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Perio Reports
Vol. 21 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.
Flossing causes bacteremia
Perio therapy reduces severity
of arthritis
Rheumatoid arthritis (RA) and periodontal disease are both
chronic inflammatory conditions with local destruction of hard
and soft tissues. Both diseases release cytokines from inflammatory cells. Progression of one disease can negatively impact the
other and vice versa.
The severity of RA is measured with The Disease Activity
Score (DSA28). This combines the erythrocyte sedimentation
rate, the number of joints, out of 28, that are swollen and tender, and the general health of the patient indicated on a visual
analog scale of 1 to 100.
Researchers at Case Western Reserve University in
Cleveland, Ohio, provided non-surgical periodontal therapy to
20 patients diagnosed with RA. A second group of 20 with RA
served as controls. All subjects were taking medications to control RA and half the group was taking an anti-TNFα drug.
Those taking the anti-TNFα drug were randomly assigned to
both treatment and control groups.
Baseline examinations included blood tests, DSA28, and
periodontal clinical indices. Half the group received SRP and
oral hygiene instructions and all subjects were evaluated six
weeks later.
Those receiving non-surgical therapy showed improved periodontal health, and those taking the TNFα drug showed greater
healing than those not taking the drug. SRP subjects not taking
anti-THFα drugs showed significant improvement in periodontal
indices as well as indicators of RA severity compared to controls,
either taking TNFα or not. Serum TNFα levels were reduced for
those receiving periodontal treatment compared to controls.
Clinical Implications: Treatment of moderate to severe periodontitis might relieve the symptoms of rheumatoid arthritis.
Ortiz, P., Bissada, N., Palomo, L., Han, Y., Al-Zahrani, M.,
Panneerselvam, A., Askari, A.: Periodontal Therapy Reduces the
Severity of Active Rheumatoid Arthritis in Patients Treated with
and without Tumor Necrosis Factor Inhibitors. J Perio 80: 535540, 2009. ■
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Oral bacteria are implicated in approximately 20
percent of infective endocarditis (IE) cases. The
mortality rate for IE cases
caused by the oral bacteria Viridans streptococci is six to
16 percent. American, European and Australian guidelines for prevention of IE recommend antibiotic prophylaxis with certain dental procedures. In contrast, British
guidelines do not recommend antibiotic prophylaxis
since bacteremia can be caused by oral hygiene.
Researchers at Westmead Hospital in Sydney,
Australia, evaluated blood samples from 60 subjects with
and without periodontal disease to detect bacteremia
immediately following professional dental flossing.
Blood samples were also taken at baseline, 30 seconds
and 10 minutes following full mouth flossing.
Flossing with waxed floss took between four and five
minutes and longer for those with periodontal disease.
Bleeding upon flossing was seen in 30 percent of papilla
in the periodontitis group compared to eight percent in
the healthy group. Twelve subjects in each group were
positive for bacteremia at 30 seconds. After 10 minutes,
eight subjects in the periodontitis group and four in the
healthy group were positive for bacteremia. It might take
longer to clear the number of bacteria associated with
periodontitis, thus twice as many more positives at 10
minutes in the periodontitis group.
Those who tested positive at 30 seconds did not
necessarily test positive at 10 minutes. Those who
tested positive at both 30 seconds and 10 minutes
sometimes had different bacteria. Viridans streptococci
were identified in seven of the periodontitis samples
and four of the healthy samples. Clinical indices were
not predictive of bacteremia.
Clinical Implications: Flossing may be similar to
some dental procedures as a risk factor for IE.
Crasta, K., Daly, C., Mitchell, D., Curtis, B., Stewart, D.,
Heitz-Mayfield, L.: Bacteraemia due to Dental Flossing. J
Clin Perio 36: 323-332, 2009. ■
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Perio and preterm, low birth weight: Is there a link?
Studies support both sides of this debate. A recent metaanalysis found women with periodontitis two to three times
more likely to have a preterm, low birth
weight baby, while other studies show
no link at all.
The results of a multi-center study
measuring the effects of periodontal
therapy on birth outcomes were published in the New England Journal of
Medicine in 2006 as the Obstetrics and
Periodontal Therapy Study (OPT). This
report further analyzes data from the
OPT study.
Periodontitis requirements for study
subjects were four or more teeth with
probing depths of 4mm or more, attachment loss of 2mm and bleeding upon
probing for at least 35 percent of sites.
Restorative, endodontic procedures and
extractions were recommended before
week 21 for 59 percent of the women
and treatment was completed by 73 percent of them. All subjects were seen monthly until delivery.
Half the group received SRP and half did not. Rescue
periodontal treatment was offered to 26 of 60 control patients
with disease progression of 3mm or more. Treatment was
offered, but not always accepted.
Preterm deliveries occurred for 75
out of 812 women or nine percent of
the subjects. Periodontal disease progression was not linked with preterm
deliveries. Pre-eclampsia or pregnancy
associated hypertension was found to
be a significant risk factor for preterm delivery.
Clinical Implications: It’s safe to provide non-surgical periodontal therapy
during pregnancy. Data are not conclusive that periodontal disease progression leads to preterm delivery.
Michalowicz, B., Hodges, J., Novak, M.,
Buchanan, W., DiAngelis, A., Papapanou,
P., Mitchell, D., Ferguson, J., Lupo, V.,
Bofill, J., Matseoane, S.: Change in Periodontitis During
Pregnancy and the Risk of Pre-Term Birth and Low Birthweight.
J Clin Perio 36: 308-314, 2009. ■
Smoking changes the free radical/antioxidant balance
Smoking induces oxidative stress in the body, allowing for an
increase in reactive oxygen species (ROS) or free radicals. These
small molecules are a by-product of oxygen metabolism and
have an important role in cell signaling. There is a balance
between these free radicals and antioxidants like superoxide dismutase (SOD), an enzyme that converts superoxide into oxygen
and hydrogen peroxide. Antioxidants are an important defense
system for nearly all cells exposed to oxygen. Reduced SOD levels lead to tissue damage and bone loss.
Researchers at the Manipal College of Dental Medicine in
India measured the influence of smoking on SOD levels in
saliva and GCF of 70 men with moderate, mild or no periodontitis. Since smoking is not very prevalent among women
in India, only men were included in this study. Smokers were
grouped as light (less than 10 cigarettes per day) and heavy
(more than 10 cigarettes per day). Ten of the subjects did not
smoke and were controls.
GCF samples were taken from the site with the deepest
probing depth and most attachment loss. Unstimulated saliva
was collected for analysis. Complete periodontal records were
also made for each subject.
SOD levels were progressively lower from periodontally
healthy non-smokers to heavy smokers with moderate disease.
Heavy smokers had lower SOD levels than light smokers. Perhaps
improving antioxidant levels will motivate smoking cessation.
Clinical Implications: Encourage smoking cessation, which
will allow the body to reestablish a balance between free radicals and antioxidants, leading to better periodontal health.
Agnihotri, R., Pandurang, P., Kamath, S., Goyal, R., Ballal, S.,
Shanbhogue, A., Kamath, U., Bhat, G., Bhat, K.: Association of
Cigarette Smoking with Superoxide Dismutase Enzyme Levels in
Subjects with Chronic Periodontitis. J Perio 80: 657-662, 2009. ■
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Hopeless teeth don’t harm adjacent teeth
Strategic extractions are often recommended to preserve the
ridge or for implant placement. However, patients don’t always
want these teeth extracted.
Researchers at Okayama University in Japan evaluated
the charts of 25 non-smoking, systemically healthy patients
after an average of eight years of maintenance therapy. Prior
to treatment in the graduate student clinic, these patients
had a total of 113 teeth with a poor prognosis recommended
for extraction. Poor prognosis was defined as teeth that had
75 percent bone loss, probing depths
8mm or more, Class II or III furcation
involvement and Class III mobility.
Patients had one to 13 hopeless teeth,
the average being five hopeless teeth
per subject.
Of the 113 hopeless teeth, 76 were
still retained at the time of examination
Severe periodontitis is found in 10 percent of adults and 30 percent of
for this study. All patients had undergone
those older than 50 years of age. It is implicated in the onset and development
non-surgical therapy and periodontal
of other chronic diseases including cardiovascular, diabetes, rheumatoid arthrimaintenance for several years. Probing
tis, and respiratory disease. Similar inflammatory pathways might be the link,
depths, attachment levels and bone loss
with cytokines and C-reactive protein associated with these chronic inflammawere no greater next to the hopeless teeth
tory conditions.
compared to non-adjacent teeth. In fact,
Researchers at University of Sao Paulo in Brazil evaluated the markers of
inflammation in 25 otherwise healthy, non-smoking individuals with periodona fraction of a millimeter greater probing
titis after providing non-surgical periodontal therapy. A group of 17 periodondepth reduction was seen on surfaces
tally healthy individuals served as controls. Both groups received oral hygiene
adjacent to hopeless teeth compared to
instructions and the periodontal disease subjects were all treated weekly by one
non-adjacent teeth. Non-surgical therapy
periodontits to complete non-surgical therapy. Thereafter, these patients were
was effective in preventing the progresseen every 15 days for three months. All subjects underwent clinical exams and
sion of disease in the hopeless teeth as
blood work at baseline and three months after treatment was complete for those
well as for those teeth adjacent to the
in the disease group.
hopeless teeth.
C-reactive protein levels should be zero. The average score for the disease
Risk factors identified for these
group
was 1.2 and in the healthy group, 0.9. At three months, the control group
hopeless teeth include: initially deep
was unchanged and the disease group has a score of 0.6 or a 50 percent reducprobing depth, furcation involvement
tion. The cytokine IL-6 was also reduced 50 percent in those receiving therapy.
and mobility.
This study confirms that periodontal disease by itself can cause increases in IL6 and C-reactive protein.
Clinical Implications: Retention of
hopeless teeth is not necessarily detriClinical Implications: Providing periodontal therapy is important to avoid
mental to patients when effective nonelevated levels of IL-6 and C-reactive protein.
surgical therapy is provided.
Non-surgical therapy reduces
C-reactive protein
Ikuni, D., Yamamoto, T., Takeuchi, N.:
Retrospective Study of Teeth with a Poor
Prognosis Following Non-Surgical Periodontal Treatment. J Clin Perio 36: 343348, 2009. ■
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June 2009 ■ hygienetown.com
Marcaccini, A., Meschiari, C., Sorgi, C., Saraiva, M., de Souza, A., Faccioli, L.,
Tanus-Santos, J., Novaes, A, Gerlach, R.: Circulating INterleukin-6 and HighSensitive C-Reactive Protein Decrease After Periodontal Therapy in Otherwise
Healthy Subjects. J Perio 80: 594-602, 2009. ■