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Perio Reports

Perio Reports Vol. 19 No. 7

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

Tongue scraping and morning bad breath

It is estimated that oral conditions constitute 90 percent of the cause of oral malodor or bad breath. Volatile sulfur compounds, released with the degradation of microorganisms and proteins, contribute significantly to bad breath. This is evident with the association between plaque-related periodontal diseases and bad breath. However, a certain number of periodontally healthy individuals exhibit noticeable bad breath. Bacterial biofilm on the dorsom of the tongue has been suggested as the probable cause in these cases.

Researchers at the Federal University of Rio Grande do Sul in Brazil evaluated the effects of tongue cleaning on morning bad breath in a small group of 10 periodontally healthy dental students. Subjects participated in two four-day sessions of no oral hygiene. Half the group was instructed to use a tongue scraper two- to three-times daily and no other oral hygiene. The other half of the group refrained from all oral hygiene for the four-day test period. Following a seven-day washout period, the groups were reversed.

Oral malodor was analyzed with a Halimeter to measure volatile sulfur compounds and by organoleptic scoring. The organoleptic examiner was positioned four inches (10 cm) from the subjects and exhaled mouth air was scored as follows: 0 = no odor, 1 = barely noticeable odor, 2 = slight, but noticeable odor, 3 = moderate odor, 4 = strong odor, and 5 = extremely foul odor. All measurements were taken between 7 a.m. and 9 a.m. following an eight-hour fast.

Tongue scraping did not result in less bad breath than no tongue cleaning. No statistically significant differences were observed between groups on day four. Clearly, oral malodor is multifactorial. These findings suggest that tongue biofilm might not be the primary source of morning bad breath in periodontally healthy subjects.

Clinical Implications: Many questions are yet unanswered as to the exact cause of morning bad breath. It is likely a combination of sources rather than one factor.

Haas, A., Silveira, É, Rôsing, C.: Effect of Tongue Cleansing on Morning Oral Malodour in Periodontally Healthy Individuals. Oral Health Prev Dent 2: 89-94, 2007.

Dental students’ attitudes toward personal oral hygiene

Dental education focuses on basic science courses, surgical and restorative procedures. Despite this focus on repairing the results of dental disease, dentists must also become counselors, role models and mentors to their patients with good daily oral hygiene, healthy diet and health promoting lifestyles. Very little research focuses on how and when dental students change their behaviors and attitudes toward their own oral health.

Researchers at the Hiroshima University in Japan have developed a 20-item questionnaire to measure dental student’s attitudes and behaviors toward personal oral hygiene. Australia, Belgium, Brazil, China, Finland, France, Germany, Greece, Hong Kong, Indonesia, Ireland, Israel, Italy, Japan, Korea, Malaysia, Thailand and the U.K. have used this inventory to determine student attitudes.

Researchers in Romania recently used this questionnaire to compare attitudes between 322 first-to sixth-year dental students. In Romania, dental school is six years: years one to four are spent on medical school courses, years five and six are spent on clinical dentistry. Dental courses are taken in the third year.

Toothbrushing frequency didn’t vary between classes, however 46 percent of 5-6 year students report daily flossing compared to only 20 percent of year 1-2 students. More students are entering school having received professional oral hygiene instructions, 30 percent of 1-2 year students compared to 12 percent of 5-6 year students. In year 1-2, 25 percent expect to have dentures, compared to 14 percent of 5-6 year students.

Clinical Implications: Although this data cannot be generalized to other dental schools in Romania or other countries, the findings are interesting.

Dumitrescu, A., Kawamura, M., Sasahara, H.: An Assessment of Oral Self-Care Among Romanian Dental Students Using the Hiroshima University-Dental Behavioural Inventory. Oral Health Prev Dent 2: 59-100, 2007.
Oral contraceptives amplify aggressive perio

Periodontal conditions are influenced by the hormonal changes during puberty, menstruation and pregnancy. In 1967, researchers identified a similar relationship between the sex steroids in oral contraceptives and gingival inflammation. Oral contraceptives now contain much lower doses of hormones than when first introduced. Periodontal researchers at Queens University in Belfast, Northern Ireland, wanted to know if the newer lower-dose oral contraceptives influenced aggressive periodontitis.

The researchers evaluated the periodontal condition of 50 women aged 20-35 years. These women were diagnosed with aggressive periodontitits and referred to the dental school by their general dentists.

Only eight of the women had never taken oral contraceptives and 21 had taken oral contraceptives previously. These 29 women comprised the no-pill group. The remaining 21 women were taking contraceptives at the time of the study. Smoking was prevalent in both groups, 67 percent of pill users and 59 percent of no pill users.

A diagnosis of aggressive periodontitis was confirmed in 40 of the women, half with generalized and half with localized. Ten cases of chronic periodontitis were confirmed. Those taking oral contraceptives had deeper pockets and more attachment loss than women not taking the pill. Average attachment loss was 1 mm greater in those taking oral contraceptives compared to those not taking the pill. The eight women who had never taken oral contraceptives had better periodontal health than those who either previously had or were currently taking oral contraceptives. Surprisingly, those taking oral contraceptives had only slightly and not significantly more plaque, gingivitis, and bleeding upon probing compared to those not taking oral contraceptives.

Clinical Implications: Women at risk of generalized aggressive periodontitis should be advised that oral contraceptive use might lead to more advanced disease.

Mullally, B., Coulter, W., Hutchinson, J., Clarke, H.: Current Oral Contraceptive Status and Periodontitis in Young Adults. J Perio 78: 1031-1036, 2007.
Root surface caries research reviewed

Root caries is primarily a problem of the elderly. Gingival recession exposes root surfaces and puts them at risk for caries. Those who have undergone periodontal surgery often have exposed root surfaces and are therefore at risk of root surface caries. Factors influencing root caries include the quality of microflora, quantity of plaque biofilm, diet, amount and composition of saliva, and fluoride exposure. Root surface demineralization is twice as fast as that of enamel. Enamel demineralizes at a critical pH of 5.5, compared to 6.2 to 6.4 for dentin. More fluoride is needed to remineralize dentin compared to enamel. Prevention of root surface caries is preferable to repair due to the access difficulties encountered with repair.

Researchers at the Academic Centre for Dentistry in Amsterdam reviewed published studies to determine the effect of specific fluoride treatments on root caries incidence and/or activity. They began with 348 papers and narrowed it down to six that fulfilled their selection criteria. Based on the findings of these studies, there is no universally accepted strategy for the management of root caries. The researchers do agree that in addition to fluoride toothpaste, those at risk for root caries should have another source of daily fluoride such as a rinse or topical application of sodium, amide or stannous fluoride. Active root surface caries can be converted to inactive lesions with additional fluoride. Those at risk should also be counseled regarding their dietary intake of fermentable carbohydrates.

Clinical Implications: Those with exposed root surfaces are at greater risk of caries and should receive additional daily fluoride and dietary counseling.

Heijnsbroek, M., Paraskevas, S., Van der Weijden, G.: Fluoride Interventions for Root Caries: A Review. Oral Health Prev Dent 2: 145-152, 2007.

Goals for plaque and bleeding scores

Research published in 1961, 1976, 1977, 1986 and 1998 shows improved oral hygiene leads to improved periodontal health as measured by reduced bleeding and gain in clinical attachment levels. However, compliance is difficult to measure. Plaque levels are not always reliable since the person may effectively remove plaque on the day of the exam, and not be effective other days. Bleeding upon probing is not predictive of attachment loss, but the lack of bleeding is a good indicator of periodontal stability. Therefore the combination of plaque and bleeding scores may be the best way to measure compliance with oral hygiene, however, the ideal scores needed to establish compliance have yet been determined.

Researchers at the National University of Singapore evaluated plaque and bleeding scores on a group of 161 patients with diabetes who were enrolled in a periodontal therapy study. Scores for probing depths and both surpragingival and subgingival calculus were combined to form a score used for determining disease.

Baseline scores for plaque and bleeding upon probing were evaluated using a graph that is compared to a cost/benefit analysis of diagnostic decision making. Various combinations of plaque and bleeding scores were assessed against a composite model that combined probing depths and supragingival and subgingival calculus scores. Plotting these combinations according to true-positive and false-positive diagnosis of periodontal disease identified the plaque and bleeding percentage that best predicts oral hygiene compliance.

The combination that provided the best diagnostic and predictive values for health was 25-15 (plaque score of 25 percent and bleeding upon probing score of 15 percent). Oral hygiene scores higher than these can be considered non-compliant. This information is helpful for researchers and those involved in community oral health projects.

Clinical Implications: These findings are a start toward establishing plaque and bleeding scores that accurately reflect compliance with oral hygiene. The ideal goal is zero plaque and zero bleeding, and the line between compliance and noncompliance may vary depending on various risk factors. In this group of diabetics, a 25 percent plaque score and 15 percent bleeding upon probing score seems to determine the difference between compliance and noncompliance.

Htoon, H., Peng, L., Huak, C.: Assessment Criteria for Compliance with Oral Hygiene: Application of ROC Analysis. Oral Health Prev Dent 2: 83-88, 2007.

 Patterns of bone loss in adults

According to many research studies, bone loss is associated with advancing age and smoking. The relationship between initial marginal bone level and further bone loss is still debated. Some researchers show that it is a predictor of future bone loss, while others have concluded the opposite.

Researchers at the University of Aarhus in Denmark monitored radiographs of nearly 500 subjects during a five-year period between 1997 and 2003 to determine marginal bone loss related to age and initial bone levels. Radiographs were taken in 1997 and again in 2003.

The overall average annual bone loss was determined to be 0.1mm, which is consistent with several other published studies. If the relative bone loss was determined to be 30 percent that would equate to 1.5mm for an individual with 5mm of initial bone loss compared to 0.3mm for someone with 1.5mm of initial bone loss. More rapid bone loss was found in those with more bone loss at the start of the study. When initial bone loss exceeded 2mm, molars and premolars experienced greater bone loss than incisors and canines.

Tooth loss measurements determined that 46 percent of all lost teeth belonged to seven percent of the subject, all with more than 5mm of initial bone loss.

Clinical Implications: Focus prevention and treatment on molars and premolars as these interproximal surfaces are first to show bone loss. Bone loss in patients 20- to 39-years-old is a serious risk factor and is predictive of future bone loss.

Bahrami, G., Vaeth, M., Isidor, F., Wenzel, A.: Marginal Bone Loss Over 5 Years in an Adult Danish Population. Oral Health Prev Dent 2: 113-118, 2007.
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