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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. 10
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 role of inflammation in periodontal disease

Inflammation is capturing headlines in both research journals and consumer publications. A one-month Google News search this year found 9,000 stories published on inflammation. There has been an explosion of scientific information on inflammation and chronic diseases of aging, like heart disease, diabetes and periodontitis.

In January 2008, a conference convened in Boston, sponsored by Colgate, titled: Inflammation and Periodontal Diseases: A Reappraisal. Leaders in the field of periodontics participated in this two-day meeting to discuss the underlying inflammatory mechanisms that tie together periodontal disease and essentially all chronic diseases of aging, of which periodontitis is one.

Highlights of this meeting include:
  1. Inflammatory mechanisms appear to be critical factors in the development and progression of most chronic diseases of aging.
  2. Diet and genetic variations interact to control difference in inflammation among individuals.
  3. Inflammation is actively resolved by specific mechanisms that help restore homeostasis, and there are ways to augment these processes.
  4. Although our genes do not change, the control of how certain genes are expressed in specific tissues can change substantially throughout our lives by factors such as diet, stress and bacterial accumulations.
  5. Visceral fat accumulations around the waist substantially increases the inflammatory burden on the body.
  6. Over expression of inflammation may be one of the key aspects of aging that influences and links different diseases in different individuals.
Clinical Implications: Periodontal researchers are focusing their work on inflammation and the role inflammation plays in the progression and resolution of periodontal disease. This is true of other medical areas as well. Your reading is sure to include more research and consumer articles dealing with inflammation.

Van Dyke, T.: Inflammation and Periodontal Diseases: A Reappraisal. J Perio 79: 1501-1502, 2008.
Anterior middle superior alveolar
injection (AMSA)

To anesthetize both facial and lingual aspects of the maxillary arch for periodontal procedures requires five separate injections: posterior superior alveolar (PSA), middle superior alveolar (MSA), anterior superior alveolar (ASA), greater palatine (GP), and the nasoplalatine (NP). Besides several needle sticks with these injections, facial structures may also be anesthetized: upper lip, lateral aspect of the nose and the lower eyelid.

In 1997, the AMSA injection was defined for computer delivery systems as an alternative to multiple maxillary injections. Injection time is approximately four minutes for a full carpule of anesthetic solution due to tissue constriction at the palatal site of needle insertion. The injection site is between the bicuspids and halfway between the midline of the palate and the gingival margin of the teeth. Slow deposition of the anesthetic solution will prevent pain. Tissue will blanch as the solution is deposited over four minutes. The tight palatal tissues promote diffusion of the solution through the palatal bone via numerous nutrient canals.

Profound anesthesia was achieved with this injection using either a computer system or a traditional syringe with a 27-gauge needle. Five patients undergoing a variety of periodontal surgical procedures reported that this injection was comfortable. One disadvantage of the AMSA injection is the lack of hemostatic control on the facial side of the maxillary arch. Bleeding may complicate vision when performing scaling and root planing.

Clinical Implications: One single AMSA injection replaces five separate injections, but doesn’t provide the facial hemostatic control needed with some procedures.

Holtzclaw, D., Toscano, N.: Alternative Anesthetic Technique for Maxillary Periodontal Surgery. J Perio 79: 1769-1772, 2008.
Daily medications and periodontal disease

Researchers at the University of Washington took advantage of a unique opportunity to evaluate the charts of 12,631 individuals who are members of Kaiser Permanente Northwest to see if periodontal disease was related to their history of prescription medication use. The subjects were between 45 and 61 years of age and were followed for seven years.
Subjects were assigned to groups based on their periodontal diagnostic classification: early periodontitis 79 percent of the group, moderate periodontitis 19 percent, and advanced 1.8 percent. These groups were further divided based on sex, diabetes and smoking. In the advanced perio group, there were more men, more who had diabetes and more who were smokers.

Long-term use of allergy and anti-infective medications was inversely related to the severity of periodontitis. Those with early perio used these drugs more than those with moderate to advanced periodontal disease. Those in the advanced perio group used these drugs the least.

The authors speculate that this may be due to a genetic predisposition to periodontal disease that provides protection against allergies. The hygiene hypothesis suggests that protecting young children from injury and illness today prevents them from developing effective immunity for the future. The idea that subgingival colonization of bacteria protects against allergies and develops immunity appears difficult to prove. In an accompanying editorial, these concepts were questioned. The long held belief that good oral hygiene protects against disease still seems to be the best explanation of who develops periodontal disease and who does not.

Clinical Implications: Look at your patients to see if this pattern is evident; that those with advanced periodontal disease take fewer prescription medications than those who are periodontally healthy.

Hujoel, P., Cunha-Cruz, J., Maupome, G., Saver, G.: Long-Term Use of Medications and Destructive Periodontal Disease.
J Perio 79: 1330-1338, 2008.
Brushing versus brushing and flossing

Disrupting bacterial biofilm on a daily basis is the goal of oral hygiene and it is accomplished with a variety of dental tools. Power toothbrushes are now widely accepted and an appealing choice for consumers. Maintaining dedication and effective use of any toothbrush or cleaning aid is essential to oral health.

Researchers at the Academic Center for Dentistry Amsterdam in The Netherlands compared a power brush (Oral-B Triumph Professional Care 9000), a manual brush (Oral-B Cross Action) and the manual brush plus dental floss (Oral-B Satin floss) in a total of 114 adults with gingivitis. The first step in the study was a three-week oral hygiene phase with instruction in manual toothbrushing using a two-minute timer and twice daily rinses with hydrogen peroxide followed by chlorhexidine. This was done to motivate the participants to improve their oral health.

Baseline data was taken at day 21, and subjects were randomly assigned to their group and given detailed instructions. These oral hygiene instructions were repeated at six weeks. Clinical examinations were performed at six weeks, 10 weeks, six months and nine months.

Bleeding scores reduced from day zero, to the lowest at 10 weeks, returning to baseline levels again at nine months, with no significant difference between groups at this point. Less important clinically are the plaque scores. They were lowest at the 21-day baseline examination and increased at 10 weeks and remained steady through the nine months. The power brush group plaque scores were 1.16 at nine months, statistically lower than 1.44 for the manual brush and floss group and 1.57 for the manual-brush-only group.

Clinical Implications: Oral hygiene needs reinforcement every few months to maintain optimal plaque control benefits.

Rosema, N., Timmerman, M., Versteeg, P., van Palenstein, W., Van der Velden, U., Van der Weijden, G.: Comparison of the Use of Different Modes of Mechanical Oral Hygiene in Prevention of Plaque and Gingivitis. J Perio 79: 1386-1394, 2008.
Eucalyptus chewing gum promotes periodontal health

Eucalyptus is native to Australia and is widely grown throughout the world. It is used as tea and added to health foods. Ethanol extracts of eucalyptus are antibacterial and antiviral. Specific components of the essential oil extract are effective against cariogenic and periodontal pathogens.

Researchers at Osaka University School of Dentistry in Japan compared the clinical effects of chewing gums with both a low and a high concentration of eucalyptus to a placebo chewing gum for a period of 12 weeks. Standard chewing gums in Japan contain both xylitol and maltitol, both known plaque controlling sugar alcohols.

The placebo gum and the base for the two test gums provided participants with 6.66 grams of xylitol per day and 5.10 grams of maltitol per day, based on instructions to chew two pieces after meals and between meals for a total of five times daily. The eucalyptus extract was added to the chewing gum base. The high concentration eucalyptus gum provided 90 mg/day and the low concentration eucalyptus gum provided 60 mg/day.

Clinical indices, including bleeding on probing, plaque, and gingivitis, were reduced more for those in the eucalyptus chewing gum groups compared to the placebo gum group. The higher concentration eucalyptus gum showed slightly greater reductions than the low concentration eucalyptus gum.

Clinical Implications: We might soon see eucalyptus extract chewing gum, sweetened with xylitol and maltitol, for the prevention of gingivitis.

Nagata, H., Inagaki, Y., Tanaka, M., Ojima, M., Kataoka, K., Kuboniwa, M., Nishida, N., Shimizu, K., Osawa, K., Shizukuishi, S.: Effect of Eucalyptus Extract Chewing Gum on Periodontal Health: A Double-Masked, Randomized Trial. J Perio 79: 1378-1385, 2008.
Subantimicrobial dose doxycycline is safe and effective long term

More than 20 years ago Dr. Lorne Golub discovered that tetracyclines could inhibit host-derived matrix metalloproteinases (MMPs), substances that cause bone loss and destruction of collagen (I think of them as chemical machetes). He also found that the tetracyclines exerted this effect when chemically altered to eliminate the antibiotic component or when the dose was lowered to subantimicrobial dose doxycycline (SDD). Short- and long-term studies have been completed over two decades, demonstrating the benefits of SDD in fighting periodontal disease.

Dr. Golub and his research team at Stony Brook University in New York evaluated the effects of SDD taken daily for two years by postmenopausal women exhibiting signs of osteopenia and with alveolar bone loss due to periodontal disease. The 128 test subjects, ranging in age from 45 to 70 years, were randomly assigned to either the SDD or the placebo group. They were all given calcium and vitamin D supplements to take daily throughout the study period. Periodontal maintenance visits were scheduled every three to four months.

Those taking the SDD had 48 percent less gingival crevicular fluid levels of collagenase compared to four percent lower levels in the placebo group. Specific MMPs were also identified and found to be lower in the SDD group. Markers for bone resorption were also lower in the SDD group.

Concerns have been raised about long term use of SDDs, but this study showed only a couple of adverse effects were reported and they were the same for both the SDD group and the placebo group.

Clinical Implications: Your patients who are postmenopausal can take subantimicrobial dose doxycycline for two years with no adverse effects and positive effects on preventing alveolar bone resorption.

Golub, L., Lee, H., Stoner, J., Sorsa, T., Reinhardt, R., Wolff, M., Ryan, M., Nummikoski, P., Payne, J.: Subantimicrobial-Dose Doxycycline Modulates Gingival Crevicular Fluid Biomarkers of Periodontitis in Postmenopausal Osteopenic Women. J Perio 79: 1409-1418, 2008.
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