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.

NovaMin toothpaste reduces plaque and bleeding

NovaMin is a particle made of calcium, phosphorus, silica, and sodium. Alone these particles do not change bone or teeth. Together they release ions, change the pH of surrounding tissue and facilitate biological healing. These particles were first used by the military in the late 1960s to repair broken bones with a product called NovaBone. From there, PerioGlas was developed to enhance healing following periodontal surgery or extractions. Now these particles are available in toothpastes (Oravive) and desensitizing products (DenShield, Butler NuCare, and OMNII SootheRx). The inventors and researchers are now working on products containing particles that offer anti-inflammatory properties.

Researchers at Wuhan University in China compared a NovaMin containing toothpaste with a comparable control of similar abrasiveness. Subjects with moderate gingivitis participated in the 6-week study. At baseline the 100 subjects received supragingival scaling and polishing and oral hygiene instructions and were randomly assigned either the test or control toothpaste.

Plaque and bleeding were measured after 8 hours of no oral hygiene. The control group showed no reduction in plaque or bleeding at the end of the study, which surprised researchers. They expected to see improvement due to the Hawthorne Effect. Study participants usually do better simply because they are in a study.

The test group showed a 16% reduction in plaque and a 59% reduction in gingival bleeding. These results rival, and in some cases, are better than results found in studies evaluating the effects of stannous fluoride pastes, amine fluoride pastes, triclosan pastes, chlorhexidine rinses, and essential oil rinses. The NovaMin particles are non-antibiotic, natural components that leave no staining or altered taste.

Clinical Implications: This is the first time a toothpaste that does not contain antibiotics and/or fluoride has shown a therapeutic effect on gingival health. NovaMin containing products are effective for remineralization of enamel and now show beneficial effects in reducing gingivitis. NovaMin has the potential of being a significant preventive agent for both caries and periodontal disease.

Being Part of Research Motivates Subjects to Perform Better review of “Management and the Worker.” Harvard University Press, 1939. Perio Reports vol. 17: 7 (July 2005; Hygienetown: vol. 1: 7).

Tai, B., Bian, Z., Jiang, H., Greenspan, D., Zhong, J., Clark, A., Du, M.: Anti-Gingivitis Effect of a Dentifrice Containing Bioactive Glass (NovaMin®) Particulate. J Clin Perio 33: 86-91, 2006.

Calculus detection and removal in one instrument

Previous research reported that microscopic evaluation of tooth surfaces found calculus on 58% of surfaces compared to 19% as identified by clinicians with explorers. Based on these findings, a more objective and reliable means of detecting calculus is needed.

Researchers in Germany have been working for several years on a piezo-ceramic ultrasonic scaler with two power settings and a new feature that differentiates between the tooth surface and calculus. This detection and removal system was developed by Sirona Dental Systems and is called PerioScan.

The computer system was “taught” by an expert to recognize the differences between cementum and calculus, based on the differing responses the oscillating ultrasonic tip emitted when moved over these surfaces. Oscillating tip movements change slightly depending on the surface contacted. These movements form a unique signal back to the system. Forty measurements per tooth on 200 teeth resulted in 7,977 measurements. These signals were then used to teach the system to differentiate between cementum and calculus. The system was able to correctly distinguish between cementum and calculus on 78% of surfaces. Following this, the system was tested on 34 different teeth it had not yet tested and was found correct in 81% of cases. Sensitivity (defined as correctly identifying calculus) was 76% and specificity (defined as identifying calculus free surfaces as such) was 86%.

Clinical Implications: There is now a “smart ultrasonic” that identifies calculus for you and allows you to remove it immediately and recheck the surface to measure your success. The PerioScan combines detection and removal in one feedback system.

Meissner, G., Oehme, G., Strackeljan, J., Kocher, T.: In Vitro Calculus Detection with a Moved Smart Ultrasonic Device. J Clin Perio 33: 130-134, 2006.

Minocycline gel compared to instrumentation – no difference

Ideally, supportive periodontal maintenance visits lead to reductions in pocket depths and bleeding, stability of the periodontum, a subgingival microflora compatible with health, cost effectiveness, and the fewest side effects possible, such as sensitivity. Subgingival instrumentation, the primary focus of maintenance care, can result in sensitivity and significant reduction in tooth structure. Since periodontal disease is a bacterial infection, a locally delivered antibiotic may be as effective as instrumentation. Researchers at the Eastman Dental Institute in London compared subgingival instrumentation and the application of 2% minocycline gel in pockets 5 mm or deeper in a group of 38 patients. At baseline, all patients received initial therapy and active treatment and still had an average of 13 teeth with probing depths of 5 mm or more. Half the subjects in this 12-month study received subgingival instrumentation using an EMS piezo-ceramic scaler and hand instruments every three months. In comparison, the test group received subgingivally delivered minocycline gel in all sites 5 mm or deeper, every three months. A third-year periodontal graduate student provided all the treatment. Subgingival instrumentation for each subject took an average of 27 minutes, while gel application visits took an average of 20 minutes. Over the 12 months, 28 minutes were saved with the gel applications compared to instrumentation.

Patients were asked to complete an evaluation form following each visit, reporting on their experience of pain, discomfort and sensitivity. The minocycline group experienced significantly less pain, discomfort and sensitivity. On a scale of 100, with higher scores meaning more pain, the scores were 3 for the gel group for pain and discomfort compared to 46 and 26 for the instrumentation group. The gel group reported a score of 2 for sensitivity following treatment compared to 11 for the instrumentation group.

Clinical Implications: If further research confirms these pilot study findings, 2% minocycline gel applications every three months may reduce the need for subgingival instrumentation to once a year. This locally applied antibiotic may also prove to be an effective alternative to instrumentation for patients with root sensitivity. The cost of the gel will be offset by the reduced treatment time required. Watch for more research on this subject.

McColl, E., Patel, K., Dahlen, G., Tonetti, M., Graziani, F., Suvan, J., Laurell, L.: Supportive Periodontal Therapy Using Mechanical Instrumentation or 2% Minocycline Gel: A 12 Month Randomized, Controlled, Single Masked Pilot Study. J Clin Perio 33: 141-150, 2006.

Aggressive periodontitis affects family members

There is a periodontal disease that often affects young people, destroys bone at a rapid rate and is associated with Actinobacillus actinomycetemcomitans also know as Aa. In the past, this condition was labeled “juvenile periodontitis.” The name was later changed to “early onset periodontitis” or EOP. In 1999, the classification of periodontal diseases introduced a new term “aggressive periodontitis” which addressed the shortcomings of previous classifications. The three criteria for a diagnosis of EOP were rapid attachment/bone loss, medically healthy, and a family history of this disease. Aggressive periodontitis now encompasses older as well as younger patients and those who are not aware of a family pattern of this disease.

The genetic component of aggressive periodontitis remains unclear as the exact gene or genes have yet to be identified and the mode of inheritance is still under discussion by researchers. When aggressive periodontitis is diagnosed, it is generally accepted that blood relatives be made aware of the genetic aspect of this disease and be encouraged to have a periodontal examination.

Researchers at the Eastman Dental Institute in London asked questions of patients diagnosed with aggressive periodontitis, regarding oral health of blood relatives. These relatives were invited to visit the clinic for an examination and those with aggressive periodontitis were also asked about other blood relatives. The rate of relatives being affected with aggressive periodontitis varies from study to study and family to family. Reports vary from 8% to 63% of relatives being affected.

Reports from patients on the positive or negative status of blood relative’s oral health were accurate in 75% of all cases; 86% accurate for those reporting relatives having gum disease.

Clinical Implications: Patients with aggressive periodontal disease who report that other family members have gum disease should be encouraged to bring those family members in for an examination.

Llorente, M., Griffiths, G.: Periodontal Status Among Relatives of Aggressive Periodontitis Patients and Reliability of Family History Report. J Clin Perio 33 121-125, 2006.

Periodontal disease may lead to miscarriages

Miscarriage is an outcome that isn’t usually included in the perio-preterm, low birth weight studies. Miscarriages in the first trimester are associated with anatomy, genetics, hormones and autoimmune diseases. Late miscarriages occur in the second trimester. A miscarriage between 12 and 24 weeks is also called a spontaneous abortion.

Infection and inflammation are important factors in both periodontal disease and adverse pregnancy outcomes. Inflammatory mediators released with periodontal disease can potentially reach the fetus. Smoking is a risk factor for both periodontitis and poor pregnancy outcomes.

Researchers at King’s College in London examined 1,793 non-smoking, pregnant women when they were scheduled for their 12-week ultrasound. An abbreviated periodontal exam was completed on only two surfaces per tooth: buccal and mesial buccal surfaces. Probing, bleeding and plaque scores were recorded.

When pregnancy outcome information was available, no association was evident between periodontal disease and preterm delivery. A total of 130 babies (7.3%) were delivered preterm. There was, however, a statistically significant, yet weak association between miscarriages and periodontal disease. Seventeen women (1%) experienced a late miscarriage. These women tended to be 3 years older on average; 10 were of black ethnic groups and 4 were white. Of these 17 women, 9 took medication in the first trimester, 7 took antibiotics, and 8 had previous miscarriages. The numbers are small in this study, so more research is needed to make sweeping statements. However, when smoking is not a factor, periodontal disease may contribute to miscarriages.

Clinical Implications: This study provides more evidence supporting the importance of good periodontal health in pregnant women. Encourage dental hygiene visits before, during and after pregnancy.

Farrell, S., Ide, M., Wilson, R.: The Relationship Between Maternal Periodontitis, Adverse Pregnancy Outcome and Miscarriage in Never Smokers. J Clin Perio 33: 115-120, 2006.

Stress may not have direct influence on periodontal disease

Periodontal disease is a bacterial infection. Researchers have suggested that stress adversely affects periodontal health. At this time, there are no biological markers to accurately measure psychiatric conditions. If the influence of stress isn’t direct, it has at least been shown to be indirect.

Those under stress often adopt habits harmful to their periodontal health, such as increased smoking, reduced oral hygiene, and altered eating habits.

Researchers in Brazil examined 1,000 patients in the dental clinic at the Federal University of Rio Grande do Sul, in South Brazil. From this group, they identified 169 adults, 96 with periodontal disease and 69 healthy controls. A smaller control group reflects the difficulty researchers had finding periodontally healthy adults. All received a complete periodontal exam and were given four questionnaires to measure stress. One measured anxiety, another depression, a third, reactions to stressful situations, and the fourth was the Life Events Scale.

Both groups reported similar responses for all four psychosocial evaluations. Both groups reported a minimum anxiety level compared to that reported for the general population of Brazil. Perhaps these people have good support systems and effective ways of coping with stress.

Clinical Implications: Based on this study, stress is not a significant factor in the onset or progression of periodontal disease. It is a bacterial infection and until controlled observational studies can show an association between stress and periodontal disease, efforts must continue to be directed toward controlling the infection.

Castro, G., Oppermann, R., Haas, A., Winter, R., Alchieri, J.: Association Between Psychosocial Factors and Periodontitis: A Case-Control Study. J Clin Perio 33: 109-114, 2006.