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Perio Reports


Perio Reports  Vol. 23 No. 9
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.
Dental Treatment and Vascular Events

Treatment and control of periodontal disease might reduce the risk of cardiovascular disease. Other research suggests a transient risk associated with invasive dental procedures and the likelihood of a heart attack or stroke in the first few weeks following treatment. Low grade chronic inflammation is linked to cardiovascular disease. Acute inflammation after surgery or a bacterial infection is associated with a short-term increased risk of changes in blood vessels leading to stroke or heart attack.

Researchers at the Eastman Dental Institute in London, England analyzed the United States Medicaid claims database to determine if invasive dental treatment led to heart attack or stroke immediately after treatment. A total of nearly 10 million patient records over a five-year period were analyzed to find 20,000 who had been hospitalized for either stroke or heart attack. Of these patients, 1,152 underwent invasive dental procedures prior to hospitalization.

Invasive dental procedures included all treatment codes related to periodontal therapy and tooth extractions, with 89 percent of these procedures relating to extractions.

No vascular event occurred on the same day as the dental visit, but the majority happened within four weeks of treatment. Although invasive dental treatment might be linked to vascular events in the month after treatment, the long-term benefit of treating dental disease far outweighs this risk. These findings do provide evidence of the link between acute inflammation and the risk of vascular events.

Clinical Implications: Within this targeted population of Medicaid patients, invasive dental treatment might present a transient risk for heart attack or stroke in the first four weeks following treatment, but this risk is outweighed by long-term benefits from dental treatment.

Minassian, C., D'Aluto, V., Hingorani, A., Smeeth, L.: Invasive Dental Treatment and Risk for Vascular Events. Ann Intern Med 153: 499-506, 2010.
Perio Patients Seen in Emergency Rooms

Periodontal disease is best controlled with regular maintenance visits and adequate daily oral hygiene. When regular dental visits are not followed, serious problems occur and patients seek treatment at hospital emergency rooms. Those without dental insurance also seek care in hospital emergency rooms. Data is collected each year from emergency rooms across the U.S. and published in a Nationwide Emergency Department Sample (NEDS).

Researchers at Harvard University in Boston, Massachusetts analyzed data from 2006 NEDS to determine how many visits were because of periodontal problems and if these emergency visits led to hospitalization.

During 2006, there were 120,033,750 emergency room visits with 85,039 of these visits being categorized with a primary diagnosis of periodontal disease. More patients were seen on weekend days than on weekdays. Some of these cases also had other medical problems including diabetes, heart disease, lung disease, liver disease, thyroid problems, alcohol abuse or HIV. A total of 1,167 of these emergency room visits required inpatient hospitalization.

The financial implications of these emergency room visits were close to $33.3 million with an average charge per visit of $456. For those who were also hospitalized, the charges escalated to $15,248 per visit.

Inpatient hospitalization occurred more often for those with multiple medical problems and for those with a primary diagnosis of acute or aggressive periodontitis rather than chronic periodontitis.

Clinical Implications: Prevention of periodontal disease with effective daily oral hygiene and regular dental and dental hygiene visits is important to treat and prevent serious periodontal conditions that might otherwise lead patients to seek treatment at a hospital emergency room.

Elangovan, S., Nalliah, R., Allareddy, V., Karimbux, N., Allareddy, V.: Outcomes in Patients Visiting Hospital Emergency Departments in the United States Because of Periodontal Conditions. J Perio 82: 809-819, 2011.
Host Modulation Helps Smokers

Smoking is a serious risk factor for periodontal disease and compromises clinical healing following therapy. Smoking suppresses the body's immune response, triggers the release of cytokines which destroy healthy connective tissue and prevent these cells from organizing and healing. Despite a great deal of research confirming the role of smoking in the progression of periodontal disease, treatment and maintenance are the same for smokers and non-smokers. There are no wellestablished protocols to follow when treating periodontal patients who continue to smoke.

Researchers at the University of Alabama, School of Dentistry in Birmingham, Alabama reviewed the literature to determine if the use of host modulation therapy in smokers would be beneficial with both scaling and root planing and during maintenance care.

They reviewed 31 abstracts on the subject and narrowed it down to 13 full articles, of which nine were relevant to their question. The two host modulation drugs tested were low-dose doxycycline and low-dose flurbiprofen. Overwhelmingly, the data demonstrated improved periodontal healing following scaling and root planing when host modulation therapy was provided for smokers. Differences were more pronounced in moderate and deep pockets compared to shallow pockets. When these low-dose drugs are given to smokers in conjunction with treatment or maintenance, bacterial counts are reduced for the most pathogenic species.

Since smoking causes an increase in inflammation, providing a host modulation drug that reduces the level of cytokines released will enhance healing.

Clinical Implications: Based on the research, it makes sense to offer a host modulation drug to smokers being treated for periodontal disease and smokers receiving periodontal maintenance.

Geisinger, M., Holmes, G., Geurs, N., Vassilopoulos, P., Reddy, M.: Host Modulation for Smokers Undergoing Periodontal Maintenance: A Review of Current Evidence. Clin Adv Periodontics 1: 54-60, 2011.
Rapid Recolonization After Treatment

Bacterial biofilm is the trigger which starts the periodontal disease cascade. Researchers have identified hundreds of bacterial species within biofilm and grouped them according to pathogenicity by color groups. Red and orange are the most pathogenic; green and yellow less so; and purple and blue the least pathogenic.

Researchers at the Forsyth Institute in Boston, Massachusetts wanted to know if there were differences in plaque recolonization and species after instrumentation in both periodontally healthy and diseased patients. A group of 38 patients participated in the study; 17 had chronic periodontitis with at least eight teeth probing over 4mm and the rest, considered healthy, had less than 20 percent of sites with gingivitis, redness or bleeding.

Supra and subgingival plaque samples were taken from 28 teeth in each individual at baseline. Subjects then received either a prophylaxis or full-mouth scaling and root planing. Plaque samples were taken immediately after treatment on all 28 teeth. Samples were taken from seven teeth in randomly selected quadrants on days one, two, four and seven.

Baseline bacterial counts were higher in periodontitis subjects compared to healthy subjects. Supra- and subgingival counts reached or exceeded baseline levels at day two.

In both groups, there were two spikes in repopulation of subgingival plaque, between days one and two and between days four and seven. This might be due to environmental changes in the subgingival area favoring different species.

Clinical Implications: Skipping oral hygiene for just two days allows bacteria to rebound to baseline levels or higher. This is good information to share with patients.

Uzel, N., Teles, F., Telles, R., Song, Z., Torresyap, G, Socransky, S., Haffajee, A.: Microbial Shifts During Dental Biofilm Re- Development in the Absence of Oral Hygiene in Periodontal Health and Disease. J Clin Perio 38: 612-620, 2011.
Listerine Used for Ultrasonic Lavage

The goal of non-surgical periodontal therapy is to reduce probing depths and bleeding and return all pockets to health. Providing scaling and root planing in chronic periodontitis cases does not always return all pockets to probing depths less than 5mm. Remaining pockets present a risk for further disease.

Researchers at the University of Sao Paulo in Brazil compared ultrasonic instrumentation using Listerine Cool Mint as the lavage to an identical tasting and colored placebo. A group of 64 patients were treated with traditional scaling and root planing using power and hand instruments in four to six sessions each. Four weeks later, these patients were again examined and all still had four to 10 sites measuring 5mm or more. This was baseline for the study.

Subjects received five minutes of ultrasonic scaling in each remaining diseased site using the randomly assigned lavage, either Listerine or control rinse. The Listerine and control rinse containers were identical, marked either Group A or Group B. No one knew the group assignments until the six-month study was completed. Periodontal exams were repeated at four, six and 24 weeks.

When comparing all data, no differences were seen between test and control groups for probing depths, clinical attachment levels, recession or bleeding on probing. A small difference was observed for pockets initially measuring 7mm or more. The Listerine group showed 0.65mm greater probing depth reduction and 0.77mm greater gain in clinical attachment. Not reported were reductions in the total number of sites 5mm or more.

Clinical Implications: For initially deep pockets, using Listerine Cool Mint in the ultrasonic scaler might enhance healing slightly.

Feng, H., Bernado, C., et al.: Subgingival Ultrasonic Instrumentation of Residual Pockets Irrigated with Essential Oils: A Randomized Controlled Trial. J Clin Perio 38: 637-643, 2011.
Pain Relief Patch for Perio Surgery Sites

Ketorolac (Toradol) is a non-sterioidal anti-inflammatory drug used to control pain and inflammation. It is delivered by injections or in oral tablets often causing gastrointestinal (GI) problems. To avoid GI problems, other delivery systems have been investigated, including transdermal delivery, ophthalmic solutions and an oral rinse. The newest delivery system is an intra-oral patch made of two bioadhesive polymers: hygroxypropyl methylcellulose and polyacrylic acid.

Researchers at King Saud University in Riyadh, Saudia Arabia tested the new adhesive patch containing 30mg of ketorolac. Test and placebo patches were tested on free-gingival graft sites in 68 patients in a double-blind study. The test group received the ketorolac patches immediately after surgery and the control group received the placebo patches. Pain levels were recorded by patients using a visual analog scale from zero to 10 with mild pain equaling zero to four, moderate pain equaling four to seven and severe pain equaling seven or higher.

Pain scores immediately after surgery were 7.7 for both groups. Test group scores were 5.2 at one hour, 3.4 at two and three hours, 2.0 at four hours and negligible after that. Pain in the control group was 7.8 at one hour and 5.63 at two hours. At this point, control patches were replaced with the ketorolac patches. One hour later, pain scores dropped to 3.4, then 2.5 at four hours, 1.3 at five hours and negligible after that up to 48 hours.

Clinical Implications: Oral pain relief patches might be available in the future for use after surgical procedures.

Hal-Hezaimi, K., Al-Askar, M., Selamhe, Z., Fu, J., Alsarra, I., Wang, H.: Evaluation of Novel Adhesive Film Containing Ketorolac for Post-Surgery Pain Control: A Safety and Efficacy Study. J Perio 82: 963- 968, 2011.
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