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Perio Reports

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Perio Reports  Vol. 22 No. 2
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.
Toothbrushing time is important

Despite the fact that periodontal disease begins between the teeth, toothbrushing remains the primary method of oral hygiene. However people do not spend adequate time brushing. Average toothbrushing time is between 30 and 60 seconds.

Researchers for GlaxoSmithKline in collaboration with Hill Top Research in Cincinnati, Ohio, compared various brushing times to see if plaque removal related to the time spent brushing. The adult subjects participated in six timed and supervised brushing sessions on different days. Brushing times tested were 30, 45, 60, 120 and 180 seconds. Subjects were randomly assigned to each of the brushing times and the clinic supervisor informed the person at the start of brushing of the time to be measure and also let them know when each quarter of the time elapsed. Aquafresh manual toothbrushes and Aquafresh toothpaste were used, with 1.5 grams of toothpaste put on a new brush for each subject. An additional 60 second brushing was done without toothpaste.

Longer brushing times resulted in more plaque removal, but even at 180 seconds, significant plaque remained along the gingival margins. Brushing for 180 seconds removed 55 percent more plaque than brushing for 30 seconds. Brushing for 120 seconds removed 26 percent more plaque than 45 seconds of brushing.

Brushing without toothpaste for 60 seconds removed as much plaque as brushing with toothpaste for 60 seconds. The toothpaste provides no added benefit for plaque removal.

Clinical Implications: Toothpaste should not be viewed as an abrasive for plaque removal, but rather for the ingredients it might deliver to the oral cavity. Encourage patients to brush for at least two minutes.

Gallagher, A., Sowinski, J., Bowman, J., Barrett, K., Lowe, S., Patel, K., Bosma, M., Creeth, J.: The Effect of Brushing Time and Dentifrice on Dental Plaque Removal In Vivo. J Dent Hyg 83: 11-116, 2009.
Dry brush inside first

This study was published in JADA in 1998, and adds to the information presented in the recent toothbrushing study on this page.

Toothbrushing instructions focus primarily on brush placement and brushing stroke without focusing on where to start or what order the teeth should be brushed.

Researchers video taped subjects brushing without their knowledge and found most followed an erratic pattern, brushing maxillary facial surfaces first, returning there several times, and brushing lingual surfaces last, if at all, and brushing less than one minute.

Twenty-nine private practice RDHs across the United States tested the “dry brushing inside first’ approach on a total of 126 recall patients. Baseline data included bleeding on probing and calculus scores measured on the lingual surfaces of the mandibular teeth.

Patients were simply instructed to brush the inside of their bottom teeth first with a dry toothbrush, no water and no toothpaste. When their mouths felt clean and tasted clean they rinsed their brushes with water and brushed again with toothpaste. Bleeding and calculus scores were recorded again at their next recall visit, an average of six months later.

Bleeding scores were reduced 55 percent overall. Calculus scores were reduced 58 percent for all mandibular lingual surfaces and 63 percent for the anterior section alone. Notes from the examiners indicated that patients reported brushing longer than usual as a result of this approach. Some of the patients were so excited with the results that they made unscheduled visits to the dental office to point out their lack of calculus and improved gingival health.

Clinical Implications: Instructing patients to dry brush first until the teeth feel clean and taste clean and then add toothpaste will lead to longer brushing times and more effective plaque removal.

O’Hehir, T., Suvan, J. Dry Brushing Lingual Surfaces First. JADA 129: 614, 1998.
Virulence of bacteria measured

The number of different bacterial species capable of colonizing the oral cavity is now over 700. Those found in subgingival plaque biofilm number just over 400. Oral bacteria fall into three categories: commensals, opportunistic pathogens and periodontal pathogens. The commensals can co-exist in the oral cavity without causing disease. Opportunistic pathogens are found in health, and can also cause disease under the right conditions. Periodontal pathogens are only found in disease and either start or exacerbate chronic periodontitis.

Epithelial cells release cytokines in response to pathogens, depending on the virulence of the bacteria. To measure the reaction of epithelial cells to bacteria, researchers at the University of Louisville grew epithelial cells in the lab and then introduced various oral bacteria, and measured the cytokine release by the tissue cells. The epithelial cells were grown from tissue removed from three periodontally healthy patients undergoing crown lengthening procedures.

The four bacteria tested were: P gingivalis, A actinomycetemcomitans, F nucleatum, and S gordonii. The pro inflammatory cytokines interleukin 1, (IL-1), IL-6 and IL-8 were measured.

S gordonii is an early commensal colonizer of oral biofilm and stimulated very little cytokine production by the epithelial cells.

A actinomycetemcomitans [Aa] and P gingivalis [Pg] are confirmed periodontal pathogens and they did stimulate cytokine production. Aa stimulated IL-8 production and Pg stimulated IL-1 production.

F nucleatum is an opportunistic pathogen found in both health and disease and in this study elicited the highest levels of all three pro-inflammatory cytokines, IL-1, IL-6 and IL-8.

Clinical Implications: A variety of bacteria live in oral biofilm, some harmless and others harmful.

Stathopoulou, P., Benakanakere, M., Galicia, J., Kinane, D.: Epithelial Cell Pro-Inflammatory Cytokine Response Differs Across Dental Plaque Bacterial Species. J Clin Perio 37: 24-29, 2010.
Periodontitis linked to pre-eclampsia

Preterm birth is a major cause of infant death worldwide. Preterm levels are reported at 12 percent in the United States, five to 10 percent in European countries and six percent in France, where this study was done. Spontaneous preterm labor accounts for 65 percent of cases and 35 percent are from identified factors, primarily pre-eclampsia (pregnancy induced high blood pressure). Preterm deliveries are identified as either spontaneous preterm (65 percent) or induced preterm (35 percent), due to medical conditions and including Caesarean section. Infection and inflammation also play a role in preterm delivery, primarily genital and uterine infections.

Researchers in France evaluated women participating in the large scale study of women giving birth in three French regions (six hospitals) between 2003 and 2006 (Epipap). Women were invited to participate in the dental study. Just over 1,000 women with preterm deliveries and 1,000 women with full-term deliveries were included in the study. Women who didn’t speak French or had a variety of medical conditions were excluded from the study. Periodontal exams were done in the hospital a few days after giving birth.

Women with preterm deliveries were often of nationalities other than French, low educational level, lived alone, unemployed, more missing teeth, heavy calculus, smoked and were overweight prior to pregnancy. Considering all potential causes of preterm delivery, periodontitis was significantly associated with preterm delivery due to pre-eclampsia.

Clinical Implications: Although not the major cause of preterm delivery, pregnant patients should be informed of the risks of periodontal disease and the value of prevention and treatment of periodontal disease during pregnancy.

Nabet, C., Lelong, N., Colombier, M., Sixou, M., Musset, A., Goffinet, F., Kaminski, M: Maternal Periodontitis and the Causes of Preterm Birth: The Case-Control Epipap Study. J Clin Perio 37: 37-45, 2010.
GCF markers for local and systemic inflammation

C-reactive protein (CRP) and interleukin 1 (IL-1) are both biomarkers of inflammation. CRP is synthesized by the liver and when elevated in response to inflammation, it creates what is referred to as an acute phase reaction. This explains why CRP is considered an acute phase protein. The purpose of CRP is to bind to substances on the surface of dead or dying cells, including bacteria, in order to activate the compliment system. This is a biochemical cascade of events to clear pathogens from the body. CRP is usually measured in the blood, but recently it has been measured in gingival crevicular fluid (GCF).

IL-1 is released locally in periodontal tissues by epithelial cells, neutrophils, macrophages, and fibroblasts. IL-1 is part of the immune system’s defense against infection.

Researchers at the University of Adelaide in Australia measured CRP and IL-1 in GCF samples of nearly 1,000 subjects taking part in the 2004-2006 Australian National Survey of Adult Oral Health to determine the connection to periodontitis. Just over 400 subjects were diagnosed with periodontitis and over 500 were healthy controls. The odds of having periodontitis were increased by 2.5 when IL-1 was detected in CGF. Those with CRP detected in GCF were twice as likely to have periodontitis. These increased levels of biomarkers in GCF might be the result of periodontitis or the consequence of systemic conditions such as cardiovascular disease, diabetes or rheumatoid arthritis.

Clinical Implications: Increased levels of biomarkers in gingival crevicular fluid indicate periodontal disease and might also indicate inflammatory systemic conditions such as diabetes and cardiovascular disease.

Fitzsimmons, T., Sanders, A., Bartold, P., Slade, G.: Local and Systemic Biomarkers in Gingival Crevicular Fluid Increase Odds of Periodontitis. J Clin Perio 37: 30-36, 2010.
Oxidative stress in periodontal pockets

Periodontal disease is triggered by bacteria, but the damage to connective tissue and bone is done by the body’s own immune system. White blood cells travel from blood vessels in healthy connective tissue to the sulcus to attack the bacteria. On the way they release enzymes as they pass through the tissue causing destruction of healthy cells along the way and causing release of free radicals and triggering oxadative stress. This cascade of events is complex, destructive and leads to the expression of pro-inflammatory genes that continue the tissue damage.

In defense, healthy cells produce antioxidants, like glutathione, a small molecule made from three amino acids that can neutralize free radicals. Higher levels of glutathione are evident in the gingival crevicular fluid of periodontal pockets, as a measure of defense activity. These levels are higher than in a healthy sulcus.

Researchers at the University of Birmingham in the United Kingdom compared glutathione levels in gingival crevicular fluid from 20 subjects with moderate periodontal disease and 20 healthy controls. At baseline, levels were much lower in healthy controls. Three months following non-surgical therapy, glutathione levels in those with periodontal disease were reduced and were closer to those of the healthy controls.

Clinical Implications: Periodontal tissue destruction results from oxidative stress and the release of free radicals. Future periodontal treatment will likely include the impact of antioxidants in the treatment and control of periodontal disease.

Grant, M., Brock, G., Matthews, J., Chapple, I.: Crevicular Fluid Glutathione Levels in Periodontitis and the Effect on Non-Surgical Therapy. J Clin Perio 37: 17-23, 2010.
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