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Perio Reports

Perio Reports Vol. 20 No. 1

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

Metabolic syndrome and advanced periodontitis

Syndrome X was identified 15 years ago as a cluster of metabolic factors predisposing one to heart disease and diabetes. More recently, coexistence of at least three of these factors in one person defines “metabolic syndrome” (MS). Included are obesity, cholesterol imbalance, insulin resistance and high blood pressure. Low-grade systemic inflammation in the body might be a causative factor in this syndrome. Researchers at the Eastman Dental Institute and Hospital in London, England, compared white blood cell counts (WBC), cholesterol and sugar levels in the blood between those with advanced periodontitis and a group of periodontally healthy controls to determine if these metabolic markers were associated with gum disease.

Severe periodontitis was diagnosed in a group of 302 patients seeking care at the Eastman Dental Hospital. A total of 183 periodontally healthy patients seeking oral surgery or restorative care provided the control group.

Those with advanced periodontitis had higher WBC counts, higher blood glucose levels, higher LDL cholesterol and lower LDL cholesterol levels. The chronic inflammation of periodontitis increases the flow of WBCs to the area which would explain the elevated WBCs. Other studies have confirmed the influence of the inflammatory process on lipid metabolism, thus explaining the less desirable cholesterol levels.

Advanced periodontitis levels observed in this group are found in a relatively small sample of the population – just one to five percent present with such advanced periodontal disease. For those with advanced disease, these conditions might influence other systemic conditions.

Clinical Implications: Those with advanced periodontal disease, as yet untreated, may be at greater risk for heart disease, elevated cholesterol levels and diabetes. When faced with a case of advanced periodontitis, ask specific questions about general overall health.

Nibali, L., D’Aiuto, F., Griffiths, G., Patel, K., Suvan, J., Tonetti, M.: Severe Periodontitits is Associated with Systemic Inflammation and a Dysmetabolic Status: A Case-Control Study. J Clin Perio 34: 931-937, 2007.

Osteoporosis in men linked to chewing problems

Data indicates that 30 percent of hip fractures occur in men, and death after a hip fracture is higher in men than women. In women, osteoporosis is linked to hormonal changes. Causative factors in men are not yet known, thus hindering effective prevention. Poor chewing in the older population is a known cause of nutritional problems. Researchers in Italy wanted to know if poor chewing is also related to osteoporosis.

A large study of those 75 years and older in Tuscania, Italy, provided the study population. Subjects underwent extensive physical exams, blood work and completed questionnaires regarding economic status, physical activity, smoking, and chewing difficulties. A bone density scan was also done on all study participants. Among the 310 subjects, chewing difficulty was reported by 129; women being 49 percent of the group with 91 and men 32 percent with 38 reporting problems. Denture wearing was equal between the groups.

Men showed higher education levels, more prevalent alcohol consumption and smoking, and chronic lung disease. Women were more frequently diagnosed with diabetes and diverticulitis, took more medications, had higher cholesterol levels and were heavier than men. Women also showed lower bone density levels than men, but no relation between chewing function and bone density. Men with chewing problems showed lowered bone density, even when smoking was taken out of the analysis.

Clinical Implications: Be sure to check chewing function in older men diagnoses with osteoporosis. Correcting the chewing problem might prevent advancing osteoporosis and thus hip fractures.

Laudisio, A., Marzetti, E., Antonica, L., Settanni, S., Georgakakis, I., Bernabei, R., Franceschi, C., Zuccala, G.: Masticatory Dysfunction is Associated with Osteoporosis in Older Men. J Clin Perio 34: 964-968, 2007.

Gradients in periodontal health status

The social gradient of health, which also applies to oral health, suggests that better health is enjoyed by those on higher social levels and that each level below them is at a lower level of health. In Japan, nine job classifications have been identified: professional, manager, officer workers, skilled factory/construction workers, shop assistants, service occupations, security guards, farmers and fisherman and truck drivers. Researchers from the Aichi-Gakuin University in Nagoya, Japan, evaluated a large group of men reporting for annual medical checkups to see if the gradient of oral health applies in Japan.

Seven dentists completed the oral exams on 15,800 men using a WHO probe to evaluate 10 teeth, two incisors and eight molars. Subjects also completed a questionnaire prior to the oral exam. Findings did confirm what has been shown for other countries, that oral health is related to employment and education. Professionals had less periodontal disease than all the jobs below them. Truck drivers had the highest number of quadrants with periodontal disease. Differences were not noticeable in the 20- to 30-year-old range, but did become evident in older workers. Levels of disease in the lower job levels reflected a 10-year difference between groups. The 20- to-29-year-old truck drivers had disease levels similar to 30-to-39-year-old professionals.

One group did have a higher than expected level of disease, the 20-to-29-year-old managers. This is probably due to the high level of stress for these workers, complicated by the high smoking rates and long work hours.

Clinical Implications: This is yet another study that confirms the relationship between socioeconomic status and oral health levels. This means greater efforts are needed to provide oral health education to all levels of society.

Morita, I., Nakagaki, H., Yoshii, S., Tsuboi, S., Hayashizaki, J., Igo, J., Mizuno, K., Sheiham, A.: Gradients in Periodontal Status in Japanese Employed Males. J Clin Perio 34: 952-956, 2007.
The challenge in China is prevention

China is a developing country with a population of more than one billion. Reliable data on the prevalence of periodontal disease is lacking. National surveys were done in 1985 and 1995. A third was completed in 2005, but data analysis has not yet been completed. In general, these surveys underestimate the level of disease in the country. A team of researchers from several universities in China selected nearly 1,600 subjects from four different regions in China to examine and question them about their periodontal health. Identifying the current periodontal status of the country may help in the development of an appropriate preventive program.

Clinical data were collected from six sites around six target teeth identified throughout the mouth. Calculus was reported on 89 percent of teeth evaluated. Bleeding upon probing was reported for 48 percent of teeth. Approximately one-third of surfaces examined showed periodontal disease.

All study subjects completed a written survey including questions on education, smoking, and oral hygiene habits. The group was roughly split between urban (866) and rural (724) dwellers. Urban dwellers were more educated and younger, compared to rural dwellers. Smokers comprised 28 percent of the group, and the average number of missing teeth was four per person.

Daily toothbrushing has improved. According to 1995 statistics, 79 percent of Chinese adults brushed their teeth daily, compared to 89 percent in this study. One-third of subjects brush for less than one minute and 35 to 56 percent report brushing only once daily. Seventy-one percent of the subjects reported bleeding during brushing. More than half (61 percent) had no knowledge of dental hygiene services. In 1995, one-and-a-half percent reported having their teeth professionally cleaned compared to 22 percent in this study. Some even believe dental cleanings might harm the teeth (two to five percent).

The prevalence and severity of periodontal disease might be due to lack of dental knowledge and lack of access to professional dental care.

Clinical Implications: Periodontal disease is at a high level in China and therefore greater emphasis should be placed on preventive programs now.

Wang, Q., Wu, Z., Wu, Y., Shu, R., Pan, Y., Xia, J.: Epidemiology and Preventive Direction of Periodontology in China. J Clin Perio 34: 946-951, 2007.

Remove plaque before using CHX rinse

Bacteria within a biofilm can alter its phenotype to adjust to the environment. When chlorhexidine (CHX) rinse is used on an established bacterial biofilm consisting of more than one bacterial species, only superficial bactericidal effects occur.

Researchers at Lutheran University of Brazil in Canoas, Brazil, modified the experimental gingivitis model to determine the effects of a 0.12 percent CHX rinse on established biofilm compared to professionally cleaned teeth. Prior to the study, the 20 dental students recruited for this study received a professional prophylaxis and oral hygiene instructions, so that all would begin the study with a healthy periodontium.

On day zero of the study, all subjects were examined for plaque levels, gingivitis levels, gingival crevicular fluid levels, and bleeding upon probing. To measure plaque a fluorescein dye was used with a blue light. From this day, subjects were instructed to refrain from all oral hygiene.

On day four, subjects were randomly assigned two quadrants for professional plaque removal and two to remain as experimental gingivitis controls. This was also the day that all subjects were given CHX rinse and instructed to rinse twice daily and continue refraining from all other oral hygiene.

On days 11, 18 and 25, clinical indices were repeated, and on day 25, all the teeth received a professional prophylaxis. The surfaces that started out covered with plaque showed greater gingivitis, higher crevicular fluid flow and more marginal bleeding than the surfaces that received a prophylaxis prior to beginning the CHX rinse. The bacterial biofilm was able to adapt and protect itself from the effects of the CHX, changing phenotypes and genotypes as necessary to protect the deeper layers of bacteria.

Clinical Implications: For best results, all plaque biofilm should be professionally removed before staring a patient on CHX rinse.

Zanatta, F., Antoniazzi, R., Rösing, C.: The Effect of 0.12% Chlorhexidine Gluconate Rinsing on Previously Plaque-Free and Plaque-Covered Surfaces: A Randomized, Controlled Clinical Trial. J Perio 78: 2127-2134, 2007.

Fluoride varnish review

Fluoride varnishes have been used to reduce dental caries since the 1940s. The active ingredient is generally a five percent sodium fluoride (NaF). Duraphat by Colgate was the first product on the market and the focus of much of the research on this subject. Despite worldwide use of Duraphat for many years, the U.S. FDA approved it for use only in 1994. Duraphat is now used in more than 40 countries.

Other brands entered the market over the years, many in dose packaging rather than a 10 oz. tube and using various fluorides and concentrations of NaF from 0.1 percent to five percent. The safety of a five percent varnish for the youngest of children has been established based on very low plasma levels of fluoride following use. Tray fluorides and even fluoride toothpaste result in higher ingestion levels than varnish.

Fluoride varnish provides a long-term effect by creating globules of calcium fluoride-like material on the tooth surfaces that are stabilized by protein phosphate in the mouth. These globules provide a reservoir of fluoride at a neutral pH. With sugar consumption comes a drop in pH and an increase in the dissolution rate of the globules, which lowers the solubility constant of calcium and phosphate ions and releases fluoride. The result is an increase in the saturation of calcium and phosphate ions in plaque fluid, which helps with remineralization or repercipitation of lost minerals from the tooth surface. Applications of fluoride varnish two to four times per year provide this long-lasting effect. Those at a high risk of caries should receive the varnish four times per year.

The average caries reduction rate reported is 30 percent, with some studies reporting reduction rates as high as 56 percent.

Clinical Implications: Fluoride varnish is a superior topical fluoride varnish for young children in particular and the general population in general since it’s safe, simple to use, and takes only seconds to apply.

Chu, C., Lo, E.: A Review of Sodium Fluoride Varnish. General Dentistry 54: 247-253, 2006.
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