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Perio Reports

Perio Reports Vol. 19 No. 10

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

Intra-oral and extra-oral malodor differentiated

According to published estimates, most people occasionally suffer from bad breath and 10-30 percent of Americans have bad breath all the time, leading to embarrassment, social isolation and personal discomfort. Bad breath originates primarily from the mouth, with no evidence to suggest that odors escape from the stomach. The connection between mouth and stomach is not an open tube. However, some oral malodor cannot be attributed to poor oral hygiene. These cases of bad breath are considered extra-oral in origin.

Researchers in The Netherlands evaluated a total of 75 patients for signs of bad breath. Of these patients referred to the Clinic for Periodontology in Amsterdam, 58 had complaints of bad breath. The additional 17 people in the study were staff of the clinic with no complaints of bad breath but who were recruited into the study. Patients were all in good general health and also periodontally healthy.

Mouth air and nose air were evaluated for volatile sulphur compounds (VSC), tongue coating was measured and odor judges evaluated both mouth and nose air. Three VSCs were evaluated: hydrogen sulphide (H2S), methyl mercaptan (CH2SH) and dimethyl sulphide (DMS). Five people were diagnosed with halitophobia, thinking they have bad breath with no signs of bad breath. Both H2S and CH2SH were strongly correlated with intra-oral malodor, while DMS was only found with extra-oral malodor. DMS is a neutral compound, difficult to remove from breath and was detected in blood samples from the six people with extra-oral malodor. H2S and CH2SH are not stable in blood and can be easily removed from the breath by binding with zinc or through oxidation by chlorine dioxide.

Extra-oral malodor is most likely due to a metabolic disorder somewhere else in the body and the DMS travels through the blood to the lungs and is excreted in nose and mouth air. Now researchers are looking for the cause of extra-oral malodor so effective treatments can be found.

Clinical Implications: Understanding the differences between intra- and extra-oral malodor will help clinicians discuss the topic with patients. Watch for future research describing the cause or causes of extra-oral malodor and potential treatments.

Tangerman, A., Winkel, E.: Intra- and Extra-Oral Halitosis: Finding of a New Form of Extra-Oral Blood-Borne Halitosis Caused by Dimethyl Sulphide. J Clin Perio 34: 748-755, 2007.

Bacteria found in blood after SRP

Previous studies have indicated the risk of cardiovascular disease due to periodontal pathogens. Bacteremia is evident after toothbrushing, periodontal probing, subgingival irrigation, scaling and root planing (SRP), surgery, and dental extractions. Researchers at the University El Bosque in Bogotá, Colombia, evaluated perpherial blood before and three times after SRP to determine the presence of oral bacteria.

A group of 42 patients, 27 with generalized severe chronic periodontitis and 15 with generalized aggressive periodontitis participated in the study. On the day of treatment, subjects were asked to refrain from toothbrushing and asked to drink only liquids for breakfast. A skilled nurse took the blood samples just prior to SRP and again after treatment, 15 minutes and 30 minutes after completion of the treatment. Blood samples were grown in culture bottles to determine the presence of pathogens.

Bacteremia was found in 14 of 15 patients with aggressive periodontitis and 20 of 27 patients with chronic periodontitis for an overall average of 74 percent. This figure was 38 percent at 15 minutes and 19 percent at 30 minutes. Pg, Mm and Aa were the species found most frequently.

Clinical Impliations: These findings do not change the way care is provided, however knowing that pathogenic bacteria enter the blood stream following periodontal treatment confirms earlier findings that oral bacteria are found in other parts of the body, providing an additional reason to prevent periodontal disease.

Lafaurie, G., Moyorga-Fayad, I., Torres, M., Castillo, D., Aya, M., Barón, A., Hurtado, P.: Periodontopathic Microorganisms in Peripheric Blood After Scaling and Root Planing. J Clin Perio 34: 873-879, 2007.

Stannous fluoride toothpaste tested

Crest Pro-Health toothpaste with 0.454 percent stannous fluoride and sodium hexametaphosphate was recently introduced in the United States. This toothpaste uses a silica abrasive for polishing. A team of researchers from Procter & Gamble, Indiana State Department of Health, and Dental Products Testing, Inc., in West Palm Beach, Florida, compared Crest Pro-Health and Aquafresh toothpaste for effects on gingivitis. Aquafresh was considered the negative control as it contains no anti-plaque or anti-gingivitis ingredients. Subjects were instructed to brush for one minute twice daily with their assigned toothpaste.

Study subjects were recruited in the West Palm Beach area, with a total of 140 subjects beginning the study and 128 completing the six-month study. Clinical scores were recorded at baseline, three months and six months. The gingival bleeding index recorded three levels of bleeding: 0=no bleeding, 1=bleeding after 30 seconds, and 2=immediate bleeding. Plaque scores were recorded from 0=no plaque to 5=plaque covering more than two-thirds of the tooth surface.

At six months, bleeding scores and gingivitis scores were reduced for both toothpaste groups while reductions in plaque scores were not reduced very much for either group. Bleeding scores for anterior and premolar teeth were below 0.5 for both toothpastes. Bleeding around molars was reduced more with the Crest Pro-Health toothpaste by a score of 0.5 (0.8 vs 1.3). The gingival index scores began at 2.0 for both groups and were reduced to 1.90 for Aquafresh and 1.58 for Crest Pro-Health. These differences were determined to be statistically significant, but the clinical relevance was not discussed.

Clinical Implications: Crest Pro-Health toothpaste was shown to reduce gingivitis and bleeding compared to Aquafresh. Further study is needed to determine if these differences are clinically relevant.

This study was funded by Procter & Gamble.

Mallatt, M., Mankodi, S., Bauroth, K., Bsoul, S., Bartizek, R., He, T.: A Controlled 6-Month Clinical Trial to Study the Effects of a Stannous Fluoride Dentifrice on Gingivitis. J Clin Perio 34: 762-767, 2007.
Smoking cessation valuable for periodontal health

Smoking is the single greatest behavioral risk factor for periodontitis, however little is known about the benefits of smoking cessation in young adults. Therefore researchers at the University of Otago in Dunedin, New Zealand, evaluated a cohort of individuals that have been studied since birth in the Dunedin Multidisciplinary Health and Development Study (DMHDS). Children born at the Queen Mary Hospital in Dunedin between April 1, 1972, and March 31, 1973, were invited to participate in the study. They have been evaluated at ages 15, 18, 21, 26 and 32.

A total of 810 individuals were available for the periodontal evaluation at both ages 26 and 32. Their smoking history was also included in the assessment.

Those who had never smoked accounted for 51percent of the group, and 49 percent had smoked at sometime between 15 and 32 years of age. Smoking prevalence increased from 26 percent at age 15, to 28 percent at 18, 37 percent at 21, and 38 percent at 26. A decline was observed at 32 with 32 percent reporting smoking.

Smokers had more evidence of periodontal disease based on probing depths and loss of attachment. Two-thirds of the increase in probing depths between ages 26 and 32 were found in smokers. Those who quit smoking before age 32 showed periodontal health comparable to those who never smoked.

Clinical Implications: Smoking cessation can improve the periodontal health of young adults, returning them to levels similar to non smokers.

Thomson, W., Broadbent, J., Welch, D., Beck, J., Poulton, R.: Cigarette Smoking and Periodontal Disease Among 32-Year-Olds: A Prospective Study of a Representative Birth Cohort. J Clin Perio 34: 828-834, 1007.

SRP improves glycemic control for Type 2 diabetics

A complex two-way relationship exists between diabetes and periodontitis. Inflammation is a critical factor in this relationship that is just being confirmed. In 1993, periodontitis was designated the sixth complication of diabetes mellitus. Now the inverse relationship is evident, as the inflammatory proces of periodontitis has been shown to influence gylcemic control in those with diabetes.

Researchers in Spain compared the effects of SRP on a small group of 20 patients, half with and half without diabetes. In addition to clinical indices, crevicular fluid samples were collected to evaluate volume and levels of interleukin 1 (IL-1) and tumor necrosis factor ? (TNF?). Blood samples were also taken to measure glycosylated hemoglobin. Indices were repeated at three and six months and supragingival prophylaxis was also provided at these visits.

Non-surgical therapy was provided in four one-hour visits using both hand and power scalers. Oral hygiene instructions were given and patients all received the tools to effectively control plaque on a daily basis.

Both groups showed significant periododontal healing at both three and six months. Probing depths were reduced by an average of 1mm in each group. Plaque levels decreased dramatically and crevicular fluid levels also dropped. The cytokines IL-1 and TNF? measured in the crevicular fluid showed reductions at both three and six months

No differences were noted periodontally between those with diabetes and those who did not have diabetes. Those in the diabetes group did show a significant reduction in glycosylated hemoglobin levels and therefore greater glycemic control following SRP.

Clinical Implications: Based on this small study, it seems that providing non-surgical periodontal therapy improves oral health and has a beneficial effect on glycemic control. Larger studies are needed to confirm this finding.

Navarro-Sanchez, A., Faria-Almeida, R., Bascones-Martinez, A.: Effect of Non-Surgical Periodontal Therapy on Clinical and Immunological Response and Glycaemic Control in Type 2 Diabetic Patients with Moderate Periodontitits. J Clin Perio 34: 835-843, 2007.

Topical and injected anesthetic compared

Patients are generally fearful of needles associated with local anesthetics. Other approaches have been used to alleviate pain including biofeedback, reassurance, distractions, transcutaneous electronic nerve stimulations (TENS), hypnosis, and nitrous oxide. Topical anesthetics used prior to needle insertion have been formulated into bioadhesive patches and combined with a thermosetting agent for use subgingivally. Topical anesthetics are preferred for the lack of post-treatment numbness associated with injectables.

Researchers at the University of Minnesota compared an injectable anesthetic with a topical gel delivered subgingivally. The 21 test subjects were schedule for scaling and root planing (SRP) by third- or fourth-year undergraduate dental students using both power and hand instruments. One quadrant was treated using 2% lidocaine with 1:100,000 epinephrine and the second quadrant was treated with 20% benzocaine Ultracare from Ultradent Products, Inc.

Pain was measured using a visual analog scale of 170mm with 0mm being no pain and 170mm being maximum possible pain. Levels in between were established for faint, weak, mild, moderate, strong, and intense pain. Pain scores were recorded before treatment, in the middle of treatment and immediately after completion of the treatment.

Pain levels were similar at baseline and post op for the injectable and the topical anesthetic. Differences were noted during treatment, with higher pain scores when the topical gel was used, 85mm vs. 44mm. Six of the subjects required rescue anesthesia injections when treated with topical gel. Just over half the study subjects preferred the topical gel to the injected anesthetic, despite the lack of pain control reported with the gel.

Clinical Implications: Patients might prefer topical rather than injected anesthetic, despite greater pain experienced during SRP.

Stoltenberg, J., Osborn, J., Carlson, J., Hodges, J., Michalowicz, M.: A Preliminary Study of Intra-Pocket Topical Versus Injected Anaesthetic for Scaling and Root Planing. J Clin Perio 34: 892-896, 2007.
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