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Perio Reports


Perio Reports  Vol. 22 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.
Passive smoke is harmful to kids

Smoking is considered the number-one risk factor for periodontal disease. Additionally, adults exposed to passive smoke are 1.6 times more likely to have periodontal disease. Passive smoke is linked to many health problems in children, asthma, ear infections, respiratory tract infections, bronchitis and pneumonia. Cotinine is a breakdown product of nicotine and a commonly used biomarker for tobacco use.

Researchers at Kirikkale University in Turkey are the first to examine the connection between passive smoking and periodontal health in children. They evaluated children under the age of 12, to avoid confounding their findings with young smokers. Two groups were evaluated, 51 children of smokers and 58 unexposed children. Clinical indices were recorded at six sites per tooth, on four teeth per child, maxillary molars and central incisors. Saliva and urine samples were taken to measure cotinine levels.

Salivary cotinine levels were twice as high in children of smokers compared to children of non-smokers. Clinical indices did not show a difference between groups, except a slightly greater clinical attachment level in children exposed to passive smoke.

However, there does seem to be an influence on periodontal health in children exposed to passive smoke, based on cotinine levels. Although not directly causing periodontal disease, periodontal tissue metabolism might be altered, explaining the loss of attachment. Based on other research, exposure to passive smoke delays eruption of permanent teeth in children, and might impact craniofacial development by reducing nasal volume.

Clinical Implications: Parents who smoke around their children should be warned of the potential harmful effects passive smoke can have on their children’s periodontal health.

Erdemir, E., Sönmez, I., Oba, A., Bergstrom, Çaglayn, O.: Periodontal Health in Children Exposed to Passive Smoking. J Clin Perio 37: 160-164, 2010.
Academic stress increases gingiva inflammation

Stress activates release of cortisol from the adrenal cortex and has been shown to elevate pro-inflammatory cytokines in the gingival tissues. Researchers at the Karolinska Institute in Sweden evaluated cytokine levels in gingival crevicular fluid (GCF) and cortisol in saliva in 20 third-year dental hygiene students as they completed three weeks of academic testing, both written and oral. Measurements were also taken four weeks after the school exams. Clinical examinations were done before and after. Students were asked to rate their stress on a visual analog scale (VAS).

Surprisingly, five of the 20 students were smokers but clinical indices were similar between smokers and non-smokers. Plaque, gingivitis, bleeding and probing depths were slightly, yet significantly worse before compared to after the exams. VAS scores were higher before the exam compared to after and cortisol levels paralleled these findings.

GCF samples were collected and tested for IL1, IL4, IL6, and IL10. During the exams, IL6 and IL10 were significantly elevated. Previous research shows that IL1 is inhibited during stress, which would explain why IL1 levels remained the same, despite clinical signs of inflammation.

From these findings, increased gingival inflammation might be due to a direct effect of stress on the immune system or from increased plaque accumulation due to reduced attention to oral hygiene during the time of stress.

Clinical Implications: Let your college student patients know that stress associated with test taking is likely to increase plaque levels and gingivitis. This is a good time to consider additional preventive strategies.

Johannsen, A., Bjurshammar, N., Gustafsson, A., The Influence of Academic Stress on Gingival Inflammation. Int J Dent Hygiene 8: 22-27, 2010.
Visceral fat linked to periodontitis

Obesity is on the rise and a risk factor for diabetes and heart disease. In Korea, obesity increased from 26 percent for men and 27 percent for women in 1998 to 34 percent for men and 29 percent for women in 2002. Death due to diabetes accounted for seven percent in 1985 and jumped to 24 percent in 2004.

Distribution of fat is more important than the amount of fat when predicting heart disease. Several measures of obesity are used in research including BMI, waist circumference to hip ratio and visceral fat area. Visceral fat is an electronic measure of fat and lean tissue, similar to underwater weighing.

Researchers from several universities in Korea participated in the periodontal portion of a large, 20-year community based study. Ten teeth were assessed using the community periodontal health index, two molars in each posterior sextant and the upper right and lower left central incisors. Each sextant was given a score and the highest score became the patient score. The total number of sextants with periodontal disease were counted.

Of the 1,046 patients evaluated, 11 percent had no periodontal problems, 57 percent had gingivitis and 32 percent had periodontitis. The periodontitis group brushed less frequently and were heavy smokers and drinkers.

All four obesity indices correlated with each other. Removing other factors, a high visceral fat area score showed that men between 45-54 years were 3.30 times more likely to have periodontal disease.

Clinical Implications: Visceral fat might be considered a risk factor for periodontal disease. Watch for future research in this area to determine if weight reduction improves periodontal health.

Han, D., Lim, S., Sun, B., Paek, D., Kim, H.: Visceral Fat Area-Defined Obesity and Periodontitis Among Koreans. J Clin Perio 37: 172-197, 2010.
Chemical markers of periodontal healing

Matrix metalloproteinases (MMPs) are enzymes released from neutrophils and responsible for destroying periodontal tissues. MMP-8 accounts for 80 percent of the collagenase measured in GCF and is reduced by approximately 50 percent following successful periodontal therapy. Other MMPs are also measured in the GCF.

Researchers at the University of Sao Paulo in Ribeirao Preto, Brazil, measured clinical indices and MMP levels in GCF in 27 test patients and 15 controls before and following non-surgical therapy. Patients all had at least 20 teeth and were between 35 and 55 years of age. Controls were periodontally healthy and only received oral hygiene instructions and suprgingival prophylaxis. Test subjects had moderate periodontitis and were treated over a period of three to four weeks by one periodontist. Instrumentation with Gracey curettes and the Cavitron ultrasonic scaler were done using local anesthesia.

Clinical indices following treatment were significantly improved in the test group. The control group showed a reduction in bleeding on probing, likely due to the oral hygiene instructions and prophylaxis. GCF flow rates remained the same from baseline to three months for both control and test subjects. MMP-8 levels were unchanged in the control group, while the test group showed significant reductions three months after non-surgical therapy. Reductions in MMP8 levels following non-surgical therapy appear to be an accurate measure of tissue healing.

Clinical Implications: We might soon see gingival crevicular fluid “dip stick” tests for several periodontitis markers that can be used to monitor healing.

Marcaccini, A., Meschiari, C., Zuardi, L., de Sousa, T., Taba, M., Teofilo, J., Jacob-Ferreira, A., Tanus-Santos, J., Novaes, A., Gerlach, R.: Gingival Crevicular Fluid Levels of MMP-8, MMP- 9, TIMP-2, and MPO Decrease After Periodontal Therapy. J Clin Perio 37: 180-190, 2010.
Plasma - new “cold” technology

Plasma is one of four kinds of matter in the universe   the others being solids, liquids and gases. Although the least recognized, plasma makes up 99 percent of the universe and is an efficient source of energy, driven by charged particles, ions and electrons. Plasma or ionized gas can be cool to extremely hot. For dense, hot plasma think of the sun, lightening and stars. For the colored glow of plasma, think of the aurora borealis. Researchers are now testing room temperature plasma technology to replace liquid chemicals or heat for decontamination, disinfection and sterilization.

Plasma medicine research uses low temperature atmospheric pressure plasma (LTAPP) or cold plasma to kill harmful bacteria in air, liquids and on hard and soft surfaces. Direct plasma exposure occurs when the plasma plume discharge comes in close contact with the target, whereas, indirect exposure occurs when there is “remote” exposure, in other words, plasma enters a chamber through a tubing system. Plasma research is being done to inactivate pathogenic microorganisms in food, water, air, instrument sterilization and for treating open wounds.

Research into dental/DH applications is underway at the Dental Hygiene Research Center, Old Dominion University with a “plasma pencil” to reach small, hard to access areas. About the size of a power toothbrush, this technology has the capability to kill S mutans, P gingivalis, T denticola, and T forsthensis by rupturing cell walls. Just imagine a tabletop unit providing a thin plasma plume killing microorganisms in carious lesions and periodontal pockets.

Clinical Implications: Atmospheric pressure plasma is a new and exciting approach to sterilization, disinfection, decontamination and wound healing.

McCombs, G., Darby, M.: New Discoveries and Directions for Medical, Dental and Dental Hygiene Research: Low Temperature Atmospheric Pressure Plasma. Int J Dent Hygiene 8: 15-20, 2010.
Tracking risk, compliance and tooth loss

Following active periodontal therapy, three to four maintenance visits per year are recommended. Patients at greater risk of recurrence might need to be seen more frequently, and those not at risk might only need to be seen once each year. To determine if risk assessment and compliance with periodontal maintenance visits influenced tooth loss, researchers at the University of Bern in Switzerland evaluated the charts of 160 perio maintenance patients who had been followed for at least 10 years. The average patient age was 56 years.

Using the Periodontal Risk Assessment model developed at the University of Bern in 2003, patients were evaluated for bleeding, probing depths 5mm or more, teeth lost, radiographic bone loss related to person’s age, systemic conditions like diabetes and smoking. Patients were determined to be of low, moderate or high risk and scheduled for perio maintenance accordingly. Low risk patients were seen once each year, moderate risk twice each year and high risk every three to four months.

Fifty-eight percent of patients were treated at the university and the others were referred back to their general dentist for maintenance. All the low risk patients complied with their yearly visits. Erratic compliers accounted for 16 percent of moderate risk patients and 48 percent of high-risk patients. Tooth loss was three times greater among moderate and high risk, erratic compliers. Overall, half the patients in this study maintained all their teeth during the 10-year study.

Clinical Implications: Those at greatest risk of periodontal disease can improve outcomes by complying with frequent periodontal maintenance visits and optimal oral hygiene.

Matuliene, G., Studer, R., Lang, N., Schmidlin, K., Pjetursson, B., Salvi, G., Brägger, U., Zwahlen, M.: Significance of Periodontal Risk Assessment in the Recurrence of Periodontitits and Tooth Loss. J Clin Perio 37: 191-199, 2010.
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