculus on Proximal Root Surfaces. Quintessence International 36: 202-208, 2005.

Women with heart disease also have periodontal disease

Several studies have demonstrated a link between periodontal disease and heart disease. Several theories are suggested to explain this link. Some suggest that the link is actually very weak and life style choices similar in both diseases, such as smoking, are the reason. Others suggest that periodontal pathogens are capable of penetrating endothelial cells and smooth muscle in arteries and can induce platelet aggregation and a systemic inflammatory response. Research so far has been limited to men. This is the first study evaluating the connection between gum disease and heart disease in women.

Test subjects were recruited from women who presented at two large hospitals in Stockholm, Sweden for angioplasty or bypass surgery. A group of 143 women with heart disease were compared to 50 randomly selected women who were found to be heart healthy. Clinical examinations and radiographs were compared between the groups.

Women with heart disease did have more periodontal disease. There were also more diabetics in that group and more denture wearers. Women with heart disease had an average of 19 teeth compared to 23 for those without heart disease. They had an average of 14 pockets 4 mm or deeper compared to 10 for the heart-healthy women. Those with heart disease had an average total of 64 mm of pocket depth, compared to 47 mm in the heart-healthy group.

Clinical Implication: These findings add to our understanding of the link between periodontal disease and cardiovascular disease. We now have evidence of a link in women as well as men.

Buhlin, K., Gustafsson, A., Ahnve, S., Jansky, I., Tabrizi, F., Klinge, B.: Oral Health in Women With Coronary Heart Disease. J Perio 76: 544-550, 2005.

Smokers under stress have deeper pockets than non-anxious smokers

Bacterial biofilm triggers periodontal infection, and stress can aggravate the situation. Past studies have demonstrated that people with psychiatric disorders have more periodontal disease. Stress is also associated with lifestyle choices, such as smoking. Researchers at the Karolinska Institute in Sweden wanted to know if stress influenced periodontal conditions, and if by asking just one question, there would be enough information about a person to determine a level of stress that would influence periodontal disease.

Test subjects were 144 men and women with untreated periodontal disease. The control group was a random sample of 26 periodontally healthy people. Just one question was asked to assess stress level: “Do you feel anxious in your every day life?” Response choices were 1) no, never, 2) yes, sometimes, and 3) yes, often. Smokers comprised 56% (80 of 144) of the test subjects with periodontal disease, compared to 23% (6 of 26) of the healthy controls. Smokers who reported higher levels of everyday stress had more deep pockets and more inflammation. Smoking appears to be a greater risk factor than stress, as non-anxious smokers had more deep pockets than anxious non-smokers. High stress levels combined with smoking may lead to more periodontal infection.

Clinical Implications: The addition of a single question to your health history that asks if the patient feels anxious each day may provide valuable information about the stress level of your patients. High-stress levels combined with smoking may lead to more periodontal infection.

Johannsen, A., Asberg, M., Söder, P., Söder, B.: Anxiety, Gingival Inflammation and Periodontal Disease in Non-Smokers and Smokers – An Epidemiological Study. J Clin Perio 32: 488-491, 2005.

First study evaluating azithromycin and non-surgical therapy in smokers

Thorough subgingival deposit removal is the key to treating periodontal disease. Smokers are at greatest risk for periodontal disease and often have less than favorable response to treatment. It has been reported that 4% to 8% of periodontal patients respond poorly to conventional, non-surgical treatment. In these “refractory” cases, antibiotics have been used, most often tetracycline, doxyclycline, minocycline, metronidazole and others. Azithromycin is now being considered as it has been found to be effective against oral infections. Laboratory studies have found it effective against periodontal pathogens. Now clinical studies need to be done.

Researchers at the University of Michigan used azithromycin as an adjunct to non-surgical therapy in a group of smokers with moderate to advanced periodontal disease. The drug was taken by 15 subjects and 16 controls received no drug. (The antibiotics were donated by Pfizer, Inc). All subjects received two scaling and root planing (SRP) visits and oral hygiene instructions.

Despite random assignment to groups, the azithromycin group began with deeper pockets and higher attachment level scores than the control group. Other parameters were consistent between groups at baseline.

At three and six months both groups showed significant healing with no differences between groups for overall probing depth and attachment loss.

Deeper sites did, however, show greater pocket depth reduction and more gain of attachment in the azithromycin group compared to the control group.

Clinical Implications: This is the first clinical study I’m aware of published in English (there is one in Russian) evaluating azithromycin for the treatment of chronic periodontal disease. More studies are needed. Systemic antibiotic use is reserved for treatment of refractory cases, and not routinely recommended with non-surgical therapy. Thorough removal of subgingival deposits is still the most effective way to treat periodontal disease.

Mascarenhas, P., Gapski, R., Al-Shammari, K., Hill, R., Soehren, S., Fenno, J., Giannobile, W., Wang, H.: Clinical Response of Azithromycin as an Adjunct to Non-Surgical Periodontal Therapy in Smokers. J Perio 76: 426-436, 2005.

Topcial cream helps relieve symptoms of lichen planus

Lichen planus affects only a small portion of the population, 0.1-4%. Reticular and plaque-like lesions are the most common and are usually asymptomatic. Ulcerative, erosive lesions are generally painful. The etiology of lichen planus is unknown and topical and systemic treatments are not always effective. However, two substances derived from soil bacteria show promise as topical creams. These substances, tacrolimus and pimecrolimus, trigger an anti-inflammatory response that reduces the symptoms associated with lichen planus.

Researchers at Baylor College of Dentistry in Dallas tested a compounded ointment containing 1% pimecrolimus and a placebo cream formulated to match the test cream except for the active ingredient. Subjects with a history of lichen planus were selected for the study, and all lesions were biopsied to confirm lichen planus. The four-week study included 10 test subjects and 10 control subjects, each instructed to apply a measured amount of the cream on the lesions twice daily. Photographs taken at baseline, two weeks and four weeks were used to determine changes in the lesions. Subjects also filled out a visual analog scale to measure pain levels. The scale consisted of a line drawn across the page with zero at one end and 100 at the other. Zero represented no pain and 100 represented severe discomfort.

The control group using the placebo cream showed no improvement, rather an increase in lesions and a tendency toward increased pain. The test group showed reduced pain and reduced lesion size and intensity.

Clinical Implications: Consider having a compounding pharmacy make a 1% pimecrolimus cream for patients suffering with erosive lichen planus and not finding relief with medications previously tried.

Swift, J., Rees, T., Plemons, J., Hallmon, W., Wright, J.: The Effectiveness of 1% Pimecrolimus Cream in the Treatment of Oral Erosive Lichen Planus. J Perio 76: 627-635, 2005.

Bleeding upon probing predicts disease progression in pregnant women

We know pregnancy does not cause periodontal disease, but it does contribute to its progression. There is also growing evidence of a link between periodontal disease and preterm, low birth weight. Researchers at the University of North Carolina, in Chapel Hill wanted to know what changes in periodontal health are seen during pregnancy.

Study subjects were recruited from patients at Duke University Hospital, Department of Obstetrics between December 1997 and July 2001. Women who completed both antenatal and postpartum dental examinations were included, for a total of 891 subjects, ranging in age from 14 to 46 years.

Antenatal dental examinations were conducted prior to 24 weeks of gestation and postpartum examinations were conducted within 72 hours of birth. Research hygienists conducted the examinations both in the dental office and while subjects were still hospitalized after giving birth. Pocket depths and bleeding scores were recorded. Attachment levels and bone levels were not included in these examinations.

Changes in probing depth and bleeding were monitored, focusing on changes of at least 2 mm of probing depth. Baseline diseased sites were those sites 4 mm or deeper. The number of sites showing periodontal changes was actually very small, 1.7%, however the percentage of women with changes in periodontal health at one or more sites was 46%. Disease occurred or progressed primarily at interproximal sites on molars and premolars. Bleeding upon probing significantly increased the risk for disease progression. New disease occurred more often than progression of disease at sites already measuring 4 mm or more. Young women of child bearing age don’t usually have extensive periodontal disease, so new disease is more likely than disease progression in this age group.

Clinical Implications: Even if the new pockets developed during pregnancy resolve after giving birth, the clinical goal should be preventing gingival inflammation during pregnancy.

Moss, K., Beck, J., Offenbacher, S.: Clinical Risk Factors Associated with Incidence and Progression of Periodontal Conditions in Pregnant Women. J Clin Perio 32: 492-498, 2005.