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Perio Reports

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Perio Reports  Vol. 22 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.
Halitosis – a review

Bad breath or halitosis is considered a problem by 50 percent of the population for which the American public spends between $1 and $3 billion dollars each year for gums, mints and other fresh breath products.

Bad breath is caused by either intraoral or extraoral conditions. Intraoral problems account for 90 percent of bad breath cases, usually due to accumulated food debris, poor oral hygiene, poor tongue hygiene, periodontal disease, caries, and xerostomia. Extraoral causes are infection or disease in other parts of the body with odors being carried by the blood to the lungs, where the odor is expelled through the nose and mouth. There is also a link between gastrointestinal reflux and self-perceived bad breath.

Bad breath is due to volatile sulfur compounds (VSCs) that are released with the putrefaction of food, breakdown of epithelial cells, blood, saliva and bacteria. VSC measurements are done organoleptically, by smelling, gas chromatography or sulfide monitoring (Halimeter). The greatest source of VSC is often the dorsum of the tongue.

Brushing, interdental cleaning and tongue cleaning are the basic approaches to reducing VSCs in the mouth. Chemicals can be effective in preventing production of VSCs (chlorhexidine and CPP) or neutralizing VSC (chlorine dioxide and zinc). Triclosan is also effective in controlling bad breath when combined with a co-polymer in toothpaste. Essential oils combined with zinc are also effective.

Halitophobia is a serious condition, believing one has bad breath despite all evidence to the contrary and these patients should be referred for counseling.

Clinical Implications: Halitosis is a significant problem affecting half the population and should be addressed by dental professionals. Diagnosing, classifying, treating and monitoring this condition provides a valuable service for your patients.

Armstrong, B., Sensat, M., Stoltenberg, J.: Halitosis: A Review of Current Literature. JDH 84: 65-74, 2010.
Hormone fluctuations impact inflammation

In 1948, Dr. Muhlemann (Switzerland) published a study showing both histologically and clinically that women with gingivitis experienced increased inflammation and increased gingival crevicular fluid (GCF) flow just prior to their menses. Gingival tissues contain receptors for androgens, estrogen and progesterone, which have an impact on inflammation.

Researchers at Ege University in Izmir, Turkey monitored bleeding upon probing (BOP), plaque, GCF and salivary levels of estrogen and progesterone during a complete menstrual cycle for 50 young women. Half the group had clinical signs of gingivitis (bleeding in more than 50 percent of sites) and the other half were considered clinically healthy (bleeding in less than 10 percent of sites). Indices were recorded at three time points: menses, ovulation and premenstruation.

BOP averages decreased for those with gingivitis from 60 sites at menses and ovulation to 40 sites at premenstruation. No differences were seen in the healthy group at the three different time points. Salivary estrogen and progesterone levels were higher at the ovulation and premenstruation time points and lowest during menses. GCF flow was slightly higher in the gingivitis group compared to the healthy group, but scores did not vary at the different time points. GCF levels of the proinflammatory cytokine IL-6 were elevated in gingivitis patients at all time points compared to healthy patients.

Clinical Implications: Hormonal changes at various points in a woman’s menstrual cycle might impact bleeding upon probing scores. In the future, researchers should gather probing scores at the same point in a woman’s cycle when probing and bleeding upon probing scores are compared over time.

Becerik, S., özçaka, ö., Nalbantsoy, A., Atilla, G., Celec, P., Behuliak, M., Emingil, G.: Effects of Menstrual Cycle on Periodontal Health and Gingival Crevicular Fluid Markers. J Perio 81: 673-681, 2010.
Animal model shows perio influence on arthritis

Clinical observations and several research studies suggest that subjects with severe rheumatoid arthritis are more likely to also have severe periodontitis and vice versa. The infection and inflammation of periodontitis is considered extra-synovial, being outside the bone joints. Just how the inflammatory response in one part of the body impacts that in another part of the body is the focus of many oral/systemic studies. Periodontitis and rheumatoid arthritis share similar pathogenesis.

Researchers at the University of Adelaide in Australia designed a proof of concept study to measure the influence of a periodontal pathogen infection on experimental arthritis in rats. Polyurethane foam sponges soaked with either sterile saline or heat-killed Porphyromonas gingivalis (Pg) were surgically implanted into the animals’ upper back/ shoulder area. The study was comprised of six test groups of six animals each. Groups one and two had sponges in place for 35 days, either saline or Pg. Groups three and four were similar to one and two, but these groups all received an injection near the base of the tail of Mycobacterium tuberculosis, which induces arthritis within 14 days. Two concentrations were used in each group, thus creating four test groups with induced arthritis.

Implanted sponges were removed after 35 days and analyzed, showing significant inflammation in the Pg samples compared to the sterile saline sponges. Changes to the hind paws of the rats showed the greatest amount of swelling and redness in the animals receiving both the Pg implanted sponges and the injection to induce arthritis.

Clinical Implications: This study proves the concept in an animal model that a Pg infection somewhere else in the body will exacerbate rheumatoid arthritis..

Bartold, P., Marino, V., Cantley, M., Haynes, D.: Effect of Porphyromonas Gingivalis-Induced Inflammation on the Development of Rheumatoid Arthritis. J Clin Perio 37: 405- 411, 2010.
Oral hygiene and Candida colonization

Several factors influence growth of Candida albicans including xerostomia, dentures or other removal appliances, HIV infection, a compromised immune system or medications. Poor oral hygiene has long been suspected to be a factor influencing Candida colonization.

Researchers at Jordan University of Science and Technology in Irbid, Jordan, used a rinse technique to measure Candida levels in the oral cavity of 149 healthy, dentate subjects. Oral hygiene and gingivitis scores were compared to the presence of Candida in the rinse and the number of colony forming units grown on agar plates.

Plaque scores were rated: very good, good, poor and very poor. There were also four levels of gingivitis: no inflammation, mild, moderate and severe inflammation. Similar to other reported findings, Candida was isolated from 58 percent of subjects. Other levels reported vary between 52 percent to 59 percent.

Oral hygiene was not significantly related to Candida levels. Increasing age was significantly related to Candida colonization, while no differences were seen between males and females. Higher colonization rates were found in those who didn’t use dental floss and smokers. The aromatic hydrocarbons in tobacco are a nutrient for yeast cells, which might explain the link with smoking. Additionally, smoking might increase salivary glucose, contributing to enhanced yeast growth.

Many contributing factors must be considered for oral Candida colonization, other than oral hygiene. General health, existing systemic diseases, medications and the cleanliness of removal oral appliances from orthodontic retainers to dentures.

Clinical Implications: Poor oral hygiene is no more likely than good oral hygiene to affect colonization of oral Candida organisms.

Darwazeh, A., Hammad, M., Al-Jamaei, A.: The Relationship Between Oral Hygiene and Oral Colonization with Candida Species in Healthy Adult Subjects. Int J Dent Hygiene 8: 128-133, 2010
Smoking inhibits bone regeneration around implants

Bone healing around an implant is a cascade of synthesis and activation of proteins, growth factors, cytokines and angiogenic stimulators. This complex process can be altered by some of the 4,000 toxins found in cigarette smoking. Nicotine, a potent vasoconstrictor, reduces blood flow and nutrient delivery to the implant site. Smoking delays bone healing by inhibiting proliferation of precursor cells essential for bone deposition.

Researchers at Guarulhos University in Brazil evaluated the effects of smoking on implant integration in a group of 13 smokers (10 or more cigarettes per day for five years or more) and 11 never-smokers. Oxidized, screw-type, micro-implants were used, one for each test subject. The implants were surgically placed and a flap sutured over the site. Most were placed in posterior maxillary sites. Clindamycin was provided three times daily for a week to prevent infection. Two months later, all the implants were clinically stable. Each implant and surrounding tissues was removed.

Bone to implant surface was analyzed finding a significant difference between smokers and never smokers. The area was 26 percent in smokers and 40 percent in never smokers. Bone density within the threads of the implant was 28 percent for smokers and 46 percent for never smokers. Bone density just outside the implant threads was 19 percent for smokers and 25 percent for never smokers. Compromised healing was due to the interactions between smoking and the immune response.

Clinical Implications: Recommending implants for smokers should be done with caution, as smoking has detrimental effects on bone healing around implants.

Shibli, J., Piattelli, A., Iezzi, G., Cardoso, L., Onuma,T., Carvalho, P., d’Avila, S., Ferrari, D., Mangano, C., Zenobio, E.: Effect of Smoking on Early Bone Healing Around Oxidized Surfaces: A Prospective, Controlled Study in Human Jaws. J Perio 81:575-583, 2010.
Zinc citrate in toothpaste reduces bacteria

Despite the fact that dental disease begins most often between the teeth, toothbrushing remains the primary patient approach to oral hygiene. Many antimicrobial agents have been tested in toothpastes, including chlorhexidine, triclosan, salts and metals. Most studies measure clinical outcomes like caries, gingivitis and oral malodor.

Researchers at West China College of Stomatology at Sichuan University in Chengdu, China, together with Colgate compared regular Colgate toothpaste and a zinc citrate toothpaste for reducing oral bacteria. Bacterial samples from four areas were tested: saliva, tongue, buccal surfaces of the teeth and oral mucosa. A total of 35 patients, between 18 and 75 years of age, participated in this 14-day, crossover study. For seven days, subjects all brushed with regular Colgate toothpaste. On day eight, subjects came to the clinic without brushing their teeth, for baseline data collection. They were then given either regular toothpaste or the test toothpaste containing one percent zinc citrate and told to brush only their teeth, twice daily for two weeks. No other oral hygiene was to be performed and no gums, mints or mouth rinses.

On day 14, oral samples were again taken prior to toothbrushing. They were then allowed to leave, to brush their teeth and returned five hours later for retesting. The entire study was repeated so each subject used both toothpastes. Both toothpastes reduced bacterial counts, with greater reductions evident with the zinc citrate toothpaste.

Clinical Implications: Toothpastes containing zinc citrate appear to reduce bacterial counts more effectively than similar toothpastes without zinc citrate. Tom’s of Maine toothpaste contains zinc citrate and is owned by Colgate.

Hu, D., Sreenivasan, P., Zhang, Y., De Vizio, W.: The Effects of a Zinc Citrate Dentifrice on Bacteria Found on Oral Surfaces. Oral Health Prev Dent 8: 47-53, 2010.
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