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Perio Reports

Perio Reports Vol. 19 No. 4

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

Periodontal bugs found in coronary arteries

Atherosclerosis is the most common cause of coronary artery disease. World Health Organization statistics for 1993 showed cardiovascular disease to be the number-one cause of death in developed countries, accounting for 47% of all deaths in those countries.

In 1999, a study was published in the journal Circulation presenting new evidence to suggest that atherosclerosis was associated with inflection and inflammation. This first study tied the herpes viruses to changes in blood vessel walls. Since then, cytomegalo virus (CMV) and C. pneumoniae (Cp) have been found in blood vessel walls associated with atherosclerosis.

Researchers at the University of Belgrade in Serbia evaluated artery samples for the presence of microorganisms. Samples were taken from 15 patients undergoing coronary bypass surgery. Involved coronary arteries and mammary arteries used to create the bypass graft were evaluated. Mammary arteries are used for bypass as they seem to be protected from the process of atherosclerosis.

No periodontal pathogens were found in the mammary vessel samples. Periodontal pathogens were found in nine of the 15 coronary artery samples (60%). CMV was found in 10 (67%) coronary artery samples and seven (47%) mammary artery samples. Cp was detected in five (33%) coronary artery samples and six (40%) mammary artery samples.

The researchers speculate that since the periodontal pathogens were found in the coronary artery samples and not the mammary samples and CMV and Cp were found in both, the periodontal pathogens may be the more likely bugs to cause atherosclerosis.

Clinical Implications: These findings add to our understanding of the perio/heart-disease link. Establishing and maintaining periodontal sulcular health is important to prevent the movement of oral bacteria to the coronary arteries.

Pucar, A., Milasin, J., Lekovic, V., Vukadinovic, M., Ristic, M., Putnik, S., Kenney, E.: Correlation between Atherosclerosis and Periodontal Putative Patholgenic Bacterial Infections in Coronary and Internal Mammary Arteries. J Perio 78: 677-682, 2007.

Periodontal bugs found in placentas

Preeclampsia (PET) is a hypertensive disorder during pregnancy that affects 6-8% of pregnancies and accounts for 15% of maternal deaths and potentially lethal complications for the baby. PET usually occurs after 20 weeks of gestation. Despite research in this area, the cause of PET is still unknown. One hypothesis is a hyperinflammatory state with cytokines contributing to injury of endothelial cells and the formation of artherosis. Acute artherosis is the placental version of PET with pathology similar to atherosclerosis. Chronic infection has recently been associated with atherosclerosis with periodontal pathogens detected in artheromas and in coronary arteries.

Researchers in Israel evaluated placenta samples of 16 women undergoing cesarean sections because of PET. The control group was composed of 14 age-matched women who underwent cesarean sections due to other reasons. Cesarean-section births were selected over vaginal births to avoid potential contamination of the placenta during the birth process.

Patients ranged from 18-46 years of age. Eight of the 16 samples from the PET group were positive for one or more periodontal pathogens. Only two of the 14 in the control group were positive for periodontal pathogens. Bacterial counts were higher in the PET group, compared to the control group.

This is the first research to demonstrate periodontal pathogens in human placental tissues. Bacterial infections are known to adversely affect a pregnancy and have been shown to lead to spontaneous preterm birth, especially in early gestation. Animal studies show adverse effects of bacterial infections that include abnormal placental architecture, altered brain development, and other problems with fetal development and delivery.

Clinical Implications: It is important to reduce the oral bacterial load and periodontal infections for pregnant women to protect both the mother and the fetus.

Barak, S., Oettinger-Barak, O., Machtei, E., Sprecher, H., Ohel, G.: Evidence of Periopathogenic Microorganisms in Placentas of Women with Preeclampsia. J Perio 78: 670-676, 2007.
Periodontal disease risk increased for young diabetics

Diabetes mellitus is characterized by high levels of blood glucose resulting from problems with insulin production and/or action. According to the Centers for Disease Control and Prevention (CDC), an estimated 20.8 million people in the United Stated had diabetes in 2005. According to the research, periodontal disease is influenced by diabetes and vice versa.

Researchers at Columbia University in New York reported on the largest study to date evaluating the periodontal status of children and adolescents with diabetes. The study included 350 patients with diabetes being treated at the Naomi Berrie Diabetes Center and 350 six- to 18-year-old patients without diabetes being seen at the dental school.

The children and adolescents with diabetes showed significantly more periodontal disease than those without diabetes. For both groups, bleeding upon probing peaked around puberty. However, those with diabetes had greater attachment loss than those without diabetes.

Periodontal disease can be prevented, even in those with more risk factors, when treatment and prevention are begun at the first signs of inflammation. Based on the current findings, children with diabetes should be examined for signs of periodontal disease and receive early intervention and prevention.

Clinical Implications: Be sure to screen your young patients with diabetes for signs of periodontal disease and begin prevention early.

Lalla, E., Cheng, B., Lal, S., Kaplan, S., Softness, B., Greenberg, E., Goland, R., Lamster, I.: Diabetes Mellitus Promotes Periodontal Destruction in Children. J Clin Perio 34: 294-298, 2007.
Vitamin C deficiency – a risk for periodontitis

Periodontitis is a multifactorial disease triggered by bacteria with tissue destruction mediated by the immune system. The host defense system is influenced by genetic factors, hormones and nutrition. Past research surrounding vitamin C and oral conditions focused primarily on the absolute deficiency of vitamin C and resulting scurvy. Some research has evaluated vitamin C levels and periodontal disease; some showing no benefit from supplemental vitamin C and others showing reduced bleeding when grapefruit was added to the diet.

Vitamin C is transported across gastrointestinal tissues into the blood stream by two specific transporter proteins. Genetic variations of these proteins lead to a reduced bioavailabilty of vitamin C. A recent study showed a link between these genetic variations and preterm birth.

Researchers in the Netherlands have gathered data on a group of Indonesian tea plantation workers over several years. These people have very little formal education, rarely receive dental care, and have remained in the same village for years. A group of 123 subjects was evaluated for clinical signs of periodontitis and blood was taken to determine vitamin C plasma levels. Vitamin C deficiency was observed in 15% of the group. More males showed a deficiency in vitamin C than women, 16% vs. 13%. Plasma levels of vitamin C ranged from 0.02 to 34.45 mg/l with an average level being 8 mg/l. A small but statistically significant relationship was found between attachment loss and vitamin C deficiency.

Clinical Implications: Encourage patients to include vitamin-C-rich fruits and vegetables in their diet each day to enhance periodontal tissue health.

Amaliya, Timmerman, M., Abbas, F., Loos, B., Van der Weijden, G., Van Winkelhoff, A., Winkel, E., Van der Velden, U.: Java Project on Periodontal Diseases: The Relationship Between Vitamin C and the Severity of Periodontitis. J Clin Perio 34: 299-304, 2007.
Which interdental brush – hard or soft?

Generally, the interdental area is filled and protected with the interdental papilla. Due to the facial and lingual architecture protecting the interdental area, this space is not easy to clean. Dental floss is recommended, but people often have difficulty handling and effectively using it. Interdental brushes are considered easier to use and therefore compliance is often better with interdental brushes.

Several studies have shown interdental brushes to be more effective than dental floss for removing interproximal plaque. These brushes are available in cylindrical or conical shapes and are most often round in cross section. They come in various sizes and stiffnesses.

Researchers at the University of Heldelberg in Germany wanted to know if bristle stiffness provide different levels of plaque removal. To answer this question, they compared interdental brushes of varying diameters and stiffness in a laboratory study.

Pairs of extracted teeth were imbedded in resin to simulate eight replicas of interdental spaces representing extra small, small, medium and large spaces. The resin created artificial gingiva around the pairs of extracted teeth. The resin molds were designed to separate, allowing complete access to proximal tooth surfaces for photographs and the application of a green dye to represent plaque.

Both soft and hard Curaprox interdental brushes were tested to determine plaque removal efficacy. Twelve cycles of cleaning were performed in each of the eight interdental models. A new interdental brush was used for each test. The interdental brush was moved back and forth three times over a span of approximately 5 mm. Brush diameters tested were 2 mm, 3 mm, and 5 mm.

No differences in removal of the green dye were noted between hard and soft brushes. More dye removal was observed as the interdental brush size increased.

Clinical Implications: Both soft and hard interdental brushes are effective for cleaning between the teeth. More care should be given to selecting the correct size brush to fit the interproximal spaces

Wolff, D., Joerss, D., Dörfer, C.: In-Vitro Cleaning Efficacy of Interdental Brushes with Different Stiffness and Different Diameter. Oral Health Prev Dent 4: 279-285, 2006.
Which diameter interdental brush works best?

Spaces between teeth with recession generally measure from 1 to 3 mm, providing a challenge for plaque removal. Interdental brushes are now available in many diameters, but we don’t know if one diameter is better than another.

Researchers at the University of Zurich in Switzerland compared nine different interproximal brushes in fixed spaces to determine efficacy. The interproximal brushes ranged from 2.5 mm diameter to 8.0 mm diameter. Brands included in the study were Paro, TePe and Curaprox.

The brushes were tested against black aluminum blocks covered with a titanium oxide slurry and adjusted to separations of 1, 2 and 3 mm. Only a single horizontal pass was made with each brush. After using the brush, the blocks were separated and the surfaces photographed. Computer imaging was used to determine cleaning efficacy.

Smaller brushes cleaned more effectively than larger one. Small diameter brushes were most effective when the blocks were separated 1 mm and 2 mm. When separated 3 mm, the middle sized brushes cleaned as well as and slightly better than either larger or smaller diameter brushes.

Clinical Implications: Smaller interproximal brushes appear to clean better than larger brushes, as the longer bristles might simply fold back on themselves.

Hofer, D., Imfeld, T., Attin, T., Schmidlin, P.: Cleaning Efficacy of Nine Interderdental Brushes. J Dent Research 86: Abstract #2812, 2007.
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