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Perio Reports


Perio Reports  Vol. 22 No. 11
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.
Calcium-Modified Acid Candies for Cancer Patients

Patients receiving head and neck radiation therapy experience reduced saliva flow, leading to dry mouth and complications with swallowing. These patients often suck acid candies to stimulate salivary flow, while eroding tooth enamel at the same time.

Researchers at the University of Copenhagen in Denmark compared acid candies to candies modified with calcium to determine the impact of each on the enamel erosive potential. Nineteen cancer patients (average age 51) who underwent radiation and a group of healthy control subjects (average age 25) participated in the one-day study. Saliva was collected for five minutes at baseline and after sucking randomly assigned control or calcium-modified candy for 10 minutes. Subjects repeated the test one hour later with the other candy.

The basic acid candy contained water, isomaltose, tartaric acid, strawberry and rhubarb flavors and light red coloring. The calcium-modified candy also contained calcium lactate. Both candies were five grams. Salivary flow rates were determined and saliva samples were collected after candy consumption.

No differences were observed between the two candies for salivary flow rates in either healthy or cancer patients compared to baseline levels. The saliva of the cancer patients was thicker and stickier than the controls and thus held more of the calcium than saliva of the controls. The erosive potential of the saliva was determined by levels of hydroxyapatite crystals in saliva samples. Levels were significantly lower for the calcium-modified candies compared to the acid candy.

Clinical Implications: Adding calcium to acid candy might be helpful for reducing postradiation enamel erosion while still stimulating salivary flow.

Jensdottir, T., Buchwald, C., Nauntofte, B., Hansen, H., Bardow, A.: Erosive Potential of Calcium-Modified Acidic Candies in Irradiated Dry Mouth Patients. Oral Health Prev Dent 8: 173-178, 2010.
Is Caries a Sugar Disease?

Diet and nutrition are important factors for many diseases, including dental caries. According to the research, dietary sugars, especially sucrose, play an important role in the etiology of caries. Recent findings suggest that other factors might be important.

A researcher from the University of Melbourne in Australia and one from the University of Peradenlya in Sri Lanka evaluated several caries risk factors among 15-year-olds in Sri Lanka. Based on statistical calculations, they needed a sample size of 1,225 students. This was easily achieved in the schools with assistance from the teachers. Students and their parents completed questionnaires and each student was examined clinically.

Caries prevalence was 47 percent of the total group with the average caries rate of just over one. Three dietary patterns were identified: sweet, healthy and affluent (desserts). These patterns were drawn from 13 foods or food groups. Those with a sweet dietary pattern were more likely to have caries. Greater household income was associated with the healthy and affluent dietary patterns. Surprisingly, the healthy dietary pattern did not predict fewer dental caries.

In a study of low-income American adults, four dietary patterns were identified, with none of them emerging as a determinant for caries. Another study of low-income African American children failed to show a link between dietary patterns and caries in deciduous teeth. More factors need to be considered besides sugar and a sugary diet. Recent findings suggest that salivary pH and the presence of specific oral bacteria might be key factors determining the risk for caries.

Clinical Implications: It seems more is at play with caries than simply a sugary diet.

Perera, I., Ekanayake, L.: Relationship Between Dietary Patterns and Dental Caries in Sri Lankan Adolescents. Oral Health Prev Dent 8: 165-172, 2010.
Bad Breath Linked to Periodontitis

Bad breath affects approximately 50 percent of the population with 90 percent of cases due to oral factors and 10 percent from disease or infection in other parts of the body. These two sources can be distinguished between mouth breath and nose breath, as the volatile sulfur compounds are expelled through the lungs with extraoral malodor.

Researchers at the Darshan Dental College and Hospital in Udaipur, India evaluated 113 patients with malodor and 109 age- and sex-matched controls to identify a relationship between oral malodor, tongue coating and periodontal disease.

An odor judge evaluated the mouth breath of each of the patients. The judge and patient were separated by a screen in which a tube was inserted from the patient's mouth to the judge's nose. Breath was scored as 0 - no malodor, 1 - slight malodor, 2 - clearly noticeable malodor or 3 - strong intensity malodor. Tongue coating was measured by dividing the dorsum of tongue into nine sections, three across and three from front to back. Periodontal disease was measured clinically with probing depths, attachment levels and bleeding.

Tongue-coating scores were significantly higher in those with oral malodor compared to controls. Average bleeding scores were 15 percent of sites in those with malodor, compared to five percent in those without malodor. Probing depths and attachment loss were also slightly greater in those with malodor compared to controls. Statistical analysis demonstrated a positive association between periodontal parameters and oral malodor.

Clinical Implications: These results are no surprise to clinicians, and these findings add to research supporting what you experience clinically.

Kumar, S., Phoophalia, A., Tibdewal, H., Tadakamadla, J., Duraiswamy, P., Kulkarni, S.: Oral Malodour: Its Association with Tongue Coating and Periodontal Disease. Dental Health 49: 5 and 6, 6-9, 2010.
Perio and Oral Piercing

Body modification including tattooing and piercing have been performed by various cultures for centuries. Today, oral piercing is becoming more popular, across both social classes and age groups. The tongue and lips are the most common sites for oral piercings. Immediate complications might include swelling, pain, speech difficulties, chewing and swallowing problems, upper airway obstruction, problems with blood vessels or nerve innervations and infection. Dental problems linked to oral piercing include tooth wear, fracture, and recession.

Researchers at the Federal University of Minas Gerais in Brazil evaluated a group of 60 individuals with tongue piercings and a control group of 120 individuals with no tongue piercings. Subjects ranged in age from 13 to 28 years and all came from a low socioeconomic area in Brazil. They were all examined clinically and completed written questionnaires.

The piercings were predominantly metal with 13 percent being metal and silicone and 15 percent being metal and plastic. Forty-three percent of subjects with piercings had them for two years or less, 43 percent had them for two to four years and eight percent had them for more than four years. Half the group reported a habit of biting the piercing and 75 percent reported a habit of rattling the piercing. Immediate complications upon insertion of the piercing were reported by 37 percent, with tooth fractures occurring in 20 percent of cases. Greater mandibular lingual recession was found in those with tongue piercings. Those with a tongue piercing were 18 times more likely to have gingival recession.

Clinical Implications: Clinicians should advise patients about the risks associated with oral piercing.

Pires, I., Cota, L., Oliveira, A., Costa, J., Costa, F.: Association Between Periodontal Condition and Use of Tongue Piercing: A Case-Control Study. J Clin Perio 37: 712-718, 2010.
Recommendations for Cleaning Between the Teeth

Neither the toothbrush nor toothpaste reaches interproximal surfaces where caries and periodontal disease begin. The primary tools for cleaning between the teeth are floss, toothpicks and interdental brushes, with variations in each category. Delivering fluoride to proximal surfaces is best done with fluoridated toothpicks and dental floss, not toothpaste.

Researchers at the University of Gothenburg in Sweden carried out a three-part study, asking clinicians and patients to complete a questionnaire and measuring the clinical effectiveness of interdental plaque removal by the patients.

Questionnaires were mailed to 500 dental hygienists and 500 dentists, with 800 returned. A total of 1,000 test subjects were selected from the town registry of Västra Götaland in southwestern Sweden to receive the questionnaire. This group was equally divided among men and women and among age groups. The clinical evaluation of proximal plaque removal was carried out with a group of randomly selected patients, 20 using dental floss, 20 using toothpicks and 20 using interdental brushes.

Dental hygienists reported more frequent recommendations of interproximal tools with more specific instructions than dentists. Dental floss was recommended for younger patients and interproximal brushes for older patients. Patients reported brushing twice daily with 57 percent of 15- to 20-year-olds cleaning between their teeth daily, 76 percent of 21- to 60-year-olds and 81 percent for those over 60 years of age.

The interdental brush was more effective in removing proximal plaque (83 percent) compared to toothpicks (74 percent) and dental floss (73 percent).

Clinical Implications: Patients should receive individualized recommendations for cleaning between their teeth.

Särner, B., Birkhed, D., Andersson, P., Lingström, P.: Recommendations by Dental Staff and Use of Toothpicks, Dental Floss and Interdental Brushes for Approximal Cleaning in an Adult Swedish Population.Oral Health Prev Dent 8: 185- 194, 2010.
Barriers to Providing Smoking Cessation Counseling

It is now estimated that 21 percent of Americans older than age 18 smoke. Approaches assisting with tobacco cessation include interactive CD ROM courses, motivational interviewing, and use of multiple nicotine replacement options. The U.S. Public Health Service Clinical Practice Guidelines suggest using the "Five A" counseling approach: Ask, Advise, Assess, Assist and Arrange. No single approach insures success, however smokers do report that advice from a health-care professional is an important motivator in their attempts to quit smoking. Despite efforts and research, tobacco cessation counseling (TCC) is not routinely offered to patients by dentists or hygienists. Ideally, it should begin in dental and dental hygiene schools and carryover into practice.

Researchers at the University of Pittsburgh School of Dental Medicine surveyed and trained both students and faculty in the "Five A" counseling approach, plus training from the School of Pharmacy in the addiction process, nicotine replacement therapies and available prescription medications.

Baseline surveys of 32 students and eight faculty members identified three barriers to TCC: time, effectiveness and confidence. Six months following training, a second survey was returned by 26 students and only four faculty members. Students reported that TCC didn't take as much time as they anticipated and they felt more knowledgeable and prepared to provide TCC. However, self-confidence was still lacking.

The lack of buy-in to this project by the faculty, with only half of the eight faculty completing final surveys, might explain an underlying problem. Faculty have heavy workloads and adding more to an already oversaturated curriculum is met with reluctance.

Clinical Implications: Tobacco Cessation Counseling should be part of dental and dental hygiene visits for smokers.

O'Donnell, J., Hamilton, M., Markovic, N., Close, J.: Overcoming Barriers to Tobacco Cessation Counseling in Dental Students. Oral Health Prev Dent 8: 117-124, 2010.
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