Perio Reports Vol. 25, 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.
|Factors Influencing Tongue Coating
Tongue coating forms on the middle and posterior portion
of the tongue in people with periodontal disease as well
as healthy individuals. Oral causes account for 76 percent of
oral malodor. Tongue coating alone accounts for 43 percent
of oral malodor, along with gingivitis and periodontitis
accounting for 18 percent. Since tongue coating is a significant
cause of oral malodor, more needs to be learned about
what causes it.
Researchers at the Catholic University Leuven in
Leuven, Belgium evaluated 96 patients seeking care at its
halitosis clinic. Subjects were instructed by letter to refrain
from eating onions, garlic or spicy food for two days before
their appointment and to refrain from drinking coffee or
alcohol or smoking cigarettes for 12 hours before the
appointment. They were also asked to refrain from using chewing gum, mints, drops, scents or mouthrinses on the
morning of their appointment.
They were asked to complete a written questionnaire
relating to general health, oral hygiene habits, ENT
problems and diet. The clinical examination included an
organoleptic (smelling of the breath) test and an evaluation
of tongue coating both visually and by weighing the scrapings
from the back of the tongue. Sulphur compounds were
measured using OralChroma, gas chromatography. Quality
and quantity of saliva were also measured.
Clear correlations were established between organoleptic
scores, tongue coating scores, the weight of tongue coating
scrapings and the objective measure of volatile sulphur
compounds using the OralChroma machine. Those who
smoked, did not clean between their teeth and preferred soft
foods had more tongue coating and higher
oral malodor scores.
Clinical Implications: Tongue coating is
indicative of oral malodor and influenced
by poor oral hygiene.
Van Tornout, M., Dadamio, J., Coucke, W., Quirynen, M.: Tongue Coating: Related Factors. J Clin Perio 40: 180-185, 2013.
Sleep Apnea and Periodontal Disease
Chronic periodontitis (CP) is linked to many systemic
diseases, without any cause and effect studies yet published.
Both CP and obstructive sleep apnea (OSA) are associated
with a systemic inflammatory response. A study of 68 subjects
by Australian researchers published in 2009 suggested a
link between OSA and CP.
Researchers at Taipei Medical University in Taipei, Taiwan
evaluated a much larger group to determine if there was a link
between OSA and CP. The Longitudinal Health Insurance
Database of Taiwan includes records of one million individuals.
From this database, researchers selected more than 7,000
patients who were diagnosed with OSA through a sleep study.
A group of 22,000 age-, gender- and country location-matched
controls with no diagnosis of OSA were also identified.
In Taiwan insurance records also provide information
about the diagnosis and treatment of periodontal disease.
From this information it was possible to determine who also
had CP. The average age of the subjects evaluated was 48
years and 62 percent were males. After adjusting for several
influencing factors, including smoking, alcohol use, hypertension,
cholesterol levels, diabetes and obstructive pulmonary
disease, a significant difference was detected between
the groups. In the group with OSA, 34 percent were diagnosed
with CP compared to 23 percent in the control group.
These findings do not suggest a cause and effect relationship
between CP and OSP, but rather a link between the two conditions.
Something not mentioned in the article is the link
between mouth breathing and both CP and OSA.
Clinical Implications: The odds ratio of 1.75 makes those with a diagnosis of chronic periodontitis 1.75 times more likely to experience obstructive sleep apnea.
Keller, J., Wu, C., Chen, Y., Lin, H.: Association Between Obstructive Sleep Apnea and Chronic Periodontitis: A Population-Based Study.
|Bacteremia from Flossing and SRP Similar
Infective endocarditis (IE) is a rare but serious infection
of the heart. Viridians streptococci bacteria (VAB) are the
primary oral bacterial associated with IE. Prophylactic antibiotics
are recommended for those at risk when undergoing
invasive dental procedures like scaling and root planing
(SRP). New research suggests that toothbrushing might be
just as risky as SRP when considering a bacteremia.
Researchers at the University of Sydney, Australia compared
bacteremia levels following SRP and flossing in a group
of 30 people with chronic periodontitis. Full-mouth flossing
was completed at the first visit and one quadrant of SRP at
the second visit. Blood samples were taken at baseline and at
30 seconds and 10 minutes after flossing. Blood samples were
taken five minutes after starting SRP and again at 30 seconds
and 10 minutes after completing SRP. A gingival index and
plaque index were taken on all subjects immediately after
baseline blood draws.
Flossing was done with waxed floss, moving the floss up
and down three times on each proximal tooth surface. SRP
was done under local anesthesia using both an EMS power
scaler and Gracey curettes.
The incidence of total bacteremia was 30 percent in the
flossing group and 33.3 percent in the SRP group. VSB bacteremia
was 27 percent in the flossing group and 20 percent
in the SRP group. These differences are not statistically different.
However, the fact that both flossing and SRP result in
similar incidence of bacteremia scores is problematic since
the recommendations for prophylactic antibiotics only apply
to invasive dental procedures.
Clinical Implications: It might be time to rethink prophylactic
Zhang, W., Daly, C., Mitchell, D., Curtis, B.: Incidence and Magnitude of Bacteraemia Caused by Flossing and by Scaling and Root Planing. J Clin Perio 40: 41-52, 2013.
CHX Gel vs. Rinse for Peri-implant Mucositis
Peri-implant mucositis is a reversible infection in
the marginal tissue surrounding implants. It is characterized
by bleeding, swelling and inflammation
with no bone loss. If left untreated, it can progress
to peri-implantitis and irreversible bone loss.
Chlorhexidine (CHX) in gel or rinse is often used to
control these infections.
Researchers at the University of Milan in Milan,
Italy compared the use of a 1% CHX gel and a
0.2% CHX mouthrinse to treat peri-implant
mucositis in a group of 23 patients. All implant sites
showed evidence of bleeding on probing, plaque
accumulation and bone loss.
Average age of the patients was 62 years, with a
range from 43 to 87. Subjects all received instrumentation
and were randomly assigned to either the
gel (13 subjects) or the mouthrinse (10 subjects) and
instructed to use their assigned product twice daily
for 10 days. Clinical indices were evaluated at 10
days, one month and three months.
At 10 days, each group showed significant
reductions in plaque and bleeding. Seventy percent
of sites in the gel group and 90 percent of sites in
the mouthrinse group were healed. Healing
remained stable through the three months of the
study. The differences between groups were not statistically
This study used a 0.2% rinse, stronger than the
typical U.S. rinse of 0.12%. The gel provided a localized
application of the CHX while the mouthrinse
was more generalized throughout the mouth.
Clinical Implications: CHX gel and mouthrinse both work well for peri-implant mucositis.
De Siena, F., Francetti, L., Corbella, S., Taschieri, S., Del Fabbro, M.: Topical Application
of 1% Chlorhexidine Gel Versus 0.2% Mouthwash in the Treatment of Peri-Implant
Mucosisit. An Observational Study. Int J Dent Hygiene 11: 62-68, 2013.
|Antimicrobial Power Scaler Coolant as Effective as Water
Power scalers are as effective as hand instruments
for the removal of subgingival deposits. It has been suggested
that using an antimicrobial coolant solution
would enhance healing. This
combination of power scaling
with an antimicrobial combines
two treatments within one and
as such might save time. Both
povidone iodine and chlorhexidine
have been tested in power
scalers and to a lesser extent,
essential oil solutions.
Researchers at the University of Ghent and the
Free University of Brussels, both in Belgium, compared
clinical outcomes after power scaling with
either Listerine or water as the coolant. Patients with
at least one pocket in each quadrant measuring
6mm with bleeding upon probing were included in
the study. A total of 29 patients completed the threemonth
study: 17 in the Listerine group and 18 in
the water group. Subjects all received two 90-minute
instrumentation visits, using only an EMS Piezon
Master 600 power scaler. Subjects were also
instructed in toothbrushing and interdental cleaning
using interdental brushes or toothpicks. All were
provided with a manual toothbrush, toothpaste and
interproximal cleaning aids.
The test group was treated with full strength
Listerine as the coolant in the power scaler. The control
group was treated with water as the coolant.
At three months, both groups showed significant
healing with 50 percent reduction in bleeding,
probing depth reductions of 1mm and attachment
gains of 0.5mm. Deep pockets reduced 2.5mm in
Clinical Implications: Listerine used as a coolant
solution with a power scaler provides no added
benefit over water when used to treat chronic
Cosyn, J., Miremadi, S., Sabzevar, M., De Bruyn, H.: Clinical Effects of an Essential Oil
Solution Used as a Coolant DUring Ultrasonic Root Debridement. Int J Dent Hygiene 11:
Essential Oil Rinse Used for Perio Maintenance
To be successful, periodontal treatment should be followed
by frequent periodontal maintenance visits with the
dental hygienist and effective daily oral hygiene. Many
antimicrobials are suggested to enhance the benefits of
mechanical plaque removal.
Researchers at the University of Ghent in Belgium compared
Listerine mouthrinse with a placebo rinse in a group of
periodontal maintenance patients over a three-month period.
Subjects were instructed to rinse twice daily. There were 23 in
the test group and 21 in the placebo group who completed
the full study. Baseline clinical indices included plaque, bleeding,
gingivitis, probing depths and clinical attachment levels.
Subgingival bacterial samples were taken from the deepest
pocket in each quadrant and analyzed. Measurements were
taken at baseline and repeated at three months.
Differences between groups were not statistically significant.
The test group began with healthy gingiva at 80 percent
of sites and at three months this was 96 percent. In the
placebo group, it began at 91 percent and increased to 97
percent. Bacterial load was similar at baseline and three
months for both groups. Despite no clinical evidence of benefit,
patients in both groups reported feeling refreshed after
rinsing. Nearly 60 percent of subjects reported they would
continue using a mouthrinse and would recommend a
mouthrinse to family and friends. The strong taste gave subjects
the perception of clinical benefits, even though the clinical
evidence does not support this.
Clinical Implications: People with good oral hygiene will experience no added benefit from daily rinsing with Listerine.
Cosyn, J., Princen, K., Miremadi, R., Decat, E., Vaneechoutte, M., De Bruyn, H.: A Double-Blind Randomized Placebo-Controlled Study on the Clinical and Microbial Effects of an Essential Oil Mouth Rinse Used
by Patients in Supportive Periodontal Care. Int J Dent Hygiene 11: 53-61, 2013.