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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. 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.
Stone Age diet reduces gingivitis

Plaque accumulation and subsequently gingivitis have been studied extensively. Within eight days of plaque accumulation an early gingivitis lesion is evident by increased gingival crevicular fluid flow. With no oral hygiene, plaque accumulates and gingivitis results. This happens when the normal diet of refined carbohydrates is continued.

Researchers evaluated a group of 10 people, two families of four, and two single men who lived for one month in a replicated Stone Age environment near the Rhine River in Switzerland. The environment was carefully controlled by archeologic experts and filmed for daily TV viewing. A sports medicine doctor monitored the subjects during the experiment and dental examinations were conducted before and after the experiment. No modern oral hygiene products were provided. Subjects were given a small supply of whole grain barley, wheat and spelt, some salt, herbs, honey, milk and meat from domestic goats and hens, but they were not given enough food for the four weeks. They supplemented their diet by foraging for berries, edible plants and catching fish without nets. They were given Stone Age clothes and provided typical huts.

As expected, plaque levels increased. However, researchers were surprised by a reduction in gingivitis, probing depths and a reduction in bleeding upon probing from 35 percent of sites to 13 percent. Bacteria samples were evaluated from the tongue and all subgingival areas, which revealed a change in the balance of bacteria favoring health rather than disease. It appears the Stone Age diet provided more antibacterial properties and more antioxidants than today’s carbohydrate-rich diet. One medical finding was a reduction in blood pressure.

Clinical Implications: Eliminating sucrose and other refined carbohydrates from the diet changes the bacterial makeup of plaque and reduces gingivitis.

Baumgartner, S., Imfeld, T., Schicht, O., Rath, C., Persson, R., Persson, G.: The Impact of Stone Age Diet on Gingival Conditions in the Absence of Oral Hygiene. J Periodontol 80: 759-768, 2009.
Will daily exercise reduce periodontitis?

Inflammation due to infection stimulates cytokines that destroy connective tissues and also stimulate C-reactive protein (CRP). An elevated CRP level is predictive of heart disease, diabetes and stroke. According to research published in Nature, 30 minutes of exercise five days per week reduces CRP levels as well as several cytokines. Researchers in Australia wanted to know if physical activity provides a preventive benefit for periodontal health.

As part of the National Survey of Adult Oral Health conducted in Australia between 2004 and 2006, researchers evaluated activity levels and periodontal health in 751 subjects.

Clinical probing depths and recession were measured on the mesial, distal and mid facial surfaces of all teeth. No lingual measurements were recorded. Crevicular fluid samples were taken to measure IL-1 and CRP. Moderate periodontitis was defined using the AAP definition, “two or more interproximal sites with clinical attachment level greater than or equal to 4mm, not on the same tooth, or two or more interproximal sites with probing depth greater than or equal to 5mm, not on the same tooth.”

Exercise was considered sufficient if it met the Australian Institute of Health and Welfare recommendation of 30 minutes five times per week. Periodontitis was diagnosed in 48 percent of subjects and of these, 38 percent has elevated inflammatory markers compared to 21 percent of those without periodontal disease.

Subjects were divided into four groups based on time spent exercising. As exercise time increased, CRP and IL- 1 levels decreased in the periodontitis group, but remained the same level for the healthy subjects.

Clinical Implications: Daily physical activity of at least 30 minutes resulted in lower levels of CRP and IL-1, for those with periodontal disease.

Sanders, A., Slade, G., Fitzsimmons, T, Bartold, P.: Physical Activity, Inflammatory Biomarkers in Gingival Crevicular Fluid and Periodontitis. J Clin Perio 36: 388-395, 2009.
Aspiration of oral bacteria leads to respiratory infections

Nosocomial respiratory tract infections account for 10-15 percent of all infections acquired while hospitalized. Twenty to 50 percent of these cases end in death, a total of 20,000. These infections account for approximately $2 billion in hospital care. Researchers in Brazil wanted to know if periodontal disease played a role in these infections.

Adult patients in the intensive care units (ICU) of the Clériston Andrade General Hospital in Feira de Santana, Bahia, Brazil participated. Following a clinical exam, periodontitis was determined if at least four teeth had probing depths of greater than or equal to 4mm, attachment loss of greater than or equal to 3mm and bleeding upon probing.

Of the 103 individuals examined, 22 experienced bronchial infection and 81 did not. Those with the infection were more likely to be intubated or require a tracheostomy, 21 out of 22. Only six out of 81 in the group without bronchial infection were intubated. Periodontitis was not a strong predictor for bronchial infection, however, in most cases, aspiration of oral bacteria was suspected as the cause. The bacterial load might be high with or without signs of moderate periodontal disease, leading to the aspiration.

Several studies point to poor oral hygiene as a predictive factor for aspiration pneumonia, a clinical manifestation of respiratory infection. Future studies should take into consideration the plaque biofilm levels as well as periodontal status when evaluating a possible link.

Clinical Implications: Aspiration of oral bacteria into the lungs might play a role in respiratory infections of hospitalized patients, therefore oral hygiene is of paramount importance for ICU patients.

Gomes-Filho, I., Santos, C., Cruz, S., Passos, J., Cerqueira, E., Costa, M., Santana, T., Seymour, G., Santos, C., Barreto, M.: Periodontitis and Nosocomial Lower Respiratory Tract Infection: Preliminary Findings. J Clin Perio 36: 380-387, 2009.
Quality of life influenced by disease and treatment

Periodontal disease is often called the “silent” disease because people don’t feel pain as the disease progresses, pockets deepen and tissues bleed. The disease does have an impact on the quality of life.

Researchers in England used a questionnaire designed to measure quality of life as it relates to oral health issues. The test group was patients referred to periodontists at the Charles Clifford Dental Hospital in Sheffield. The control group was comprised of periodontally healthy maintenance patients at the same clinic.

On the first visit, patients were interviewed by a dentist asking how often the mouth or teeth affected 14 aspects of daily life. Patients were given a card with five responses to choose from: never, hardly ever, occasionally, fairly often and very often.

Those with periodontal disease were instructed in oral hygiene and received full-mouth root surface debridement, under local anesthesia, within 24 hours by a dental hygienist. Control patients received either oral hygiene instructions alone or with instrumentation as needed.

For each of the next seven days, subjects in both groups answered the quality of life questionnaire over the phone with a dental assistant. The questionnaire was completed once again in person several months after treatment.

The control group of 14 reported no change in their quality of life answers, which revealed extremely low scores. The test group of 13 reported a high level of impact on quality of life at baseline, with scores going down significantly over the seven days post treatment and remaining low at the follow-up.

Clinical Implications: Non-surgical treatment of periodontal disease improved not only the oral health of the patient, but also their reported quality of life.

Jowett, A., Orr, M., Rawlinson, A., Robinson, P.: Psychosocial Impact of Periodontal Disease and It’s Treatment with 24-Hour Root Surface Debridement. J Clin Perio 36: 413-419, 2009.
Do bisphosphonates have a role in periodontal therapy?

Toxins from bacterial plaque biofilm pass through the junctional epithelium, trigger the immune response which in turn stimulates osteoclasts that cause alveolar bone resorption. Bisphosphonates (BPs) have been studied for their ability to control bone resorption, but they are not without serious side effects.

BPs are synthetic yet similar to inorganic pyrophosphates found in blood serum. BPs can chelate calcium and regulate bone mineralization. They are resistant to enzymatic and chemical breakdown and show an affinity for bone due to their calcium chelating properties.

The three generations of BPs can be distinguished by different molecular side chains. Bone is constantly remodeling and in periodontitis, bone resorption out paces bone formation. BPs inhibit bone resorption by altering osteoclast functioning and they can cause apoptosis, or the programmed cell death of osteoclasts. On the negative side, systemic use of BPs both IV and orally have resulted in cases of avascular osteonecrosis of the jaw.

Despite the benefits of preventing bone resorption, BPs interfere with repair and healing of other periodontal tissues by stimulating the release of pro-inflammatory cytokines. While bone loss in controlled, periodontal inflammation continues within the connective tissue.

Local delivery of BPs has been studied. Incorporating BPs into synthetic bone replacement material in animals reveals conflicting results. Stopping bone resorption comes with undesirable side effects.

Clinical Implications: Bisphosphonates can stop bone loss, however the side effects outweigh the benefits at this point. Work is still being done on locally delivered BPs.

Badran, Z., Kraehenmann, M., Guicheux, J., Soueidan, A.: Bisphosphonates in Periodontal Treatment: A Review. Oral Health and Preventive Dentistry 7: 3-12, 2009.
Group vs. individual oral hygiene instructions

Dental disease, specifically caries and periodontal disease, are among the most prevalent health problems in the world. Both of these diseases are triggered by bacterial biofilm accumulating on the teeth. The prevalence of these two diseases affects 95 percent of people in developed countries, according to the World Health Organization. The prevalence of gingivitis is reported to be between 60 and 100 percent in Germany. By contrast, Switzerland reported in 2005 a decrease of 80 percent in gingivitis. This is most likely due to the introduction of intensive preventive measures.

Researchers in Germany compared clinical indices in a group of 104 male military recruits following individual oral hygiene instructions, group instructions, a combination of both instructions, or no instructions. All subjects received a prophylaxis at baseline and a final clinical exam at 13 weeks.

All four groups showed improved plaque, bleeding and gingivitis scores. No differences were evident between the test groups and the control group. The Hawthorne Effect was evident in the results of this study, since simply being in the study motivated the control group to do as well as the three test groups.

The researchers concluded that providing oral hygiene instructions to groups instead of individuals would be more cost effective. It might be just as effective to put all patients into a research study.

Clinical Implications: When you are running short of time for oral hygiene instructions, simply put the patient in a “study” and tell them you will be measuring their oral hygiene next time for the “study.” You should definitely see improvement, at least as much as you would if you took the time to provide individual instructions, according to these findings.

Ziebolz, D., Herz, A., Brunner, E., Hornecker, E., Mausberg, R.: Individual Versus Group Oral Hygiene Instructions for Adults. Oral Health & Preventive Dentistry 7: 93-99, 2009.
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