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Perio Reports

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Perio Reports  Vol. 22 No. 3
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.
Bad breath might inhibit bone regeneration

The two primary volatile sulphur compounds (VSCs) causing bad breath are hydrogen sulfide and methyl mercaptan. VSCs are toxic compounds that cause pathogenic changes in periodontal tissues. VSCs strongly suppress the synthesis of gingival collagen cells through several means, including apoptosis, which is programmed cell death or cell suicide.

Using animal models, researchers have reported that hydrogen sulfide passes through non-keratinized sublingual mucosa in 30 minutes, allowing it to reach the alveolar bone surface quickly. Hydrogen sulfide also increases the permeability of the sulcular epithelium and breaks down basement membrane cells. With increased permeability, bacterial toxins including lipopolysaccharide and prostaglandin can move through the epithelium and into the connective tissue, triggering the periodontal pathogenesis process. VSCs are also released with cell death from subgingival pocket epithelium.

VSCs of bad breath are involved with both onset of periodontal disease and chronic destruction of periodontal tissues. VSCs initiate the periodontal pathogenesis process by enhancing permeability of the junctional epithelium and VSCs are released at the time of cell death during chronic periodontitis.

Researchers in Nippoin Dental University in Tokyo, Japan, wanted to know if the impact of hydrogen sulfide on osteoblasts would prevent bone repair and therefore indirectly lead to ongoing bone loss.

Laboratory studies measured the effect of hydrogen sulfide on osteoblast cells and found evidence in the cascade of reactions that DNA synthesis was reduced, which inhibited osteoblast cell proliferation. Changing the equilibrium between osteoblasts and osteoclasts will allow proliferation of osteoclasts, potentially leading to bone loss.

Clinical Implications: Bad breath is both the result and the cause of tissue destruction in periodontal disease.

Imai, T., Ii, H., Yaegaki, K., Murata, T., Sato, T., Kamoda, T.: Oral Malodorous Compound Inhibits Osteoblast Proliferation. J Perio 80: 2028-2034, 2009.
Grape seed extract might protect against collagen breakdown

Matrix metalloprotienases (MMPs) are released by monocytes and macrophages in response to the bacterial infection of periodontal disease, MMPs are also responsible for connective tissue breakdown. MMPs 1, 3, 7, 8, 9 and 13 are associated with collagen destruction. MMP 1 is collagenase and MMP 9 is gelatinase. To block MMP production, clinicians have used subantimicrobial doses of doxycycline (SDD, Periostat), which controls granulation tissue formation and connective tissue breakdown. Researchers have demonstrated the capacity of other natural substances to inhibit MMPs. Proanthocyanidin from cranberries, green tea polyphenols and flavonoids have all been shown to inhibit specific MMP production or activities. Medical research findings indicate that preventing MMP production can prevent tumor growth.

Researchers at Laval University in Quebec City, Canada and scientists from Tom’s of Maine evaluated the potential of grape seed extract to inhibit MMP secretion in laboratory studies. Macrophages were exposed to varying concentrations of grape seed extract for two hours. The cells were then stimulated with lipopolysaccharide (LPS) from Aa bacteria for one hour and incubated for 24 hours in an anaerobic chamber at 98.6 degrees Fahrenheit (37 degrees Celsius). Control cells were exposed to the grape seed extract but not the LPS.

The grape seed extract inhibited the secretion of the MMPs in the LPS stimulated macrophages. Cells treated with higher concentrations of grape seed extract showed a greater MMP inhibitory effect.

Clinical Implications: We might see grape seed extract formulations used for host modulation treatment of periodontal disease in the future.

La, V., Bergeron, C., Gafner, S., Grenier, D.: Grape Seed Extract Suppresses Lipopolysaccharide-Induced Matrix Metalloproteinase (MMP) Secretion by Macrophages and Inhibits Human MMP-1 and -9 Activities. J Perio 80: 1875-1882, 2009.
Biofilm formation around implants

Peri-implantitis is triggered by the same bacteria that cause periodontitis. Researchers have reported colonization of periodontal pathogens on the inner threads of specific implant designs. External hex implant designs are reported to allow bacterial colonization. However, this bacterial leakage doesn’t seem to affect implant survival rates, based on long term studies. It might however lead to peri-implantitis. The use of one percent chlorhexidine gel or 0.2 percent chlorhexidine solution to disinfect the internal part of the fixture, prior to abutment placement and screw tightening, effectively reduced bacterial colonization for six months.

Researchers at the University of Florida in Gainesville compared two implant designs in the laboratory to evaluate microbial colonization in the microgap at the fixture-abutment interface. One implant design had the Morse-taper connection and the other had a tri-channel internal connection. A third group was created by placing a vertical 0.5mm deep groove on the abutment of the Morse-taper design prior to fixture-abutment connection, to insure bacterial penetration. Ten implants were included in each of the three groups. Implants and abutments were assembled and incubated in anaerobic conditions for five days in a bacterial solution of Aa and Pg, early colonizers of periodontal biofilms.

Only one of 10 Morse-taper implants developed a single colony forming unit of Aa and none of the 10 developed any Pg colonies. All of the implants in the other two groups developed numerous colonies of both bacterial species.

Clinical Implications: The geometry of implant-abutment connections will influence the colonization of periodontal pathogens. The Morse-taper design was less likely to allow bacterial colonization.

Tesmer, M., Wallet, S., Koutouzis, T., Lundgren, T.: Bacterial Colonization of the Dental Implant Fixture-Abutment Interface: An In Vitro Study. J Perio 80: 1991-1997, 2009.
Does instrument choice matter on implants?

Dental implants are susceptible to peri-implantitis due to bacterial biofilm accumulation. Studies have evaluated instrument changes to implant surface with no consensus as to the best choice for removing plaque and calculus.

Researchers at Guarulhos University in Brazil performed laboratory tests to compare surface changes and bacterial adhesions to rough and smooth titanium discs treated with one of four instruments plus a control: Er:YAG laser, plastic curette, metal curette and abrasive air polishing. Surface roughness was measured and images were taken with a scanning electron microscope.

To measure bacterial adhesions, the discs were exposed to saliva for pelicle formation and then S. sanguinis bacteria. Saliva was donated by four healthy young men who collected saliva for one hour per day for seven days. The saliva was pooled, frozen, and pasteurized before use. Following incubation, some discs were viewed microscopically and others were rinsed to dislodge free floating bacteria and then placed in sterile tubes with water and shaken vigorously for two minutes to dislodge the attached bacteria. The liquid was then plated and grown to determine the number of colony forming units for each disc.

No changes on the rough titanium surfaces were seen with any of the test instruments compared to control discs. On smooth discs, only metal curettes increased surface roughness. Bacterial adhesion was nearly the same for all surfaces, including the control discs that received no treatment.

Clinical Implications: These laboratory findings suggest very little difference between instruments used on implant surfaces. The real test is how the tissue responds clinically, which depends on both instrumentation and daily oral hygiene.

Duarte, P., Reis, A., de Freitas, P., Ota-Tsuzuki, C.: Bacterial Adhesion on Smooth and Rough Titanium Surfaces After Treatment with Different Instruments. J Perio 80: 1824-1832, 2009.
Sex hormones increase bleeding on probing

Hormonal fluctuations during puberty, pregnancy and menopause impact the periodontal tissues. Very little research has been reported about the impact of hormonal changes during the menstrual cycle and even less about the impact of these changes during premenstrual syndrome (PMS). Estimates suggest that 80 percent of women experience PMS, which occurs seven to 10 days before menstruation.

Researchers at Istanbul University in Turkey monitored a group of 27 female dental students to determine if changes in sex hormones impacted clinical signs of gingivitis. Plaque scores were recorded weekly for two months. Probing, bleeding and gingival crevicular fluid (GCF) samples were taken on the first day of the period, the estimated day of ovulation and the estimated day of highest progesterone secretion. Blood samples were taken to determine these days. Duration and regularity of menstrual cycles were also reported. Oral hygiene instructions were given at the start of the study to insure optimal gingival health.

Plaque levels remained the same during the study while bleeding scores, GCF levels and IL-1 scores were highest when progesterone levels were at their peak.

Complaints of PMS were reported by 12 of the women and six of these women also reported oral complaints during this time. Menstrual cycles were reported to be 20 to 32 days with duration of four to six days.

Progesterone receptors are more evident following ovulation, however little is know about receptor levels in the gingiva. Complaints of gingival tissue irritation during PMS and changes in the tissues during the menstrual cycle might be due to increased progesterone receptor expression in the gingival tissues.

Clinical Implications: An unexpected increase in bleeding on probing scores for a periodontally healthy female patient might be due to hormonal changes associated with menstruation.

Baser, U., Cekici, A., Tanrikulu-Kucuk, S., Kantarci, A., Ademoglu, E., Yalcin, F.: Gingival Inflammation and Interleukin 1-Beta and Tumor Necrosis Factor- Alpha Levels In Gingival Crevicular Fluid During the Menstrual Cycle. J Perio 80: 1983-1990. 2009.
Photodynamic therapy is useful adjunct

The goal of periodontal therapy is to return the tissues to homeostasis, where the tissues and the oral biofilm are in balance. Mechanical instrumentation is the standard treatment for periodontal disease. Antibiotics are used in some cases, in either local or systemic form.

Another adjunct to scaling and root planing (SRP) is antimicrobial photodynamic therapy. Following SRP, a photosensitizer formulation made of 0.01 percent methylene blue in a phosphate buffered system with viscosity enhancers, sweetener and a preservative agent is applied subgingivally, followed by a 60 second non-thermal diode laser application. The laser activates the methylene blue which has attached to cell walls of subgingival bacteria, generating highly reactive oxygen species, killing the bacteria and speeding periodontal healing. This technology is currently available in Canada and Europe from Ondine Biopharma as Periowave.

Researchers at the University of Washington in Seattle and a scientist from Ondine Biopharma designed laboratory studies using 96 well plates to test the effectiveness of the Periowave technology against Pg bacteria, bacterial proteases and human host derived cytokines.

The Periowave was effective at killing the Pg bacteria and at the same time inactivating the protease released by the bacteria. To test the Periowave against the destructive host derived cytokines interleukin and tumor necrosis factor, researchers used human umbilical vein endothelial cells. The Periowave was effective in inactivating both of these cytokines.

Clinical Implications: Antimicrobial photodynamic therapy works by killing the bacteria and inactivating bacterial virulence factors and host cytokines that compromise periodontal healing. This technology should soon be available in the U.S.

Braham, P., Herron, C., Street, C., Darveau, R.: Antimicrobial Photodynamic Therapy May Promote Periodontal Healing Through Multiple Mechanisms. J Perio 80: 1790-1798, 2009.
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