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Perio Reports

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Perio Reports  Vol. 24, 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.
Tongue Coating and Oral Malodor

Tongue coating forms for most people with or without periodontal disease. More coating is associated with gingivitis and periodontitis. It generally forms on the dorsum of the tongue in varying thicknesses and colors. It consists of bacteria, desquamated epithelial cells, blood metabolites, food particles and leukocytes from periodontal pockets. Anaerobic bacteria within the tongue coating breaks down organic substances, which produces sulphur compounds - the smell of bad breath. It is a well-established fact that tongue coating is the primary source of oral malodor, but what influences its formation is not well understood.

Researchers at Catholic University of Leuven in Belgium used several indices to evaluate both oral malodor and tongue coating in 96 patients seeking treatment for halitosis. The plaque was then scraped from the tongue with a plastic instrument and placed into a plastic container and weighed. A thorough medical history and clinical examination were gathered from each test subject. Questions were asked about oral hygiene habits and products, mouth breathing, diet relating to hard and soft foods, smoking, coffee and water consumption and denture or partial replacement of teeth.

Only a few of the test subjects were mouth breathers, smoked, or had xerostomia or periodontitis. Poor oral hygiene was the most likely to be correlated with increased tongue coating. Those who cleaned between their teeth daily, had less tongue coating, perhaps because of more awareness of tongue hygiene. Dentures, smoking, coffee drinking and soft foods showed correlation with two of the four indicators, with poor oral hygiene the strongest indicator.

Clinical Implications: Tongue coating is a critical aspect of oral malodor and should be evaluated and discussed when counseling patients about fresh breath.

Van Tornout, M, Dadamio, J, Coucke, W., Quirynen, M.: Tongue Coating: Related Factors. J Clin Perio doi:10.1111/jcpe.12031, 2012.

Tongue Cleaning

Several research studies confirm the relationship between bacteria in tongue coating and the volatile sulphur compounds of bad breath. Tongue cleaning is done with either a brush or a scraper and successfully reduces bad breath. Substances that reduce the overall bacterial load are also used.

Researchers at the proDERM Institute for Applied Dermatological Research in Schenefeld, Germany, tested a tooth and tongue gel and tongue scraper from GABA International. The tooth and tongue gel contains amine fluoride, stannous fluoride and 0.5 percent zinc lactate. The test group of 54 people all had bad breath confirmed with organoleptic testing. The crossover study design tested three oral hygiene approaches: 1. toothbrushing using a control toothpaste with sodium monofluorophosphate and no tongue cleaning, 2. toothbrushing with the control toothpaste and mechanical tongue cleaning and 3. toothbrushing and tongue cleaning with the tooth and tongue gel. Each test period was seven days with a seven-day washout between tests.

The tongue scraper has four scraping blades and a platform at the top for placement of the tooth and tongue gel. Tongue cleaning instructions were to scrape twice in the middle of the tongue from the back to the tip, followed by twice on both the right and left sides of the tongue.

Eight odor judges rated the organoleptic odor levels. All three treatments reduced oral malodor at five minutes, less so at 60 minutes and the overnight effect was only slightly better than baseline. The gel and scraper combination provided only slightly better odor control than the other two approaches.

Clinical Implications: Tongue scraping with or without a tongue gel reduces oral malodor.

Wihelm, D, Himmelmann, A., Axmann, E., Wihelm, K.: Clincial Efficacy of a New Tooth and Tongue Gel Applied with a Tongue Cleaner in Reducing Oral Halitosis. Quintessence Int 43: 709-718, 2012.

Saliva Test for Compounds Causing Oral Malodor

Bad breath is a common complaint that is best treated by dental professionals. Volatile sulphur compounds (VSCs) have been researched extensively and expensive technology is available to clinicians for testing hydrogen sulfide and methyl mercaptan levels chairside as part of a Fresh Breath Program. In addition to VSCs, polyamines such as putrescine and cadaverine may also contribute to oral malodor. Salivary levels of polyamines are significantly correlated with oral malodor.

Researchers at the Catholic University of Leuven in Belgium evaluated a chairside salivary test that might become a reliable way to measure oral malodor levels. Fifty men and 50 women agreed to participate in this study. Two months before the study, subjects received written instructions to refrain from spicy food for two days before the testing and no alcohol or coffee for 12 hours before testing. On the morning of their appointment, they were asked not to use mints, gum, toothpaste, mouthrinses or perfume, and also asked not to smoke.

On test day, breath odor was measured using several methods: organoleptic testing (smelling the mouth odor), OralChorma (gas chromatography) and the new chairside saliva test for amines, which has a 10-step white to dark pink color scale. Tongue coating and clinical indices were also recorded.

Organoleptic testing identified 52 subjects with moderate to severe oral malodor. Comparison of the saliva test to established breath odor tests showed significant correlation.

Clinical Implications: Rather than an expensive gas chromatography machine, clinicians may soon be testing breath odor with a simple saliva test.

Dadamio, J., Van Tornout, M., Vancauwenberghe, F., Frederico, R., Dekyser, C., Quirynen, M.: Clinical Utility of a Novel Colorimetric Chair Side Test for Oral Malodour. J Clin Perio 39: 645- 650, 2012

Individualized Oral Hygiene More Cost Effective than Standardized OHI

Effective non-surgical periodontal treatment relies on patient cooperation with daily oral hygiene to be successful. Without this, maintenance therapy is likely to require more time and, in the end, increase treatment cost.

Researchers at Dalarna University in Falun, Sweden, and Uppsala University in Uppsala, Sweden, compared individualized oral hygiene instruction and standardized instructions in conjunction with non-surgical periodontal therapy. The 113 patients with moderate to severe periodontitis all had set clinical goals to meet in probing depths and bleeding scores over the 12 months following treatment. Patients were seen by a hygienist every three months.

The individualized oral hygiene program consisted of seven components: 1. interview covering periodontal disease and oral health goals of the person, 2. analysis of current brushing and interdental cleaning, 3. practice with new oral hygiene tools, 4. creating an action plan based on patient’s readiness to change, 5. structured diary to keep track of oral hygiene activities, 6. coordination of predetermined oral hygiene tools, and 7. problem solving strategies identified for high-risk sites, like interproximals. Re-evaluation and restructuring of the action plan was scheduled as needed.

Standard instructions involved disclosing solution and oral hygiene tools selected by the hygienist. Patients demonstrated techniques and interproximal areas were a strong focus of the daily cleaning.

An initial investment of more time for individualized oral hygiene instruction led to greater health achievements, 35 successful and 22 not, compared to 19 successful and 37 not in the standardized group.

Clinical Implications: Individually tailored oral hygiene programs achieve better oral health long term than standardized oral hygiene instructions.

Jönsson, B, Öhrn, K., Lindberg, P, Oscarson, N.: Cost-Effectiveness of an Individually Tailored Oral Heath Educational Programme Based on Cognitive Behavioural Strategies in Non-Surgical Periodontal Treatment. J Clin Perio 39: 659-665, 2012.
Triple-Headed Toothbrush More Effective than Standard Toothbrush

Despite the fact that more disease occurs between the teeth, toothbrushing remains the primary means of daily oral hygiene. Most people brush the facial and occlusal surfaces, often neglecting to brush lingual surfaces. Hand-eye coordination, frequency, time and consistency of brushing are all problems interfering with toothbrushing effectiveness. A triple-headed toothbrush design places bristles on facial, occlusal and lingual surfaces at the same time, requiring only a back and forth movement to remove plaque.

Researchers at several universities in Israel collaborated on a study comparing the triple-headed toothbrush and a standard single-head toothbrush in a group of 190 18-21-year-olds. In addition to measuring plaque scores, examiners also observed toothbrushing to record the Toothbrushing, Performance, Skill Index or Ashkenazi Index. The Ashkenazi Index counts the number of times the subject reaches each of the 16 identified areas of the dental arch and how many strokes in each of these areas, with 10 strokes in each area the goal.

Subjects were randomly assigned to one of two toothbrush groups by a coin toss. They were all given toothbrushes and asked to brush without instructions. Plaque and the Ashkenazi Index were recorded. Immediately afterward, subjects were given personalized instructions on the use of their toothbrush. One week later they were again observed brushing their teeth and plaque scores and the Ashkenazi Index were recorded.

After instructions, higher brushing skills and greater plaque reductions were measured with the triple-headed brush. Plaque reduction was better for both groups following instructions.

Clinical Implications: Unique brush head design provides easier toothbrushing and better plaque removal for young adults.

Levin, L., Marom, Y., Ashkenazi, M.: Brushing Skills and Plaque Reduction Using Singleand Triple-Headed Toothbrushes. Quintessence Int 43: 525-531, 2012.

Oral Health Impacts Quality of Life

Halitosis or bad breath is one side effect of periodontal disease that can impact the social interactions of a person. A case report of one institutionalized man demonstrated the benefits of dental hygiene care to reduce halitosis and increase the quality of life. This 36-year-old Dutch man was diagnosed with obesity at age three and mild mental retardation. His highest level of education was secondary special education. The most recent dental examination provided a treatment plan of full-mouth extractions due to aggressive periodontal disease.

Because of his severe halitosis, staff and other residents avoided interaction with him, so it was recommended that he see the dental hygienist. The RDH provided education and individualized oral hygiene instructions. At this visit, the severely obese man was sloppily dressed and generally unkempt. Three weeks later the RDH followed up and found less plaque and inflammation and less severe bad breath. At this visit the patient’s appearance also changed. He was clean, well dressed and cheerful. Following the second dental hygiene session, the patient was asked to fill out several short questionnaires focusing on quality of life relating to both now and before the first dental hygiene visit. Before the dental hygiene visits, he was withdrawn and ashamed of his bad breath. Now his attitude improved and he changed his oral hygiene habits, as he stated, "Because now at last I know what I should do and how."

Clinical Implications: While dental hygiene treatment and instructions focus on plaque, calculus and controlling and preventing dental disease, the outcomes also impact self-esteem and quality of life.

Buunk-Werkoven, Y., Dijkstra-le Clercq, M., Verheggen-Udding, E., de Jong, N., Spreen, M.: Halitosis and Oral Health-Related Quality of Life: A Case Report. Int J Dent Hygiene 10: 3-8, 2-12.
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