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Perio Reports

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Perio Reports  Vol. 23 No. 6
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.
Hospitalization Bad for Oral Health

For hospitalized patients, oral health and oral hygiene are not usually top priorities. Consequently, poor oral health and hygiene impact quality of life, nutrition and general health. Poor oral health and hygiene are associated with hospital-acquired infections, specifically respiratory diseases with intubated patients.

Researchers at the Eastman Dental Institute in London, U.K. reviewed the research to determine oral health changes during hospitalization. More than 9,000 potential records were found in a literature search and of these 37 full articles were evaluated and five papers fit the study design criteria for the systematic review.

Four of the studies included patients in intensive care (ICU) and the other study included both ICU and cardiac surgery patients. Two studies were from the U.S. and one each from the U.K., France and Holland. Patients in three studies were intubated. Oral hygiene for study patients varied considerably from wiping the mouth with a sterile cloth or using a sponge swab to using toothbrushes with toothpaste. Frequency also varied from twice to six times daily.

Plaque levels were monitored and showed significant increases during the hospital stay in four of the five studies. One study reported baseline plaque scores of 23 percent and 93 percent after 10 days hospitalized. Gingival inflammation was also reported to increase during hospitalization. Intubated patients experienced increased mucositis compared to non-intubated patients.

Clinical Implications: Hospitalization is associated with an increase in plaque and deterioration in oral health. Encourage patients who are hospitalized to maintain oral health or seek the help of dental professionals to ensure good oral health and hygiene during hospitalization.

Terezakis, E., Needleman, I., Kumar, N., Moles, D., Agudo, E.: The Impact of Hospitalization on Oral Health: A Systematic Review. J Clin Perio 3, 2011
Non-invasive Periodontal Diagnosis

Periodontitis is primarily diagnosed with radiographs and clinical examinations using periodontal probes to measure probing depths, attachment levels and bleeding. Going to the next level, genetic and laboratory tests measure oral microbiology, one aspect or bacteria at a time. The future will bring noninvasive modes of diagnosis.

Non-invasive diagnostic methods do not use ionizing radiation, are not uncomfortable for the patient and do not manipulate the tissue. Non-invasive diagnostics will provide information about current disease and also predict disease progression. Three approaches being investigated are: infrared spectroscopy, optical coherence tomography and ultrasound imaging.

Infrared spectroscopy distinguishes between healthy and diseased tissue by detecting through the tissue chemical bonds and molecular and sub-molecular profiles. Covalent bonds vibrate and absorb energy from the infrared light. This information creates a unique molecular fingerprint of the tissue. If the disease progresses or treatment is provided, the fingerprint will change. Infrared spectroscopy analyzes complex biologic systems, rather than single biomarkers. Infrared spectroscopy can also analyze gingival crevicular fluid, detecting an entire spectrum of biomarkers related to various stages of health and disease.

Optical coherence tomography creates a high-resolution cross-sectional image of periodontal soft tissues and bone using low-level laser light. These three-dimensional images capture micro-structural details of the periodontium without having to touch the tissue.

Another imaging modality widely studied in dentistry is ultrasound, producing ecographs of bone and tissue without radiation to the tissues.

Clinical Implications: One day periodontal disease will be diagnosed with non-invasive modalities, providing more information in less time and without discomfort to the patient.

Xiang, X., Sowa, M., Iacopino, A., Maev, R., Hewko, M., Man, A., Liu, K.: An Update on Novel Non-Invasive Approaches for Periodontal Diagnosis. J Perio 81: 186-198, 2011.
Disease and Risk Scores Predict Tooth Loss

One goal of periodontal therapy is to stop bone loss and prevent tooth loss. Calculating a mean tooth loss rate among those with periodontitis is difficult due to variation in disease severity among people. Those with the most severe disease experience the most lost teeth. Those diagnosed with early periodontitis who receive treatment are less likely to lose teeth.

Researchers associated with the PreViser diagnostic and risk assessment system and periodontists in clinical practice evaluated patients who had periodontal treatment to determine tooth loss levels, associated disease severity and risk level at the beginning of treatment.

Nine periodontists using the PreViser system entered data on a total of 776 patients who received treatment between 1971 and 2003. The average treatment time was 13 years, ranging from three to 33 years with a total of 980 teeth lost. The PreViser system provides a disease score from one to 100. For this study, the disease scores were grouped into nine categories: health (1), mild periodontitis (2, 3), moderate periodontitis (4, 5) and severe periodontitis (6, 7, 8, 9). The majority of subjects, 98.5 percent, were in categories 4 to 9.

No teeth were lost by 61 percent of the group. No one with a disease score of 1 or 2 lost any teeth. Seven percent lost four to six teeth (advanced periodontitis group) and two percent lost 10 teeth or more and they were in disease score categories 8 and 9. The higher the disease score and the risk score, the greater the tooth loss risk.

Clinical Implications: Diagnosing and treating periodontitis early provides the best chance of preventing future tooth loss.

Martin, J., Page, R., Loeb, C., Levi, Jr., P.: Tooth Loss in 776 Treated Periodontal Patients. J Perio 81: 244-250, 2010.
Local Delivery of Statin Drug for Bone Regeneration

The local delivery of drugs sub-gingivally is used to improve periodontal healing after instrumentation. Several drugs are now available for local delivery: tetracycline, minocycline, doxycycline, metronidazole and chlorhexidine. Delivery systems now include gels, cellulose fibers, ointments, chips and microspheres.

Researchers at the Governmental Dental College and Research Institute in Kamataka, India evaluated a new local delivery system using a methylcellulose gel of the statin drug simvastatin. This six month study evaluated clinical and radiographic outcomes after scaling and root planing (SRP) plus the new local delivery drug or a placebo.

A total of 60 patients with chronic periodontitis participated, 30 in the test group and 30 in the placebo group, each with one test or control site. After SRP, the 1.2 percent simvastatin gel (SMV) or the placebo was injected into the pocket areas using a blunt cannula. No periodontal dressing was used and patients were instructed to refrain from interdental cleaning for one week.

Data collection included clinical indices, radiographs and gingival crevicular fluid (GCF). Plaque reductions were similar for both test and control groups. Significant healing was evident in both groups, but the test group showed more significant probing depth reductions, attachment level gains and gingival index reductions than the placebo group. The test group showed significant bone regeneration interdentally compared to the control group. Evidence of the SMV drug in GCF was measured at all test points, up to and including day 30.

Clinical Implications: Drugs other than antimicrobials and antibiotics might soon be available in local delivery systems to not only enhance healing but also to stimulate bone regeneration.

Pradeep, A., Thorat, M.: Clinical Effect of Subgingivally Delivered Simvastatin in the Treatment of Patients with Chronic Periodontitis: A Randomized Clinical Trial. J Perio 81: 214- 222, 2010.
NovaMin Compared to Potassium Nitrate

NovaMin is an amorphous sodium calcium phosphosilicate that was first developed as a bone regenerative material for long bone fractures. In smaller particle size, it is now available in dental products to occlude open dentinal tubules associated with root surface sensitivity.

Researchers at the SDM College of Dental Sciences in Dharwad, India compared a toothpaste containing five percent NovaMin, a toothpaste containing five percent potassium nitrate and a control toothpaste with fluoride. Thirty patients with sensitivity volunteered for the study. All received a prophylaxis and two weeks later, the study began. Baseline sensitivity was measured using three tests: tactile with a dental explorer, air using the air syringe and cold water by placing melted ice water on the surface.

Subjects were randomly assigned to one of the three toothpastes and told to brush twice daily as usual and to refrain from eating or drinking for 30 minutes after brushing. Patients were seen at two and four weeks to measure sensitivity. Both the NovaMin and the potassium nitrate toothpastes reduced sensitivity compared to the control toothpaste. NovaMin was more effective than the potassium nitrate in reducing the subjects' reported pain on the three sensitivity tests.

Dentin discs were also tested in the lab by brushing with the three toothpastes and evaluated for tubule closer after two, 10, 30 and 120 minutes. NovaMin was the only toothpaste that blocked the open tubules. Potassium nitrate works by blocking nerve transmission, not by blocking tubules, explaining why the tubules were still open.

Clinical Implications: New toothpastes containing NovaMin provide an alternative choice for patients seeking relief from dentinal hypersensitivity.

Salian, S., Thakur, S., Kalkarni, S., LaTorre, G.: A Randomized Controlled Clinical Study Evaluating the Efficacy of Two Desensitizing Dentifrices. J Clin Dent 21: 82-87, 2010.
NovaMin Compared to Potassium Nitrate and Stannous Fluoride

Hypersensitivity affects as much as 57 percent of the general population. Desensitizing toothpastes work in one of two ways, either occluding open dentinal tubules or depolarizing nerve conduction. Fluoride occludes open tubules and potassium nitrate depolarizes the nerve. NovaMin, a new ingredient for the treatment of dentin hypersensitivity, occludes open dentinal tubules.

Researchers at the Armed Forces Medical Center in Pune, India compared three desensitizing products: 7.5 percent NovaMin toothpaste (Soothe Rx), five percent potassium nitrate toothpaste (Sensodent K) and 0.4 percent stannous fluoride (Colgate Gel-Kam). The 12-week study included 120 subjects who were sensitive when tested with an explorer along the cervical areas of the teeth. All received an ultrasonic prophylaxis, followed by a four-week wash-out period before the study began.

Sensitivity was measured on the facial surfaces of incisors, cuspids and premolars with a blast of cold air and melted ice dripped on the cervical area from a micropipette. Subjects reported their pain on a visual analog scale from zero to 10. Sensitivity was measured at two, four and 12 weeks.

Subjects were randomly assigned to one of the three test groups and instructed to brush twice daily with their assigned toothpaste and refrain from eating or drinking for 30 minutes after brushing.

All three test products reduced sensitivity significantly by 12 weeks. NovaMin was able to reduce the sensitivity earlier and more significantly than the other two products.

Clinical Implications: Toothpaste containing NovaMin reduces dentinal hypersensitivity faster than potassium nitrate or stannous fluoride.

Sharma, N., Roy, S., Kakar, A., Greenspan, D., Scott, R.: A Clinical Study Comparing Oral Formulations Containin 7.5% Calcium Sodium Phosphosilicate (NovaMin), 5% Potassium Nitrate, and 0.4% Stannous Fluoride for the Management of Dentin Hypersensitivity. J Clin Dent 21: 88-92, 2010.
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