An overview of periodontal regenerative procedures for the general dental practitioner.

The complete regeneration of the periodontal tissues following periodontal disease remains an unmet challenge, and has presented clinicians with a remarkably difficult clinical challenge to solve given the extensive research in this area and our current understanding of the biology of the periodontal tissues. In particular as clinicians we look for treatments that will improve the predictability of the procedure, improve the magnitude of the effect of treatment, and perhaps most importantly in the long term would extend the indications for treatment beyond the need for single enclosed bony defects to allow for suprabony regeneration, preferably with beneficial effects on the gingival soft tissues. A rapid development in both innovative methods and products for the correction of periodontal deficiencies have been reported during the last three decades. For example, guided tissue regeneration with or without the use of bone supplements has been a well-proven treatment modality for the reconstruction of bony defects prior to the tissue engineering era. Active biomaterials have been subsequently introduced to the periodontal community with supporting dental literature suggesting that certain factors should be taken into consideration when undertaking periodontal regenerative procedures. These factors as well as a number of other translational research issues will need to be addressed, and ultimately it is vital that we do not extrapolate results from pre-clinical and animal studies without conducting extensive randomized clinical trials to substantiate outcomes from these procedures. Whatever the outcomes, the pursuit of regeneration of the periodontal tissues remains a goal worth pursuing for our patients. The aim of the review, therefore is to update clinicians on the recent advances in both materials and techniques in periodontal regenerative procedures and to highlight the importance of both patient factors and the technical aspects of regenerative procedures.

Is there a role for community pharmacists in promoting oral health?

AIM: The main aim of the present study was to investigate whether pharmacists recognised that they have a role in the promotion of oral health advice within the community. METHODS: A cross sectional survey was conducted using a structured questionnaire which was distributed to randomly selected pharmacies (n = 1,500) in the London area. RESULTS: Six hundred and forty-five pharmacies (43%) responded to the initial invitation and 589 (39%) of pharmacy participants acknowledged that pharmacists should have a role in oral health promotion. Participants from 354 pharmacies (23.6%) subsequently agreed to complete the questionnaire. Of those pharmacies completing the questionnaire, 99.4% of the pharmacy participants recognised that there was a role for pharmacists in oral health promotion. Although 91.5% of the pharmacists reported a fairly high level of knowledge for most of the common oral conditions, they also indicated that they were interested in receiving further training on oral conditions through continuing professional development (CPD) courses. A number of the pharmacies (72.5%) expressed a willingness to incorporate oral health promotion within the NHS pharmacy contract. CONCLUSION: Pharmacies may be used effectively in oral health promotion by virtue of their frequent contact with members of public. As a result of their established role in promoting and improving the health within the community, it may possible to incorporate oral health within the existing NHS contract.

Dentifrice abrasivity and cervical dentinal hypersensitivity. Results 12 weeks following cessation of 8 weeks' supervised use.

Following an 8-week controlled investigation of 2 strontium chloride hexahydrate dentifrices (SCH) of differing abrasivity, 2 groups of 20 subjects each, with cervical dentinal hypersensitivity, were re-examined at 20 weeks; that is, 12 weeks after the active period. The examination procedures were conducted in the same manner as in the main clinical trial. Sensitivity levels were assessed by 2 instrument methods: tactile (Yeaple probe), and cold air (dental air syringe), and by subjective perception of pain by means of a Visual Analogue Scale. The results from these methods of assessment demonstrated that 12 weeks following the cessation of 8 weeks' controlled use of standard and low abrasive SCH dentifrices, sensitivity levels reversed on slightly in both groups and, overall, sensitivity remained significantly lower than at baseline. The abrasivity of the dentifrice did not affect the desensitivity activity.

Comparison of 2 desensitizing dentifrices with a commercially available fluoride dentifrice in alleviating cervical dentine sensitivity.

Previous studies have demonstrated efficacy of desensitizing dentifrices containing strontium acetate/sodium fluoride (SrAc2F) and potassium chloride/sodium monofluorophosphate (KCl/MFP) in alleviating discomfort arising from cervical dentine sensitivity (CDS). The aim of this investigation, therefore, was to determine efficacy of a SrAc2F dentifrice compared with KCl/MFP and a commercially available fluoride dentifrice containing sodium fluoride/sodium monofluorophosphate (NaMFP). Fifty-six patients participated in a 2-center double-blind, 3-way comparative parallel 6-week clinical study. Patients were evaluated at 0, 2, and 6 weeks for tactile (Yeaple probe), air sensitivity (dental air syringe), and subjective perception of pain (VAS scores). Results for Yeaple probe scores (Wilcoxon tests) between 2 weeks and baseline were highly significant for KCl/MFP, significant for NaMFP and nonsignificant for SrAc2F; scores between 6 weeks and baseline were, however, highly significant for all groups. Subjective Yeaple probe VAS scores (paired t-tests) between 6 weeks and baseline were significant for all groups; significance was demonstrated in the KCl/MFP group between 2 weeks and baseline. Subjective air visual analogue scores (paired t-tests) between 2 weeks and baseline were highly significant for all groups. There were no significant differences between groups at any time point. The results of the study demonstrated that the commercially available fluoride-containing dentifrice was as effective as the 2 desensitizing dentifrices in alleviating CDS over time.

The efficacy of potassium salts as agents for treating dentin hypersensitivity.

Formulations containing potassium salts (e.g., chloride, nitrate, citrate, oxalate) are widely used for treating dentin hypersensitivity (DH). The purpose of this review was to evaluate evidence for the clinical efficacy of potassium salts in reducing DH and also to consider the biologic basis for any effects. Literature searches were used to identify reports of clinical trials of potassium-containing preparations. Searches revealed 3 trials of potassium nitrate solutions or gels; 2 trials of mouthwashes containing potassium nitrate or citrate; 6 trials of potassium oxalates; and 16 double-blind randomized trials of toothpastes containing potassium nitrate, chloride, or citrate. The toothpaste studies provided quantitative data on treatment effects. These outcome measures were expressed as percentage reductions in sensitivity to cold air and mechanical stimulation and the patients' subjective reports. Trials of topically applied solutions yielded inconsistent results. Potassium-containing mouthwashes produced significant reductions in sensitivity. All potassium-containing toothpastes produced a significant reduction in sensitivity to tactile and air stimuli, as well as subjectively reported sensitivity. In most studies, the active agent (potassium) was superior to the minus-active control (placebo), but a few of the more recent trials have demonstrated significant placebo effects. It is postulated that potassium ions released from toothpastes diffuse along the dentinal tubules to inactivate intradental nerves. However, this principle has never been confirmed in intact human teeth. The mechanism of the desensitizing effects of potassium-containing toothpastes remains uncertain at present.

A pilot assessment of alternative methods of quantifying dental pain with particular reference to dentine hypersensitivity.

OBJECTIVE: The overall aim of this pilot study was to establish the usefulness and comparability of selected verbal and non-verbal methods in the quantification of sensory and affective aspects of dental pain associated with dentine hypersensitivity (DH). DESIGN: The assessment of dental pain was conducted during an eight week clinical study. Patients were asked to rate their perception of dental pain using selected methods of quantification following tactile (Yeaple Probe-an electronic pressure-sensitive probe) and evaporative (cold air from a dental air syringe) stimulation; together with an overall assessment of perception to daily stimuli (e.g., cold air/water, toothbrushing, sweet and sour foods). The assessment methods used to quantify pain arising from DH were a continuous visual analogue scale (VAS), a 0-10 numerical rating VAS scale (NRS), and a separate intensity verbal descriptor (IVD) and unpleasantness verbal descriptor (UVD) word scales. SETTING: A specialist department at a postgraduate dental institute and hospital in London, UK. SUBJECTS: Twenty-five adult patients (8M + 17F) with a mean age of 42.6 years (95 per cent C.I. 38.8 to 46.4 years) attending the department for a clinical study evaluating the efficacy of a desensitising toothpaste agreed to participate. OUTCOME MEASURES: The study compared a continuous visual analogue scale (VAS), a 0-10 numerical rating visual analogue scale (NRS), and a separate intensity (IVD) and unpleasantness verbal descriptor (UVD) scales to quantify sensory and affective aspects of pain. An unweighted moving average technique was used to construct graphs of the relative frequency of reported severity gradings over a range of 0-10. RESULTS: The results of the study indicated that cold air appeared to cause greater discomfort to the patient than tactile sensitivity, with the air intensity curve for both IVD and 0-10 VAS peaking at a severity score of 5 while continuous VAS peaked at a score of 3-4. All methods peaked at score 2 for tactile sensitivity. The UVD scale peaked at score 2-3 and again at 6 for air sensitivity, but conformed to the other scales by peaking at score 2 for tactile sensitivity. NRS and IVD scales therefore appeared to provide acceptable alternatives to continuous VAS, but the UVD scale, probably because of the imprecise nature of the words used in the scale, did not. CONCLUSIONS: This study partially confirms previous conclusions that both verbal and non-verbal techniques quantify sensory and affective aspects of pain. However, the imprecise nature of UVD words provided misleading information in terms of both accuracy and sensitivity (except at very low levels of discomfort), when assessing pain arising from dentine hypersensitivity. In view of the highly subjective data arising from studies of this nature, the use of a moving average technique may be considered a more pragmatic method of analysis.

The effect of oral care feed-back devices on plaque removal and attitudes towards oral care.

OBJECTIVES: Two studies were carried out to investigate whether the effect of specific oral care feed-back devices would result in better plaque removal (Study 1) and lead to changes in attitudes and views relating to oral health (Study 2). The objective of the first study was to compare the ability of a toothbrush system consisting of a new toothbrush plus plaque disclosing tablet (SIGNAL Integral) to remove supra-gingival plaque to that of a marketed toothbrush (Oral B Cross Action) following a single unsupervised brushing. METHODS: Study 1 had a cross-over design and included 21 healthy adult volunteers. Subjects refrained from any form of oral hygiene for 24 hours prior to each test session. Plaque levels (Modified Quigley-Hein Plaque index) were assessed prior to and following each unsupervised brushing. When the new toothbrush was used, subjects self-disclosed their plaque with a disclosing tablet (erythrosine) immediately prior to brushing. At each occasion, brushing time (in sec) was also recorded. Study 2 had a two-cell, parallel design (test and control group) and lasted for five days. Healthy adult volunteers were enrolled. Subjects in the test group (n = 30) were given a fluoride toothpaste and four saliva test strips to use at home. The saliva test strip is designed to change colour in the pH range of 6.5 to 10, allowing the user to verify the effect of brushing. The control group (n = 29) received no saliva test strips. Subjects completed a questionnaire after 4 days of product use. RESULTS: In Study 1, significantly more plaque was removed (p < 0.05) and brushing time was increased by more than 20% when subjects used the new toothbrush together with the disclosing tablet compared to brushing with the marketed toothbrush. In Study 2, significant increases in motivation relating to oral hygiene were found in the test group who had been using the saliva test strip. CONCLUSION: The two studies have provided significant evidence that the provision of feed-back devices in an oral care context can lead to improved removal of plaque and increased motivation.

The effect of a toothpaste containing 2% zinc citrate and 0.3% Triclosan on bacterial viability and plaque growth in vivo compared to a toothpaste containing 0.3% Triclosan and 2% copolymer.

OBJECTIVE: To compare the antimicrobial efficacy and effect on plaque growth of a new silica-based fluoride toothpaste containing 2% zinc citrate/ 0.3% Triclosan with a silica-based fluoride toothpaste containing 0.3% Triclosan/2% copolymer. METHODS: In Study 1, plaque was collected after one week's use of each toothpaste and assessed for bacterial viability, live/ dead ratio and microbial membrane integrity. In study 2, plaque was measured immediately and 18 hours after a single brushing with the specified toothpastes. RESULTS: The 2% zinc citrate/0.3% Triclosan formulation significantly reduced the total number of viable aerobic and anaerobic bacteria (p = 0.0223 and p = 0.0443 respectively) compared to the 0.3% Triclosan/2% copolymer formulation. Both toothpastes increased the bacterial membrane permeability significantly. However, the proportion of live bacteria for the 2% zinc citrate/0.3% Triclosan product was significantly reduced (p < 0.05). Study 2 showed significantly less plaque growth 18 hours after using the 2% zinc citrate/0.3% Triclosan toothpaste compared to the 0.3% Triclosan/2% copolymer toothpaste (p < 0.01). CONCLUSION: Regular use of a fluoride toothpaste containing 2% zinc citrate and 0.3% Triclosan, significantly reduced the viability of plaque bacteria compared to a fluoride toothpaste containing 0.3% Triclosan/ 2% copolymer 12 hours after brushing. In addition, a clinical plaque growth study confirmed that this anti-microbial efficacy leads to a significant reduction in plaque growth.

Clinical trial designs for testing of products for dentine hypersensitivity--a review.

Dentine hypersensitivity (DH) is a perplexing clinical entity. There is no doubt that patients self-report discomfort arising from various stimuli, but the highly subjective nature of the condition makes it extremely difficult to evaluate DH objectively. This is particularly true when evaluating the efficacy of desensitizing agents in the clinical trial setting. This paper attempts to provide an overview on clinical trial management to evaluate both in-office and over-the-counter (OTC) desensitizing agents. The importance of correct clinical trial design (type, allocation, blinding) with emphasis on patient selection, sample size, statistical power, duration, choice of positive/negative controls, treatment outcomes, and data collection, will be discussed.

Mechanisms of stimulus transmission across dentin--a review.

Several investigators have demonstrated that intradental A-type (A beta and A delta) nerve fibers are responsible for the sensitivity of dentin and that the endings of the responding fibers are located in the pulp-dentin area of the tooth. The exact mode of transmission of stimuli (e.g., thermal, chemical, mechanical, etc.) across dentin, however, is still unclear, although several hypotheses have been proposed. These include direct nerve stimulation, dentinal receptor (transducer/modulation), hydrodynamic, and direct ionic diffusion hypotheses. Currently, the most accepted mechanism of intradental nerve activation associated with dentin sensitivity appears to be hydrodynamic in nature, although alternative mechanisms of transmission (e.g., direct ionic diffusion) cannot be ruled out. Recent investigations (in the cat), however, appear to provide evidence substantiating the hydrodynamic hypothesis.

The effectiveness of desensitizing agents for the treatment of cervical dentine sensitivity (CDS)--a review.

The treatment of dentine sensitivity or cervical dentine sensitivity (CDS) has been in the form of dentifrices, mouth rinses, sealants, and other therapeutic techniques. Claims of efficacy of the "so-called" active ingredients of these desensitizing agents have been made on the basis of the proposed mode of action generally extrapolated from in vitro or animal studies. Evidence from published, well-controlled clinical studies, however, generally has failed to substantiate such claims, although there has been a reported significant reduction in discomfort by subjects participating in these studies. Currently, the most accepted mechanism of intradental nerve activity associated with dentine sensitivity appears to be hydrodynamic in nature, although other mechanisms cannot be eliminated. The concept of tubule occlusion as a method of dentine desensitization is a logical conclusion from the hydrodynamic hypothesis. This paper reviews the present position with regard to the treatment of dentine sensitivity by various desensitizing agents and evaluates their claims of efficacy in the context of available scientific evidence.

The Efficacy of Selected Desensitizing OTC Products: A Systematic Review.

Objectives. The aim of the present study was to review the published literature in order to identify relevant studies for inclusion and to determine whether there was any evidence on the clinical effectiveness of selected desensitizing toothpastes, calcium sodium phosphosilicate (CSPS), amorphous calcium phosphate (ACP), nanohydroxyapatite, and casein phosphopeptide-amorphous calcium phosphate (tooth mousse) on reducing dentine hypersensitivity (DH). Materials and Methods. Following a review of 593 papers identified from searching both electronic databases (PUBMED) and hand searching of relevant written journals, only 5 papers were accepted for inclusion. Results. Analysis of the included studies (3 CSPS and 2 ACP) would suggest that there may be some benefit for patients using these products for reducing DH. No direct comparative studies were available to assess all these products under the same conditions neither were there any comparative randomised controlled studies that compared at least two of these products in determining their effectiveness in treating DH. Conclusions. Due to the small number of included studies, there are limited clinical data to support any claims of clinical efficacy of these OTC products. Further studies are therefore required to determine the efficacy of these products in well-controlled RCT studies with a larger sample size.

Preferences of UK-Based Dentists When Undertaking Root Coverage and Regenerative Procedures: A Pilot Questionnaire Study.

Objectives. The purpose of the present study was to evaluate the awareness and preferences of registered United Kingdom (UK) dentists specialising or with an interest in periodontics in root coverage and regenerative procedures. Methods. A cross-sectional postal survey of 366 dentists was conducted. The questionnaire was divided in two sections and most of the questions were giving the option of multiple answers. Frequencies and associations between the demographic profiles of the participants with their answers were evaluated. Results. 63% of dentists with an interest in periodontics and 32% of specialists returned the questionnaire. Guided tissue regeneration procedures and the use of enamel matrix derivatives were recommended for the reconstruction of bony defects and both subepithelial connective tissue graft and coronally advanced flap with or without enamel matrix derivatives were the most popular choices for root coverage. Smoking was considered a contraindication by most of the participants and conflicting responses were given regarding the use of antibiotics as part of the care following regenerative procedures. Conclusions. The participants incorporated both traditional and "novel" techniques and products in reconstructive procedures and appeared to be up to date with the evidence from the dental literature. However, it was evident that there was confusion regarding the role of antibiotics in regenerative procedures.

In-vitro accuracy and reproducibility evaluation of probing depth measurements of selected periodontal probes.

AIM: The purpose of the present in vitro study was to measure the accuracy and reproducibility of three periodontal probes. To eliminate environment- or examiner-related probing errors, two aluminum blocks with predrilled holes of varying depths were examined by participants who had been trained in probing before the study. This methodology improved the likelihood that any probing errors identified were generated by the probes themselves. MATERIALS AND METHODS: Three probes, Williams 14 W (Hu-Friedy Mfg. Co., LLC, UK), Chapple UB-CF-15 (Implantium, Shrewsbury, UK), and Vivacare TPS (Ivoclar Vivadent, Enderby, UK), were randomly distributed to 23 participants (9 males and 14 females; mean age: 31.35 years). Participants measured 30 holes in two aluminum blocks, average 20 days, SD = 341.05. For each hole, the mean measured depth was calculated for each participant and compared to the true depth. Intra- and inter-examiner accuracy and reproducibility for each of the duplicate measurements were calculated. Data were analyzed by paired-samples t-test with the SPSS 18 software package (IBM Portsmouth, UK). A p-value <0.05 indicated statistical significance. Tables were constructed from the data. RESULTS: When used by participants, the Williams 14 W probe was reproducible but not necessarily accurate; Vivacare TPS was neither accurate nor reproducible; and Chapple UBCF-15 was both accurate and reproducible. CONCLUSION: Depth measurements with the Chapple UB-CF-15 probe were more accurate and reproducible compared to measurements with the Vivacare TPS and Williams 14 W probes. This in vitro model may be useful for intra-examiner calibration or clinician training prior to the clinical evaluation of patients or in longitudinal studies involving periodontal evaluation.

Accuracy and reproducibility of probe forces during simulated periodontal pocket depth measurements.

AIM: The aim of the present study was to measure the accuracy and reproducibility of probe forces in simulated assessments of periodontal pocket depth. The study included experienced and inexperienced examiners and used manual and pressure-sensitive probes. MATERIALS AND METHODS: Sixty-one participants were divided into seven groups and asked to probe selected anterior and posterior sites with three different probes (Williams 14W, Chapple UB-CF-15, and Vivacare TPS probes). The model was positioned on a digital electronic balance to measure force, which was recorded initially and after 15 min. Probe preferences were recorded. Accuracy was measured by comparing to a standardized 25 g force, and reproducibility was calculated for all duplicate measurements. RESULTS: The Vivacare probe produced the most accurate and most reproducible forces, whereas the Williams probe produced the least accurate and least reproducible forces. Probe forces were lighter at anterior sites compared to posterior sites at baseline. Probe forces were reduced at both sites after 15 min compared to baseline. CONCLUSIONS: Vivacare TPS periodontal probes are more accurate and reproducible than Chapple and Williams probes. Many clinicians in this study preferred the Chapple probe.

The efficacy of strontium and potassium toothpastes in treating dentine hypersensitivity: a systematic review.

Objectives. The aim of the present paper was to review the published literature in order to identify all relevant studies for inclusion and to determine whether there was any evidence of the efficacy of strontium and potassium toothpastes in the treatment of dentine hypersensitivity (DH). Methods. Following a review of 94 relevant papers both from searching electronic databases (PUBMED) and hand searching of relevant written journals, 13 studies were identified, and 7 papers (1 for strontium-based toothpastes and 6 for potassium-based toothpastes) were finally accepted for inclusion. The main outcome measures were the methodology and assessment used by Investigators in studies designed to evaluate DH. Results. The results of the present paper would indicate that the reported efficacy of both strontium- and potassium-based toothpastes in relieving DH is questionable. Conclusions. The results from the present paper would appear to support the conclusions of previous investigators that there is only minimal evidence for the efficacy of both strontium- and potassium-based toothpastes in relieving symptoms of DH.

The Prevalence of Root Sensitivity following Periodontal Therapy: A Systematic Review.

The reported prevalence of dentine/root (hyper)sensitivity (DH/RS) in the published literature varies, and this may be due in part to a) the different study populations and (b) the different methodologies employed in evaluating the pain response. According to von Troil et al. (2002) there are limited data available in terms of the prevalence and intensity of DH/RS following periodontal therapy. Objectives. The aim of the present study was therefore to review the literature in order to identify all relevant studies for inclusion and to determine whether there was any evidence of DH/RS following periodontal procedures in the published literature up to 31st December 2009 using an agreed search protocol. Methods. 840 papers were identified, from searching both electronic databases (PUBMED) and hand searching of relevant written journals. Twelve papers were subsequently accepted for inclusion. Results. The results of the present study would indicate that the reported prevalence for DH/RS (following nonsurgical therapy) was between 62.5% and 90% one day after treatment decreasing to approximately 52.6% to 55% after one week. The prevalence of DH/RS following surgical therapy was between 76.8% and 80.4% one day after treatment subsequently decreasing over time to 36.8% after 1 week, 33.4% after 2 weeks, 29.6% after 4 weeks, and 21.7% after 8 weeks. Conclusions. It is evident from reviewing the included studies that patients may suffer from mild discomfort following periodontal procedures although both the prevalence and intensity of DH/RS may vary depending on the duration and the type of procedure involved. Most of the studies included in this paper would tend to suggest that DH/RS may be relatively mild/moderate in nature and transient in duration.

In vitro quantification of changes in human dentine tubule parameters using SEM and digital analysis.

Dentine hypersensitivity is recognized as a pain arising from fluid movement within dentine tubules that are open to the oral environment. Blocking the tubules is considered to be the principal aim of treatment, and the accurate assessment of tubule occlusion is the primary goal of many in vitro studies. This assessment usually comprises either measuring tubule permeability or scanning electron microscope examination of the dentine surface. Several scanning microscopy studies have claimed to quantify tubule occlusion, but are descriptive, qualitative or semi-quantitative evaluations. The present study was undertaken to assess the use of digital image analysis in quantifying the effectiveness of a selected desensitizing agent from micrographs of control and treated dentine surfaces. Using a dentine disc model, an accurate methodology was sought to investigate the occluding potential of Butler Protect (J.O. Butler, Chicago, IL, USA). Subjective examination of the images indicated there was little difference after a single application, but considerable effect after 20 applications. Quantitative digital analysis of a test image, demonstrated reproducibility between two examiners when used in fully- and semi-automated mode. After a single application of Butler Protect, multilevel statistical modelling demonstrated decreases in tubule area and maximum, minimum and mean diameter measurements (P < 0.001), whereas single level analysis showed increases in area and maximum and mean diameters. Multiple application of Butler Protect demonstrated even greater decreases in all parameters (P < 0.001). This quantitative methodology was reproducible between examiners and, when combined with good controls and multilevel statistical modelling, was able to discriminate a single application of desensitizing agent.

Aetiology, prevalence and clinical features of cervical dentine sensitivity.

Cervical dentine sensitivity (CDS) is a painful response to thermal, physical or chemical stimulation of the cervical area of the tooth. The reported prevalence of this clinical condition ranges from 8 to 35% depending on the population studied and methodology used to evaluate CDS. Detailed epidemiology is lacking with regard to possible causal factors. Well conducted studies in larger populations using accepted standardized methodology for both questionnaire and clinical examination are essential if these factors are to be identified and the condition successfully prevented and treated. This paper reviews current literature on the prevalence, aetiology and oral distribution of this troublesome condition.