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Perio Reports

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Perio Reports  Vol. 23 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.
Toothbrush Better Than Sponge for
Intubated Patients

Patients in intensive care units that have been intubated are at risk for ventilator-associated pneumonia (VAP), a life-threatening condition. The incidence varies between nine and 45 percent of those intubated, with a mortality rate of 50 percent. Risk factors for VAP include underlying medical conditions, immunosuppression, brain injury, factors related to airway and ventilator management, presence of naso- or orogastric tubes and medication. Another risk factor is aspiration of oral bacterial biofilm in saliva. Although low levels of respiratory pathogens are found in oral plaque, oral pathogens are detected in the lungs preceding the development of VAP.

Researchers at University College London compared power toothbrushing to the use of a sponge toothette for plaque control for intubated patients recently admitted to the National Hospital for Neurology and Neurosurgery in London, U.K. Colgate Actibrush was compared to a sponge toothette. Both treatments were provided by the nursing staff every six hours for two minutes. Chlorindioxide was used on the brush and the sponge each time.

Plaque levels and bacterial counts were gathered on day one before the first oral hygiene intervention and again on days three and five. More plaque was removed by the Actibrush than by the sponge. A distinction was made by the authors between decontamination with chlorhexidine and plaque removal with either the Actibrush or sponge. Mechanical disruption of the plaque with the power toothbrush is considered more effective than antimicrobial chemicals to control oral biofilm and prevent VAP.

Clinical Implications: Toothbrushing is more effective in reducing oral biofilm than wiping with a sponge toothette.

Needleman, I., Hirsch, N., et. al.: Randomized Controlled Trial of Toothbrushing to Reduce Ventilator-Associated Pneumonia Pathogens and Dental Plaque in a Critical Care Unit. J Clin Perio 38: 246-252, 2011.
Soft Bristle Toothbrushes Best

Oral bacterial biofilm is the primary etiologic factor in both caries and periodontal disease. Mechanical disruption using a toothbrush is the best way to remove biofilm from facial and lingual surfaces of the teeth.

Researchers at Witten/Herdecke University in Witten, Germany compared similar manual toothbrushes with different bristle stiffness to determine effects on plaque removal, gingival bleeding and tissue damage.

Dr. Best toothbrushes from GlaxoSmithKline were used for the study creating three groups: soft, medium and hard. A total of 120 healthy volunteers participated in this eight-week study. Subjects were instructed to brush twice daily for two minutes each time.

At four weeks and eight weeks, plaque levels were reduced for all groups, with plaque levels reduced slightly more for the hard-bristle toothbrush group. Bleeding was reduced significantly more for those in the soft toothbrush group and increased from baseline levels in the hard toothbrush group. The medium toothbrush fell between the soft and hard bristle toothbrushes. The soft bristles might reach subgingivally more comfortably to remove subgingival plaque, thus explaining lower bleeding scores for the soft toothbrush users.

Evaluation of gingival abrasion revealed an average of 20 lesions in the hard toothbrush group, six in the medium toothbrush group and only two in the soft toothbrush group.

Clinical Implications: Hard bristle toothbrushes will remove more plaque from smooth surfaces, but they will also cause tissue trauma compared to soft bristle toothbrushes and lead to higher bleeding scores.

Zimmer, S., Öztürk, M., Barthel, C., Bizhang, M., Jordan, R.: Cleaning Efficacy and Soft Tissue Trauma After Use of Manual Toothbrushes with Different Bristle Stiffness. J Perio 82: 267-271, 2011.
Like Father, Like Son – Like Mother, Like Daughter

Intergenerational studies show associations between the parents and offspring for cardiovascular disease, diabetes, metabolic syndrome, cancer, asthma, obesity, smoking, alcohol use and drug abuse. Many studies have evaluated the familial role played in aggressive periodontitis, but few studies are available evaluating the intergenerational effect of chronic periodontitis.

Researchers at Otago University in Dunedin, New Zealand wanted to know if family history of periodontal disease was a risk factor for future disease in the offspring.

Study subjects were part of the Dunedin Multidisciplinary Health and Development Study (DMHDS). During the age- 32 assessments, a total of 913 subjects received a complete periodontal examination. Parents of these subjects participated in interviews about their periodontal health, being asked if they were ever told they had periodontal disease, were ever treated for periodontal disease or if they lost teeth due to periodontal disease. One or both parents were interviewed for 849 subjects and both parents were interviewed for 625 subjects.

Parents were divided into two groups – high risk and low risk. Subjects whose parents were in the high risk group were more likely to show early signs of pocketing and attachment loss. Not surprising, those who smoked and had higher plaque scores also had deeper pockets and more attachment loss.

Identifying high-risk individuals early might lead to earlier preventive intervention and thus prevent the disease and the associated cost involved with treatment later.

Clinical Implications: Parents share not only their genes and their saliva; they also share environmental and oral hygiene habits, leading to similar periodontal health between parents and offspring.

Shearer, D., Thomson, M., Caspi, A., Moffitt, T., Broadbent, J., Poulton, R.: Inter-Generational Continuity in Periodontal Health: Finding from the Dunedin Family History Study. J Clin Perio 38: 301-309, 2011.
Risk for Tooth Loss After Therapy



Aggressive periodontitis (AgP) also called "early onset periodontitis" or "localized juvenile periodontitis" is a rare disease that is characterized by rapid attachment loss and bone loss. It affects young people and can lead to edentulism early in life. AgP runs in families and affects less than one percent of the population. Treatment is similar to that provided for chronic periodontitis, non-surgical, surgical and oral hygiene.

Researchers at the University of Heidleberg in Germany wanted to know the risk for tooth loss after treatment for AgP. They invited patients who had been treated at the University Hospital Periodontology Clinic between 1992 and 2005 to participate in the study. A total of 84 patients agreed to be re-examined. A full periodontal examination was done and past records were evaluated to determine the supportive periodontal therapy (SPT) intervals and if any teeth had been lost.

Less than half of the subjects lost teeth during the ensuing years of SPT and only a few lost more than three teeth. A total of 133 teeth were lost following therapy, or 0.6 percent. Those with only a high school education experienced more tooth loss than those with a college education. Smoking also increased risk of tooth loss. Those who routinely kept their SPT appointment were less likely to experience tooth loss. Those with generalized disease compared to localized disease also experienced more tooth loss. Recurrence of the disease was evident in 24 percent of those evaluated.

Clinical Implications: Following treatment for AgP, patients should abstain from smoking and follow the recommended perio maintenance interval to avoid the risk of tooth loss.

Bäumer, A., Sayed, N., Reitmeir, P., Eickholz, P., Pretzl, B.: Patient-Related Risk Factors for Tooth Loss in Aggressive Periodontitis After Active Periodontal Therapy. J Clin Perio 38: 347-354, 2011.
Smoking Cessation in the Hands of Hygienists

Tobacco use is a significant risk factor for many diseases, including periodontitis. Many governments have set smoking cessation goals and guidelines to encourage professionals to provide the services necessary for smokers to quit. Dental hygienists are in the perfect position to question and counsel smokers who are ready to quit, but several studies show the number of dental hygiene clinicians offering smoking cessation counseling to patients is low.

Researchers at Kings College London Dental Institute at Guys Hospital in the U.K. evaluated hygienists' attitudes and participation in smoking cessation activities using a questionnaire. There are approximately 4,000 dental hygienists in the U.K. Surveys were sent to 671 hygienists in the east of England, an area called the Home Counties. The return rate was 61 percent, with 412 surveys returned.

When asked if hygienists should set a good example by not smoking, 97.4 percent agreed. Also, 93.5 percent of respondents felt it was important to ask patients about smoking habits. Although hygienists were optimistic about offering smoking cessation, 62.8 percent think most people will not give up tobacco due to the nicotine addition, even if their hygienist tells them they should.

Based on other studies, hygienists who don't offer smoking cessation counseling and activities lack the knowledge, training, time, educational materials and confidence to achieve success with smoking cessation.

Clinical Implications: Hygienists with positive attitudes about the effectiveness of smoking cessation are more likely to initiate smoking cessation counseling and activities for their patients.

Pau, A., Olley, R., Murray, S., Chana, B., Gallagher, J.: Dental Hygienists' Self- Reported Performance of Tobacco Cessation Activities. Oral Health Prev Dent 9: 29-36, 2011.
Review of Black Stain

Black stain, also known as brown stain, black line stain or pigmented dental plaque, has been investigated for more than a century and the exact cause still remains unknown. Researchers agree it is most likely caused by specific chromogenic bacteria and perhaps metabolism by the bacteria of iron molecules. The stain might be a thin line or unconnected dots on the enamel along the gingival margin. Examination of the black stain finds high levels of calcium, phosphate and an insoluble ferric salt.

Black stain is found in children and disappears before age 20. Prevalence is reported to be from one to 20 percent, depending on the subjects evaluated and the criteria used for identifying black stain.

Over the years several chromogenic bacteria have been suggested as the cause of black stain, primarily Prevotella melaninogenica and Actinomycetes species. Salivary levels don't differ between those with and without the stain, but the pH is elevated and higher levels of calcium and phosphate minerals are found in the saliva of those with black stain.

Black stain is not easily removed with toothbrushing, instead requiring professional dental hygiene care to remove it with instrumentation and polishing. Removal reveals intact, healthy enamel with no demineralization. Not in all, but in many studies, caries rates are reported lower for children with black stain compared to children without the stain.

The unusual nature of black stain and the likelihood that specific bacteria are responsible for black stain and lower caries rates presents a model for the oral probiotic replacement of missing oral microorganisms.

Clinical Implications: Black stain occurs most often in children and is linked to slightly lower caries rates and higher oral pH levels.

Ronay, V., Attin, T.: Black Stain - A Review. Oral Health Prev Dent 9: 37-45, 2011.
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