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Periodontitis -- It's Not Your Father's Plaque!

Periodontitis: An Archetypical Biofilm Disease.

Schaudinn C, Gorur A, et al:

J Am Dent Assoc 2009; 140 (August): 978-986

The nature of biofilm existence is the reason that periodontitis is so persistent and explains why antibiotic therapy is so ineffective.

Background: Periodontitis is a biofilm-mediated disease. Design: Literature review. Discussion: Oral bacteria, formerly called plaque, grow in matrix-enclosed biofilms, which are multi-species communities. These matrices consist mostly of polymers produced by sessile (attached) bacteria that are part of the biofilm. There is nearly a complete absence of planktonic (floating) bacteria. This biofilm paradigm transcends the anthropocentric community into other fields of science. Sessile bacteria in the biofilm community are extremely resistant to host defenses and antibiotics. These bacteria appear to be genetically programmed to live in matrix-bound ecosystems that are nutrient sufficient and release planktonic bacteria only to infect other sights. These sessile bacteria express a different phenotype, explaining their resistance to host forces and antibiotics that can penetrate the matrix and would normally be effective against a planktonic form of the same bacteria. This explains the chronic nature of periodontitis that occurs in an area readily accessible to local antibiotic therapy. The dynamics of periodontal biofilm formation are studied by using a biofilm potential technique, sampling over time within the sulcus itself. These techniques are also used to assess the efficacy of anti-biofilm therapy. Culture methods fail to detect as many as 99% of bacteria present, so research has turned to DNA-based detection systems. These systems will, in time, expand our list of putative pathogens seen in periodontitis. Within the National Institutes of Health study of the human microbiome, it has been shown that some species can differ up to as many as 500 genes when differing strains are sequenced. A super genome can then be established for the species. Conclusions: Because so much of this information has been developed outside of the dental community, it is mandatory that we, as dentists, keep a connection with our brothers in the general scientific community. Being a chronic, mixed-species, inflammatory bacterial infection caused by biofilms, periodontitis defies traditional antibiotic therapy and host resistance. Strategies should include disruption by scaling and root planing, plus adjunctive treatment with antibiotics and/or oxygenating agents. Reviewer's Comments: This review of the biofilm concept reiterates the importance of interdisciplinary cooperation in the search for answers to the archetypical question of resistance to treatment of periodontitis. Modern methods of identification and isolation will certainly continue to increase our knowledge base of the nature of periodontitis. (Reviewer-Charles R. Hoopingarner, DDS). © 2009, Oakstone Medical Publishing

Keywords: Bacteria, Biofilms, Periodontitis

Print Tag: Refer to original journal article

Predictable Periodontal Response to Restorative Margin Placement

Using Margin Placement to Achieve the Best Anterior Restorative Esthetics.

Spear F:

J Am Dent Assoc 2009; 140 (July): 920-926

You can use the sulcus as a determinant for biologic width issues and restorative margin placement.

Background: Esthetic demands and choice of restorative materials can present a dilemma for the dentist. Discussion: The choice of supragingival, equigingival, or subgingival margin placement involves the restorative material and underlying color of the teeth to be restored. Materials with high cervical translucency should be used for supragingival or equigingival margin placement because of their high esthetics and high degree of tissue acceptance. Extensive caries, previous restorations, retention requirements, and gingival coloration are reasons that subgingival margins may need to be considered. Tissue stability and biologic width management control the gingival inflammatory response or presence of recession. Deeper sulci, as a result of altered passive eruption, have the potential to recede if they are shortened during restorative treatment. A thin fragile gingiva with scalloped form also demonstrates instability. The classic concept of using total tissue height above the bone as a reference for margin placement is based on evaluation of the width of the attachment and placement of the margin 2.5 to 3.0 mm from the bone. If the gingival crest is <3 mm from the bone, any subgingival placement will result in an attachment violation and inflammatory response. If the attachment is >2 mm and the gingival sulcus is also extended, subgingival margin placement is unpredictable. The biologic width should be calculated and the gingival apparatus altered appropriately before marginal placement location is determined. An alternative reference is the gingival sulcus. If the sulcus is shallow (<1.5 mm), a margin may be placed at 0.5 to 0.7 mm predictably as long as the attachment is not invaded. If the sulcus is 1.5 to 2.0 mm, a margin placement at 50% of the depth will be maintainable. If the sulcus is deep (>2 mm), placing a margin anywhere in the sulcus can be unpredictable with regard to recession and/or biologic width inflammatory response. The rule then becomes to convert this to a 1.5-mm sulcus by crown lengthening then follow the rules for a normal sulcus depth. Impressions involve the double-cord technique with variations present for differing sulcus depths. The purpose of packing is to protect the tissue from abrasion and to create access to the margin. Preparation cord is placed to the level in the sulcus of the desired margin. After re-preparing the margin, a second larger impression cord is placed only to the depth of the margin itself. This impression cord is removed for taking the impression, and the preparation cord is removed after the impression is complete. Conclusions: If the dentist understands and uses periodontal principles to determine final margin position, highly predictable outcomes are possible. Reviewer's Comments: Using sulcus depth as a reference is an alternative to biologic width determination, which may not always be as accurate. (Reviewer-Charles R. Hoopingarner, DDS). © 2009, Oakstone Medical Publishing

Keywords: Esthetics, Gingival Marginal Stability


Increased Mandibular Retention -- Free!

Improved Denture Retention in Patients With Retracted Tongues.

Lee J-H, Chen J-H, et al:


Patients should hold their tongue with the tip against the lingual gingival border of the lower denture.

Background: Mandibular denture retention is perhaps one of the most challenging prosthetic procedures that presents in general practice. Objective: To quantify the increased denture retention obtained by optimizing tongue position. Participants/Methods: 85 edentulous subjects were recruited, and the dislodging force was measured with the patient's tongue in a retracted resting position and in an ideal resting position against the base of the lower incisor teeth. Ridge quality was assessed and quantified in 3 strata. In the class III poor ridge forms, the increase was 59%. Results: The results indicated an approximate 58% increase in the amount of force necessary to dislodge the denture. This was statistically significantly consistent across all 3 strata. Discussion: It is thought that the forward positioning of the tongue does not alter the shape of the lingual sulcus and will not interfere with the peripheral seal of the mandibular denture. This does not allow air under the denture and a resultant loss of retention, as is the case with a retracted tongue position. It is reported that patients can be trained to hold their tongues in this ideal position, and that this alone would be a significant source of improvement in the retention and stability of the denture prosthesis. Practicing by pronouncing the "long e" sound will produce tongue posture that is appropriate and increases denture retention. Valuable information can be obtained diagnostically that will help to establish realistic treatment expectations with your patients. Conclusions: Improved tongue posturing is listed as a modifying agent that can increase the retention of the lower denture. As the alveolar ridge deteriorates with age, neuromuscular control of the denture base becomes increasingly important to successful use of the denture prosthesis. Reviewer's Comments: The described technique has been previously described but not quantified. This simple help thought is well described and can be successfully used on a routine basis. (Reviewer-Charles R. Hoopingarner, DDS). © 2009, Oakstone Medical Publishing

Keywords: Dentures, Retention, Patient Education, Retracted Tongues


CBCT Detects Root Fractures Not Seen on Periapical Radiographs

Use of Cone-Beam Volumetric Tomography in the Diagnosis of Root Fractures.

Bernardes RA, de Moraes IG, et al:

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 108 (August): 270-277

Three-dimensional cone-beam CT images are better for detection of root fractures than are conventional radiographs.

Background: Root fractures can be difficult to diagnose if specific clinical signs and symptoms are lacking. Conventional radiographs may fail to detect root fractures if the x-ray beam is not projected parallel to the fracture. Cone-beam volumetric tomography (CBCT) may be more sensitive for detecting root fractures because its images can be viewed in multiple planes, and superimposed structures can be eliminated. Objective: To compare images from conventional intraoral radiography and CBCT for diagnosis of root fracture. Participants/Methods: 20 subjects with endodontically treated teeth participated. Some had suspected root fracture with discomfort, but there were no or few specific signs and symptoms such as large radiolucent lesions, pain on percussion or palpation, abscess, or sinus tract and periodontal pockets. Periapical radiographs were taken with E-speed film and paralleling periapical technique, then scanned and digitized. Three-dimensional CBCT images were obtained using the Accuitomo 3DX. Two scout images were taken, then a 17-second 360° scan was performed. Volume reconstruction was performed using I-dixel software. After reconstruction, the volumes were saved on CD-Rom and loaded into viewing software (3D Tomo X) for evaluation. Images were assessed on a 19-inch LCD monitor by 1 radiologist and 1 endodontist, who were blinded to clinical status. Root fractures were scored as the following: 0 = absent, 1 = present poorly defined, and 2 = present and well defined. Observers could click on a location of interest and view it in any plane. Results were compared by the Wilcoxon test. Inter-examiner variability was analyzed by the Kendall test. Results: There was a significant difference between conventional radiography and 3D CBCT in the diagnosis of root fracture (P <0.0001). In 18 of 20 cases, CBCT clearly revealed the fracture, which was confirmed by checking against clinical symptoms in 15 cases. In the remaining 2 cases, neither examiner was able to detect fractures using 3D imaging. Metallic artifacts may have contributed to this difficulty. The 2 examiners could detect fractures on conventional radiographs in 8 and 6 cases, respectively. There was excellent inter-examiner agreement (P =0.002) Conclusions: CBCT performed better than conventional radiographs for detection of root fractures. Artifacts from radiopaque materials can limit its performance. Reviewer's Comments: CBCT can be very useful for endodontic practice. Interpretation of the entire image volume requires special skill and expertise. If adequate training is not available, a radiologist report may be needed for every scan as the dentist is responsible for the information found in the entire scan. (Reviewer-Carol Anne Murdoch-Kinch, DDS, PhD). © 2009, Oakstone Medical Publishing

Keywords: Diagnosis, Root Fractures, Cone-Beam Volumetric Tomography


Improved Mastication Can Improve Salivary Function in Denture Wearers

Increase of Salivary Flow Rate Along With Improved Occlusal Force After the Replacement of Complete Dentures.

Matsuda K-I, Ikebe K, et al:


Providing replacement dentures with increased maximal occlusal force increases unstimulated and stimulated salivary flow rates in elderly edentulous patients.

Background: Dry mouth is common in elderly patients who wear dentures. Salivary flow rates and maximal occlusal forces are positively correlated. Unstimulated salivary flow rates increase with the placement of new dentures. It is not known whether improved mastication alone can improve salivary function. Objective: To determine whether salivary flow rates change with improved occlusal force after replacement of complete dentures in elderly patients. Participants/Methods: A random selection of consecutive, healthy, elderly, edentulous patients who needed replacement dentures at a dental school in Japan participated. All had worn maxillary and mandibular complete dentures for >5 years. New dentures had anatomic 20° teeth set in lingualized occlusion. Unstimulated salivary rate, then stimulated saliva flow rate and occlusal force were measured twice: first with old dentures and again with new dentures, adjusted and comfortable. Unstimulated salivary flow was measured without dentures. Stimulated salivary flow was measured after chewing paraffin wax. Maximum occlusal force was measured bilaterally using pressure-sensitive sheets, 97 μm thick, and a colorimetric scale. Differences were analyzed using Wilcoxon signed rank test. Results: 22 subjects (11 men and 11 women) with a mean age of 77.5 ± 6.1 years (range, 64 to 88 years) participated. Interval between insertion of new dentures and post-measurements was 20 to 77 days (median, 35 days). Mean number of adjustments was 2.7 ± 1.1 (median, 2). Median maximal occlusal force significantly increased from 84 N before to 165 N after new dentures (P <0.001). Stimulated salivary flow rates significantly increased from 0.45 mL/minute (0.40 to 0.95 mL/minute) before to 0.75 mL/minute (0.55 to 1.15 mL/minute) after new dentures (P =0.001). Unstimulated salivary flow rates increased from 0.06 mL/minute (0.04 to 0.12 mL/minute) before to 0.10 mL/minute (0.04 to 0.20 mL/minute) after new dentures (P =0.003). There was no significant difference between genders. Subjects with stimulated flow <0.5 mL/minute (hyposalivation) decreased from 50% to 5% after new dentures. Subjects with unstimulated flow <0.1 mL/minute (hyposalivation) decreased from 68% before to 41% after new dentures. Stimulated and unstimulated salivary flows were positively correlated. Before and after measurements were also significantly correlated. Conclusions: Proper prosthetic treatment can improve salivary function as well as maximal occlusal force. Reviewer's Comments: The possible influence of wearing dentures for the first time on salivary function was removed by selecting subjects who had already worn dentures. This is an exciting study because it shows that the dentist can help patients with salivary gland hypofunction by improving masticatory function. (Reviewer-Carol Anne Murdoch-Kinch, DDS, PhD). © 2009, Oakstone Medical Publishing

Keywords: Complete Dentures, Salivary Function, Occlusal Force


Gingival Recession Can Be Controlled, Reduced With Manual, Power Toothbrush

A Prospective Clinical Study to Evaluate the Effect of Manual and Power Toothbrushes on Pre-Existing Gingival

Recessions.

Dörfer CE, Joerss D, Wolff D:

J Contemp Dent Pract 2009; 10 (July 1): 1-8

There is no difference in progression of gingival recession in patients whether a manual or power toothbrush is being used.

Objective: To study differences in gingival recession in subjects using either a power or manual toothbrush to see if either is superior in treating this condition. Participants/Methods: 2 groups of subjects with pre-existing gingival recession were selected to use either the Oral-B ProfessionalCare® 7000 D17U power brush or an American Dental Association flat trim manual brush for twice-daily use over a period of 6 months. The same sodium fluoride dentifrice was used by all subjects who brushed their teeth twice daily for 2 minutes each time. Clinical measurements were recorded of gingival recession, pocket depth, and attachment levels. New toothbrushes were provided after 3 months, and after 6 months, clinical measurements were once again taken on all 106 subjects. Improvements, unchanged areas, and increases in the amount of recession were recorded and compared with previous numbers. Results: Both groups demonstrated significant reductions of recession from the beginning of the study. The study disputed some earlier research that claimed power toothbrushes caused greater gingival recession than did manual toothbrushes. This article also discusses another variable…the frequency of toothbrushing and its influence on recession. This increased frequency not only did not cause more recession, but it will lead to a reversal in the development of gingival recession. This assumes that the patient is using a soft toothbrush and correct toothbrushing techniques. The authors also discuss a phenomenon known as the "Hawthorne effect." This refers to a situation in human experiments where an unexpected result occurs. This may be due to changes in the behavior of the subject due to his participating in a clinical trial. In this study, it is discussed that participants demonstrated improved toothbrushing, which in turn reduced gingival recession in both groups. Conclusions: There was no significant difference between groups in gingival recession whether they used a manual or power toothbrush, despite the fact that the rotating-oscillating and pulsating action in power toothbrushes is superior in plaque removal and gingival control that the manual toothbrush. Both groups had a reduction in the amount of gingival recession during the 6-month period of the study. Reviewer's Comments: This study provides a good comparison of the 2 methods of toothbrushing available today. Despite the expense and sophistication of the various models of power toothbrushes, use of a manual toothbrush can achieve the same favorable results of preventing or minimizing gingivitis, gingival recession, and other periodontal problems. The patient's technique and thoroughness of the toothbrushing is of prime importance in the long run, as the data in this article demonstrate. (Reviewer-Edward N. Friedman, DDS). © 2009, Oakstone Medical Publishing

Keywords: Oscillating-Rotating Power Toothbrush, Gingival Recession


New Restorative Materials Allow for More Conservative Preparations

Clinical Evaluation of Polyamide Polymer Burs for Selective Carious Dentin Removal.

Prabhakar A, Kiran NK:


Carbon steel round burs are more efficient at removing decay from teeth than are polyamide polymer burs. However, steel burs tend to over-prepare the cavity more than do self-limiting burs.

Background/Objective: To preserve carious "unaffected" dentin, a more conservative technique may be used. The difference between tooth preparation and caries removal using a polyamide polymer bur versus a carbon steel bur were studied. The effect the self-limiting caries removal property of these burs has on the durability and rate of secondary decay on the teeth treated was then calculated. Participants/Methods: 40 children with carious bilateral mandibular first molars were stratified into 2 groups; 1 group was to be treated with the conventional carbon steel bur, and the other group was to be treated with a polyamide polymer bur. Excavation of the decay using the steel bur continued until the operator, using a straight probe, determined that all soft dentin had been removed. The polymer bur, SmartPrep® in sizes 2, 4, or 6, removed the soft decay. The bur progressed only until it removed the softened dentin but did not penetrate sound dentin. Cavities were restored with GC Fuji lX GP cement. Six months later, restorations were checked clinically and radiographically. Results: Complete removal of caries was seen in the carbon steel group. In the polymer bur group, 65% of teeth showed complete removal of caries, while 35% had partial caries removal. Carbon burs were significantly faster in decay removal. After 6 months, there were no changes in the status of restorations. The polymer bur was shown to be more efficient in treating soft carious lesions, and therefore preserved more of the dentin. This created suitable conditions for it to undergo physiological remineralization. Conclusions: Carbon steel burs result in a greater loss of tooth structure and remove caries more efficiently. However, polymer burs do preserve tooth structure since they are self-limiting. The remaining dentin could remineralize, especially if the tooth is restored with a cariostatic filling material and if the nutrient supply of the caries is eliminated. Reviewer's Comments: Newer restorative materials involving bonding for their retention allow the dentist to make more conservative types of preparations. The polyamide polymer bur studied in this article preserved more tooth structure, as it is not hard enough to remove sound dentin. This self-limiting type of caries removal allows the dentist to preserve more tooth structure. This study presents a good summary of this innovative type of "smart bur," which enhances a more conservative approach used when restoring teeth with composite. Studies covering the longevity of these restorations for a longer period would be helpful to truly evaluate if preserving some of the affected dentin is a valid treatment option for the long term. (Reviewer-Edward N. Friedman, DDS). © 2009, Oakstone Medical Publishing

Keywords: Polymer Bur, Caries Removal, Carious Dentin


Extended Use of Whitening Strips

Effects of Duration of Whitening Strip Treatment on Tooth Color: A Randomized, Placebo-Controlled Clinical Trial.

Swift EJ Jr, Heymann HO, et al:

J Dent 2009; 37 (Suppl 1): e51-e56

Use of 6% peroxide strips, worn for 30 minutes twice a day for up to 6 weeks, are associated with minimal to no side effects.

Background: The popularity of whitening strips continues to grow, especially among patients using over-the-counter products. Prior studies have demonstrated the efficacy of whitening strips with minimal side effects; however, concern still exists over safety outcomes for users who may extend recommended treatment times without professional monitoring. Objective: To determine the efficacy and safety of using peroxide whitening strips over an extended 6-week period. Participants/Methods: 40 patients were recruited to participate in this clinical whitening study. Half the subjects received 6% hydrogen peroxide strips to wear for 30 minutes twice a day, while the remaining subjects were treated with a placebo strip for the same period. To determine efficacy, color measurements were taken prior to treatment and at each recall visit (2, 4, and 6 weeks). Subjects self-reported tooth sensitivity and soft tissue irritation throughout the duration of the study. A comprehensive oral exam was also provided at each recall visit to confirm absence or presence of any soft tissue irritation. Results: Subject using peroxide strips continued to show a significant change in color over the extended treatment period, as teeth became less yellow and increased in lightness. Tooth sensitivity was experienced in 35% of subjects treated with peroxide strips, and 25% claimed some form of gingival irritation. However, clinical oral examination was unable to detect any form of gingival irritation for any subjects participating in the study. Conclusions: The results of this clinical study demonstrate a continued efficacy of 6% peroxide strips for up to 6 weeks with minimal to no side effects. Reviewer's Comments: It's a good sign that the authors reported no dropouts due to adverse effects. Side effects of tooth sensitivity and gingival irritation were described in this study as minor or mild in severity. A categorical basis for distinguishing levels of severity would have been helpful for comparison purposes. (Reviewer-Joe C. Ontiveros, DDS, MS). © 2009, Oakstone Medical Publishing

Keywords: Whitening, Bleach, Clinical Study, Peroxide Strips


Defining the Perfect Color Match

Clinical Evaluation of Perceptibility of Color Differences Between Natural Teeth and All-Ceramic Crowns.

Ishikawa-Nagai S, Yoshida A, et al:

J Dent 2009; 37 (Suppl 1): e57-e63

A color difference (deltaE) value of <3 can be considered within the range of an excellent color match.

Background: There are conflicting reports in the dental literature as to how to define a good color match and what constitutes an acceptable color difference between a dental restoration and a natural tooth. An objective approach is to define some perceptibility standard using instrumental methods to determine some value where the color difference between the 2 objects is minimally detectable to the human eye. Different perceptibility threshold values have been proposed in the past derived from using different methods and materials. Objective: To set a new perceptibility standard in dentistry based on color differences between all-ceramic crowns and natural teeth. Design: Clinical study. Participants/Methods: Baseline color differences (deltaE) between natural central incisors of 22 subjects were determined using a dental spectrophotometer. Evaluators considered to be experts in color science were asked to visually assess 11 maxillary-central-incisor all-ceramic crowns compared to contralateral natural incisors. A unanimous consensus among evaluators was reached categorizing ceramic crowns to be a "Perfect/Excellent Color Match." The color difference among the 11 crowns and the contralateral natural teeth was then objectively measured using an intraoral noncontact spectrophotometer. Results: Mean color difference between natural maxillary central incisors was approximately 1 deltaE unit (range, 0.1 to 1.6). Mean color difference between all-ceramic crowns and natural teeth was 1.6 deltaE (range, 0.2 to 2.9). Conclusions: A restoration with a measured deltaE value of 1.6 is undetectable to the human eye and can be defined as a perfect or excellent color match. Reviewer's Comments: The perceptibility standard of 1.6 deltaE proposed in this study is much lower than the 3.7 deltaE often cited in the literature as the standard perceptibility threshold level to use in dentistry (Johnston and Kao, 1989). However, since the high end of the range still considered to be a perfect or excellent color match in this study was 2.9, it is possible to approximate a deltaE of <3 to be within the range of an excellent match. (Reviewer-Joe C. Ontiveros, DDS, MS). © 2009, Oakstone Medical Publishing

Keywords: Color/Perceptibility Standard, Natural Teeth, All-Ceramic Crowns


Common Local Anesthetics Disappoint When Used for Mandibular Infiltration

The Efficacy of Six Local Anesthetic Formulations Used for Posterior Mandibular Buccal Infiltration Anesthesia.

Abdulwahab M, Boynes S, et al:


Evidence to date suggests that articaine is still the best choice for infiltration anesthesia of the mandible, but probably requires a full cartridge to be effective.

Background: Recent reports indicate that articaine may be used to produce mandibular posterior anesthesia when administered via buccal infiltration, while other anesthetics typically have not shown promise in this regard. Objective: To determine the efficacy of 6 commonly used dental local anesthetics in producing mandibular anesthesia of adult posterior teeth when administered via buccal infiltration. Design: Randomized double-blind design. Participants: 18 adult volunteers (12 females and 6 males) aged 18 to 65 years with no medical conditions. Methods: Patients received 1 of 6 dental local anesthetics and assessed mandibular posterior pulpal anesthesia using an electric pulp tester. A randomized double-blind protocol was used in all subjects, each of whom received each anesthetic administered by the same operator on successive appointments. Prior to administration of local anesthetic, baseline values for the electrical pulp tester (EPT) for the mandibular first molar were established. Over a 30-second period, an investigator then injected 0.9 mL (half cartridge) of 1 of the 6 local anesthetic formulations under the mucosa adjacent to the first molar. Local anesthetics tested were lidocaine 2.0% with 1:100,000 epinephrine, articaine 4.0% with 1:100,000 epinephrine, articaine 4.0% with 200,000 epinephrine, prilocaine 4.0% with 1:100,000 epinephrine, mepivacaine 3.0% plain, and bupivacaine 0.5% with 1:200,000 epinephrine. Subjects rated the pain of injection using a visual analog scale (VAS). Anesthesia was tested with the EPT every minute up to 20 minutes after injection, and volunteers also rated anesthesia subjectively using 4 descriptors (no change in sensation to complete numbness). An EPT value of 80 indicated complete pulpal anesthesia. Results: Average age of patients was 25 years. Baseline EPT values averaged 34 ± 4.5, and there were no differences in VAS scores for injection pain among the 6 local anesthetics. The percentage of cases that achieved complete pulpal anesthesia ranged from 11.1 (for bupivacaine) to 38.9 (with articaine plus 1:100,000 epinephrine), and only articaine with 1:100,000 epinephrine performed better than lidocaine 2% with 1:100,000 epinephrine on a statistically significant basis. Conclusions: Buccal infiltration with a half cartridge of all local anesthetics tested provided only partial pulpal anesthesia of mandibular first molars, and therefore would not be sufficiently effective for most types of procedures. Reviewer's Comments: This study differed from previous studies on buccal infiltration of the mandible in that many of those studies reported using larger volumes (ie, full cartridge), with better success rates. However, like those other studies, articaine appears to be the best choice when attempting to provide local anesthesia using this technique. (Reviewer-Arthur H. Jeske, DMD, PhD). © 2009, Oakstone Medical Publishing

Keywords: Posterior Mandibular Buccal Infiltration Anesthesia, Local Formulations


Antibodies to CMP Associated With Recurrent Aphthous Ulcers

Humoral Immunity to Cow's Milk Proteins and Gliadin Within the Etiology of Recurrent Aphthous Ulcers?

Besu I, Jankovic L, et al:

Oral Dis 2009; June 29 (epub ahead of print):

Serum reactivity to cow's milk proteins may be within the etiology of recurrent aphthous ulcers, according to this study.

Background: Patients with gluten intolerance and antigliadin antibodies have an increased incidence of aphthous ulcers. Increased incidence of serum antibodies to cow's milk proteins (CMP) and gliadin has been observed in patients with recurrent major aphthous ulcers (RAU), but has never been studied. Increased permeability of the gut mucosa in these patients may stimulate the humoral immune response and contribute to autoimmunity, presenting as aphthous ulcers. Objective: To determine whether patients with RAU have increased serum antibodies to gliadin and antibodies to cow's milk proteins compared to healthy patients without RAU. Participants/Methods: 50 patients with RAU and no gastrointestinal or other diseases and 50 healthy normal subjects without RAU were studied. All were Serbian and were recruited from a single oral medicine clinic in Belgrade over a 2-year period. Serum was collected and immunoreactivity of IgA and IgG to gliadin and IgA, IgG, or IgE to cow's milk proteins were assessed using enzyme-linked immunosorbent assay (ELISA). Results: 19 males and 31 females with RAU (mean age, 39.4 years) and 13 male and 37 female controls without RAU (mean age, 43.0 years) participated. IgA antigliadin occurred in 3 of 50 RAU patients and 2 of 50 healthy controls (P =0.937); IgG antigliadin occurred in 4 of 50 RAU patients and 2 of 50 controls (P =0.1854), but was not significant. Overall, 19 of 50 patients with RAU and 4 of 50 controls had IgA (P <0.005) and 30 of 50 RAU patients and 3 of 50 controls had IgG (P <0.002) anti-CMP antibodies. Anti-CMP IgE was found in 28 of 50 patients with RAU and 4 of 50 controls (P <0.001). Increased humoral immunity to CMP (IgA or IgG) was found in 32 of 50 RAU patients. Increased humoral immunity to CMP (IgA, IgG, and IgE) was found in 16 of 50 RAU patients. Conclusions: This study did not show increased humoral immunity to gliadin in patients with RAU. There was a strong association between humoral immunity to CMP and RAU. This may reflect increased mucosal permeability. Further study is needed to see if a CMP-free diet can reduce frequency of RAU in susceptible patients. Reviewer's Comments: This study may have been underpowered to detect a significant difference in serum IgA and IgG reactivity with gliadin in patients with RAU and healthy controls, and should be repeated with a larger sample. Given the high prevalence of anti-CMP antibodies in the RAU group, diet modification for the treatment of RAU should be tested in a future interventional clinical trial. (Reviewer-Carol Anne Murdoch-Kinch, DDS, PhD). © 2009, Oakstone Medical Publishing

Keywords: Recurrent Aphthous Ulcers, Diet, Serum Antibodies


Age Predictive of Complications Following Dentoalveolar Surgery

Body Mass Index and the Risk of Postoperative Complications With Dentoalveolar Surgery: A Prospective Study.

Waisath TC, Marciani RD, et al:


In this study, obesity and BMI were not significantly associated with risk of post-surgical complications following dentoalveolar surgery.

Background: Post-surgical complications are generally increased in obese patients. It is not clear if oral surgical procedures are also associated with increased risk of complications in addition to the increased risk of anesthesia complications. Objective: To investigate the frequency and nature of postoperative complications of office-based oral surgical dentoalveolar procedures as they relate to body mass index (BMI). Design/Methods: Patients presenting for dentoalveolar outpatient ambulatory surgery over a 1-year period at a single university-based oral and maxillofacial surgery department were studied prospectively. Before surgery, height, weight, age, and BMI were recorded. Subjects were underweight if BMI <18.5; normal if 18.5 ≥BMI <25; overweight if 25 ≥BMI <30; and obese if BMI ≥30. Dentoalveolar procedures were performed in an outpatient clinic setting using deep sedation/general anesthesia. Number of postoperative visits up to 1 year after the procedure and postoperative complications occurring during that period were recorded, including infection, irregular ridge healing requiring alveoloplasty, nerve damage, bony sequestra, dry socket, pain, wound dehiscence, retained tooth, oral antral fistula, constipation, nausea, soft tissue defect and temporomandibular joint dysfunction. Pain was defined as a complication if a solitary finding and if the patient returned for ≥2 visits in >1 week. The associations of BMI to total complications, individual complications to BMI, and BMI to multiple complications were tested using t tests. The ability to predict complications based on BMI was analyzed by linear regression analysis. Results: 1205 subjects participated; 441 patients were obese and 34 were underweight. In total, 167 (13.9%) subjects had complications; 13 (1.08%) had 2 and 0 had >2. Postoperative infection was most common, occurring in 3.82%. No significant differences were seen in combined complication rate, individual complications, or number of postoperative visits according to BMI. Age was the only significant predictor of postoperative complications (P =0.0016) and number of postoperative visits (P <0.0001). Conclusions: Increased BMI was not a significant predictor of postoperative complications associated with outpatient dentoalveolar surgery. Increased age was associated with increased risk of postoperative complications of dentoalveolar surgery performed in an outpatient clinic setting. Reviewer's Comments: In this study, the risk of outpatient anesthesia complications and increased BMI was not assessed. Increased BMI may still be associated with increased risk of anesthesia complications. Patients treated in a hospital setting were not included, which may bias the study regarding the risk of obesity and related disorders and postoperative complications of dentoalveolar surgery. (Reviewer-Carol Anne Murdoch-Kinch, DDS, PhD). © 2009, Oakstone Medical Publishing

Keywords: Dentoalveolar Surgery, Postoperative Complications, Body Mass Index


Longevity of Bonded FRP May Depend on Your Adhesive Strategy

Push-Out Stress for Fibre Posts Luted Using Different Adhesive Strategies.

Mazzoni A, Marchesi G, et al:

Eur J Oral Sci 2009; 117 (August): 447-453

Bonding fiber-reinforced posts using conventional etch-and-rinse/dual-cure resin cement approach is still the way to go.

Background: To help retain the coronal build-up for endodontically treated teeth, various types of posts and luting materials are available from which to choose. An increasing trend is to adhesively bond a fiber-reinforced post (FRP) with a self-adhesive resin cement. Using self-adhesive resin cement with a fiber post simplifies the luting procedure over the conventional etch-and-rinse adhesive strategy, but long-term success is still in question. Objective: To determine the stress effect of thermocycling on the retentive strength of FRPs bonded with different adhesive/resin cements. Methods: Crowns of 84 extracted teeth were sectioned, and the remaining roots were cleaned, shaped, and obturated with gutta-percha. The teeth were divided into 3 adhesive/resin cement/post groups as follows: (1) XP Bond/CoreXFlow2 (Dentsply)/DT Light-Post (RTD); (2) ED Primer/Panavia F 2.0 (Kuraray)/Tech 21 Post (Abrasive Technology), and (3) RelyX Unicem/RelyX Post (3M ESPE). All materials were applied according to the manufacturer's instructions. Bonded post specimens were sectioned into 5 to 6 slices per tooth. Half the slices were subjected to thermocycling for 40,000 cycles (experimental), while the remaining half were stored in artificial saliva (control). The push-out test was used to determine the retentive strength of posts for all groups. Additional specimen slices were immersed in silver nitrate solution and prepared for nanoleakage analysis along the bonded interface. Results: Among control groups, the highest mean bond strength was 8.3 MPa with RelyX. After thermocycling, the highest mean bond strength was with the conventional etch-and-rinse adhesive XP Bond at 6.4 MPa. The lowest mean value was shown for the Panavia F at 4.3 MPa after thermocycling. Interfacial nanoleakage analysis revealed no difference in silver nitrate penetration among control groups. However, for specimens that were thermocycled, leakage increased for all groups. Conclusions: Compared to self-etch (Panavia F) and self-adhesive (RelyX) resin cements, conventional etch-and-rinse adhesive/dual-cure resin cement (XP Bond/CoreXFlow2) was shown to be the most adhesively stable combination for bonding an FRP after thermocycling and mechanical loading. Reviewer's Comments: Bonding an FRP using conventional etch-and-rinse techniques is tedious, but appears to remain the standard. However, RelyX self-etch cement performed nearly as well. Considering the results and the rigorous thermal stress applied to the specimens (40,000 cycles estimated to be approximately 4 years of service), the simplified method of using self-etch cement is promising. (Reviewer-Joe C. Ontiveros, DDS, MS). © 2009, Oakstone Medical Publishing

Keywords: Fiber Posts, Adhesive Resin Cements, Thermocycling


Where There's Smoke, There's Fire--Providing Smoking Cessation Info for Patients

Smoking Cessation Practices in the Dental Profession.

Lozier EB, Gonzalez YM:


Dentists can improve the overall health of the general public by being informed about the harmful effects of smoking and providing recommendations for smoking cessation to their patients.

Discussion: The Surgeon General's report of 1964 was a turning point in the recognition of the hazards of tobacco smoking. At that time, >40% of Americans smoked, as opposed to a smoking prevalence of around 20% in 2005. Approximately 2.3% of the adults in the U.S. use smokeless tobacco. Increased mortality, lung cancer, and chronic bronchitis were mentioned at the time of the initial report as being directly a result of cigarette smoking. Today it is recognized that tobacco affects not only the respiratory system, but also virtually every area of the body. Heart disease, sudden infant death syndrome, and multiple forms of cancer have been traced to this habit, as well as several oral diseases. As dentists, we are aware of the relationship of tobacco use to oral and pharyngeal cancers, as well as its contribution to delayed healing after extractions. There is a 5- to 20-fold increased risk for periodontal disease among smokers compared to those who have never smoked. One study done in 2000 found that the rate of implant failure in smokers (16.6%) compared to non-smokers (6.9%) was largely attributed to the inhibition of wound healing due to tobacco use. Addressing the Problem: The dentist is in a primary position to advise the patient about the dangers of tobacco use and the availability of cessation options. The National Institutes of Health, National Cancer Institute, and the American Academy of Family Physicians have established protocols for use by health professionals. Medications, available either over the counter or by prescription, are used by many people. These include the nicotine patch, nicotine gum, nicotine lozenges, sprays, or inhalers, Zyban (Bupropion), and Chantix (Varenicline). Conclusions/Recommendations: Recent data reported in the J Am Dent Assoc stated that only 33% of dentists discussed tobacco use with most of their patients. Many dentists feel that they would need additional training in discussing smoking cessation techniques. More dental schools are including cessation education in their curriculum, and the Institute of Medicine recommends that insurance companies cover effective smoking cessation intervention programs that could be distributed to the public through healthcare providers. Already, New York State requires dental health professionals to take courses on the effects of tobacco on oral health as part of their license renewal. Reviewer's Comments: The author presents a review of the role dentists play in making their patients aware of the various smoking cessation initiatives available. With the internet and all the other media sources of information about health, people now find much of their knowledge about medical problems in places other than their doctor's office. Dentists still need to be aware of the various cessation techniques to properly discuss the options with patients even though much of this knowledge is readily available elsewhere. (Reviewer-Edward N. Friedman, DDS). © 2009, Oakstone Medical Publishing

Keywords: Tobacco Cessation, Nicotine Replacement, Smoking Prevalence


Bond Strength Not Compromised With Astringent-Contaminated Dentin

Bond Strengths of Resin Cements to Astringent-Contaminated Dentin.

Harnirattisai C, Kuphasuk W, et al:

Oper Dent ; ():

Dentin contaminated with astringent containing 25% aluminum chloride (Racestyptine) had comparable bond strengths to normal dentin of both resin luting cements evaluated in this study.

Background: Astringent materials are frequently used for hemostasis and the control of gingival fluids during the cementation of resin-bonded restorations. Contamination of dentin with astringent materials could affect the bond strength at the dentin resin cement interface. Objective: To determine the effects of astringent contamination to dentin on micro-shear bond strengths of 2 resin cements. Methods: Dentin discs were sectioned to create 24 dentin specimens and were divided into a control and experimental (contaminated) group. Dentin specimens in the experimental group were treated with 25% aluminum chloride (Racestyptine) for 2 minutes and water rinsed for 30 seconds. Specimens were further divided and treated according to 1 of 2 resin cements/adhesive combinations (Panavia F/ED II Primer or Variolink II/Excite DSC). After 24 hours of water storage, specimens were subjected to micro-shear bond testing. Fracture mode and morphological analysis of etched and bonded interfaces were conducted under scanning electron microscope. Results: The mean bond strength to normal, non-contaminated dentin was approximately 22 MPa for both resin cements. The mean bond strength to contaminated dentin was approximately 24 and 25 MPa for Variolink and Panavia, respectively. The fracture mode revealed primarily adhesive failures and morphological study revealed open dentinal tubules for both groups after etching. Conclusions: Dentin contamination with aluminum chloride astringent had no significant effect on bond strengths. Reviewer's Comments: This study has shown similar results as other studies demonstrating no reduction in bond strengths when dentin is contaminated with an astringent containing aluminum chloride. However, astringent materials containing ferric sulfate have been shown to reduce bond strengths in other studies. (Reviewer-Joe C. Ontiveros, DDS, MS). © 2009, Oakstone Medical Publishing

Keywords: Bond Strength, Contamination, Astringent


Stable Implant Integration Using Immediately Loaded Implant

Immediate Provisionalization of Single-Tooth Implants in Fresh-Extraction Sites as the Maxillary Esthetic Zone: Up to 6

Years of Follow-Up.

Mijiritsky E, Mardinger O, et al:

Implant Dent 2009; 18 (August): 326-333

Immediate loading of single-tooth implants into recent extraction sites in the anterior maxilla appear to result in stable implant integration.

Background: The early years of dental implant treatment were characterized by a long treatment time, several surgical procedures, and a period of time where providing optimal esthetics for the patient presented a challenge. This study presents a new protocol that addresses some of the previous limitations encountered with implants. Objective: To study the long-term success of placing single-tooth implants into fresh extraction sites in the maxillary anterior region. These teeth were then loaded with infra-occlusal-provisional restorations. Participants/Methods: 24 adult patients aged 23 to 62 years underwent extractions and immediate placement of a tapered titanium implant (several types of implant abutments were used, but all were tapered titanium). Implant selection was based on the size of the tooth socket, both for tooth length and mesio-distal diameter. The implants were restored with pre-fabricated plastic provisional abutments, avoiding any occlusal contacts. A diet of soft food was recommended. Follow-up evaluation of the implants was done over the next 6 years. The tissue response around the implants, abutment stability, and changes in the level of bone to the implant were recorded for every restored implant site. Results: The overall survival rate for the implants was 95.8%, with minimal bone loss averaging 0.9 mm from placement to the final examination. This compares favorably with sites around implants done using the conventional, long-term approach. No differences between the sites or abutment type were evident. The authors do point out that some other studies showed a poorer success rate, and this most likely occured if the prostheses were in occlusal or full functional contact. Soft tissue response was very favorable due to the presence of the temporary crowns. Conclusions: There should be an increased indication to place implants in fresh extraction sites in the anterior maxillary region. Successful integration of the implant is enhanced by minimizing micromovement, thereby providing a stable, osseointegrated abutment. Once these immediately loaded implants integrate, their long-term prognosis is comparable to those of conventionally loaded implants. Reviewer's Comments: This article discusses a major issue for the clinician; how to restore function and esthetics as quickly as possible after the loss of a tooth. It is not all that uncommon to need to immediately treat a root fracture, endodontic failure, non-restorable crown, or trauma to a tooth. Although the data in this study is limited to 6 years, this does provide credible evidence of the success of this approach. The statistics do support the fact that there is favorable long term survival of implants placed in fresh extraction sites if appropriate restorative guidelines are followed. As the results of other long term studies are presented, this immediate implant loading technique should achieve widespread acceptance. (Reviewer-Edward N. Friedman, DDS). © 2009, Oakstone Medical Publishing

Keywords: Immediate Provisionalization, Single Tooth Implants, Anterior Maxilla


Ibuprofen Superior to Acetaminophen as a Combination Additive Postoperatively

Evidence-Based Review of Clinical Studies on Pharmacology (Non-Anesthetic Studies).

Staff Writers:

J Endod 2009; 35 (August): 1123-1129

In endodontics cases, consider ibuprofen and dexamethasone as good analgesic "additives" to endodontic pain-control regimens.

Background: The best evidence for current clinical practices comes from randomized, controlled clinical trials, and the Journal of Endodontics emphasizes that periodically with focused literature reviews--in this case focusing on non-anesthetic medications. Objective: This "integrated mini-review" was designed to update endodontists on key issues in non-anesthetic pain control. Design: The editorial leadership of the Journal of Endodontics selected 4 research reports for summarizing the status of current lines of investigation in the use of various drugs for pain control. Methods: Studies using evidence level 1 (randomized controlled trials) and level 2 (systematic reviews of controlled clinical trials) were selected for inclusion based on standardized classification criteria. Results: 2 studies at evidence level 1 were identified, one of which compared the analgesic efficacy and tolerability of oxycodone 5 mg + ibuprofen 400 mg, oxycodone 5 mg + acetaminophen (APAP) 325 mg, and hydrocodone 7.5 mg + acetaminophen 500 mg for moderate-to-severe postoperative pain, and the second of which evaluated the efficacy of supraperiosteal injection of dexamethasone 4 mg for postoperative periapical pain. Two studies at evidence level 2 were included, one of which compared ibuprofen alone versus an ibuprofen + acetaminophen combination for endodontic postoperative pain, and a second study which compared pretreatment administration of 600 mg ibuprofen oral gel versus placebo for the control of endodontic postoperative pain. In the study comparing oxycodone/ibuprofen, oxycodone/APAP with hydrocodone APAP, and hydrocodone/APAP, the oxycodone/ibuprofen combination provided significantly better and longer-lasting analgesia than the comparator drugs and placebo, with adverse effects the same as placebo. In the study evaluating the efficacy of supraperiosteal injection of dexamethasone, dexamethasone was more effective than placebo for 24 hours, but not after 48 hours, in relieving postoperative pain following endodontic treatment for irreversible pulpitis. Conclusions: The authors concluded that lack of operator calibration may have compromised both of the level 2 studies, but that the positive outcome for the ibuprofen + APAP combination indicates that this would be a valid strategy for pain control, although pretreatment with ibuprofen prior to endodontics would not be. In the opinion of the authors, the level 1 studies indicate that ibuprofen is preferred over APAP in combination with an opioid, and that while dexamethasone reduces postoperative endodontic pain, its use must be restricted in presence of infection. Reviewer's Comments: The Journal of Endodontics' critical review of current literature on analgesic and anti-inflammatory medications is accompanied by careful definition of the experimental conditions. Caution is advised when translating outcomes from endodontic studies to other postoperative circumstances such as oral and periodontal surgery. The effect of preoperative administration of NSAIDs remains unsettled. (Reviewer-Arthur H. Jeske, DMD, PhD). © 2009, Oakstone Medical Publishing

Keywords: Pain, Endodontics, Analgesics, Ibuprofen, Acetaminophen, Oxycodone, Hydrocodone, Dexamethasone


Key Issues in Use of Anesthesia for Obtaining Pulpal Anesthesia

Evidence-Based Review of Clinical Studies on Local Anesthetics.

Staff Writers:

J Endod 2009; 35 (August): 1130-1134

While long-acting local anesthetics do not appear to offer advantages for maxillary infiltration, articaine does, except for in the first molar.

Background: Application of scientific studies in clinical dentistry requires the availability of outcomes obtained in high-level research protocols, such as the randomized controlled clinical trial. Objective: This "integrated mini-review" was designed to update endodontists on key issues involved with selection of local anesthetic agents and techniques for their administration. Design: The editorial leadership of the Journal of Endodontics selected4 research reports for summarizing the status of current lines of investigation in the use of local anesthesia for obtaining pulpal anesthesia. Methods: Studies using high-quality protocol design (randomized controlled clinical trials) were selected for inclusion, based on standardized classification criteria. Results: 4 studies at the highest level of scientific evidence (Level 1) were identified, covering the comparative efficacy of adding buccal versus lingual infiltration to inferior alveolar local anesthesia in the adult mandible, comparative efficacy of buccal infiltration of lidocaine versus bupivacaine for maxillary anesthesia, comparative efficacy of buccal infiltration of lidocaine versus articaine for maxillary anesthesia, and comparative efficacy of mandibular buccal infiltration technique versus a combination mandibular buccal and lingual infiltration technique. Conclusions: With regard to the comparative efficacy of adding either buccal or lingual infiltration to an inferior alveolar nerve block for mandibular anesthesia, neither infiltration technique significantly enhanced local anesthetic outcomes for lower posterior teeth. For the comparative efficacy of lidocaine and bupivacaine for maxillary infiltration, lidocaine performed better with a faster onset. Regarding the comparative efficacy of lidocaine versus articaine for maxillary infiltrations, articaine yielded a significantly better success rate for incisor teeth, but not for the first molar. As for the effect of buccal-only versus buccal + lingual infiltration of the lower first molar, there were no significant differences in anesthetic success rates between the 2 approaches. Reviewer's Comments: The Journal of Endodontics has provided important evidence-based findings on current questions in local anesthesia, all of which tend to support the notion that local anesthesia of mandibular posterior teeth remains dependent primarily on the inferior alveolar nerve block, and that articaine has an edge over other agents for infiltration, especially in the maxilla. (Reviewer-Arthur H. Jeske, DMD, PhD). © 2009, Oakstone Medical Publishing

Keywords: Local Anesthetics, Pulpal Anesthesia, Bupivacaine, Lidocaine, Articaine


Are Clinic Coats a Source for Contamination?

Clinic Jackets and Coats: Possible Vectors of Microbial Infection?

Molinari JA:

Dent Econ 2009; (July): 36

Clinic coats can be the source of cross contamination of surface-born microbial infection.

Background: The OSHA December 1991 Bloodborne Pathogens standard requires the use of Personal Protective Equipment (PPE). Discussion: Protective clothing, ie, clinic coats need to cover the forearms and prevent potentially infectious material from contaminating the skin or underlying clothing. Employers are required to launder this clothing or make disposable gowns available. These must be laundered in the office or sent to a commercial facility and should not be worn away from the office. While these need not be fluid impervious, they should be changed if wet, penetrated, or if there is visible blood or contamination present. To date there has not been a case of bloodborne disease transmission due to contaminated clinic attire. It has been established that many microbes can remain viable on inanimate surfaces for extended periods of time. Dr Molinari states that a study was done where clinic coats were cultured and it was found that Staphylococcus aureus and Enterococci were able to be grown. These could be spread by hand-to-hand or hand-to-surface contact. Because these bacteria can be antibiotic resistant, further investigation should be performed to evaluate the possibility of clinical or hospital contaminations. Conclusions: As we learn more about the ability to pass viable microbes by personal contact, we may find that our PPE protocol needs to be adjusted to insure patient and personal protection. Reviewer's Comments: This brief review article indicates the need to constantly be aware of our need to minimize bacterial cross contamination. There are definitely questions as to the efficacy of our standard protocols and our abilities to minimize personal exposure and exposure to our patients. (Reviewer-Charles R. Hoopingarner, DDS). © 2009, Oakstone Medical Publishing

Keywords: OSHA, Infection Control, Personal Protective Equipment


mPI Is Better Than Other Clinical Indices for Evaluating Peri-Implantitis

Clinical, Histological, and Microbiological Findings in Peri-Implant Disease: A Pilot Study.

Ferreira SB Jr, Figueiredo CM, et al:

Implant Dent 2009; 18 (August): 334-344

Plaque accumulation is an indicator of peri-implantitis, but we have yet to determine the optimum clinical parameters to assess this important disease.

Background: Probing the tissues surrounding dental implants yields little information on their true histological and inflammatory state, creating a need for studies correlating clinical indices of peri-implant health with histological findings. Objective: To relate clinical gingival and plaque observations with a histological index (HI) and the presence of significant periodontal pathogenic microorganisms. Participants/Methods: 10 adult subjects were enrolled, none of whom smoked, took antibiotics or anti-inflammatory medications, or had hormonal imbalances (eg, diabetes). Clinical evaluations included gingival index (GI), GI modified by Mombelli (mGI), sulcus bleeding index (SBI), and plaque index modified by Mombelli (mPI). Multiple sites within histologic biopsy sections were scored for degree of inflammation (0-3) to determine the HI, and the presence of A actinomycetemcomitans, P gingivalis, and T forsythia was determined by DNA extraction and polymerase chain reaction (PCR) assay. Results: The mPI correlated significantly with HI in central lingual sites, but not other lingual or buccal ones. No correlation between histologic findings and any of the other clinical indices of peri-implantitis was found, and the presence of the periodontopathic organisms did not correlate with HI. However, lymphocyte counts did positively correlate with HI. Conclusions: The authors of this complex study concluded that mPI "seems" to be a useful clinical tool for assessing the severity of peri-implantitis, but the subject warrants further studies for better understanding of the relationship between the inflammatory state of peri-implant tissues and clinical observations. Reviewer's Comments: As the authors of this paper note, their study is subject to the limitations of a very small sample size, but it points out the inadequacy of conventional periodontal assessment tools in determining the true inflammatory state of tissues around implants. Plaque control remains important for maintaining both implants and natural teeth. (Reviewer-Arthur H. Jeske, DMD, PhD). © 2009, Oakstone Medical Publishing

Keywords: Implants, Peri-Implantitis, Gingival Index, Sulcus Bleeding Index, Gingival Index


Triclosan/Copolymer Dentifrice Twice Daily Enhances Periodontal Health

Is There a Role for Triclosan/Copolymer Toothpaste in the Management of Periodontal Disease?

Blinkhorn A, Bartold PM, et al:

Br Dent J 2009; 207 (August 8): 117-125

Triclosan/copolymer toothpaste can be confidently recommended to patients for both an anti-gingivitis and anti-caries effect.

Background: Toothpaste is an essential part of preventive dentistry for the topical delivery of fluorides and is increasingly being evaluated for delivery of agents that prevent or reduce the severity of periodontal disease. Objective: To review the scientific literature related to the effectiveness and safety of triclosan/copolymer dentifrice (eg, Colgate Total Advanced Clean) in the management of gingivitis, periodontitis, caries, and calculus accumulation. Design: The study used a standard protocol for conducting a systematic review of the literature. Methods: The authors reviewed 198 research reports on triclosan and/or copolymer published from 1989 through May 2008 in English and other foreign languages, but excluded abstracts and letters. Results: For plaque and gingivitis, short-term (6 months) studies substantiated that a twice-a-day regimen yields a 23% overall reduction in plaque and gingivitis, as assessed by mean plaque index and gingival index scores. For periodontitis, the literature evaluated in this study confirmed a beneficial effect on probing depths, which varied by patient group and duration of use. No clinically significant conclusions could be drawn regarding beneficial effects of triclosan/copolymer on calculus accumulation, but the literature indicated that triclosan/copolymer had no adverse effects on the anti-caries action of co-administered sodium fluoride, and that triclosan/copolymer toothpaste is as good as conventional sodium fluoride-containing dentifrices in this regard. Conclusions: The authors of this review concluded that scientific evidence available to date indicates that triclosan/copolymer toothpaste significantly improves plaque control, reduces gingivitis, and appears to slow the rate of progression of periodontitis. Reviewer's Comments: This review provides a good scientific assessment on which to base the recommendation of triclosan/copolymer toothpaste (eg, Colgate Total Advanced Clean) as a component of a regimen for patients with gingivitis or periodontitis, without sacrificing the anti-caries effect. This information should be shared with the office hygiene department. (Reviewer-Arthur H. Jeske, DMD, PhD). © 2009, Oakstone Medical Publishing

Keywords: Gingivitis, Periodontitis, Triclosan Copolymer, Toothpaste, Dentifrice, Calculus, Caries


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