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Perio Reports

Perio Reports  Vol. 20 No. 8
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.
Pregnancy gingivitis reversed after delivery

Pregnancy gingivitis, with no increase in plaque levels, is attributed to increases in the hormones of pregnancy: estrogen, progesterone and estradiol. These hormones are known to enhance vascular permeability of the gingiva, increase production of the pro-inflammatory cytokine, prostaglandin E2, and reduce the defensive abilities of the neutrophils.

Researchers at the University of Helsinki, in Helsinki, Finland, compared age-matched groups of women to determine if the gingival changes during pregnancy remained and even progressed on to periodontitis. Two groups of approximately 20 women each — one group pregnant and the other not — were compared during and after the delivery of the babies in the pregnant group. Exams were done three times during pregnancy, once after delivering the baby and once after lactation. The control subjects were seen once a month for three months.

Bleeding and probing depths increased simultaneously between the first and second trimester in the pregnant group, without increases in plaque levels. Pockets were found between posterior teeth and were due to tissue swelling rather than loss of attachment. These scores decreased in subsequent visits. Bleeding in the control group was dependent on the plaque levels. No pocketing or changes in attachment levels was noted for this group.

Clinical Implications: Despite increases in bleeding and probing depths during pregnancy, women who began their pregnancies with healthy oral tissues, will see a reversal of gingivitis after their babies are born. Pregnancy gingivitis did not progress to periodontitis for these subjects.

Gürsoy, M., Pajukanta, R., Sorsa, T., Könönen, E.: Clinical Changes in Periodontium During Pregnancy and Post-Partum. J Clin Perio 35: 576-583, 2008.
Minimally invasive surgery plus Emdogain
Traditional pocket elimination surgical techniques generally remove the papilla and reflect the tissue off
the bone. This technique often results in reduced probing depths, but also bone loss is evident with a greater distance from CEJ to the attachment.

More conservative procedures plus the development of enamel matrix derivatives for the regeneration of the attachment provide an alternative to traditional pocket elimination surgery. Researchers in Italy undertook this study in a private clinical practice to determine the outcome of combining a minimally invasive technique and the placement of an enamel matrix derivative gel (Emdogain). The approach was done using an intraoral microscope. Prior to this technique being done, patients were seen for oral hygiene instructions, scaling and root planing, maintenance and any periodontal surgery needed in other areas of the mouth. Following the minimally invasive surgery and Emdogain placement, the papilla were sutured to achieve primary closure. Patients were instructed to rinse twice daily with 0.12 percent chlorhexidine. For the next six weeks, they were seen weekly for polishing with chlorhexidine gel. This was followed by three-month maintenance visits for one year.

A total of 44 intra-bony defects in 20 patients were treated with this protocol. Average probing depths reduced from 7.1mm to 2.5mm for a difference of 4.6mm. Attachment levels changed from 8.7mm to 4.3mm, a difference of 4.4mm. Recession increased an average of only 0.2mm.

Clinical Implications: Minimally invasive access to deep pockets plus Emdogain placement provides excellent results with reduced probing depths and radiographic evidence of defect reversal.

Cortellini, P., Mieri, M., Pini Prato, G., Tonetti, M.: Single Minimally Invasive Surgical Technique with an Enamel Matrix Derivative to Treat Multiple Adjacent Intra-Bony Defects: Clinical Outcomes and Patient Morbidity. J Clin Perio 35: 605-613, 2008.
Calorie restricted diet dampens immune response in monkeys

Obesity and diabetes both have deleterious effects on the severity and extent of periodontal disease. In a variety of laboratory and clinical studies, restricting the caloric intake has beneficial effects on host response, hormonal balance, the aging process, and expression of inflammatory cytokines and free radicals.

Researchers from several United States dental schools joined an ongoing rhesus monkey study conducted at the National Insititute on Aging (NIA) comparing the effects of a calorie restricted diet and ad libitum intake, or eating freely. The NIA study has been going on for 17 years. The NIA goal is to determine the effects of a restricted caloric diet on the aging process. The periodontal researchers selected 55 monkeys and tied suture ligatures around the maxillary bicuspids and molars to enhance plaque accumulation, periodontal inflammation and connective tissue destruction.

Clinical indices were recorded at baseline, one, two and three months. Following ligature placement, plaque accumulation increased as did gingival inflammation. The monkeys on the calorie restricted diets had the same amount of plaque as the controls, but showed less inflammation, less bleeding, less probing depth and less attachment loss. This is the first long-term study providing evidence that a restricted calorie diet dampens the clinical inflammatory response, and reduces the degree of periodontal destruction secondary to bacterial challenge, in an animal model.

Clinical Implications: A reduced calorie diet may be an effective part of the treatment plan for periodontal disease, depending on how this model works with humans.

Branch-Mays, G., Dawson, D., Gunsolley, J., Reynolds, M., Ebersole, J., Novak, K., Mattison, J., Ingram, D., Novak, M.: The Effects of a Calorie-Reduced Diet on Periodontal Inflammation and Disease in a Non-Human Primate Model. J Perio 79: 1184-1191, 2008.
Vitamin D receptor gene interacts with smoking

Vitamin D is important for calcium metabolism, immune modulation, regulation of cell growth and regulation of cell death. A small segment of the vitamin D receptor (VDR) gene has been linked to various infections and pathologies, including periodontitis. Exactly how this happens is still unclear. However, genetics do play a role in both the onset and the progression of periodontal disease.
Salmon is a natural source of Vitamin D.
Smoking compromises neutrophil function and immune response. It also affects bone metabolism as smokers have reduced bone density compared to nonsmokers. Smoking also interacts with genetic factors contributing to the pathogenesis of stroke and diabetes. Smoking may interact with genetic factors to increase an individual's susceptibility to periodontitis.

Researchers at the Eastman Dental Hospital in London, England, evaluated 534 smoking and non-smoking subjects with and without periodontal disease to determine if there is an association between smoking and the VDR gene. Blood samples were taken from the subjects and DNA was extracted from leukocytes for analysis. Sixty-one subjects participated in a oneyear observation study as well.

An association was evident in those who smoked and had periodontal disease. Of those who showed disease progression of 2mm or more over one year, six of eight also had this genetic pattern.

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.
Repeated instrumentation compared to surgery

Controversy exists suggesting the benefits of repeated scalings every three months are outweighed by the accumulated trauma to teeth and tissues. Researchers at the University of Greifswald, in Germany compared repeated subgingival instrumentations to periodontal surgery in young adults between 30 and 40 years of age.

Subjects were seen weekly by the hygienist for one month for oral hygiene instruction including the Bass toothbrushing technique and interdental cleaning, primarily with interdental brushes. Scaling and root planing were performed without anesthesia using the Cavitron and Gracey curettes. At week eight, patients were seen by a periodontist for subgingival debridement under local anesthesia using the Cavitron, KaVo SONICflex and Gracey curettes. The hygienist followed up with scheduled appointments for oral hygiene and supragingival polishing over the next three months.

At five months, subjects with remaining probing depths of 5mm or deeper received half mouth surgery and half mouth instrumentation, performed by the periodontist. Subjects saw the hygienist one, three, seven and 15 weeks postoperatively for oral hygiene reinforcement and supragingival cleaning.

Both treatments resulted in reductions in probing depths and gains in clinical attachment levels. The study began with 47 subjects, but 21 were excluded after the first dental hygiene treatment phase. Eleven of those were for general health and compliance reasons. The surprise was that 10 subjects were excluded at this point in the study because of favorable healing after instrumentation by the hygienist, leaving them with no probing depths 5mm or deeper.

Clinical Implications: Repeated subgingival instrumentation results in healing that might prevent the need for surgery.

König, J., Schwahn, C., Fanghänel, Plötz, J., Hoffmann, T., Kocher, T.: Repeated Scaling Versus Surgery in Young Adults with Generalized Advanced Periodontitis. J Perio 79: 1006-1013, 2008.
Review of full-mouth treatment concepts

Periodontal disease results from the complex interaction of a bacterial infection and the host response modified by various risk factors. Subgingival instrumentation is done to rid the area of the colonizing bacteria. Pockets may be re-colonized from bacteria on the tongue, tonsils, and other oral sites. Full-mouth disinfection is the completion of all subgingival instrumentation within 24 hours followed by extensive use of chlorhexidine to prevent re-colonization of treated areas.
Several researchers in Germany and England evaluated published research to determine the effectiveness of full-mouth disinfection compared to the traditional quadrant approach. They screened 216 articles and abstracts and found seven randomized clinical trials that fit the criteria set for review.

Minor differences were observed in favor of the full-mouth disinfection, for example there was 0.53mm greater reduction in probing depth in singlerooted teeth with initial measurements of 5-6mm. Studies were difficult to compare due to variations in protocols. Some studies probed before calculus removal, others after. Some used constant force probes and others used manual probes. A variety of instruments were used for instrumentation. Results may vary as some researchers withheld oral hygiene instructions until after instrumentation. Unless researchers follow the same protocol, comparisons are difficult.

Clinical Implications: Both full-mouth and quadrant approaches to non-surgical therapy are viable choices. Deciding which to use should be based on patient preference and the convenience of scheduling. For some, four appointments are preferred, while others would prefer to accomplish the treatment in just one or two visits.

Eberhard, J., Jervøe-Strom, P., Needleman, I., Worthington, H., Jepsen, S.: Full-Mouth Treatment Concepts for Chronic Periodontitis: A Systematic Review. J Clin Perio 35: 591-604, 2008.
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