Prevention and therapeutic approaches to gingival inflammation

Clinical and biochemical evaluation of oral irrigation in patients with peri-implant mucositis: a randomized clinical trial

OBJECTIVE

This randomized clinical trial aimed to compare the efficacy of an oral irrigator and an interdental brush in patients with peri-implant mucositis clinically and biochemically at different time points (at baseline and at the 2nd, 4th, and 12th weeks).

MATERIALS AND METHODS

Forty-five patients with at least one implant with peri-implant mucositis were included in the present study (n = 45). The patients were divided into three groups: oral irrigator + toothbrush (OI group, n = 15), interdental brush + toothbrush (IB group, n = 15), and toothbrush only (control) (C group, n = 15). The modified plaque index (mPlI), modified sulcus bleeding index (mSBI), probing pocket depth (PPD), probing attachment level (PAL), and bleeding on probing (BOP) were recorded at baseline and at the 2nd, 4th, and 12th weeks. The levels of interleukin 1 beta (IL-1β), transforming growth factor-beta (TGF-β), tissue-type plasminogen activator (t-PA), and plasminogen activator inhibitor-1 (PAI-1) were also determined in the peri-implant crevicular fluid samples biochemically.

RESULTS

The mSBI and t-PA at the 2nd week (p = 0.003; p = 0.003); the mPlI, mSBI, BOP, t-PA, and PAI-1 at the 4th week (p < 0.05; p < 0.001; p < 0.001; p = 0.015; p = 0.011); and the mPlI, mSBI, IL-1β, t-PA, and PAI-1 at the 12th week (p < 0.05; p < 0.001; p = 0.013; p < 0.001; p = 0.002) were significantly lower in the OI group compared with those in the C group. Meanwhile, PAI-1 at the 2nd week, mSBI at the 4th week, and t-PA at the 12th week were significantly lower in the OI group compared with those in the IB group (p < 0.001; p = 0.011; p = 0.003). At the 2nd, 4th, and 12th weeks, all other parameters were not statistically different in the three groups.

CONCLUSION

The clinical indexes (such as mSBI and BOP) that play an important role in the diagnosis of peri-implant mucositis showed the lowest means (although limited) in the OI group at all evaluation time points. Moreover, when the clinical and biochemistry results were interpreted altogether, it became apparent that the OI group exhibited similar or more effective results than the IB group in resolving peri-implant mucositis. In light of the foregoing, this study concluded that the use of an oral irrigator can be as effective as an interdental brush in interdental cleaning.

CLINICAL RELEVANCE

In this study, it is suggested that the regular use of an oral irrigator along with a toothbrush could be an appropriate alternative to other oral hygiene products such as dental floss and interdental brush for the management of peri-implant mucositis by preventing the accumulation of dental plaque (NCT03844035).

The lived experience of performing a periodontal treatment in the context of general dentistry

Aim

To describe what characterises the lived experience of performing a periodontal treatment in the context of general dentistry.

Materials and methods

Three dental hygienists from general dentistry in Sweden, were purposively selected as participants and interviewed. The participants described a situation in which they had performed a periodontal treatment. The descriptions were analysed using the descriptive phenomenological psychological method.

Results

The general meaning structure of the lived experience of performing a periodontal treatment comprised five constituents, (a) an established treatment routine, (b) importance of oral hygiene, (c) self-awareness and motivation of the patient, (d) support and doubt, and (e) mechanical infection control. The periodontal treatment is perceived as being set prior to its commencement and as following established routines, in which the patients’ oral hygiene is experienced as a crucial part. The patients’ self-awareness and a supportive clinician are seen as important factors in motivating the patient towards positive behavioural change, although there is a presence of doubt in patients’ ability to maintain this positive change. Mechanical infection control is perceived as successful but sometimes difficult to perform.

Conclusions

Important, patient-related, factors are constituting the phenomenon of performing a periodontal treatment but an experience that the pre-existing standardised workflow influences patient management was also present.

Efficacy of a Hybrid Toothbrush versus Comparative Manual Toothbrush for Plaque Removal - Randomized In-Use Study

Purpose

An innovative hybrid toothbrush was designed to function either in manual sonic mode or combined mode (manual and sonic). The primary objective was to assess the efficacy of a new hybrid powered toothbrush (PTB) used in combined mode versus a comparative manual toothbrush (MTB) for plaque removal, after 14 days of twice-daily use under normal conditions. The secondary objectives were to evaluate the gingival state, to evaluate the tolerance of the hybrid PTB and to evaluate its acceptability.

Materials and Methods

This study was a monocentric, block-randomized, dual treatment, parallel group, and examiner-blinded trial with before and after evaluation. It was conducted on two groups of 55 subjects presenting a visible plaque accumulation (score ≥2 as measured by the Turesky Modification of the Quigley-Hein Plaque Index (TMQHPI)). On Day 1/Day 8/Day 15, the same investigator conducted blind clinical examinations on each subject and evaluated TMQHPI and Papillary Bleeding Score (PBS). On Day 1, the subjects received either the hybrid PTB or the comparative MTB and used it twice daily under normal conditions of use.

Results

The hybrid PTB used in its combined mode eliminates dental plaque more efficiently than the comparative MTB, especially in difficult-to-access areas such as posterior and interproximal dental surfaces, while remaining gentle on the gingivae. The PBS was significantly lower with the hybrid toothbrush compared with the reference manual one.

Conclusion

The new device confirmed previous findings and should improve oral hygiene following the manufacturer's instructions. Moreover, the specific design of the toothbrush means that it can be used according to the oral environment conditions and personal feeling.

One-to-one oral hygiene advice provided in a dental setting for oral health

BACKGROUND

Effective oral hygiene measures carried out on a regular basis are vital to maintain good oral health. One-to-one oral hygiene advice (OHA) within the dental setting is often provided as a means to motivate individuals and to help achieve improved levels of oral health. However, it is unclear if one-to-one OHA in a dental setting is effective in improving oral health and what method(s) might be most effective and efficient.

OBJECTIVES

To assess the effects of one-to-one OHA, provided by a member of the dental team within the dental setting, on patients' oral health, hygiene, behaviour, and attitudes compared to no advice or advice in a different format.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 10 November 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 10) in the Cochrane Library (searched 10 November 2017); MEDLINE Ovid (1946 to 10 November 2017); and Embase Ovid (1980 to 10 November 2017). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were also searched for ongoing trials (10 November 2017). No restrictions were placed on the language or date of publication when searching the electronic databases. Reference lists of relevant articles and previously published systematic reviews were handsearched. The authors of eligible trials were contacted, where feasible, to identify any unpublished work.

SELECTION CRITERIA

We included randomised controlled trials assessing the effects of one-to-one OHA delivered by a dental care professional in a dental care setting with a minimum of 8 weeks follow-up. We included healthy participants or participants who had a well-defined medical condition.

DATA COLLECTION AND ANALYSIS

At least two review authors carried out selection of studies, data extraction and risk of bias independently and in duplicate. Consensus was achieved by discussion, or involvement of a third review author if required.

MAIN RESULTS

Nineteen studies met the criteria for inclusion in the review with data available for a total of 4232 participants. The included studies reported a wide variety of interventions, study populations, clinical outcomes and outcome measures. There was substantial clinical heterogeneity amongst the studies and it was not deemed appropriate to pool data in a meta-analysis. We summarised data by categorising similar interventions into comparison groups.Comparison 1: Any form of one-to-one OHA versus no OHAFour studies compared any form of one-to-one OHA versus no OHA.Two studies reported the outcome of gingivitis. Although one small study had contradictory results at 3 months and 6 months, the other study showed very low-quality evidence of a benefit for OHA at all time points (very low-quality evidence).The same two studies reported the outcome of plaque. There was low-quality evidence that these interventions showed a benefit for OHA in plaque reduction at all time points.Two studies reported the outcome of dental caries at 6 months and 12 months respectively. There was very low-quality evidence of a benefit for OHA at 12 months.Comparison 2: Personalised one-to-one OHA versus routine one-to-one OHAFour studies compared personalised OHA versus routine OHA.There was little evidence available that any of these interventions demonstrated a difference on the outcomes of gingivitis, plaque or dental caries (very low quality).Comparison 3: Self-management versus professional OHAFive trials compared some form of self-management with some form of professional OHA.There was little evidence available that any of these interventions demonstrated a difference on the outcomes of gingivitis or plaque (very low quality). None of the studies measured dental caries.Comparison 4: Enhanced one-to-one OHA versus one-to-one OHASeven trials compared some form of enhanced OHA with some form of routine OHA.There was little evidence available that any of these interventions demonstrated a difference on the outcomes of gingivitis, plaque or dental caries (very low quality).

AUTHORS' CONCLUSIONS

There was insufficient high-quality evidence to recommend any specific one-to-one OHA method as being effective in improving oral health or being more effective than any other method. Further high-quality randomised controlled trials are required to determine the most effective, efficient method of one-to-one OHA for oral health maintenance and improvement. The design of such trials should be cognisant of the limitations of the available evidence presented in this Cochrane Review.

Distribution of dental plaque and gingivitis within the dental arches

Objective The natural accumulation of supragingival plaque on surfaces of human teeth is associated with gingival inflammation and the initiation of common oral diseases. This study evaluated the distribution of dental plaque and gingivitis scores within the dental arches after prophylaxis. Methods Adult subjects from the Dharwad, India area representing the general population who provided written informed consent were scheduled for screening. Healthy subjects over the age of 18 years, not currently requiring any medical or dental care, and presenting with a complement of at least 20 natural teeth were recruited for this parallel design study. Enrolled subjects (n = 41) underwent oral examinations for dental plaque (PI) and gingivitis (GI) using the Turesky modification of the Quigley-Hein and the Löe-Silness Index, respectively, at the baseline visit, followed by a whole mouth dental prophylaxis. Subjects were given fluoride toothpaste for twice daily oral hygiene for the next 30 days. Subjects were recalled on days 15 and 30 for PI and GI examinations identical to baseline. Results Analyses indicated that mean scores for PI and GI on either arch and the whole mouth were higher than 2 and 1, respectively, during all examinations. Anterior surfaces consistently exhibited lower PI scores than posterior regions of either arch, or the entire dentition. Regional GI differences within the dentition were similar to PI scores, with lower scores on anterior than posterior teeth. Prophylaxis reduced both the frequency and mean scores of both PI and GI, irrespective of arch, with lower scores observed on anterior than posterior regions during all recall visits. Molar and lingual regions consistently exhibited higher PI and GI scores compared with anterior surfaces. At all examinations, mean scores for both plaque and gingivitis were higher on approximal vestibular than mid-vestibular surfaces. Conclusions Differences observed in PI and GI within the dentition have several practical implications: (a) there are advantages of whole mouth assessments for oral health (b) a need for oral hygiene formulations to reduce the larger deposits of dental plaque in the posterior region and resultant gingival inflammation, and

Chlorhexidine mouthrinse as an adjunctive treatment for gingival health

BACKGROUND

Dental plaque associated gingivitis is a reversible inflammatory condition caused by accumulation and persistence of microbial biofilms (dental plaque) on the teeth. It is characterised by redness and swelling of the gingivae (gums) and a tendency for the gingivae to bleed easily. In susceptible individuals, gingivitis may lead to periodontitis and loss of the soft tissue and bony support for the tooth. It is thought that chlorhexidine mouthrinse may reduce the build-up of plaque thereby reducing gingivitis.

OBJECTIVES

To assess the effectiveness of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for the control of gingivitis and plaque compared to mechanical oral hygiene procedures alone or mechanical oral hygiene procedures plus placebo/control mouthrinse. Mechanical oral hygiene procedures were toothbrushing with/without the use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment.To determine whether the effect of chlorhexidine mouthrinse is influenced by chlorhexidine concentration, or frequency of rinsing (once/day versus twice/day).To report and describe any adverse effects associated with chlorhexidine mouthrinse use from included trials.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 28 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 28 September 2016); MEDLINE Ovid (1946 to 28 September 2016); Embase Ovid (1980 to 28 September 2016); and CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 28 September 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials assessing the effects of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for at least 4 weeks on gingivitis in children and adults. Mechanical oral hygiene procedures were toothbrushing with/without use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. We included trials where participants had gingivitis or periodontitis, where participants were healthy and where some or all participants had medical conditions or special care needs.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference (MD) and 95% confidence interval (CI). We combined MDs where studies used the same scale and standardised mean differences (SMDs) where studies used different scales. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. Due to anticipated heterogeneity we used random-effects models for all meta-analyses.

MAIN RESULTS

We included 51 studies that analysed a total of 5345 participants. One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however, this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect. Gingivitis After 4 to 6 weeks of use, chlorhexidine mouthrinse reduced gingivitis (Gingival Index (GI) 0 to 3 scale) by 0.21 (95% CI 0.11 to 0.31) compared to placebo, control or no mouthrinse (10 trials, 805 participants with mild gingival inflammation (mean score 1 on the GI scale) analysed, high-quality evidence). A similar effect size was found for reducing gingivitis at 6 months. There were insufficient data to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 (moderate or severe levels of gingival inflammation). Plaque Plaque was measured by different indices and the SMD at 4 to 6 weeks was 1.45 (95% CI 1.00 to 1.90) standard deviations lower in the chlorhexidine group (12 trials, 950 participants analysed, high-quality evidence), indicating a large reduction in plaque. A similar large reduction was found for chlorhexidine mouthrinse use at 6 months. Extrinsic tooth staining There was a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 4 to 6 weeks. The SMD was 1.07 (95% CI 0.80 to 1.34) standard deviations higher (eight trials, 415 participants analysed, moderate-quality evidence) in the chlorhexidine mouthrinse group. There was also a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 7 to 12 weeks and 6 months. Calculus Results for the effect of chlorhexidine mouthrinse on calculus formation were inconclusive. Effect of concentration and frequency of rinsing There were insufficient data to determine whether there was a difference in effect for either chlorhexidine concentration or frequency of rinsing. Other adverse effects The adverse effects most commonly reported in the included studies were taste disturbance/alteration (reported in 11 studies), effects on the oral mucosa including soreness, irritation, mild desquamation and mucosal ulceration/erosions (reported in 13 studies) and a general burning sensation or a burning tongue or both (reported in nine studies).

AUTHORS' CONCLUSIONS

There is high-quality evidence from studies that reported the Löe and Silness Gingival Index of a reduction in gingivitis in individuals with mild gingival inflammation on average (mean score of 1 on the 0 to 3 GI scale) that was not considered to be clinically relevant. There is high-quality evidence of a large reduction in dental plaque with chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for 4 to 6 weeks and 6 months. There is no evidence that one concentration of chlorhexidine rinse is more effective than another. There is insufficient evidence to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 indicating moderate or severe levels of gingival inflammation. Rinsing with chlorhexidine mouthrinse for 4 weeks or longer causes extrinsic tooth staining. In addition, other adverse effects such as calculus build up, transient taste disturbance and effects on the oral mucosa were reported in the included studies.

Lack of adjunctive effect of 0.1% sodium hypochlorite mouthwash combined to full-mouth ultrasonic debridement on supragingival plaque, gingival inflammation, and subgingival microbiota: A randomized placebo-controlled 6-month trial

To test the adjunctive effect of 0.1% sodium hypochlorite (NaOCl) mouthwash combined to full‐mouth ultrasonic debridement (FMUD) on reducing supragingival plaque, gingival inflammation, and microbial pathogens. In this 6‐month double‐blinded randomized clinical trial, individuals with gingivitis were assigned to test (n = 16) or placebo group (n = 16) and received FMUD followed by rinsing with 0.1% NaOCl (test) or distilled water (placebo), respectively, twice a day for 1 month. Full‐mouth periodontal examination was performed at baseline, 1, 3, and 6 months posttherapy, and subgingival plaque samples were obtained at the same time points and analysed for their composition by checkerboard. Differences between groups over time were examined by Student t test, Mann–Whitney, generalized linear model, and Friedman and chi‐square tests. Both therapeutic protocols resulted in significant clinical improvement in periodontal parameters over time, except for probing depth and attachment level, which had a slight mean increase of 0.2 mm (p < .01). No significant differences between groups were observed for any clinical parameter (p > .05). Most species (>65%) decreased similarly in levels in both groups over time. Significant reductions in the microbial complexes were seen mainly at 1 and 3 months, but they returned to baseline levels in both groups, except for the red and yellow complexes, and other oral species, which were kept in low levels at 6 months (p < .05). A 0.1% NaOCl mouthwash did not provide additional benefits to FMUD in reducing supragingival plaque, gingivitis, and/or microbial pathogens.

Interdisciplinary health promotion: a call for theory-based interventions drawing on the skills of multiple disciplines

Promoting the health of populations demands the adoption of a perspective exploring the societal, political, community, family and individual determinants of health. I will argue that to develop interventions to modify health-related behaviours and health risks requires collaboration with a range of disciplines, in order to draw upon their theoretical, empirical and oftentimes political knowledge. To illustrate this thesis, I will draw upon research in three areas: improving oral health-related behaviours in individuals with periodontal disease and childhood caries; encouraging early recognition in head and neck cancer; and managing dental anxiety. Reviews of oral health education in the early 1990 s suggested that approaches based on education were largely ineffective in the absence of the provision of fluoride supplementation. More recently, high-quality research has identified simple, theory-based interventions that can improve adherence to specific oral hygiene-related behaviours. Similarly, a range of studies have demonstrated the effectiveness of motivational interviewing for targeting caries-related behaviours in targeted groups. Dental anxiety remains a significant barrier to the uptake of dental services, and again, by working in multi-disciplinary teams, a proportionate and comprehensive range of interventions can be adopted to alleviate the burden of dental fear. Finally, head and neck cancer has potentially serious effects for sufferers, but often presents late for a variety of reasons. Through developing a theoretical model of help-seeking behaviour, psychologists have been able to identify targets for interventions and work together with the healthcare team to develop these.

Effectiveness of a motivational-behavioural skills protocol for oral hygiene among patients with hyposalivation

BACKGROUND

The main objective of this study was to assess the effectiveness of a motivational-behavioural skills protocol for plaque control in patients with hyposalivation.

PATIENTS AND METHODS

In a randomised, evaluator-blinded, controlled trial, 60 subjects with hyposalivation (12 men and 48 women) were randomly assigned to two groups: the control group received basic oral hygiene instruction, while for the study (intervention) group, oral hygiene instruction was based on cognitive behavioural principles and motivational interviewing (MI). Both groups were given oral hygiene instruction once every 15 days, with a total of four sessions over a 2-month period: plaque extension and community periodontal index of treatment needs (CPITN), frequency and duration of brushing, frequency of interdental cleaning and scores based on scale of 'self-efficacy for brushing of the teeth'. Clinical characteristics were compared between the two groups.

RESULTS

Both control and intervention group patients showed significantly lower plaque indices, bleeding indices and an improvement in probe depth after the 2-month study period. Interproximal brushing was significantly more frequent among the intervention group (p = 0.016).

CONCLUSION

In patients with hyposalivation, the application of oral hygiene instruction based on cognitive principles and MI offers benefits for periodontal health. Longer-term studies are needed to confirm these results.

Antimicrobial effects of o-cymen-5-ol and zinc, alone & in combination in simple solutions and toothpaste formulations

OBJECTIVES

This study aimed to evaluate antimicrobial effects of an o-cymen-5-ol/zinc system.

METHODS

o-Cymen-5-ol and zinc gluconate minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) were determined against Streptococcus mutans, Actinomyces viscosus, Porphyromonas gingivalis, Fusobacterium nucleatum and Candida albicans. Synergy was investigated by checkerboard MIC/MBC; inhibition of P. gingivalis protease activity and S. mutans glycolysis were investigated. Slurried toothpastes containing the system were assessed in kill time assays against S. mutans and E. coli.

RESULTS

o-Cymen-5-ol MIC was between 1.7 mM to 3.4 mM; MBC was 3.4 mM to 6.7 mM. Zinc gluconate MIC was 2.8 mM to 11 mM; MBC was between 11 mM and >44 mM. The two agents in solution showed synergy (FICI≤0.50) against P. gingivalis and F. nucleatum, with MIC of 0.42 mM/0.69 mM for o-cymen-5-ol/zinc gluconate, respectively. Zinc inhibited glycolysis and protease to a greater degree than o-cymen-5-ol; glycolysis inhibition by the two agents was additive. o-Cymen-5-ol/zinc chloride in toothpaste showed greater effects than placebo (120s log10 kill=7.35±0.40 and 4.02±0.40, respectively).

CONCLUSIONS

The zinc/o-cymen-5-ol system has direct antimicrobial effects and inhibits oral disease-related processes. Synergistic effects were seen against anaerobes. A system combining o-cymen-5-ol and zinc shows properties desirable for incorporation in toothpastes.