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Perio Reports

Perio Reports Vol. 19 No. 5

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

Interproximal brushes superior to dental floss

Two studies were recently published which compared the effects of interdental brushes and dental floss for patients with early-to-moderate periodontal disease. The first study was conducted in the Periodontology Department at Guy’s Hospital, in London, England, with a group of 10 patients who had early-to-moderate periodontal disease. Patients were instructed to use dental floss on one side of their mouth and an interdental brush on the other side of their mouth for one month. Ten interproximal sites were evaluated, from the distal of the central incisor to the mesial of the second molar for plaque, bleeding, probing depth and recession. After one month, both interdental products showed significant reductions in plaque, bleeding and probing depths, with differences slightly greater for the interdental brush sites. When questioned, seven patients preferred the interdental brush, two preferred the dental floss and one had no preference.

The second study was conducted at the Federal University of Rio Grande do Sul in Porto Alegre, Brazil. Fifty periodontal maintenance patients were instructed to use three different interdental tools, one in each of three quadrants. The three Johnson & Johnson products tested were dental floss, a conical interdental brush and a cylindrical interdental brush. Three interdental sites in each quadrant were selected for testing. Following instructions, the plaque was stained and the patients were given one minute to clean each of the three quadrants with a different tool. Plaque was again stained and revealed nearly complete plaque removal with the interdental brushes, and much less effectiveness with the dental floss.

Clinical Implications: Interdental brushes are preferable to dental floss for patients with periodontal disease. Interdental brushes remove plaque more effectively, reduce bleeding and lead to probing depth reductions better than dental floss. Patient compliance is greater with interdental brushes compared to floss, resulting in better oral health.

Rösing, C., Daudt, F., Festugatto, F., Oppermann, R.: Efficacy of Interdental Plaque Control Aids in Periodontal Maintenance Patients: A Comparative Study. Oral Health & Prev Dent 4: 99-103, 2006.

Ishak, N., Watts, T.: A Comparison of the Efficacy and Ease of Use of Dental Floss and Interproximal Brushes in a Randomized Split Mouth Trial Incorporating an Assessment of Subgingival Plaque. Oral Health Prev Dent 5: 13-19, 2007.

New approach for brushing partially erupted teeth

Occlusal surfaces of permanent teeth are the most likely to decay and erupting teeth are at greatest risk. Full eruption may take six-to-12 months and the gingival tissue covering the surface makes toothbrushing difficult. Researchers in the Department of Orthodontics at the University of San Paulo, Brazil compared standard toothbrushing (anterior-posterior scrubbing), transverse toothbrushing (buccal-lingual scrubbing) and the end-tuft brush (sweeping from inside out). Five-to-seven-year-olds with at least one erupting lower first molar were included in this crossover study.

The children were examined at four visits, one-week apart, after 24-hour plaque accumulation. The initial visit was for evaluation and the next three were to test the three approaches to plaque removal. For each method tested, the children were instructed that day in the importance of cleaning their first molars and the method to be tested was demonstrated on a typodont. After plaque levels were recorded, the children cleaned the occlusal surface of the erupting molar, looking in the mirror, with no time limit. A tiny amount of fluoridated toothpaste was used.

The standard toothbrushing method removed the least amount of plaque. Both the transverse and end-tuft brush removed more plaque, even in the presence of gingival operculum.

Clinical Implications: Brushing across the occlusal surface or using an end-tuft brush is best for removing plaque on partially erupted molars.

Goncalves, A., Rocha, R., Oliveira, M., Rodrigues, C.: Clinical Effectiveness of Toothbrushes and Tooth-brushing Methods of Plaque Removal on Partially Erupted Occlusal Surfaces. Oral Health Prev Dent 5: 33-37, 2007.
Oral-B power toothbrush safe for use during periodontal therapy

Most power toothbrush studies involve people with gingivitis or those in the maintenance phase of periodontal therapy. This may be the first study to evaluate the effectiveness of a power toothbrush during initial periodontal therapy.

Researchers at the University of Geneva in Switzerland compared a manual toothbrush and the Oral-B Professional Care Series 8000 power toothbrush in a group of 70 patients determined to have Class II chronic periodontitis. At the first visit, baseline data was collected and the clinician spent 15 minutes with each patient explaining oral hygiene instructions, including interdental cleaning. Toothbrushing was demonstrated on a typodont and patients were instructed to brush twice daily as instructed. Supragingival instrumentation and polishing was completed at this time.

Patients returned on days seven, 14 and 28 for examination. No significant tissue trauma was observed for either toothbrush. Greater plaque reductions were evident for the group using the power toothbrush, primarily on the lingual surfaces of mandibular premolars and cuspids. With less plaque, the power toothbrush group also showed less bleeding upon probing. No differences were observed for gingival index or probing depths between the two groups.

Clinical Implications: It’s safe to recommend the Oral-B power toothbrush to patients undergoing the initial phase of periodontal therapy.

Gugerli, P., Secci, G., Mombelli, A.: Evaluation of the Benefits of Using a Power Toothbrush During the Initial Phase of Periodontal Therapy. J Perio 78: 654-660, 2007.
New ultrasonic scaling system available in Europe

In 2000, the Vector piezoelectric ultrasonic scaling system was introduced in Germany by the Dürr Company. This 25kHz power scaler has a resonating ring that converts horizontal ossilations into pure vertical movements at an amplitude of about 30µm. The tip movements are therefore parallel to the root surface. The straight, bent and curette tips are attached at a right angle to the handpiece and the coolant is an abrasive slurry containing hydroxyapatite particles that is applied with intermittent pulsations. Hydroxyapatite particles promote energy transmission to enhance calculus removal and prevent root surface damage.

Researchers at the University of Kiel in Germany compared the Vector system to supragingival rubber cup polishing with pumice, American Eagle Gracey curettes used by a hygienist and the curettes used by a dentist. Patients with 5-8mm probing depths around single-rooted teeth participated in the study. Quadrants were randomly assigned to one of the four treatments. Probing scores were determined with the Florida Probe.

The hygienist provided three quadrants of treatment, including the Vector system, which she was given instructions on, but had not used to the extent she had curettes.

After six months, all four treatments resulted in clinical healing. Baseline probing depths up to 6mm were reduced by 1.2mm in the Vector group and 1.5mm in the two curette groups. Baseline probing depths more than 6mm were reduced 2.5mm in the Vector group and 2.6 in the curette group. Long-term studies are now needed to see if these effects can be maintained.

In another study, researchers at the University of Regensburg in Germany compared half-mouth Vector treatment with half-mouth Hu-Friedy Gracey curettes in a group of 19 patients with moderate-to-severe chronic periodontal disease. Similar healing was demonstrated in this study with 1mm reduction in pockets 4-6mm and 2mm reduction on pockets more than 7mm. Subgingival bacterial sampling showed similar decreases and increases for both groups. Sensitivity after treatment was reported for those in the curette group (average six teeth per patient) compared to no sensitivity reported in the Vector group.

Clinical Implications: This product is not yet available in the United States, but it may be one day. It’s an alternative to traditional power scalers that produces similar clinical results with potentially less root surface damage and less sensitivity.

Kahl, M., Haase, E., Kocher, T., Rühling, A.: Clinical Effects After Subgingival Polishing with a Non-Aggressive Ultrasonic Device in Initial Therapy. J Clin Perio 34: 318-324, 2007.

Christgau, M., Männer, T., Beuer, S., Hiller, K., Schmalz, G.: Periodontal Healing After Non-Surgical Therapy with a New Ultrasonic Device: A Randomized Controlled Clinical Trial. J Clin Perio 34: 137-147, 2007.

PerioChip is as effective as scaling and root planing at maintenance visits

Several local drug delivery systems have been tested in combination with both non-surgical and maintenance therapy. Based on current findings, these products seem to have a better place used for treating non-responding areas during maintenance therapy. Researchers at the School of Dentistry at Piracicabe, University of Campinas, Brazil, wondered if placing PerioChips in non-responding areas would be as effective and less time consuming than traditional scaling and root planing (SRP). To find out, they designed a six-month study to determine the clinical results of such a comparison.

Periodontal patients underwent SRP by a graduate student and were examined three months later. Non-smokers with pockets between 5 and 8mm on single-rooted teeth were included in the study. Treatments were assigned randomly and took place at the three-month evaluation visit. Those in the test group had PerioChips, 2.5mg chlorhexidine gluconate placed in periodontal pockets. The control group received SRP under local anesthesia by the same graduate student. All subjects were instructed to refrain from using dental floss for 10 days and to avoid mouthrinses for the six-month study. Supragingival polishing and review of oral hygiene was provided to all study subject at seven-10 days, six weeks, three months and six months.

Clinical healing was similar for both groups. Average probing depths were reduced 2.78mm in the PerioChip group and 2.22mm in the SRP group. When comparing healing in the 22 deep sites measuring 7-8mm, the PerioChip reduced probing depths 3.60mm compared to 2.83mm for the SRP group. In the PerioChip group, 85% of sites showed probing depth reductions of 2mm or more, compared to 76% in the SRP group.

Clinical Implications: PerioChip used alone was as effective as scaling and root planing when used at maintenance visits and showed 0.77mm more pocket depth reduction in deep pockets (7mm to 8mm).

Rodrigues, I., Machion, L., Casati, M., Nociti, F., Toledo, S., Sallum, A., Sallum, E.: Clinical Evaluation of the Use of Locally Delivered Chlorhexidine in Periodontal Maintenance Therapy. J Perio 78: 624-628, 2007.

 Low-dose doxycycline provides no added benefit for smokers

Smoking is a major risk factor for periodontal disease and contributes to less than optimal healing following periodontal therapy. Smokers have increased levels of pro-inflammatory cytokines, which might explain a greater level of connective tissue destruction. Researchers at the Eastman Dental Institute in London, England, wondered if low-dose doxycycline, which inhibits cytokine production, might enhance periodontal healing in smokers.

Subjects recruited for this study were about to undergo non-surgical periodontal therapy. Four sessions of oral hygiene instructions and supra and subgingival instrumentation were provided by a periodontist. There were no time limits on the therapy appointments. At the first treatment visit, half the group was given low-dose doxycycline and the other half a look-alike placebo and instructed to take the medication twice daily for three months. A total of 34 patients completed the six-month study.

Clinical measures included probing depths, recession and clinical attachment levels. The rate of change over the test period was faster for those taking the low-dose doxycycline compared to those taking the placebo pills. However, by six months, both groups reached the same level of healing. Different results might be produced in a study including more subjects and with a medication phase lasting longer than three months.

Clinical Implications: Low-dose doxycycline provided no additional benefit over instrumentation alone in a group of smokers. Smoking cessation is still the best way to enhance periodontal healing in smokers.

Needleman, I., Suvan, J., Gilthorpe, M., Tucker, R., St. George, G., Giannobile, W., Tonetti, M., Jarvis, M.: A Randomized-Controlled Trial of Low-Dose Doxycycline for Periodontitis in Smokers. J Clin Perio 34: 325-333, 2007.
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