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Perio Reports Trisha E. O'Hehir, RDH, BS, Editorial Director, Hygienetown Magazine

More by this author (282)
Perio Reports  Vol. 20 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.
Subgingival air polishing with Clinpro powder

Subgingival debridement for periodontal maintenance visits is usually done with power scalers and/or hand instruments. Since subgingival calculus deposits are removed at scaling and root planing (SRP) appointments, the goal for periodontal maintenance visits is to thoroughly disrupt subgingival bacterial biofilm. According to the research, only 4.7 percent of subgingival surfaces have calculus three months after SRP.

Glycine powder, used in Clinpro Prophypowder by 3M ESPE, is effective in removing subgingival bacterial deposits in shallow pockets when used for five seconds per surface compared to power scalers and curettes used for 38 seconds per surface. Researchers at Westfalian Wilhelm University in Münster, Germany, designed a study to see if these findings were also true for deeper pockets.

Sixty patients with advanced periodontal disease and at least one tooth scheduled for extraction were included in the study. Air polishing for five seconds was performed on teeth three months after instrumentation, allowing for bacterial biofilm formation; and on teeth that had not been instrumented. A group of control teeth receiving no treatment was included. The teeth were carefully extracted to preserve the subgingival surfaces for evaluation.

The air polishing with glycine powder was effective to a depth of 4mm for both the instrumented and non-instrumented teeth. The subgingival calculus on the non-instrumented surfaces did not impede biofilm removal. On a scale of zero to 10 (least to most comfortable) patients gave air polishing a score of nine compared to a score of five for hand and power instrumentation.

Clinical Implications: For deplaquing, you might want to consider replacing your power scaler with an air polisher using Clinpro Prophypowder that reaches subgingivally without harming the tissue and effectively removes bacterial biofilm in much less time.

Flemmig, T., Hetzel, M., Topoll, H., Gerss, J., Haeberlein, I.: Subgingival Debridement Efficacy of Glycine Powder Air Polishing. J Perio 78: 1002-1010, 2007.
Subgingival use of Clinpro powder safe for tissue

Glycine particles are about four times smaller than sodium bicarbonate particles and because of this and the particle shape they are less abrasive to the tissue.

Air polishing has been limited to supragingival surfaces, due to the tissue damage caused by the sodium bicarbonate particles. Glycine particles allow air-polishing to comfortably reach subgingival surfaces.

Researchers at Westfalian Wilhelm University in Münster, Germany, compared air-polishing with sodium bicarbonate; air polishing with glycine (Clinpro Prophypowder by 3M ESPE); instrumentation with a Gracey 7/8; and a control group receiving no treatment. Treatments were performed on facial and lingual surfaces of a designated quadrant (one treatment per tooth), followed by a biopsy along the gingival margin on the day of treatment and another biopsy from another site 14 days later, all part of scheduled surgeries. Aluminum foil was used to isolate teeth during treatment.

Microscopic examination of the tissue specimens revealed no alterations to the gingival sulcular tissue for controls or Clinpro treated sites. Sites treated with sodium bicarbonate and the curette did show signs of change. Scores from one to four (least to most damage) were given, with a score of one for both control and Clinpro treated sites, three for sodium bicarbonate treated sites and a score of four for curette treated sites.

Clinical Implications: Air-polishing with Clinpro glycine powder results in less tissue alteration than hand instruments or sodium bicarbonate air-polishing powder. Air polishing with Clinpro glycine powder is now a choice for subgingival biofilm removal without causing tissue damage.

Petersilka, G., Faggion, C., Stratmann, U., Gerss, J., Ehmke, B., Haeberlein, I., Flemmig, T.: Effect of Glycine Powder Air-Polishing on the Gingiva. J Clin Perio 35: 324-332, 2008.
Chlorhexidine provides no added benefit as power scaler lavage

Since both ultrasonic mechanical scaling and the use of chlorhexidine are effective in reducing bacterial levels in the mouth, researchers at the University of Ferrara in Italy wondered if combining the two would provide a synergistic effect.

This pilot study included nine patients in the test group, receiving piezoelectric scaling with a 0.02 percent chlorhexidine lavage and 10 subjects following the same protocol without the chlorhexidine lavage. The test group also had a professional tongue brushing with 0.2 percent chlorhexidine. They were instructed to rinse twice at the time of treatment with 0.2 percent chlorhexidine, gargling to reach the tonsils.

All patients in this 12-week study were receiving supportive periodontal therapy for generalized aggressive periodontitis. Clinical indices and microbial changes were recorded at baseline, three, six and 12 weeks. At each of these visits, oral hygiene was reinforced.

No additional benefit was evident with the added use of chlorhexine. No significant differences in probing depths, plaque levels, bleeding or gingivitis scores were seen between the two groups. No differences were noted in total bacterial counts between the two groups either.

Clinical Implications: Repeated oral hygiene instructions and thorough instrumentation with the power scaler overshadowed any benefit from adding chlorhexidine to the power scaler lavage.

Guarnelli, M., Franceschetti, G., Manfrini, R., Trombelli, L.: Adjunctive Effect of Chlorhexidine in Ultrasonic Instrumentation of Aggressive Periodontitis Patients: A Pilot Study. J Clin Perio 35: 333-341, 2008.
CRP related to periodontitis
C-reactive protein (CRP) is a key marker for atherosclerosis. Elevated levels of CRP are considered a predictor for cardiovascular disease. Since periodontal disease has been linked to myocardial infarction, stroke and heart disease it is conceivable that elevated levels of CRP due to periodontitis might explain the association between periodontitis and cardiovascular disease. If there is a causal association between the two, perhaps periodontal treatment would lower CRP levels. However, CRP is a non-specific marker triggered by things like chronic infection, inflammatory conditions, smoking, obesity or trauma.
Researchers in The Netherlands, with a grant from Philips Oral Healthcare (Europe, Middle East and Asia) reviewed 53 research articles to determine the relationship between CRP and periodontitis. Normally, the CRP level is zero. Not all studies used highly sensitive methods for measuring CRP levels. Elevated levels were considered to be greater than 2.1 mg/l, so studies that could not measure below 3 mg/l were excluded from the analysis. Of the 53 articles, 18 included the required data to be analyzed as a group.

Based on these studies, periodontitis elicits a mild acutephase response with elevated CRP levels compared to healthy controls. Perodontitis could be the reason for the elevated level, or it could be one of several factors responsible. A few studies showed reductions in CRP levels following periodontal treatment. More research is needed to determine if periodontal treatment will in fact reduce the risk for cardiovascular disease.

Clinical Implications: Testing for CRP levels in the blood is not yet part of periodontal records, but might be considered in the future to determine the effect of therapy on those levels. More research is needed first.

Paraskevas, S., Hulzinga, J., Loos, B.: A Systematic Review and Meta-Analyses on C-Reactive Protein in Relation to Periodontitis. J Clin Perio 35: 277-290, 2008.
Liquid toothpaste used by the drop
The use of fluoride has helped reduce the rate of caries, but ingestion of fluoride in toothpaste leads to fluorosis. Fluoride toothpastes are responsible for approximately 60 percent of total fluoride ingestion by four- to five-year-old children. Young children are often unable to spit out toothpaste and consequently swallow it.

Liquid toothpaste was introduced to better reach interproximal sites and is available in many countries worldwide. The dose tip allows for only a drop to be dispensed at a time. Researchers at the Universidade de Sao Paulo, Brazil compared liquid and traditional toothpaste use among school children to determine the amount used.

Children from four to eight years of age were included in the study. Children were asked to place toothpaste on their toothbrush and then the brush was weighed. This was repeated with the liquid dentifrice.

Children four and five years old applied the toothpaste in the new transverse approach, across the long axis of the toothbrush. Older children used the traditional technique of applying the toothpaste along the long axis of the brush, resulting in more toothpaste being applied.
On average, three times less dentifrice was applied when the liquid dentifrice was used compared to traditional toothpaste. This is most likely due to the dose tip, which allows the liquid dentifrice to be applied by the drop.

Clinical Implications: Instructions to use only a small quantity or a pea-sized amount of toothpaste results in varying amounts being used. Liquid dentifrice that can be dispensed by the drop, will reduce the potential for small children to ingest large amounts of fluoride, leading to fluorosis.

Vilhena, F., Silva, H., Peres, S., Caldana, M., Buzalaf, M.: The Drop Technique: A Method to Control the Amount of Fluoride Dentifrice Used by Young Children. Oral Health Prev Dent 6: 61-65, 2008.
Obesity weakly linked to periodontal disease

Besides cardiovascular disease and diabetes, obesity has recently been suggested as a risk factor for periodontal disease. Several studies have examined this association with inconsistent findings.

Researchers in Finland analyzed data from the National Public Health Institute of Finland study carried out in 2000 and including more than 8,000 subjects representative of the Finnish population. Data was collected through oral interviews and clinical examinations. A subset of nearly 3,000 non-diabetic subjects between the ages of 30 and 49 years was analyzed for this study.

A weak association was noted between the number of teeth with deepened probing depths and increased body weight. Several theories have been suggested for this link. First, an impaired glucose tolerance level in the body might be responsible. Others suggest that variations in lipid profiles could link obesity to periodontal disease. Another theory suggests that substances secreted from adipose tissue, such as pro-inflammatory cytokines, might be the mediating factors. These mechanisms might act alone or simultaneously to influence periodontal health.

Bacterial plaque and oral hygiene habits are still significant factors in the progression of both caries and periodontal disease. Study authors remind us that behavioral habits are critical factors to be consider when measuring risk factors.

Clinical Implications: We have more to learn about the potential link between obesity and periodontal disease, as seen in this group of 30- to 49-year-old, non-smoking, non-diabetic adults.

Ylöstalo, P., Suominen-Talpale, L., Knuuttila, M.: Association Between Body Weight and Periodontal Infection. J Clin Perio 35: 297-304, 2008.
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