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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. 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.
Inflammatory bowel disease and oral health

Inflammatory bowel disease (IBD) includes Crohn's disease (CD) and ulcerative colitis (UC), two distinct chronic disorders. The pathogenesis of IBD is still unknown, however distinct immune abnormalities play a major role. IBD can affect areas other than the intestines, including joints, eyes, skin, mouth and liver. Oral lesions might coincide, precede or follow intestinal symptoms. Oral manifestations have been reported in up to nine percent of adults with IBD. A few studies have reported higher levels of oral disease in those with IBD compared to controls. This study separated CD and UC to determine if they have different oral manifestations.

Researchers at the Rio de Janeiro State University in Brazil compared 99 CD patients and 80 UC patients to a group of 74 systemically healthy university employees who comprised an age matched control group. Dental and periodontal examinations were completed for all subjects.

Overall, both CD and UC groups had higher decayed/missing/filled teeth (DMFT) scores and more periodontal disease than the control group. Smokers in all three groups had more periodontal disease than nonsmokers. Non-smoker CD and UC groups had deeper probing depths compared to controls. UC patients (both smokers and non-smokers) had more sites with attachment loss of 3mm or more than the CD or control groups. The authors suggest that the response to bacterial plaque biofilm might be different for those with CD and UC.

Clinical Implications: Be watchful for oral manifestations in your patients with either Crohn's disease or ulcerative colitis.

Brito, F., et al: Prevalence of Periodontitis and DMFT Index in Patients with Crohn's Disease and Ulcerative Colitis. J Clin Perio 35: 555-560, 2008.
Perio linked to subclinical atherosclerosis in young adults

Periodontal disease affects 30 percent of the population and in 13 percent of those individuals, the condition is severe. During the past few decades, significant associations between periodontitis and atherosclerosis were reported. Periodontal disease in middle-aged and elderly subjects is linked to carotid intima-media thickness (IMT), which is generally an external ultrasound measurement of vessel wall thickness. Scores between 0.75 and 0.82 are considered borderline values associated with greater cardiovascular risk. Carotid artery thickness is an indicator of sub-clinical atherosclerosis.

Researchers at the University of Florence in Italy wanted to know if carotid IMT scores were higher than normal for younger people with periodontal disease. They compared a group of 45 subjects between 18 and 40 years of age with severe, generalized periodontitis to an age, gender, BMI, and smoking history matched group with no signs of periodontitis.

Half of the periodontitis group had chronic periodontitis and the other half had aggressive periodontitis. The mean carotid IMT scores for the periodontitis group were 0.82 compared to 0.72 in the control group. In the periodontitis group, 20 subjects had IMT scores over 0.82 compared to only four subjects in the control group. Periodontitis subjects had higher C-reactive protein, serum cholesterol and LDL cholesterol levels than the control subjects. Subjects who engaged in regular activity had lower carotid IMT scores.

These findings suggest that periodontal disease is associated with elevated carotid IMT scores in young people as well as the elderly.

Clinical Implications: In the future, periodontal conditions might be evaluated to determine potential systemic atherosclerosis conditions decades before cardiovascular events occur.

Cairo, F., Castellani, S., Gori, A., Nieri, M., Baldelli, G., Abbate, R., Pini-Prato, G.: Severe Periodontitis in Young Adults is Associated with Subclinical Atherosclerosis. J Clin Perio 35: 465-472, 2008.
Arthritis and perio linked

Rheumatoid arthritis (RA) is a systemic, inflammatory disorder seen three times more often in women than men and affects 0.5 to one percent of the population. RA causes destruction of cartilage and bone in the joints through synovitis, the accumulation of proinflammatory cell infiltrates in the synovial membrane. When joints of the fingers are affected, oral hygiene becomes difficult, leading to plaque accumulation and periodontal disease.

Researchers at the Charité-Medical Faculty in Berlin, Germany, compared 57 subjects (eight males and 49 females) with RA to an age- and gender-matched control group of 52 subjects (nine males and 43 females) without RA. Subjects with RA qualified for the study if they met at least four of the seven following criteria: morning stiffness, arthritis in three or more joints, arthritis in the hand, symmetric arthritis, rheumatoid nodules, serum rheumatoid factors and radiographic changes. All of the RA subjects were taking some type of anti-rheumatic drugs, including NSAIDs, corticosteroids, and/or tumor necrosis factor-alpha antagonists. A Disease Activity Score (DAS) was calculated for each RA subject, based on movement of 28 joints, blood work, and a subjective visual analog score completed by the patient about their activity level.

Oral indices included probing scores, clinical attachment levels, plaque, bleeding and gingivitis scores. Smoking and alcohol consumption were assessed as risk factors. Medical conditions were also noted: Sjögren's syndrome, osteoporosis, diabetes, hypertension, coronary heart disease and cholesterol levels.

Probing depths and CAL were 0.5 to 1mm higher in the RA group compared to the controls. More sites with CAL greater than 4mm were found in the RA group compared to the controls, 35 percent vs. 10 percent. After adjusting for age, those in the RA group were eight times more likely to have periodontal disease than those in the control group. Both RA and periodontitis exhibit increased levels of proinflammatory mediators, which may explain the association of RA with periodontitis, even after taking oral hygiene into consideration.

Clinical Implications: These findings suggest the need for close collaboration between physicians, dentists and dental hygienists when treating people with rheumatoid arthritis.

Pischon, N., Pischon, T., Kröger, J., Gülmez, E., Klepber, B.-M., Bernimoulin, J.-P., Landau, H., Brinkmann, P.-G., Schlattmann, P., Zernicke, J., Buttgereit, F., Detert, J.: Association Among Rheumatoid Arthritis, Oral Hygiene, and Periodontitis. J Perio 79: 979-986, 2008.
More periodontitis seen in alcoholics
Clinicians see the effects of alcohol dependence in their patients, but only a few studies have confirmed this association. The World Health Organization estimates that two billion people around the world consume alcohol and that 76 million experience alcohol-related complications. In Brazil, 68 percent of the population consumes alcohol and 11 percent are alcoholics.

Researchers at the Federal University of Rio de Janeiro in Brazil compared the periodontal status of 49 alcoholic and 49 non-alcoholic men. The alcoholics were all receiving treatment at the Philippe Pinel Institute in Rio de Janeiro. The non-alcoholic subjects were recruited from visitors at the Philippe Pinel Institute.

To confirm alcoholism, subjects completed the CAGE questionnaire. The acronym comes from key words in the four-question test: "cut down," "annoyed," "guilty," and "eyeopener." The questions are: Have you ever felt you should cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?

Alcohol dependence was significantly associated with increased attachment loss and pocket depths. Plaque and bleeding levels were similar for both groups. Other alcohol dependence factors that were not considered in this study are malnutrition, stress, depression and behavior. This study does not establish a causal link, but does suggest that alcohol dependence may be a predictor of periodontal disease.

Clinical Implications: Scientific research is growing to support what you have known empirically, that periodontal health is worse in alcoholic patients.

Amaral, C., Luiz, R., Leáo, T.: The Relationship Between Alcohol Dependence and Periodontal Disease. J Perio 79: 993-998, 2008.
Arestin used with Modified Widman Flap


Surgical and non-surgical therapy both result in healing, with good daily oral hygiene. Recent studies reported better healing with surgery in pockets exceeding 6mm. Systemic and locally delivered antibiotics are used with non-surgical therapy. Systemic antibiotics have been used with surgery, but not locally delivered.
A team of researchers in private practice in Aurora, Colorado, and at Göteborg University in Sweden compared the Modified Widman Flap (MWF) with and without Arestin in a total of 60 patients with moderate to severe chronic periodontitis. Half of the subjects (control group) received two quadrants of scaling and root planing (SRP) and two quadrants of surgery without Arestin. The other half of the subjects (test group) received two quadrants of surgery and two quadrants of SRP with Arestin placed in all sites 5mm or more, in all four quadrants at each visit. Arestin was placed again at week five in all four quadrants for the test subjects. SRP results were not reported in this article.

At week 13, the mean difference in probing depth reductions was not statistically significant at 0.2 mm. At week 25, the mean difference was 0.3 mm and was considered statistically significant. This difference was also seen when comparing smokers in each group. More sites in the test group showed reductions of 2mm or more: 93 percent of sites compared to 83 percent of sites at week 25 in the non-smokers, and 85 percent compared to 74 percent in the smokers. At week 13, smokers in the test group showed a difference in the number of sites with 2mm or more of reduction, 93 percent compared to 83 percent smokers in the control group.

Clinical Implications: Periodontists might consider using Arestin when doing Modified Widman Flap procedures, especially for smokers, whose healing is generally compromised.

Hellström, M., McClain, P., Schallhorn, R., Bellis, R., Hanlon, A., Ramberg, P.: Local Minocycline as an Adjunct to Surgical Therapy in Moderate to Severe, Chronic Periodontitis. J Clin Perio 35: 525-531, 2008.
Perio therapy might improve quality of life

According to the research, both hand instruments and power scalers achieve similar clinical results following non-surgical treatment of periodontal disease. Based on these findings, clinicians now use a combination of hand and power instruments for non-surgical therapy. Researchers at the Eastman Dental Hospital in London, England, wanted to know if the patient's perception of pain and quality of life were different based on the instruments used for non-surgical therapy.

Patients with mild to moderate periodontal disease were treated with either Gracey standard and mini, after-five curets (29 patients), or the EMS piezo-ceramic power scaler (30 patients). Full-mouth treatment was provided in a single two-hour session. In addition to clinical indices, several questionnaires relating to pain, sensitivity and quality of life were completed by the patients at each of five visits: prior to treatment, immediately after treatment and at one, four and eight weeks post op.

Clinical indices showed similar improvement for both groups after eight weeks. Pain scores also showed similar changes for both groups. On a scale of zero to three (zero meaning no pain, and three meaning severe pain), the baseline score for both groups was one, which increased to two at week one and dropped to zero by week eight. Sensitivity scores didn't change significantly over the eight weeks for either group, however lower sensitivity scores were reported for the power scaler group at all time points. Oral health/quality of life scores moved slightly in a positive direction for both groups following treatment. Looking at four specific life domain sections within the quality of life questionnaire revealed a slight but significant improvement in the function and psychosocial domains for the power scaler group compared to the curet group.

Clinical Implications: Research demonstrates that treating periodontal disease may improve the patient's quality of life.

Åslund, M., Suvan, J., Moles, D., D'Aiuto, F., Tonetti, M.: Effects of Two Different Methods of Non-Surgical Periodontal Therapy on Patient Perceptions of Pain and Quality of Life: A Randomized Controlled Clinical Trial. J Perio 79: 1031-1040, 2008.
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