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Perio Reports

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Perio Reports  Vol. 22 No. 12
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.
Caries and Perio Found Together

With studies showing caries and periodontitis found together and other studies showing either one disease or the other, research is contradictory. Both are bacterial in nature, impacted by the accumulation of bacterial biofilm. It is suspected that salivary pH might contribute to disease selection, with an acid pH leading to more caries and a basic pH contributing to calculus formation and periodontitis. Research hasn't evaluated this theory.

Researchers from the University of Oulu in Finland compared the incidence of both caries and periodontal disease in a group of 5,000 adults older than age 30 who were part of a national health survey. Clinical examinations were conducted by five field teams in community settings using a headlamp for light, a mouth mirror, a periodontal probe and explorer. Compressed air was available to dry teeth prior to examination.

The deepest probing depth for each tooth was recorded in one of three categories: none, 4-5mm or 6mm. Dental caries were recorded if cavitation was present and the lesion was extending into the dentin.

Of this group, 65 percent had 4mm probing depths; 21 percent had 6mm probing depths; and 29 percent had dental caries. The caries incidence was significantly lower than reported for the UK or the U.S. Perhaps the use of xylitol in Finland is responsible.

In the group with 6mm probing depths, 44 percent also had caries. In the periodontally healthy group, 23 percent had caries. More severe periodontal disease and caries tend to be found in the same patients.

Clinical Implications: Observe your patients to see how often they present with both caries and periodontal disease.

Mattila, P., Niskanen, M., Vehkalahti, M., Nordblad, A., Knuuttila, M.: Prevalence and Simultaneous Occurrences of Periodontitis and Dental Caries. J Clin Perio 37: 962-967, 2010.
Vitamin B12 and Folate Prevent
Aphthous Ulcers

Recurrent aphthous stomatitis (RAS) is a widespread, common oral mucousal lesion. Incidence levels vary with reports as high as 50 percent in women and 40 percent in men. The lesions are small, oval in shape with necrotic tissue in the center and a red inflamed border. The lesions are painful, especially with eating and regular oral hygiene. RAS is more common in younger people than older people. This difference might be explained by dietary intake of nutrients. Younger people are less likely to eat healthy, well balance meals than older people.

Researchers at the University of Connecticut in Farmington analyzed the dietary intake of 100 subjects who experienced at least three episodes of RAS in the past year. These findings were compared to age- and gender-matched participants in the U.S. National Health and Nutrition Examination Survey (NHANES). Dietary intake was evaluated using DietCalc software that calculates specific nutrients based on the reported food intake. This allowed daily nutrient comparisons between the two groups.

Nine nutrients were identified for comparison: vitamins A, B6, B12, C, E, thiamin, riboflavin, niacin and folate. Those in the RAS group had higher levels of seven of the nine nutrients than the controls. The two nutrients that were lower in this group were vitamin B12 and folate. This correlates to seven percent of the recommended daily intake level for vitamin B12 and 20 percent of the recommended level for folate. Just how vitamin deficiencies affect RAS is unknown.

Clinical Implications: Increasing dietary B12 and folate or adding nutritional supplements seems an easy way to prevent recurrent aphthous ulcers.

Kozlak, S., Walsh, S., Lalla, R.: Reduced Dietary Intake of Vitamin B12 and Folate in Patients with Recurrent Aphthous Stomatitis. J Oral Pathol Med 39: 420-423, 2010.
Systemic Markers After SRP and SX

Periodontal infection is associated with several systemic inflammatory markers. Low-grade systemic inflammation is evident by increased concentrations of biomarkers including C-reactive protein (CRP), leucocyte counts, serum amyloid-A and other blood markers.

Researchers at the University of Pisa in Italy monitored these serum inflammatory markers at baseline, and days seven, 30, 90 and 180 following SRP. They were also monitored after flap surgery out to day 270. The 14 study subjects all had chronic moderate periodontitis. Baseline probing depths revealed an average of 64 pockets measuring 4mm or more per patient. Patients all received baseline data collection, oral hygiene instructions and full-mouth SRP completed within 24 hours. Pockets were reduced at three months to 16 and by six months to 15. Surgery was done in two sessions after the six-month visit and resulted in further pocket depth reductions to eight pockets per patient on average.

CRP levels increased after the SRP visit and to a lesser level after each surgery. Other serum markers also showed more significant increases after SRP, with much smaller impacts after the two surgeries. This is most likely attributed to the fact that full-mouth SRP was done when the area of periodontal infection was considerably larger than the areas undergoing localized surgery. The extent of periodontal infection influences the changes in inflammatory markers following treatment more than the particular treatment provided.

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.
C-reactive Protein Produced Systemically

Periodontitis, as well as other systemic diseases are associated with elevated levels of C-reactive protein (CRP) measured in both serum and gingival crevicular fluid (GCF). Treatment of periodontitis reduces CRP levels.

CRP is produced by the liver in response to inflammation or tissue necrosis. Even mild serum levels of CRP are evidence of a tissue damaging process going on somewhere in the body. Recent research shows evidence that CRP can be produced in small amounts by cells other than hepatic cells. Based on these findings, researchers at the University of Adelaide in South Australia wondered if CRP might originate in gingival and periodontal tissues as well as systemically from the liver.

If CRP is synthesized in gingival tissues, signs of mRNA would be present in tissue samples. Tissue samples were collected from patients undergoing periodontal surgery and from periodontally healthy patients undergoing crown lengthening or who allowed a tissue biopsy prior to tooth extraction. GCF samples were also collected and analyzed.

Tissue samples were collected from 46 subjects with periodontal disease and 13 periodontally healthy subjects. GCF flow in those with periodontal disease was double that of the healthy subjects. Polymerase chain reaction was used to determine if CRP was manufactured within gingival tissue. No evidence of mRNA was found in the tissue samples. The authors conclude that CRP measured in GCF is indicative of systemic inflammation, either periodontal disease or infection somewhere else in the body.

Clinical Implications: Chairside kits are being developed that have the potential to provide an alternative to blood tests for measuring systemic CRP that might reflect systemic inflammation.

Megson, E., Fitzsimmons, T., Dharmapatni, K., Bartold, M.: CReactive Protein in Gingival Crevicular Fluid May be Indicative of Systemic Inflammation. J Clin Perio 37: 797-804, 2010.
Oral Cancer Screening Devices Compared

In 2008, oral cancer cases numbered 35,000, with 7,500 deaths. ViziLite Plus with TBlue and the VELscope were developed to enhance oral cancer screening exams in the hope of identifying lesions not readily seen by clinicians.

Researchers at Moti Lal Nehru Medical College in India compared two diagnostic light systems, ViziLite Plus and VELscope. The study took place at a rural district hospital in central India. A total of 258 patients were examined using an overhead dental light and found to have clinically innocuous lesions that the examiners decided required no further attention other than routine follow-up. Subjects were randomly assigned to examination with either the ViziLite Plus system or the VELscope. All subjects then underwent surgical biopsies.

The ViziLite system was used on 102 subjects. Biopsies revealed one mild dysplasia, two moderate dysplasias and one cancer. None were correctly identified by the ViziLite or the clinicians. ViziLite correctly identified 74 out of 98 benign lesions as negative. Incorrectly identified as positive were 24 benign lesions.

The VELscope was used on 156 subjects. Tissue biopsies revealed 11 dysplasias, and one cancer. The VELscope correctly identified five dysplasias and the cancer, thus half were correctly identified by the VELscope. The VELscope correctly identified 56 of 144 negative findings and six of the 12 positive findings. Eighty-eight VELscope positives were actually benign.

Clinical Implications: Identifying precancerous and cancerous lesions is difficult for clinicians, and the VELscope appears to provide benefit in identifying cancer, but also identifies as positive lesions that are not cancer. Doing an oral cancer screening examination on every patient is essential.

Mehrotra, R., Singh, M., Thomas, S., et al: A Cross-Sectional Study Evaluating Chemiluminescence and Autofluorescence in the Detection of Clinically Innocuous Precancerous and Cancerous Oral Lesions. JADA 141: 151- 156, 2010.
Antibiotics for Third Molar Extraction

Prescribing antibiotics to prevent infection resulting from third molar extractions is a topic of considerable debate. In 2007 the American Heart Association issued new antibiotic prophylaxis guidelines based on current evidence of the risks associated with antibiotic overuse. Adverse reactions to the drugs and development of drug-resistant bacteria are greater risks than infection.

Researchers at the University of Otago, in Dunedin, New Zealand compared impacted third molar extractions in the same patient with and without antibiotic prophylaxis. Ninety-five patients were divided into two groups and each served as their own control, receiving the assigned antibiotic dose for one surgery and a placebo for the other surgery. Group one received 1g of amoxicillin one hour before surgery. In addition, group two also received 500mg of amoxicillin every eight hours for two days after surgery.

No significant differences were observed between test and placebo groups for pain, swelling, temperature or trismus. Post-operative infections occurred in just six cases or two percent of the 380 extractions. Three dry sockets were reported in the placebo group and one in the group receiving one dose of amoxicillin. In the group receiving multiple doses of amoxicillin, one patient experienced a dry socket after both the antibiotic and the placebo. Differences between the groups were not significant as the overall rate of post-operative infection was so low.

Clinical Implications: Each case must be evaluated individually, however the risks associated with taking antibiotics seem to outweigh the risks due to infection after extractions.

Siddiqi, A., Morkel, A., Zafar, S.: Antibiotic Prophylaxis in Third Molar Surgery: A Randomized Double-Blind Placebo-Controlled Clinical Trial Using Split-Mouth Technique. Int J Oral Maxillofac Surg 39: 107-114, 2010.
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