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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. 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.
New directions in host modulation

Research over the past 30 years has added to our understanding of the pathogenesis of periodontal disease. Bacteria produce toxins that pass through the epithelial attachment triggering the immune response. White blood cells, particularly neutrophils, come to the area to phagocytize the bacteria, destroying healthy connective tissue in the process. It is only when these white blood cells leave the area that resolution of the infection takes place.

Researchers have identified specific biochemical pathways that bring the neutrophils to the area and specific actions and specific molecules that resolve the inflammation. Acute inflammation must be resolved to protect the tissues. Two resolution agents have been identified: resolvin and protectin. These endogenous molecules trigger cell activity that resolves the inflammation. Resolution takes place from the point of maximum neutrophil infiltration to the loss of these cells from the tissue.

Methods and drugs to block inflammation are considered anti-inflammatory. Another option is moderating the immune response to influence the resolution cascade and trigger resolution. For example, the introduction of resolving agents might trigger changes in the sulcus and tissues that remove the food source for bacteria and therefore the disappearance of these bacteria that trigger inflammation.

Development of drugs that promote resolution rather than just anti-inflammation might be able to use the resolution cascade to lead to a speedy return to health. In addition to the search for pro-resolving agents, new indices will be developed to add to our measurements of inflammation by also measuring signs of resolution.

Clinical Implications: New drugs and periodontal therapeutics will be developed to enhance the resolution of inflammation, not just blocking inflammation.

Bhatavadekar, N., Williams, R.: New Directions in Host Modulation for the Management of Periodontal Disease. J Clin Perio 36: 124-126, 2009.
The effect of xylitol on biofilm formation

The first step in biofilm formation is the development of a salivary protein and enzyme layer on the tooth surface. The enzymes are glucosyltransferase and fructosyltransferase. Bacteria are attracted, form micro-colonies and continue to proliferate. Biofilms associated with caries and periodontal disease are difficult to control. Chemicals that control planktonic cells are not as effective against an organized biofilm. Researchers have investigated anti-adhesion compounds to prevent the bacteria from colonizing tooth surfaces. Xylitol seems to be a promising molecule as a non-cariogenic sweetener that inhibits growth and acid production of Mutans streptococci.

Researchers at the Université Victor Ségalen in Bordeaux, France, compared the effects of xylitol and saline on biofilm growth in the laboratory. Bacteria associated with both caries and periodontal disease were grown in the biofilm: M streptococci, S sobrinus, L rhamnosus, A viscosus, P gingivalis and F nucleatum. Before anaerobic incubation, biofilm samples were treated with one percent or three percent xylitol, saline or left as controls.

The saline treated biofilms were similar to the control biofilms in thickness and bacterial growth. The xylitol treated biofilms lacked cohesive formation and four of the bacterial species were not recovered at all and the other two were significantly reduced.

Clinical Implications: Xylitol reduces both the acid produced by caries causing bacteria and the ability of bacteria to form a biofilm. Xylitol has benefits for prevention of both caries and periodontal disease.

Badet, C., Furiga, A., Thébaud, N.: Effect of Xylitol on an In Vitro Model of Oral Biofilm. Oral Health and Preventive Dent 6: 337-341, 2008.
Comparison of round and triangular toothpicks

Dental floss is recommended for plaque removal between the teeth when no bone loss is evident, however compliance is extremely poor for several reasons. Manual dexterity, motivation, commitment and expense of floss are identified problems. Interdental brushes and toothpicks are suggested for larger interdental areas. Most toothpick research has focused on triangular shaped wooden toothpicks.

Researchers at Franciscan University Center in Rio Grande do Sul, Brazil, compared plaque removal using triangular and round wooden toothpicks in a group of 15 dental students. At baseline, they all received a professional prophylaxis and oral hygiene instructions, including the use of toothpicks. Seven days later the toothpick test was performed under supervision.

Subjects were asked to refrain from all oral hygiene for 72 hours. Plaque scores were taken with the use of fluorescein dye and subjects were given triangular and round toothpicks. With the flip of a coin, they used the triangular toothpick on one half of the mouth and the round toothpick on the other half with 45 seconds for each quadrant. Post-toothpicking plaque scores were taken with the fluorescein dye.

Plaque scores both facially and lingually were reduced from baseline, with no significant difference between triangular and round toothpicks. Slightly more plaque was removed on lingual proximal surfaces using the round toothpick, which was smaller than the triangular toothpick and perhaps passed further through the interdental space. Although some plaque was removed with the toothpicks, significant plaque still remained. The toothpicks did not provide complete plaque removal in this group of dental students.

Clinical Implications: Perhaps these dental students, with healthy interdental papilla, can remove more proximal plaque using dental floss rather than toothpicks.

Zanatta, F., de Mattos, W., Moreira, C., Gomes, S., Rösing, C.: Efficacy of Plaque Removal by Two Types of Toothpick. Oral Health and Prev Dent 6: 309-314, 2008.
Two-visit rather than four-visit SRP preferred by patients

Traditionally, scaling and root planing (SRP) is performed by quadrants one week apart. SRP completed in two close-together visits rather than four weekly visits results in similar clinical outcomes. Both approaches have advantages and disadvantages.

Researchers in Sweden compared quadrant SRP to two long visits scheduled within 24 hours. Besides clinical outcomes, travel time, loss of work and need for pain medication, patient preferences were measured.

The 25 patients all had at least four teeth with probing depths of 5mm or more in each quadrant. One RDH provided the treatment and one clinician performed clinical exams at baseline and eight weeks after the last SRP visit. In addition to oral hygiene instructions, subjects were instructed to rinse twice daily with 0.2 percent chlorhexidine for five weeks.

Both groups showed significant reductions in probing depths, plaque and bleeding. Those treated by quadrant missed more days of work and spent an average of six hours traveling to and from the dental visits compared to two hours for the two-visit group. Nearly half of patients in the quadrant group took pain medications compared to 17 percent in the two-visit group.

When asked at the end their treatment, 60 percent of all subjects preferred the two-visit approach, 16 percent preferred quadrant visits and the rest had no preference. Two-visits were preferred because they wanted it done quickly, less time lost from work and fewer visits with anesthesia.

Clinical Implications: In this study, patients preferred the intensive SRP as it reduced their time away from work and time needed to travel to appointments.

Rann, S., Holmlund, A., Rahm, V.: Clinical, Socioeconomic and Patient Outcomes of Intensive Versus Conventional Scaling and Root Planing in the Treatment of Periodontal Infection. Oral Health and Prev Dent 6: 303-308, 2008.
Ultrasonic scaler tip movement compared

Previous studies recorded ultrasonic tip movement with reflected light in a single plane. Magnetostrictive ultrasonic tips are reported to move in an elliptical direction and piezoelectric ultrasonic tips move in a linear direction with very little lateral motion. Based on these findings, it was assumed, depending on the researcher, that one or the other movement was the better choice for debridement.

Researchers now use 3D laser vibrometry to evaluate tip movements from both longitudinal and lateral directions. Researchers at the University of Birmingham in the UK compared standard and thin tips (three of each) for the piezoelectric EMS MiniMaster, and the magnetostrictive PSP Select by Dentsply. Movements were recorded with the tip moving freely in the air, prior to touching the tooth, and when applied to the tooth surface with a controlled amount of force. These laboratory tests were done on extracted teeth, with the crowns removed and then cut in half longitudinally. Both sides of each tooth root were then mounted in resin. Standardized force was used for all the tips when placed against the mounted root surfaces. Ten repeat measurements were taken for each power setting and for each tip.

All of the ultrasonic tips revealed elliptical motion both held freely in the air or when loaded against the tooth. With higher power, the longer, thinner tips produced increased elliptical movement compared to shorter, broader tips used at lower power. Tip shape and ultrasonic power setting influenced tip movement more than the type of machine, either magnetostrictive or piezoelectric.

Clinical Implications: These findings add to the discussion of which power scaler is the most effective, a question that remains unanswered by scientific research.

Lea, S., Felver, B., Landini, G., Walmsley, A.: Three-Dimensional Analyses of Ultrasonic Scaler Oscillations. J Clin Perio 36: 44-50, 2009.
Curettes versus a piezoelectric power scaler

Removal of subgingival bacteria and calculus are necessary for tissue healing. Because the bacteria can repopulate the sites within weeks, subgingival instrumentation needs to be repeated periodically. Both hand and power scalers are used for this procedure with comparable results reported for each approach.

Researchers at the Aristotle University of Thessaloniki in Greece compared clinical and microbiological results after subgingival instrumentation using either Hu-Friedy Gracey curettes or the EMS Piezon, piezoelectric ultrasonic scaler. A total of 33 patients completed the six month study. At baseline, six subgingival bacterial samples were taken; two taken from from shallow, two from moderate and two from deep pockets. Oral hygiene instructions consisted of the modified Bass technique and interdental brushes. One week later, quadrant treatment appointments began using local anesthesia and either curettes or the ultrasonic scaler.

Patients were seen at three and six months to repeat clinical examinations, microbial sampling, review oral hygiene and repeat subgingival instrumentation with their assigned instrument type.

Both treatment groups showed reductions in clinical indices and bacterial levels. More time was needed for instrumentation using curettes. Six-month plaque levels were slightly higher in the ultrasonic group, 0.49 versus 0.26. Despite these differences, bleeding scores were the same for both groups. According to the researchers, higher plaque levels may explain the higher subgingival counts for T forsythia and T denticola found at six months in the ultrasonic group. The ultrasonic group also showed less gain in clinical attachment than the curette group, 4.78mm versus 4.32mm.

Clinical Implications: According to clinical outcomes, Gracey curettes and the EMS piezoelectric scaler produced similar results after six months. Longer studies are needed.

Ioannou, I., Dimitriadis, N., Papadimitriou, K., Sakellari, D., Vouros, I., Konstantinidis, A.: Hand Instruments Versus Ultrasonic Debridement in the Treatment of Chronic Periodontitis: A Randomized Clinical and Microbiological Trial. J Clin Perio 36: 132-141, 2009.
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