Assessment of Prognosis and Periodontal Treatment Goals Among General Dental Practitioners and Dental Hygienists

PURPOSE

To evaluate general dental practitioners' (GDPs) and dental hygienists' (DHs) assessment of prognosis, suggested treatment goals, and estimated number of treatment sessions in patients with varying severity of periodontal disease.

MATERIALS AND METHODS

Seventy-seven GDPs and fifty DHs in a Swedish county participated in a questionnaire study, based on three patient cases: a patient with generalised bone loss but no clinical signs of inflammation (well-maintained); a patient with clinical signs of inflammation and generalised bone loss (periodontitis); and a patient with clinical signs of inflammation but no bone loss (gingivitis). In open-ended questions, the clinicians assessed the prognosis in case of no treatment and proposed treatment goals. Furthermore, based on given fixed-alternative options, they estimated the number of treatment sessions needed for successful management of the condition.

RESULTS

Based on a response rate of 94%, the majority of clinicians expected a worsening of the periodontal condition in all three patients (well-maintained: 80%; periodontitis: 94%; gingivitis: 60%). The most common treatment goal in all 3 cases was to improve oral health awareness. The majority of clinicians estimated that the periodontitis case needed slightly more treatment sessions (mean: 3.04, 95% CI: 2.83-3.24) compared to the gingivitis (mean: 1.93, 95% CI: 1.75-2.11) or well-maintained patient case (mean: 1.84, 95% CI: 1.60-2.07).

CONCLUSIONS

The majority of included clinicians did not perform an individualised risk assessment and did not individually match the number of appointments to the actual periodontal treatment needs of the patient. This may result in overtreatment in some cases and in undertreatment in others, and possibly in suboptimal use of resources.

Probiotic supplements and debridement of peri-implant mucositis: a randomized controlled trial

OBJECTIVE

The aim of this double-blind randomized placebo-controlled trial was to evaluate the effects of probiotic supplements in adjunct to conventional management of peri-implant mucositis.

MATERIALS AND METHODS

Forty-nine adult patients with peri-implant mucositis were consecutively recruited after informed consent. After initial mechanical debridement and oral hygiene instructions, the patients received a topical oil application (active or placebo) followed by twice-daily intake of lozenges (active or placebo) for 3 months. The active products contained a mix of two strains of Lactobacillus reuteri. Patients were clinically monitored and sampled at baseline and after 1, 2, 4, 12 and 26 weeks. The clinical end-points were pocket-probing depth (PPD), plaque index (PI) and bleeding on probing (BOP). In addition, the subgingival microbiota was processed with checkerboard DNA-DNA hybridization and samples of gingival crevicular fluid (GCF) were analyzed for selected cytokines with the aid of multiplex immunoassays.

RESULTS

After 4 and 12 weeks, all clinical parameters were improved in both the test and the placebo group. PPD and BOP were significantly reduced compared with baseline (p < 0.05), but no significant differences were displayed between the groups. The clinical improvements persisted 3 months after the intervention. No major alterations of the subgingival microflora were disclosed and the levels of inflammatory mediators in GCF did not differ between the groups.

CONCLUSIONS

Mechanical debridement and oral hygiene reinforcement resulted in clinical improvement of peri-implant mucositis and a reduction in cytokine levels. Probiotic supplements did not provide added benefit to placebo.

Reproducibility of subgingival bacterial samples from patients with peri-implant mucositis

OBJECTIVE

The aim of the present study was to investigate the reproducibility of bacterial enumeration from subsequent subgingival samples collected from patients with peri-implant mucositis.

MATERIAL AND METHODS

Duplicate microbial samples from 222 unique implant sites in 45 adult subjects were collected with paper points and analyzed using the checkerboard DNA-DNA hybridization technique. Whole genomic probes of 74 preselected bacterial species were used. Based on the bacterial scores, Cohen's kappa coefficient was used to calculate the inter-annotator agreement for categorical data. The percentage agreement was considered as "good" when the two samples showed the same score or differed by 1 to the power of 10.

RESULTS

Moderate to fair kappa values were displayed for all bacterial species in the test panel (range 0.21-0.58). There were no significant differences between Gram-positive and Gram-negative species. The percentage of good agreement between the first and second samples averaged 74.7 % (n = 74; range 56-83 %), while the proportion of poor agreement ranged from 1 to 19 % for the various strains.

CONCLUSION

While an acceptable clinical agreement was obtained in most cases, diverging bacterial scores may appear in subgingival samples collected at the same time point from patients with peri-implant mucositis.

CLINICAL RELEVANCE

The broad bulky base of implant crowns may present an obstacle for the collection of reproducible subgingival samples with paper points.

Different treatment strategies are applied to patients with the same periodontal status in general dentistry

OBJECTIVE

To analyse how general dental practitioners (GDPs) and dental hygienists judge and plan to treat patients with different periodontal conditions.

MATERIALS AND METHODS

Seventy-seven GDPs and 50 dental hygienists in a Swedish county, Halland, participated in a questionnaire study. The response rate was 94%. The questionnaire consisted of four simulated patient cases and an attached answer sheet. The patient cases had different periodontal status, ranging from healthy to moderate bone loss with general inflammation. The clinicians judged the periodontal status as healthy or diseased. If judged as diseased the clinicians suggested a diagnosis, selected treatment options and estimated the number of treatment sessions for each patient case. The clinicians were compared to each other regarding their judgement, as healthy or diseased, diagnostics and treatment.

RESULTS

Three out of four patients were judged both as healthy and diseased by different clinicians. If judged as diseased the patients were diagnosed as having gingivitis or periodontitis. Regardless of the clinicians' former judgement and diagnostics there were no differences (p > 0.05) in the selected treatment options but there was a difference (p < 0.05) in the suggested number of treatment sessions.

CONCLUSIONS

Clinicians' judgement of the same periodontal condition, as healthy or diseased, varies, which partly results in different treatment decisions considering the number of treatment sessions. The suggested number of treatment sessions varied also between clinicians even if they judged and diagnosed the condition likewise. The willingness to treat and suggested treatment options were not influenced by the variation in judgement and diagnostics.

Effect of probiotic lozenges on inflammatory reactions and oral biofilm during experimental gingivitis

AIM

Probiotic bacteria have been introduced for prevention and treatment of periodontal diseases. The aim was to assess if daily oral administration of probiotic bacteria could influence the inflammatory response and the composition of supragingival plaque in an experimental gingivitis model.

MATERIALS AND METHODS

Eighteen healthy female adults volunteered after informed consent. A double-blind randomized placebo-controlled cross-over design was used. The buccal surface of first molars was used as experimental sites. A mouth-guard covering the first premolar to second molar was used when brushing, preventing accidental cleaning during 3 weeks of plaque accumulation. Lozenges containing L. reuteri (ATCC55730 and ATCC PTA5289) or placebo were taken twice a day. During the run-in and washout periods, professional tooth cleaning was performed 5 days/week. At baseline and follow-up, plaque index, gingival index and bleeding on probing were recorded. Samples of gingival crevicular fluid (GCF) were analysed for concentration of seven inflammatory mediators. Bacterial samples were processed with checkerboard DNA/DNA-hybridization.

RESULTS

All subjects presented a local plaque accumulation and developed manifest gingivitis at the test sites during the intervention periods. The volume of GCF increased in both groups but was statistically significant only in the placebo group (p < 0.05). The concentrations of IL1-β and IL-18 increased significantly (p < 0.05), while IL-8 and MIP1-β decreased (p < 0.05). No differences were displayed between test and placebo. Likewise, the microbial composition did not differ between the groups.

CONCLUSION

Daily intake of probiotic lozenges did not seem to significantly affect the plaque accumulation, inflammatory reaction or the composition of the biofilm during experimental gingivitis.

Comparison of different methods of assessing alveolar ridge dimensions prior to dental implant placement

BACKGROUND

The aim of this study was to compare ridge-mapping measurement before surgical flap reflection and measurement using images from cone beam computerized tomography (CBCT) to direct caliper measurement following surgical exposure of the bone.

METHODS

Sixteen subjects with 25 sites for planned implant placement or ridge augmentation were recruited. An acrylic stent was fabricated for each subject. The stent provided three buccal/lingual pairs of consistent measurement points for each implant site located 4, 7, and 10 mm from the summit of the alveolar soft tissue. Two independent examiners participated.

RESULTS

Comparisons of bucco-lingual ridge width using ridge-mapping versus direct caliper measurements showed that 94% and 89% of the pairs of measurement deviations were within +/- 1 mm for examiners 1 and 2, respectively. The corresponding comparison of CBCT images versus direct caliper measurements showed 70% and 55% agreement for examiners 1 and 2, respectively. CBCT image measurements provided lower levels of agreement than ridge-mapping measurements because of the more frequent and larger magnitudes of deviations compared to direct caliper measurements.

CONCLUSIONS

Most often, ridge mapping provides measurements of the bucco-lingual ridge width consistent with those obtained by direct caliper measurement following surgical exposure of the bone. As applied in this study, CBCT was less consistent compared to direct caliper measurements and did not provide any additional, significant diagnostic information.

What findings do clinicians use to diagnose chronic periodontitis?

The prevalence of chronic periodontitis is around 40% in the adult population and most patients visiting a dental clinic experience an intervention related to this disease, either as prophylaxis, e.g. disease information, oral hygiene instruction and polishing, or as treatment of the disease, per se. Hence, chronic periodontitis is a diagnosis that initiates time and costs consuming interventions. The findings clinicians use to diagnose chronic periodontitis are probably also the base for their choice of treatment. The aim of this study was to examine: What findings dental students, dental hygienist students, dental teachers, and supervisors in Public Dental Health use to diagnose patients with chronic periodontitis. If different categories of clinicians use different findings to diagnose chronic periodontitis. A questionnaire was distributed. Seventy-six clinicians representing the four categories answered the question: "What findings, or combinations of findings, do you use when you diagnose chronic periodontitis"? Twenty-five different findings were identified as findings the clinicians use when they diagnosed chronic periodontitis. The most frequently reported findings were bleeding, deepened pockets and loss of marginal bone tissue. Variations between different categories of clinicians were identified. For example, dental hygienist students used more findings (P < 0.05), and were also more inclined to use irrelevant findings like calculus, plaque, smoking, compared to the other categories of clinicians (P < 0.05). The majority of clinicians used only one finding at a time to diagnose chronic periodontitis, and more seldom combined findings. Only 12 out of 76 clinicians used a finding that provided soft tissue inflammation, e.g. bleeding, in combination with a finding that provided loss of supporting tissue, e.g. marginal bone loss. Few clinicians commented that there should be a progressive loss of supporting tissue over time. Further research is needed to investigate if these variations in findings used to diagnose chronic periodontitis indicate variations in treatment of these patients.

Evaluation of tongue coating indices

AIM

The purpose of this study was to determine inter-examiner reproducibility of two modified Winkel tongue coating indices and to study the relationship between each of these two indices and the amount of tongue coating as determined by wet weight of scrapings from the dorsum of the tongue.

MATERIALS AND METHODS

Twenty-five participants were selected for the study from among dental students. The selection was made to assure that a wide range of degrees of tongue coating were represented. Two independent examiners scored the tongue coatings using the two modified Winkel tongue coating indices (mWTCI 1 + 2 and mWTCI 2). After completion of index recordings, tongue scrapings were performed by one of the examiners.

RESULTS

Inter-examiner reproducibility of mWTCI 1 + 2 and mWTCI 2 using Pearson's coefficients of correlation amounted to r = 0.48 and 0.93 respectively. Overall, mWTCI 2 showed higher correlations to wet weight of tongue scrapings than mWTCI 1 + 2.

CONCLUSION

The mWTCI 2 was found to be highly reproducible and also valid as related to wet weight of tongue scrapings. This index would seem suitable for further studies on tongue coatings; effect of tongue cleaning; and rate of reformation of coatings after cleaning.

Coffee, tea and caffeine consumption in relation to osteoporotic fracture risk in a cohort of Swedish women

INTRODUCTION

Consumption of coffee and tea, and total intake of caffeine has been claimed to be associated with osteoporotic fracture risk. However, results of earlier studies lack consistency.

METHODS

We examined this relation in a cohort of 31,527 Swedish women aged 40-76 years at baseline in 1988. The consumption of coffee, caffeinated tea and the intake of caffeine were estimated from a self-administered food frequency questionnaire (FFQ). Multivariate-adjusted hazards ratios (HRs) of fractures with 95% confidence intervals (95% CIs) were estimated by Cox proportional hazards models.

RESULTS

During a mean follow-up of 10.3 years, we observed 3,279 cases with osteoporotic fractures. The highest (>330 mg/day) compared with the lowest (<200 mg/day) quintile of caffeine intake was associated with a modestly increased risk of fracture: HR 1.20 (95% CI: 1.07-1.35). A high coffee consumption significantly increased the risk of fracture (p for trend 0.002), whereas tea drinking was not associated with risk. The increased risk of fracture with both a high caffeine intake and coffee consumption was confined to women with a low calcium intake (<700 mg/day): HR 1.33 (95% CI: 1.07-1.65) with > or =4 cups (600 ml)/day of coffee compared to <1 cup (150 ml)/day. The same comparison but risk estimated for women with a high propensity for fractures (> or =2 fracture types) revealed a HR of 1.88 (95% CI: 1.17-3.00).

CONCLUSIONS

In conclusion, our results indicate that a daily intake of 330 mg of caffeine, equivalent to 4 cups (600 ml) of coffee, or more may be associated with a modestly increased risk of osteoporotic fractures, especially in women with a low intake of calcium.

Microbiological findings and host response in patients with peri-implantitis

The aim of the present study was to characterise microbiota and inflammatory host response around implants and teeth in patients with peri-implantitis. We included 17 partly edentulous patients with a total of 98 implants, of which 45 showed marginal bone loss of more than three fixture threads after the first year of loading. Nineteen subjects with stable marginal tissue conditions served as controls. Oral hygiene, gingival inflammation, and probing pocket depth were evaluated clinically at teeth and implants. Microbiological and crevicular fluid samples were collected from five categories of sites: 1) implants with peri-implantitis (PI), 2) stable implants (SI) in patients with both stable and peri-implantitis implants, 3) control implants (CI) in patients with stable implants alone, 4) teeth in patients (TP) and 5) controls (TC). Crevicular fluid from teeth and implants was analysed for elastase activity, lactoferrin and IL-1 beta concentrations. Elastase activity was higher at PI than at CI in controls. Lactoferrin concentration was higher at PI than at SI in patients with peri-implantitis. Higher levels of both lactoferrin and elastase activity were found at PI than at teeth in patients. The concentrations of IL-1 beta were about the same in the various sites. Microbiological DNA-probe analysis revealed a putative periodontal microflora at teeth and implants in patients and controls. Patients with peri-implantitis harboured high levels of periodontal pathogens, Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Bacteroides forsythus and Treponema denticola. These findings indicate a site-specific inflammation rather than a patient-associated specific host response.

Comparison of ready-to-use EMDOGAIN-gel and EMDOGAIN in patients with chronic adult periodontitis

OBJECTIVES

The aim of this multicenter trial was to compare the clinical and radiographical outcome of a ready-to-use Emdogain-gel (test) with the marketed Emdogain (control).

METHODS

Subjects with bilateral infrabony defects > or =4 mm deep and > or =2 mm wide according to radiographs were selected. 88 subjects with probing pocket depth (PPD) > or =6 mm > or =1 month after supervised oral hygiene and scaling participated. At baseline plaque index, bleeding on probing, PPD and probing attachment level were recorded and reproducible radiographs for computer-based bone level measurements were taken. In each subject, 1 tooth was randomly treated with the test and 1 tooth with the control gel. Examinations were repeated 8 and 16 months post-operatively.

RESULTS

After 16 months, the mean test PPD was 4.1 mm and the mean control PPD 4.2 mm. The mean gain of attachment was 2.7 mm for test and 2.9 mm for the control sites, and the radiographic measurements demonstrated a mean gain of 1 mm for both test and control sites.

CONCLUSION

This series of cases demonstrated a statistically significant reduction of pocket depths and gain of attachment and bone after 8 and 16 months with no difference between the 2 preparations.

Guided tissue regeneration for the treatment of intraosseous defects using a biabsorbable membrane. A controlled clinical study

The aim of this controlled, clinical study was to evaluate guided tissue regeneration using a bioabsorbable membrane in periodontal intraosseous defects. Forty patients, each contributing one defect > or =4 mm in depth participated. The control group (18 individuals) received conventional flap therapy, while the test group (22 individuals) was treated using the bioabsorbable membrane, Guidor. Clinical assessments were made by one examiner, blinded with respect to treatment group, at baseline, 6 and 12 months following surgery. Baseline probing pocket depths of 7.7+/-1.4 mm in the membrane group and 7.6+/-1.9 mm in the control group were measured. Twelve month results showed a significant clinical attachment level gain in both control (1.1+/-1.8 mm), and membrane group (1.3+/-2.1 mm). Probing pocket depth reduction of 2.6+/-1.9 mm and 2.7+/-1.9 mm was observed in the respective groups. Bone sounding showed a non-significant gain of 0.4+/-1.8 mm and 0.6+/-1.4 mm at membrane and control sites, respectively. Radiographic evaluation confirmed these results. There were no significant differences found between treatment groups for any of the tested variables. Smoking had a negative effect on healing in both groups. In conclusion, clinical and radiographic results indicate that guided tissue regeneration using a bioabsorbable membrane at intraosseous defects did not predictably achieve greater clinical attachment level gain nor bone gain when compared to conventional flap therapy.

Toxicological evaluation of myristicin

Myristicin, or methoxysafrole, is the principal aromatic constituent of the volatile oil of nutmeg, the dried ripe seed of Myristica fragrans. Myristicin is also found in several members of the carrot family (Umbelliferae). Several intoxications have been reported after an ingestion of approximately 5 g of nutmeg, corresponding to 1-2 mg myristicin/kg body weight (b.w.). Although these intoxications may be ascribed to the actions of myristicin, it is likely that other components of nutmeg may also be involved. The metabolism of myristicin resembles that of safrole. No information is available, however, concerning the quantitative importance of the different metabolic pathways. The acute toxicity of myristicin appears to be low. No toxic effects were observed in rats administered myristicin perorally at a dose of 10 mg/kg b.w., while 6-7 mg/kg b.w. may be enough to cause psychopharmacological effects in man. A weak DNA-binding capacity has been demonstrated, but there are no indications that myristicin exerts carcinogenic activity in short-term assays using mice. Intake estimations indicate that nonalcoholic drinks may be the most important single source of myristicin intake. Based on available data, it seems unlikely that the intake of myristicin from essential oils and spices in food, estimated to a few mg per person and day in this report, would cause adverse effects in humans. It is, however, at present not possible to make a complete risk assessment, as studies regarding genotoxicity and chronic toxicity, including reproductive toxicity and carcinogenicity, are still lacking.

A new method to obtain bone biopsies at implant sites peri-operatively: technique and bone structure

This study aims at evaluating an objective method for the description of bone structure in the human mandible. Human bone biopsies were harvested at mandibular implant sites prior to insertion of self-tapping Mark II fixtures. Altogether 15 biopsies were taken from 12 patients. Three patients donated 2 biopsies each, one proximally and one distally taken. Ground sections of about 100 microns thickness were prepared prior to microradiography. These sections were ground to a final thickness of about 10 microns followed by histological staining. Histomorphometrical analyses were performed on the microradiographed plates and on the ground sections. On average there was a bone area of about 54% calculated on the microradiographed plates (the 100-microns sections) versus a mean bone area of 62% light microscopically (the 10-microns sections). Bone lengths were calculated on the 10-microns sections in the central part (mid-line) and on each side of the mid-line, revealing a mean of 58% in the former case and a mean of 61% in the latter case. The amount of bone varied between individuals and in different locations of the same jaw. The postoperative healing period following fixture installation is standardized regardless of bone structure. It may in the future be appropriate to more individualize this healing period based on an objective bone quality score.