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Perio Reports Trisha E. O'Hehir, RDH, BS Editorial Director, Hygienetown Magazine

More by this author (282)
Perio Reports  Vol. 21 No. 4
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.
Detecting the CEJ with a probe

It is difficult to accurately detect the cementoenamel junction (CEJ) when positioned subgingivally. Researchers at Academic Centre for Dentistry in Amsterdam compared probe readings on extracted permanent and deciduous teeth. The teeth were cleaned after extraction, dried and root tips were placed in plaster. Artificial gingiva was created using a green plastic material and adapted to cover half the clinical crowns of the teeth.

The examiners were two dentists and two dental hygienists using three different probes: Hu-Friedy Merrit-B with Williams marking; Vivacare TPS probe with a pressure detecting arm; and the Hu-Friedy CPITN probe, also known as the WHO probe. The TPS and CPITN probes both have ball tips. Duplicate measurements were done for each site after one hour. A total of 70 permanent teeth and 30 deciduous teeth were included in the study.

Lines were drawn on each tooth at the six measurement points, but did not extend beyond the artificial gingiva. After all measurements were recorded, the gingiva was removed and using a microscope, accurate measurements were made from the end of the black line to the CEJ. These measurements were compared to the readings recorded by the clinicians.

Most of the readings were within a millimeter above or below the actual measurement: 99 percent for the Merritt-B, 93 percent for the TPS and 91 percent for the CPITN probe. The Meritt-B or standard probe was more accurate in detecting the CEJ than the other probes.

Clinical Implications: Probing scores can vary two millimeters between clinicians. Standard probes are more accurate than ball-tip probes.

Barendregt, D., van der Velden,U., Timmerman, M., Bulthuis, H., van der Weijden, F.: Detection of the Cemento-Enamel Junction with Three Different Probes: An “In Vitro” Model. J Clin Perio 36: 212-218, 2009.
Antibiotic combo reduced need for more treatment

Researchers at the University of Geneva in Switzerland compared the effects of full-mouth (both sides within 48 hours) scaling and root planing (SRP) with and without systemic antibiotics. One clinician performed the examinations on 47 patients and another provided the treatment. Oral hygiene was provided at the beginning of the study, as well as supragingival calculus removal. Only after patients demonstrated good oral hygiene were they scheduled for root planing under local anesthesia. Root planing was done with an EMS power scaler and Gracey curettes. Following instrumentation, pockets were irrigated with 0.1 percent chlorhexidine (CHX) and patients were instructed to rinse twice daily with 1.2 percent CHX.

At the end of the last treatment visit, subjects were given packets of either 500mg metronidazole and 375mg amoxicillin or placebo pills to be taken three times per day for seven days. They were reevaluated one week later and again at three and six months.

The test subjects taking the antibiotics healed better than the control group. At three months, test subjects had an average of 1.3 probing sites measuring 4mm or more with bleeding upon probing, compared to 4.4 sites in the control group. These figures at six months were 0.4 sites in the test group and 3.0 in the control group. The greatest healing was seen in pockets 6mm or deeper. Average probing depths reduced from 7.3 to 3.6 for test subjects and 7.2 to 5.2 for controls at three months. At six months, measurements were 3.7 for tests and 4.9 for controls.

Clinical Implications: These findings challenge current thought about the use of antibiotics in combination with thorough subgingival instrumentation. Significant healing was evident for those taking the antibiotics.

Cionca, N., Giannopoulou, C., Ugolotti, G., Mombelli, A.: Amoxicillin and Metronidazole as an Adjunct to Full-Mouth Scaling and Root Planing of Chronic Periodontitis. J Perio 80: 364-371, 2009.
Chairside diagnostics are being developed

Current periodontal diagnostics lack the ability to determine disease onset or predict further disease. Radiographs and probing scores provide a history of the disease, but do not show current disease activity. Current diagnostics must detect significant tissue destruction to show changes in disease and are therefore poor predictors.

Diagnostics for other diseases use bodily fluids tested at the time of care or as the new terminology states: “point of care diagnostics” or “lab on a chip technologies.” Salivary tests are easy to carry out and offer significant potential for periodontal diagnosis.

Researchers at Forsyth Institute in Boston analyzed biomarkers from saliva and subgingival plaque biofilm to determine disease status. Ninety-nine subjects were categorized as healthy (no bone loss, no probing depths over 4mm, and less than 20 bleeding points (BOP)), gingivitis (no bone loss and more than 20 BOP), mild periodontitis (less than 30 percent of sites with attachment loss (AL) of 3mm or more) or moderate to severe periodontitis (more than 30 percent of sites with 3mm or more AL). The number of smokers in each group increased from zero percent in the healthy group to 81 percent in the moderate to severe group.

Biomarkers associated with three distinct phases of disease were measured and found to be higher with advancing disease. Cytokines associated with inflammation, connective tissue destruction and changes in bone were measured and correlated with clinical signs of disease. Bacteria identified in the biofilm changed with advancing disease to include more of the “red complex” or periodontal disease specific bugs, P gingivalis, T denticola and T forsythia.

Clinical Implications: We will soon see chairside diagnostics to distinguish between health, gingivitis and advancing periodontitis.

Ramseier, C., Kinney, J., Herr, A., Braun, T., Sugai, J., Shelburne, C., Rayburn, L., Tran, H., Singh, A., Giannobile, W.: Identification of Pathogen and Host-Response Markers Correlated with Periodontal Disease. J Perio 80: 436-446, 2009.
Ultrasonic coolant supply

Heat is produced when ultrasonic scalers convert electrical energy to mechanical vibrations. The temperature inside the tooth should not exceed an 8° temperature change, so water or fluid is used for cooling. Laboratory studies show a 35°C increase in dentin temperature when used without water. Adequate water for cooling should be 20-30 ml/minute.

It is important that the coolant reach the end of the tip when it is placed in a deep pocket. When used on high power settings, the water is often thrown off the instrument before reaching the very tip.

Researchers at the Academic Centre for Dentistry in Amsterdam, The Netherlands compared coolant water flow between five, stand alone, ultrasonic scalers. The study included three units of each brand: EMS PM-400, EMS-PM600, Satelec P-max, Dürr Vector and Dentsply Cavitron. A variety of tips were tested for each unit running them for one minute, unloaded at full and medium water flow settings. Testing was repeated five times for each tip.

Adjusting from high power to medium power corresponded to a 50 percent reduction in fluid for the EMS units, 40 percent for the Cavitron and 25 percent for the Vector. At full water flow rates, the EMS units and the Cavitron provided more than the recommended 20-30 ml/minute. Indicators on the units did not accurately reflect the amount of coolant flowing. Perio tips for the EMS units and the Cavitron allowed less coolant water flow than standard tips. Variation in the amount of fluid was evident when comparing different tips of the same design.

Clinical Implications: When changing ultrasonic inserts, water flow should be checked due to variations between tips.

Koster, T., Timmerman, M., Feilzer, A., Van der Velden, U., Van der Weijden, F.: Water Coolant Supply in Relation to Different Ultrasonic Scaler Systems, Tips, and Coolant Settings. J Clin Perio 36: 127-131, 2009.
Obesity is systemic inflammation

Obesity is considered to be low-grade, systemic inflammation. Adipose tissue cells secrete cytokines similar to those associated with periodontitis. Cytokines play an essential part in the regulation of inflammation, both in causing tissue damage and activating defense mechanisms. Interleukin 6 (IL-6) and Tumor Necrosis Factor-∂ (TNF-∂) are two of more than 50 other bioactive substances known as adipokines.

Researchers at the University of Oulu in Finland investigated the role of IL-6 and TNF-∂ in periodontal disease in overweight subjects. Between 2000 and 2001, the National Public Health Institute of Finland gathered data on a group of more than 8,000 subjects. A subset of 425 subjects from 45 to 74 years, free of diabetes, arthritis and nonsmokers underwent testing for blood serum levels of IL-6 and TNF-∂. Clinical indices were also recorded for probing depths and plaque levels. Body Mass Index (BMI) is a calculation of body weight related to height. A score of 25 or higher is considered overweight, and 30 and higher is considered obese.

An association was found between serum IL-6 levels, deepened periodontal pockets, and elevated BMI scores. No association was found between TNF-∂ levels, probing depths and BMI scores.

It may be that the IL-6 produced by the adipose tissue exerts some biological mechanism making the overweight person more susceptible to periodontal disease. From these findings we see a link, but no cause and effect. Further study is needed.

Clinical Implications: With more research we will better understand the inflammatory processes involved with both obesity and periodontal disease.

Saxlin, T., Suominen-Taipale, L., Leiviskä, J., Jula, A., Knuuttila, M., Ylöstalo, P.: Role of Serum Cytokines Tumour Necrosis Factor-∂ and Interleukin-6 in the Association Between Body Weight and Periodontal Infection. J Clin Perio 36-100-105, 2009.
Obesity linked to risk of periodontitis

Obesity is on the rise and becoming a significant worldwide health problem. According to the CDC, 34 percent of U.S. adults older than the age of 20 were obese in 2006. Obesity is associated with serious life-threatening diseases including cardiovascular disease, cancer, and diabetes. Several recent publications show that obesity is also linked to an increased risk for periodontal disease.

Researchers at the Forsyth Institute in Boston evaluate 745 subjects enrolled in 15 different studies within the Department of Periodontology at the Forsyth Institute. They wanted to determine whether being overweight or obese was associated with a greater risk for periodontal disease. They also compared the bacterial makeup of subgingival biofilm between obese and healthy weight subjects.

Two-thirds of those categorized as healthy/gingivitis subjects had a normal BMI. In contrast, only one-third of subjects with periodontitis had a normal BMI. Subjects considered overweight or obese were three to five times more likely to have periodontal disease. More periodontal disease was observed in obese subjects under 45 years of age compared to non-obese subjects. Overweight and obese subjects, younger than 47 years, were nearly four times more likely to have periodontal disease than those with a normal BMI.

Tannerella forsythia is a bacteria usually associated with deep pockets. Among subjects in the healthy/gingivitis group, T forsythia was found in higher levels in the obese subjects compared to the normal weight subjects.

Clinical Implications: As more research findings are published linking obesity in patients under 47 years of age to a greater risk for periodontitis, more aggressive preventive therapy may be recommended for these patients.

Haffajee, A., Socransky, S.: Relation of Body Mass Index, Periodontitis and Tannerella Forsythia. J Clin Perio 36: 89-99, 2009.
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