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Perio Reports

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Perio Reports   Vol. 23 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.
Antioxidant Defense in Oral Health

Free radicals (FR) and reactive oxygen species (ROS) are part of physiologic and pathologic functions in the body. FR are molecules with unpaired electrons that are highly reactive and associated with both beneficial functions and when uncontrolled, degenerative diseases and cancers. ROS denotes the group of free radicals derived from oxygen. The electron structure of oxygen with two unpaired electrons makes it especially susceptible to radical formation through oxidation or loss of electrons.

Antioxidants delay or prevent oxidation. Vitamin C in lemon juice is an antioxidant that prevents a cut apple from turning brown (oxidation). Antioxidants counter formation of damaging FR by donating electrons. Saliva provides a valuable source of antioxidants to counter infection, inflammation and neutralize metal allergic reactions. Antioxidants can change calculus deposits from calcium carbonate to calcium bicarbonate, thus making them water-soluble. Tooth staining can be prevented by antioxidants. A body in balance produces enough antioxidants to keep the FR in balance.

Periodontal tissue breakdown follows the triggering of the immune system by bacterial toxins penetrating the sulcular epithelium. PMNs are the first line of defense and trigger formation of ROS to kill the bacteria, but they also cause damage to connective tissue and bone. From the periodontal tissues they enter the blood stream, impacting other parts of the body.

Dental sources of FR are bleaching agents, cements, ceramic restorations, metals and implants. Tobacco use also promotes release of ROS leading to oxidative damage to connective tissue and bone.

Clinical Implications: Topical antioxidant therapy can block ROS production in the mouth, potentially providing valuable new approaches to several dental problems.

San Miguel, S., Opperman, L., Allen, E., Svoboda, K.: Reactive Oxygen Species and Antioxidant Defense Mechanisms in the Oral Cavity: A Literature Review. Compendium of CE in Dent 32: online, 2011.
Measuring Oxidative Stress

Periodontal disease triggers oxidative stress reactions within periodontal tissues, increasing levels of reactive oxygen species (ROS).

Researchers at Cork University in Cork, Ireland, measured the impact of periodontitis on oxidative stress indicators in patients with diabetes. They compared three groups of 20 patients each: 1) Type 2 diabetes with periodontitis, 2) Type 2 diabetes with no periodontitis and 3) no diabetes with periodontitis. Patients were recruited from a diabetes clinic and the dental school. Care was taken to match subjects between groups regarding age, gender and periodontal status.

Clinical indices, body mass index (BMI) and a variety of blood assays were evaluated. Oxidative damage of proteins leads to formation of carbonyl groups, which can be measured in IgG proteins. The availability of antioxidants to counteract oxidative stress is measured through availability of vitamins C, E and A. Antioxidant capacity was lower in those with both diabetes and periodontitis.

Both diabetes groups had higher BMI scores than the non-diabetes periodontitis group. The diabetes plus periodontitis group had higher bleeding on probing (BOP) levels than non-diabetes periodontitis group. C-reactive protein (CRP) levels were similar between the two diabetes groups and lower in the non-diabetes subjects. This suggests the variable is diabetes, not periodontitis. Beta cells in the pancreas make and release insulin to control glucose levels in the blood. Beta cell function was significantly lowered in patients with diabetes and periodontitis compared to those with diabetes without periodontitis. HbA1c levels were higher in patients with diabetes and periodontitis compared to those with diabetes without periodontitis. Periodontitis has a negative effect on an already compromised oxidative status in those with diabetes.

Clinical Implications: Let your patients with Type 2 diabetes know the importance of frequent maintenance visits and good oral health as it relates to their overall metabolic status.

Allen, E., Matthews, J., O'Halloran, D., Griffiths, H., Chapple, I.: Oxidative and Inflammatory Status in Type 2 Diabetes Patients with Periodontitis. J Clin Perio 38: 894- 901, 2011.
Antioxidant and Oxidative Stress in Smokers

Smoking has several detrimental effects on periodontal health: reduced blood flow, altered neutrophil functions, increased cytokine production, inhibition of fibroblast growth and attachment, decreased collagen production and reduced vascularity. Smoking stimulates the oxidative burst of neutrophils, increasing reactive oxygen species (ROS) levels. The body's reserves of antioxidants (AO) are used to combat this imbalance. Periodontitis leads to elevated AO levels and quitting smoking leads to lower levels of AO measured in blood and body tissues.

Researchers at Suleyman Demirel University in Isparta, Turkey, evaluated the AO levels in blood and gingival tissues of smokers. They also measured malondialdehyde (MD) levels as an indicator of oxidative stress. A total of 65 patients with periodontitis and 20 periodontally healthy non-smokers participated in the study. Those with periodontitis were categorized as current smokers (23), former smokers (23) and non-smokers (19).

Gingival tissue samples were taken from interproximal pocket areas around teeth scheduled for extraction due to caries. Blood samples were also taken.

In the periodontitis group, plaque scores were significantly higher for the current smokers. Other clinical indices for probing depths and attachment levels were similar among those in the periodontitis group. AO levels were elevated in smokers with periodontitis compared to former smokers and non-smokers in the periodontitis group. AO levels were lowest in the periodontally healthy control subjects. Measures of MD reflective of oxidative stress were lower in the healthy subjects and higher in those with periodontitis, especially the smokers.

Clinical Implications: Oxidative stress and antioxidant levels are becoming reliable measures of periodontal health and disease.

Tonguc, M., Öztürk, O., Sütcu, R., et al: The Impact of Smoking Status on Antioxidant Enzyme Activity and Malondialdehyde Levels in Chronic Periodontitis. J Perio 82: 1320-1328, 2011.
Hopeless Teeth Can Be Saved

Teeth with endodontic involvement and periodontal attachment loss to the apex are generally considered hopeless teeth, with extraction the only predictable treatment option. Regenerative therapy does provide an option for these teeth, but long-term prognosis has not yet been determined.

Researchers with the European Research Group on Periodontology (ERGOPERIO) compared the long-term outcomes of regenerative treatment, and extraction and restoration on hopeless teeth. A total of 50 patients each with a periodontally hopeless tooth took part in the study. Half of the test group received regenerative therapy and the control half of the group had the tooth extracted and replaced with an implant or conventional fixed prosthetic. Control replacements for the hopeless tooth included: 14 implant-supported restorations, eight tooth-supported bridges, two Maryland bridges and one tooth was not replaced.

After five years, 23 of the 25 teeth receiving regenerative therapy were healthy and functioning. Two teeth experienced problems and were extracted at one year. This was a 92 percent success rate. Average clinical attachment gains were 7.7mm, radiographic bone gains were 8.5mm, probing depth reductions were 8.8mm and residual probing depths were 4mm.

Those in the control group receiving extractions and restorative treatment were doing well at year five, with many surgical procedures needed initially and over the test period. All implants and appliances were stable and healthy. Both regenerative treatment and extraction and restorative replacements were successful.

Clinical Implications: Periodontal regenerative procedures rather than extraction, can be used successfully on what might be considered hopeless teeth.

Cortellini, P., Stalpers, G., Mollo, A., Tonetti, M.: Periodontal Regeneration versus Extraction and Prosthetic Replacement of Teeth Severely Compromised by Attachment Loss to the Apex: 5-Year Results of an Ongoing Randomized Clinical Trial. J Clin Perio 38: 915-924, 2011.
Non-surgical Therapy Faster than Surgical Treatment

Where access allows, minimally invasive instrumentation effectively accesses deep pockets. A minimally invasive surgical technique (MIST) accesses deep pockets with tissue reflection without using releasing incisions.

Researchers at the University of Campinas in Piracicaba, Brazil, compared MIST and non-surgical techniques in isolated intra-bony pockets. Patients were seen for initial therapy and oral hygiene instructions. Those with isolated intra-bony defects remaining after six months were randomly assigned to the treatments. A total of 29 patients received treatment using a microscope and microsurgical instruments, 14 surgical and 15 non-surgical. Maintenance visits were provided at three and six months, with 27 patients completing the six-month study.

Non-surgical treatment was completed with power and hand instruments. MIST included vertical releasing incisions and minimal full-thickness flaps reflected off the bone. Visible calculus was removed with power and hand instruments. The flaps were repositioned and sutured. Patients completed surveys regarding pain, discomfort and feelings about treatment outcome.

Careful manipulation of the tissues in each case resulted in desired clinical outcomes and no clinical differences between treatments. Oral hygiene was good with 10 percent plaque levels. Probing depth reductions were more than 3mm and attachment level gains nearly 3mm. The only significant difference was treatment time, 30 minutes per site for non-surgical treatment compared to 60 minutes per site for MIST. Patients experienced very little discomfort with either treatment and were pleased with the results.

Clinical Implications: Minimally invasive treatment provides a cost-effective approach to isolated intrabony defects.

Ribeiro, F., Casarin, R., Palma, M., Júnior, F., Sallum, E., Casati, M.: Clinical and Patient-Centered Outcomes After Minimally Invasive Non-Surgical or Surgical Approaches for the Treatment of Intrabony Defects: A Randomized Clinical Trial. J Perio 82: 1256-1266, 2011.
Factors Influencing Perio Referrals

Periodontists rely on referrals from general dentists to grow their practices. Since the 1980s, research findings and new technologies have led to more periodontal treatment being provided in general dental practices. As a result, patients referred to the periodontist in the year 2000 had more severe disease and needed more extractions than patients referred in 1980. Despite more awareness of periodontal disease, it is still under-diagnosed and when diagnosed, 40 percent of cases go untreated.

Researchers at the University of Kentucky in Lexington, Kentucky, wanted to know what factors influenced the general dentists' decision to refer to a particular periodontist. They surveyed dentists and specialists across several states: Florida, Georgia, Kentucky, North Carolina, Ohio, Tennessee and Virginia. Statistical calculations determined that each group needed 80 subjects. They contacted 533 in each group and the 20 percent response rate provided 100 clinicians from each group.

General dentists and periodontists were asked to rate 16 factors influencing referrals on a scale of 1 to 5. The number-one rated factor for general dentists was the specialist's clinical skills. Number one for the periodontists was a previous positive experience between general dentist and specialist. Last on the list for both was the specialist having a teaching appointment. Being board certified was higher on the list for the general dentists than for the periodontists, who ranked that factor second to last. The periodontists ranked referral of new patients to the general dentist higher than the general dentists ranked it.

Clinical Implications: This information might be helpful for general dentists and specialists as they build their referral relationships.

Park, C., Thomas, M., Branscum, A., Harrison, E., Al-Sabbagh, M.: Factors Influencing the Periodontal Referral Process. J Perio 82: 1288-1294, 2011.
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