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Perio Reports

Perio Reports   Vol. 20 No. 2
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.

The value of brushing between the teeth

Preventive research has focused on children and young adults, with very little published about what is best for people as they age and have trouble with eyesight and dexterity. Researchers at the University of Hamburg in Germany compared four approaches to oral hygiene in a group of
106 people between 55 and 84 years of age. Group one received toothbrushing and interdental brushing instructions using TePe products. Group two followed their regular oral hygiene and added Meridol, a European fluoride mouthrinse. Group three combined the mechanical oral hygiene of group one and the rinse used by group two. Group four was a control group, told to continue their regular oral hygiene.

Following baseline data collection, all subjects received a professional prophylaxis with both hand and power scalers. Three weeks later the indices were again taken and oral hygiene instructions repeated for groups one and three and instructions about the mouthrinse for groups two and three. Final data were collected at six months.

Plaque and gingivitis scores were improved for all groups, including the control group at both three weeks and six months, in part due to the prophylaxis and the novelty of being in a study. The greatest improvement in oral health was seen in the group that was instructed in interproximal cleaning using TePe interdental brushes. The addition of fluoride mouthrinse provided no added benefit over the mechanical interdental brushing. Disrupting plaque between the teeth was the most effective approach to gingivitis.

Clinical Implications: For those older than 55 years of age, interproximal brushing is more effective than a mouthrinse to control plaque and gingivitis.

Schiffner, U., Bahr, Mathias, Effenberger, S.: Plaque and Gingivitis in the Elderly: A Ramdomized, Single-Blind Clinical Trial and the Outcome of Intensified Mechanical or Antibacterial Oral Hygiene Measures. J Clin Perio 34: 1068-10-73, 2007.
H. pylori found in pockets with chronic periodontitis

Helicobacter pylori (H. pylori) is a curved, spiral, gram-negative motile bacterium responsible for gastritis and peptic ulcers and is a risk factor for gastric cancer. Approximately 10 percent of the population will experience gastritis or gastric ulcers while 50 percent of the population may carry this bacterium. The oral cavity provides a reservoir for H. pylori proliferation and eventual re-infection of the stomach. Oral bacteria associated with health produce a substance that is toxic to H. pylori, which might explain greater numbers of H. pylori in periodontal pockets than in healthy sites.

Researchers at the University of Rio de Janeiro in Brazil evaluated 225 adults seeking treatment at the dental school. None of the subjects had a history of gastric infections. After thorough clinical examinations, 56 were found to be periodontally healthy and 169 were found to have chronic periodontitis. Samples of saliva and subgingival bacterial biofilm were analyzed to determine the presence of H. pylori.

H. pylori was detected in 24 percent of all samples with higher levels in biofilm than saliva, 33 percent vs. 20 percent. Half of those with chronic periodontitis were positive for H. pylori compared to 11 percent of the healthy subjects.

Clinical Implications: Periodontal pockets favor the proliferation of H. pylori, so consider this when talking to patients with chronic periodontitis. They might not have signs of gastric problems currently, but the potential is there for bacteria to infect the stomach.

Souto, R., Colombo, A.: Detection of Helicobacter Pylori by Polymerase Chain Reaction in the Subgingival Biofilm and Saliva of Non-Dyspeptic Periodontal Patients. J Perio 79: 97-103, 2008.

Folic acid levels lower in smokers

It is a well researched fact that smoking is a preventable risk factor influencing the incidence and severity of periodontal disease. Smoking also negatively influences vitamin B12 and folic acid levels. Compounds in cigarette smoke transform these nutrients into biologically inactive substances.

Researchers at Kirikkale University in Turkey monitored Vitamin B12 and folic acid levels for six months in smokers and nonsmokers, following non-surgical therapy. A total of 88 subjects participated in the study, 45 smokers and 43 nonsmokers. Subjects all had chronic periodontitis with probing depths of 6mm or more at 80 percent of interproximal sites and radiographic bone loss of 50 percent or more. Baseline indices included probing depths, plaque levels and gingivitis scores. Blood serum levels of vitamin B12 and folic acid were also measured at baseline one, three, and six months.

Treatment included one 60-minute session of oral hygiene instructions and scaling and polishing. One week later, subgingival debridement was completed under local anesthesia with Hu-Friedy Gracey curettes in one 60-minute session.

Plaque and gingivitis scores were not reduced a great deal, but greater reductions were seen in non-smokers compared to smokers. Baseline vitamin B12 levels were similar for both groups. Both smokers and non-smokers showed a reduced levels of vitamin B12 at six months. In contrast, folic acid levels were higher in non-smokers at baseline and increased over the six-month study period while folic acid levels in smokers were lower at baseline and decreased during the study period.

Clinical Implications: Because of lower folic acid levels in smokers, dietary supplementation may be a consideration prior to non-surgical therapy. This should be evaluated in future studies.

Erdemir, E., Bergstrom, J.: Effect of Smoking on Folic Acid and Vitamin B12 After Nonsurgical Periodontal Intervention. J Clin Perio 34: 1074-1081, 2007.


Hopeless teeth can be saved with surgery

Advanced periodontitis affects approximately 10 to 15 percent of people. Studies have shown reduced tooth loss following surgery with good oral hygiene and frequent dental hygiene visits. Hopeless teeth are considered a risk to neighboring teeth and thus the approach of "strategic extractions" has evolved. That is, extracting hopeless teeth to prevent bone loss on adjacent teeth. Today we see even more extractions in favor of implant placement.
Researchers looked at charts of 93 non-smoking patients at the Rambam Health Care Campus in Haifa, Israel, to determine if keeping hopeless teeth compromised the bone of adjacent teeth. Average time post treatment was four years. All subjects received presurgical treatment, flap surgery in sites 6mm or deeper and dental hygiene maintenance every three or six months. Patients were informed that they had hopeless teeth, and the decision to keep or remove the teeth was left to the patient. A total of 57 hopeless teeth were retained in 50 patients and 53 teeth were extracted at the time of periodontal surgery in 43 patients. Custom software was used to measure bone differences on digitized radiographs.

The retained hopeless teeth showed an average gain of nearly one millimeter of bone. Teeth adjacent to the hopeless teeth or the extracted teeth also showed bone gain, slightly more on sites adjacent to extraction sites which was only significant for distal surfaces, 1.5 percent vs 11 percent or one-third of a millimeter vs. one millimeter gain.

Clinical Implications: Despite the trend to remove teeth and place implants, hopeless teeth can be retained without causing bone loss to adjacent teeth. Each case must be considered individually.

Machtei, E., Hirsch, I.: Retention of Hopeless Teeth: The Effect on the Adjacent Proximal Bone Following Periodontal Surgery. J Perio 78: 2246-2253, 2007.

Pocket closure and bone regeneration is predictable

In 1995, Drs. Harrel and Rees proposed a minimally invasive surgical technique (MIST) that reduced appointment time, resulted in 5mm probing depth reductions and was more comfortable for patients than traditional full flap surgery. Researchers in Italy combined MIST with the enamel matrix derivative Emdogain, in 40 isolated intra-boney defects in 40 patients. Prior to the test procedure, patients received oral hygiene instructions, scaling, root planing and any necessary flap surgery for pocket elimination in other parts of the mouth.

MIST incisions were made to preserve the papilla and avoid unnecessary reflection of tissue. The defects were debrided with microsurgery instruments and the aid of a microscope. Measurements were taken during surgery within the defects. Following debridement, root surfaces were dried and EDTA was applied for two minutes, to condition the surfaces. After rinsing with saline and drying again, the Emdogain was used to fill the defect and the papilla sutured from buccal to lingual. Patients completed questionnaires following treatment.

Patients refrained from brushing and flossing for three to four weeks at MIST sites, were seen weekly for six weeks and then every three months for periodontal maintenance visits. They took 100mg of doxycycline systemic antibiotic twice daily for a week and rinsed with 0.12 percent chlorhexidine for one month.

Clinical results were excellent after one year. Average plaque scores were 11 percent and average bleeding scores were six percent. Gain in clinical attachment level averaged 5mm. Patients reported very little discomfort with this procedure.

Clinical Implications: This conservative approach to tissue reflection, combined with an enamel matrix derivative, results in excellent and predictable closure of intra-boney defects.

Cortellini, P., Tonetti, M.: Mimimally Invasive Surgical Technique and Enamel Matrix Derivative in Intra-Boney Defects. I. Clinical Outcomes and Morbidity. J Clin Perio 34: 1082-1088, 2007.


Hopeless teeth - not the ideal for using Perioscope

The Perioscope is an endoscope allowing visualization of subgingival root surfaces at a magnification of 48X, thus allowing for more thorough deposit removal. With proper training, clinicians learn to recognize deposits, some dark, some light and some as tiny as glitter. Clinicians often use the Perioscope to treat non-responding areas, after traditional scaling and root planing and oral hygiene are completed, allowing the tissue to begin to heal, reducing bleeding and providing a clear view of the remaining root surface deposits.

Researchers at the University of Texas Health Sciences Center at San Antonio compared subgingival instrumentation with and without the aid of the Perioscope on highly inflamed, hemorrhagic, hopeless teeth scheduled for extraction. The teeth were extracted immediately after instrumentation.
A total of 70 teeth, 35 tooth pairs of multi-rooted teeth in 24 patients were treated. Test teeth treated with the aid of Perioscopy were treated for an average of 20 minutes compared to 14 minutes per tooth instrumenting blindly. Remaining calculus was found on all surfaces of the teeth, regardless of the treatment received. This confirms that bleeding and granulation tissue hamper viewing with the Perioscope. Calculus removal was more effective on interproximal surfaces using the Perioscope compared to the control group, while other surfaces had comparable levels of remaining calculus.

Clinical Implications: The Perioscope works best with some control of tissue inflammation and bleeding, allowing the clinician to see the root surface being treated. It provides very little added benefit over blind instrumentation when treating highly inflamed, hemorrhagic, hopeless teeth scheduled for extraction.

Michaud, R., Schoolfield, J., Mellonig, J., Mealey, B.: The Efficacy of Subgingival Calculus Removal with Endoscopy-Aided Scaling and Root Planing: A Study on Multirooted Teeth. J Perio 78: 2238-2245, 2007.
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