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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. 5
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.
Perio therapy reduces severity of arthritis

Rheumatoid arthritis (RA) and periodontal disease are both chronic inflammatory conditions with local destruction of hard and soft tissues. Both diseases release cytokines from inflammatory cells. Progression of one disease can negatively impact the other and vice versa.

The severity of RA is measured with The Disease Activity Score (DSA28). This combines the erythrocyte sedimentation rate, the number of joints, out of 28, that are swollen and tender, and the general health of the patient indicated on a visual analog scale of 1 to 100.

Researchers at Case Western Reserve University in Cleveland, Ohio, provided non-surgical periodontal therapy to 20 patients diagnosed with RA. A second group of 20 with RA served as controls. All subjects were taking medications to control RA and half the group was taking an anti-TNFa drug. Those taking the anti-TNFa drug were randomly assigned to both treatment and control groups.

Baseline examinations included blood tests, DSA28, and periodontal clinical indices. Half the group received SRP and oral hygiene instructions and all subjects were evaluated six weeks later.

Those receiving non-surgical therapy showed improved periodontal health, and those taking the TNFa drug showed greater healing than those not taking the drug. SRP subjects not taking anti-THFa drugs showed significant improvement in periodontal indices as well as indicators of RA severity compared to controls, either taking TNFa or not. Serum TNFa levels were reduced for those receiving periodontal treatment compared to controls.

Clinical Implications: Treatment of moderate to severe periodontitis might relieve the symptoms of rheumatoid arthritis.

Ortiz, P., Bissada, N., Palomo, L., Han, Y., Al-Zahrani, M., Panneerselvam, A., Askari, A.: Periodontal Therapy Reduces the Severity of Active Rheumatoid Arthritis in Patients Treated with and without Tumor Necrosis Factor Inhibitors. J Perio 80: 535- 540, 2009.
Flossing causes bacteremia

Oral bacteria are implicated in approximately 20 percent of infective endocarditis (IE) cases. The mortality rate for IE cases caused by the oral bacteria Viridans streptococci is six to 16 percent. American, European and Australian guidelines for prevention of IE recommend antibiotic prophylaxis with certain dental procedures. In contrast, British guidelines do not recommend antibiotic prophylaxis since bacteremia can be caused by oral hygiene.

Researchers at Westmead Hospital in Sydney, Australia, evaluated blood samples from 60 subjects with and without periodontal disease to detect bacteremia immediately following professional dental flossing. Blood samples were also taken at baseline, 30 seconds and 10 minutes following full mouth flossing.

Flossing with waxed floss took between four and five minutes and longer for those with periodontal disease. Bleeding upon flossing was seen in 30 percent of papilla in the periodontitis group compared to eight percent in the healthy group. Twelve subjects in each group were positive for bacteremia at 30 seconds. After 10 minutes, eight subjects in the periodontitis group and four in the healthy group were positive for bacteremia. It might take longer to clear the number of bacteria associated with periodontitis, thus twice as many more positives at 10 minutes in the periodontitis group.

Those who tested positive at 30 seconds did not necessarily test positive at 10 minutes. Those who tested positive at both 30 seconds and 10 minutes sometimes had different bacteria. Viridans streptococci were identified in seven of the periodontitis samples and four of the healthy samples. Clinical indices were not predictive of bacteremia.

Clinical Implications: Flossing may be similar to some dental procedures as a risk factor for IE.

Crasta, K., Daly, C., Mitchell, D., Curtis, B., Stewart, D., Heitz-Mayfield, L.: Bacteraemia due to Dental Flossing. J Clin Perio 36: 323-332, 2009.
Perio and preterm, low birth weight: Is there a link?

Studies support both sides of this debate. A recent meta analysis found women with periodontitis two to three times more likely to have a preterm, low birth weight baby, while other studies show no link at all.

The results of a multi-center study measuring the effects of periodontal therapy on birth outcomes were published in the New England Journal of Medicine in 2006 as the Obstetrics and Periodontal Therapy Study (OPT). This report further analyzes data from the OPT study.

Periodontitis requirements for study subjects were four or more teeth with probing depths of 4mm or more, attachment loss of 2mm and bleeding upon probing for at least 35 percent of sites. Restorative, endodontic procedures and extractions were recommended before week 21 for 59 percent of the women and treatment was completed by 73 percent of them. All subjects were seen monthly until delivery.

Half the group received SRP and half did not. Rescue periodontal treatment was offered to 26 of 60 control patients with disease progression of 3mm or more. Treatment was offered, but not always accepted.

Preterm deliveries occurred for 75 out of 812 women or nine percent of the subjects. Periodontal disease progression was not linked with preterm deliveries. Pre-eclampsia or pregnancy associated hypertension was found to be a significant risk factor for preterm delivery.

Clinical Implications: It’s safe to provide non-surgical periodontal therapy during pregnancy. Data are not conclusive that periodontal disease progression leads to preterm delivery.

Michalowicz, B., Hodges, J., Novak, M., Buchanan, W., DiAngelis, A., Papapanou, P., Mitchell, D., Ferguson, J., Lupo, V., Bofill, J., Matseoane, S.: Change in Periodontitis During Pregnancy and the Risk of Pre-Term Birth and Low Birthweight. J Clin Perio 36: 308-314, 2009.
Smoking changes the free radical/antioxidant balance

Smoking induces oxidative stress in the body, allowing for an increase in reactive oxygen species (ROS) or free radicals. These small molecules are a by-product of oxygen metabolism and have an important role in cell signaling. There is a balance between these free radicals and antioxidants like superoxide dismutase (SOD), an enzyme that converts superoxide into oxygen and hydrogen peroxide. Antioxidants are an important defense system for nearly all cells exposed to oxygen. Reduced SOD levels lead to tissue damage and bone loss.

Researchers at the Manipal College of Dental Medicine in India measured the influence of smoking on SOD levels in saliva and GCF of 70 men with moderate, mild or no periodontitis. Since smoking is not very prevalent among women in India, only men were included in this study. Smokers were grouped as light (less than 10 cigarettes per day) and heavy (more than 10 cigarettes per day). Ten of the subjects did not smoke and were controls.

GCF samples were taken from the site with the deepest probing depth and most attachment loss. Unstimulated saliva was collected for analysis. Complete periodontal records were also made for each subject.

SOD levels were progressively lower from periodontally healthy non-smokers to heavy smokers with moderate disease. Heavy smokers had lower SOD levels than light smokers. Perhaps improving antioxidant levels will motivate smoking cessation.

Clinical Implications: Encourage smoking cessation, which will allow the body to reestablish a balance between free radicals and antioxidants, leading to better periodontal health.

Agnihotri, R., Pandurang, P., Kamath, S., Goyal, R., Ballal, S., Shanbhogue, A., Kamath, U., Bhat, G., Bhat, K.: Association of Cigarette Smoking with Superoxide Dismutase Enzyme Levels in Subjects with Chronic Periodontitis. J Perio 80: 657-662, 2009.
Hopeless teeth don’t harm adjacent teeth

Strategic extractions are often recommended to preserve the ridge or for implant placement. However, patients don’t always want these teeth extracted.

Researchers at Okayama University in Japan evaluated the charts of 25 non-smoking, systemically healthy patients after an average of eight years of maintenance therapy. Prior to treatment in the graduate student clinic, these patients had a total of 113 teeth with a poor prognosis recommended for extraction. Poor prognosis was defined as teeth that had 75 percent bone loss, probing depths 8mm or more, Class II or III furcation involvement and Class III mobility. Patients had one to 13 hopeless teeth, the average being five hopeless teeth per subject.

Of the 113 hopeless teeth, 76 were still retained at the time of examination for this study. All patients had undergone non-surgical therapy and periodontal maintenance for several years. Probing depths, attachment levels and bone loss were no greater next to the hopeless teeth compared to non-adjacent teeth. In fact, a fraction of a millimeter greater probing depth reduction was seen on surfaces adjacent to hopeless teeth compared to non-adjacent teeth. Non-surgical therapy was effective in preventing the progression of disease in the hopeless teeth as well as for those teeth adjacent to the hopeless teeth.

Risk factors identified for these hopeless teeth include: initially deep probing depth, furcation involvement and mobility.

Clinical Implications: Retention of hopeless teeth is not necessarily detrimental to patients when effective non-surgical therapy is provided.

Ikuni, D., Yamamoto, T., Takeuchi, N.: Retrospective Study of Teeth with a Poor Prognosis Following Non-Surgical Periodontal Treatment. J Clin Perio 36: 343- 348, 2009.
Non-surgical therapy reduces C-reactive protein

Severe periodontitis is found in 10 percent of adults and 30 percent of those older than 50 years of age. It is implicated in the onset and development of other chronic diseases including cardiovascular, diabetes, rheumatoid arthritis, and respiratory disease. Similar inflammatory pathways might be the link, with cytokines and C-reactive protein associated with these chronic inflammatory conditions.

Researchers at University of Sao Paulo in Brazil evaluated the markers of inflammation in 25 otherwise healthy, non-smoking individuals with periodontitis after providing non-surgical periodontal therapy. A group of 17 periodontally healthy individuals served as controls. Both groups received oral hygiene instructions and the periodontal disease subjects were all treated weekly by one periodontits to complete non-surgical therapy. Thereafter, these patients were seen every 15 days for three months. All subjects underwent clinical exams and blood work at baseline and three months after treatment was complete for those in the disease group.

C-reactive protein levels should be zero. The average score for the disease group was 1.2 and in the healthy group, 0.9. At three months, the control group was unchanged and the disease group has a score of 0.6 or a 50 percent reduction. The cytokine IL-6 was also reduced 50 percent in those receiving therapy. This study confirms that periodontal disease by itself can cause increases in IL- 6 and C-reactive protein.

Clinical Implications: Providing periodontal therapy is important to avoid elevated levels of IL-6 and C-reactive protein.

Marcaccini, A., Meschiari, C., Sorgi, C., Saraiva, M., de Souza, A., Faccioli, L., Tanus-Santos, J., Novaes, A, Gerlach, R.: Circulating INterleukin-6 and High- Sensitive C-Reactive Protein Decrease After Periodontal Therapy in Otherwise Healthy Subjects. J Perio 80: 594-602, 2009.
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