Relationship Between Periodontal Screening and Recording Index Scores and Need for Periodontal Access Surgery.

BACKGROUND: The validity of using pretreatment Periodontal Screening and Recording (PSR) index sextant scores to estimate periodontal access surgery needs is evaluated in patients with chronic periodontitis before and after completion of non-surgical periodontal therapy. METHODS: In 110 adults, pretreatment probing data identified 486 sextants with PSR scores of 4 and 125 sextants with PSR scores of 3. Periodontal access surgery needs for all sextants were determined prior to treatment and after completion of non-surgical periodontal therapy for 213 sextants in 38 patients by two experienced periodontist examiners. RESULTS: PSR scores of 4 identified untreated sextants with periodontal access surgery needs significantly better than PSR scores of 3 (odds ratio = 27.8; P <0.001) in multilevel, mixed-effects, logistic regression modeling analysis. However, only 37.6% of sextants with both pretreatment PSR scores of 4 and a pretreatment periodontal access surgery need continued to have surgical access needs after completion of non-surgical periodontal therapy. A higher percentage of sextants with PSR scores of 4 or 3 revealed periodontal access surgical needs when Class II or III furcation involvements and/or Grade II or III tooth mobility were also detected in the sextant than when these parameters were not detected. CONCLUSIONS: Pretreatment PSR index scores of 4 were a strong indicator of periodontal access surgery needs in untreated dentition sextants but markedly overestimated surgical access needs remaining after completion of non-surgical periodontal therapy. These findings raise questions about the usefulness of pretreatment PSR evaluations for estimating potential periodontal access surgery needs in patients to be initially treated with non-surgical periodontal therapy.

Using chlorhexidine varnish to prevent early childhood caries in American Indian children.

OBJECTIVES: To test the efficacy of 10% chlorhexidine (CHX) dental varnish applied to the mothers' dentition in preventing caries in American Indian children. METHODS: This was a placebo-controlled, double-blind, randomized clinical trial. Mother-child pairs were enrolled when the child was 4.5-6.0 months. Mothers received 4 weekly applications of the study treatment (CHX or placebo) followed by single applications when her child was age 12 and 18 months. Children received caries examinations at enrollment, 12, 18 and 24 months. Analyses were limited to the intent-to-treat (ITT) group: children whose mothers received the first study treatment and who received at least one post-baseline exam. The outcome variable was the number of new carious surfaces (NNCS) at the child's last visit. Wilcoxon nonparametric and Fisher's exact tests were used to test differences between the active and placebo groups. RESULTS: We randomized 414 mother-child pairs, with 367 (88.6%) included in the ITT group (active = 188, placebo = 179). The proportion of children caries-free at their final exam was 51.1% and 50.8% for the active and placebo groups (P > 0.99). The mean NNCS for the active and placebo groups was 3.82 (standard deviation [SD] = 8.18) and 3.80 (SD = 6.08), respectively (P = 0.54). The proportion with NNCS > 6 was 18.1% for active children versus 27.9% for placebo (relative risk [RR] = 0.65, P = 0.03). The number needed to treat to shift one child from NNCS > 6 to a lower severity was 10.2. CONCLUSIONS: In this population CHX varnish did not reduce the mean NNCS or proportion of children with caries, but did reduce the proportion with severe caries.

Bacterial and salivary biomarkers predict the gingival inflammatory profile.

BACKGROUND: The aim of this human investigation is to explore the relationship of gingivitis with salivary biomarkers, periodontal pathogens, and interleukin (IL)-1 polymorphism after a transient inflammatory burden. METHODS: Thirty healthy human participants were randomized by IL-1 genotype status to control for potential influences of this particular single nucleotide polymorphism on the inflammatory profile. Oral hygiene practices ceased for 21 days to induce gingivitis (induction), after which home care was reinstated until 35 days (resolution). Clinical parameters included plaque (PI) and gingival (GI) indices and papillary bleeding score (PBS). Levels and proportions of 40 subgingival bacteria were determined using checkerboard DNA-DNA hybridization. Saliva was analyzed using a multiplex protein array for 30 biomarkers associated with host defense, inflammation, tissue destruction, and angiogenesis. RESULTS: Mean PI, GI, and PBS values were significantly increased during induction and decreased during resolution as measured at 35 days (P <0.01), although no differences were observed between IL-1 groups. Participants were stratified as either "high" or "low" responders based on inflammatory response (high: GI >1.5; low: GI ≤1.5). Baseline levels of salivary IL-6 and IL-8 demonstrated the highest ability to discriminate between high and low responders (area under the curve [AUC] of 0.81 and 0.72, respectively). Salivary biomarkers, matrix metalloproteinases (MMPs), and bacterial biofilm were combined to generate receiver operating characteristic curves. High levels of IL-6 and MMP-1 at baseline demonstrated the strongest ability to predict high responders (AUC of 0.89; odds ratio of 17.0; 95% confidence interval, 1.7 to 171.7). CONCLUSION: In this proof-of-concept investigation, we identified specific biomarker and microbial signatures that are associated with gingival inflammation (ClinicalTrials.gov number NCT00980525).

Issues of recruitment and rationale for conducting clinical trials on mutans streptococci suppression in mothers.

The aims of this study are (1) to describe issues related to recruitment of mothers participating in a clinical trial of transmission of mutans streptococci (MS) from mother to child in Bauru, Brazil and (2) to perform cross-cultural and temporal comparisons of levels of infection of the MS in mothers of Bauru. A total of 1422 mothers were visited at their domiciles. Cutoff levels for the MS were established at ≥10(5) CFU/mL saliva. The main reason for a mother not enrolling was not being highly infected by the MS, yet 76% of mothers presented with levels ≥10(5) CFU/mL saliva. Recent studies in industrialized countries showed a negative coefficient for linear tests indicating significant decline overtime in the levels of MS in mothers. Intercountry comparisons for mothers' salivary levels of the MS with the Bauru study as the reference revealed significant differences with studies conducted in the last two decades.

Periodontal disease activity measured by the benzoyl-DL-arginine-naphthylamide test is associated with preterm births.

BACKGROUND: Infection is a risk factor for preterm birth. This study was conducted in the field and addressed the link between periodontal pathogens measured with the benzoyl-DL-arginine-naphthylamide (BANA) test and preterm birth. METHODS: This prospective study was performed in Changhua, Taiwan. Periodontal examinations included the plaque index, papillary bleeding scores, and measurement of the BANA enzyme in plaque samples at the second and third trimesters. Independent variables included maternal demographic characteristics, previous pregnancy histories, risk factors, plaque and gingivitis scores, and current pregnancy outcomes. RESULTS: There were 19 (7%) preterm deliveries among the 268 subjects. A history of a previous preterm birth and low birth weight, frequency of prenatal visits, preterm uterine contractions, antepartum hemorrhages, placenta previae, and preterm premature rupture of membranes were significantly related to preterm birth (P = 0.035, 0.027, <0.001, 0.025, 0.006, 0.014, and <0.001, respectively). Maternal weight gain was higher with a normal term delivery (P = 0.003). Multivariable logistic regression analyses showed that the number of BANA-infected sites in the third trimester (odds ratio [OR]: 5.89; 95% confidence interval [CI]: 1.5 to 31.6), maternal weight gain (OR: 0.78; 95% CI: 0.65 to 0.91), antepartum hemorrhages (OR: 10.0; 95% CI: 2.2 to 46.9), and preterm premature rupture of membranes (OR: 12.6; 95% CI: 3.97 to 42.71) had significant influences on preterm-birth outcomes. CONCLUSIONS: BANA-positive plaque in the third trimester was associated with preterm births after controlling for other risk factors. The BANA test can be used to screen pregnant women at chairside and/or bedside to apply suitable intervention tactics.

Anaerobic dental flora and the acute coronary syndrome.

OBJECTIVE: Evidence exists that coronary heart disease is influenced by anaerobic bacterial flora and gingival inflammation. We assessed the association of periodontal bacteria, coronary artery disease, and acute coronary events. METHODS: The benzoyl-DL-arginine naphthylamide test, which detects several periodontal pathogens, and the papillary bleeding score were used to quantify gingival health. Participants with coronary heart disease (n=245) presenting with (n=92) and without an acute coronary syndrome were compared with persons seeking dental treatment (University dental, n=195) and a healthy cohort (Healthy dental, n=156). RESULTS: An 'infection', defined by a positive benzoyl-DL-arginine naphthylamide test score in>or=50% of sampled sites, was present in 408 participants. Compared with Healthy dental, the odds ratio for coronary heart disease having an infection was 8.6 (95% confidence interval, 4.0-18.4) and for University dental odds ratio=16 (95% confidence interval, 6.5-39.5). Patients with an acute coronary syndrome at the time of benzoyl-DL-arginine naphthylamide sampling were 3.95 times more likely to have an infection compared with coronary heart disease patients with no history of acute coronary syndrome (P=0.003), a finding independent of other covariates. CONCLUSIONS: Persons with coronary heart disease, particularly associated with an acute coronary syndrome, have anaerobic bacterial dental flora similar to individuals seeking periodontal dental care, and unlike periodontally healthy individuals.

The transmission of BANA-positive periodontal bacterial species from caregivers to children.

BACKGROUND: The purpose of the authors' study was to use the N-benzoyl-DL-arginine-2-naphthy-lamide (BANA) test (BANAMet LLC, Ann Arbor, Mich.) to obtain information regarding the prevalence of an enzyme unique to certain periodontal pathogens in plaque samples of children, as well as the potential transmission of these pathogens from caregivers to children. METHODS: The authors tested 218 subjects (3 to 10 years old) and 195 care-givers at four pediatric dentistry clinics in Taipei, Taiwan. RESULTS: Forty-four percent of the children had at least one plaque sample that tested positive and/or weakly positive. Positive results were more frequent in the mixed dentition, as well as in children with gingivitis (P < .001). A logistic regression model showed that if the BANA test results for the care-giver were positive, the odds of the child's also having positive test results were 55 times greater (P < .001; confidence interval [CI] = 14 to 224) than those for a child whose caregiver had negative BANA test results. Other predictors were the presence of a mixed dentition (P < .001; odds ratio [OR] = 11; CI = 3.5 to 33.5) and the children's papillary bleeding scores (P < .001, OR = 3.1, CI = 2.0 to 4.7). CONCLUSION: The BANA test results were positive for almost one-half of the children. A positive reaction was associated with gingivitis, a mixed dentition, a BANA-positive caregiver or a caregiver with a history of periodontal disease in the family. CLINICAL IMPLICATIONS: The authors propose an anaerobic periodontal infection risk model in which children with a mixed dentition who have gingivitis and a caregiver with a history of periodontal disease would undergo the BANA test.

Compliance with Xylitol and Sorbitol Chewing Gum Regimens in Clinical Trials.

OBJECTIVE: The purpose of this study was to investigate compliance of long-term xylitol and sorbitol chewing gum regimens in adult women participating in a double-blind randomized controlled clinical trial. DESIGN: The participants included 122 mothers (age range: 16-35 years) residing in the city of Bauru, São Paulo, Brazil. Compliance with the xylitol and sorbitol chewing gum regimens was assessed by weighing, with a precision balance, all used gums returned in zip-lock bags during the study period of 33 months. The total number of returned bags in both chewing gum groups was computed and the differences between groups were determined by one-way ANOVA. Compliance was further categorized into excellent, good, fair or poor based on the distribution of the combined data for both groups by quartiles. These distributions for the xylitol and sorbitol groups were subjected to chi-square analysis. RESULTS: Compliance was always superior for the xylitol group in all categories. These distributions were, however, not significantly different in statistical terms. Average compliance in the xylitol chewing gum group was significantly higher when compared to the sorbitol chewing gum group (p=0.0481). CONCLUSIONS: The results suggest that compliance, and possibly acceptance in this population, was superior for xylitol chewing gum than for sorbitol chewing gum.

On the Acquisition of Periodontopathic Bacteria by Children from Mothers: A Randomized Double-Masked Placebo-Controlled Trial in Bauru, Brazil.

OBJECTIVE: The purpose of this study was two-fold: 1) to determine the effects of mechanical and chemical modalities treatments on periodontal clinical and microbiological parameters of mothers; and 2) to determine the subsequent colonization of periodontal pathogens in tongue samples from their infants. DESIGN: A total of 168 mothers met inclusion criteria to participate in a randomized double-masked placebo-controlled clinical trial. Of those, 121 mothers (and their infants) of 158 seen at baseline provided complete data during study protocols from when their infants were 3 months old until the infants were about 2 years old. Treatments consisted of a combination of xylitol chewing gum, fluoride and chlorhexidine varnishes. The control/placebo group received sorbitol chewing gum and placebo varnishes. The effect of these treatments on periodontal clinical and microbiological parameters of mothers and on microbiological parameters of their infants was assessed by generalized estimating equation models. RESULTS: Microbiological outcomes using the BANA Test were lower for the majority of the visits in the test group when compared to the control/placebo group. These differences, however, were not statistically significant. Similarly, mean PBS results were lower for all follow-up visits for test-group mothers when compared to the control/placebo group's mothers, but of no statistical significance. Colonization of the tongue in infants by periodontal pathogens as measured by the BANA Test showed no distinct patterns concerning the stability of colonization of periodontal pathogens throughout the study period, albeit slightly superior for the test group. CONCLUSIONS: We have demonstrated that a combined chemical modalities treatment consisting of xylitol chewing gum, fluoride varnish and chlorhexidine varnish was moderately superior to control/placebo treatments on periodontal clinical and microbiological parameters of mothers throughout the study period, but of no statistical significance. Similar results were found for the infants in the test group when compared to infants of the control/placebo groups.

The nonsurgical treatment of patients with periodontal disease: results after 6.4 years.

In a previous study involving patients at the dental clinic of the Detroit Receiving Hospital, 87% of teeth that initially had been recommended for surgery or extraction were spared either treatment through a combination of debridement and short-term usage of antimicrobial agents. The object of the present study was to determine what changes occurred to these teeth after 6.4 years in the maintenance phase of treatment. Patients were scheduled for maintenance therapy at three-month intervals over a period of 6.4 years. They were evaluated "annually" (that is, the patients were scheduled for annual visits) for surgical needs by a clinician who was not aware of the treatment received by the patients. Multivariate statistical models were used to determine which variables predicted subsequent surgical needs. The initial treatment benefits were sustained, as the majority of patients showed no increase in surgical needs after 6.4 years. When relapse occurred, those who were smoking when the study began and an increased number of sessions of debridement were predictors. Surgical needs were reduced when metronidazole was dispensed after the first and second annual examinations.

Microbiology and Treatment of Halitosis.

The many thousands of individuals who experience oral malodor that stems from the overgrowth of proteolytic, anaerobic bacteria on their tongue surfaces can be successfully treated by a regimen that includes tongue brushing and tooth brushing, often in combination with a mouthrinse containing an antibacterial agent. Several candidate mouthrinses containing essential oils (Listerine; Warner-Lambert, Morris Plains, NJ), ZnCl(2), chlorine dioxide, or an oil:water-cetylpyridium chloride mouthrinse have reduced the organoleptic scores of individuals with moderate levels of oral malodor in the absence of tongue brushing. Very little long-term data beyond 6 weeks of use are available.

Preventing the transfer of Streptococcus mutans from primary molars to permanent first molars using chlorhexidine.

PURPOSE: The purpose of this study was to determine if the application of 1% chlorhexidine-containing wax on primary molars during the period of eruption of the first permanent molars could prevent the transfer of certain oral flora, namely Streptococcus mutans, to the permanent molars. METHODS: Fourteen children with a mean age of 6.5 years (7 males and 7 females) were assigned into two groups: a chlorhexidine group (n=9) in which 1% chlorhexidine-containing wax was painted on primary molars on one side of the mouth; and a placebo wax group (n=5) in which a similar wax, but without chlorhexidine, was painted on primary molars on the other side of the mouth. Baseline saliva samples and pooled plaque samples from the primary molars on both sides of the dentition were obtained from the two treatment groups. Following treatment, plaque samples from the occlusal fissures of the first permanent molars on both sides of the dentition were obtained. The levels of S.mutans and other members of the oral flora on the treated sides (chlorhexidine or placebo) were compared with those on the untreated sides. RESULTS: The results showed that the proportions of S.mutans to S.sanguinis were significantly lower in the chlorhexidine-treated sides compared to the untreated (P=0.04) and in the chlorhexidine-treated patients compared to placebo (P=0.029). CONCLUSIONS: Since lower mutans to sanguinis ratios have been associated with lower caries experience, treating primary molars with 1% chlorhexidine wax during eruption of permanent first molars may be a simple means for shifting the fissure flora of the permanent molars towards a more favorable balance.

Microbiology and treatment of halitosis.

The prevalence of oral malodor is probably high in the United States, although precise epidemiological data are missing. The many thousands of individuals who experience oral malodor from the overgrowth of proteolytic, anaerobic bacteria on their tongue surfaces can be successfully treated by a regimen that includes tongue brushing, toothbrushing and possibly the usage of mouthrinses containing various agents. Several candidate mouthrinses containing essential oils (Listerine), ZnCl2, or an oil, water and cetylpyridum chloride mouthrinse have reduced the organoleptic scores of individuals with moderate levels of oral malodor in the absence of tongue brushing. Very few long-term data beyond 6 weeks of usage are available. Anecdotal evidence suggests that other agents such as chlorine dioxide may be helpful. These mouthrinses should be marketed as oral deodorants that are analogous in purpose to the usage of deodorant soaps to control and/or eliminate body malodors. In this way the mouthrinse could be considered as a cosmetic by the FDA, provided that there are data on the safety of the various ingredients in the mouthrinse. Mouthrinses containing zinc ions are able to reduce the levels of volatile sulfur compounds by converting these volatile compounds to non-volatile, and therefore, non-malodorous zinc sulfides, and this mode of action would appear to support a cosmetic claim.

The nonsurgical treatment of patients with periodontal disease: results after five years.

BACKGROUND: In a previous study involving patients seen at the dental clinic of the Detroit Receiving Hospital, the authors found that 87 percent of teeth initially recommended for surgery or extraction were spared those treatments by a combination of debridement and short-term usage of antimicrobial agents. The objective of the present study was to determine how long the surgery-sparing benefits of less invasive treatment would persist. METHODS: Ninety of these patients were scheduled for maintenance therapy at three-month intervals over a five-year period. They were evaluated periodically for surgical needs by a clinician who was not aware of the nonsurgical periodontal treatment the patient had received. RESULTS: The initial treatment benefits were sustained, as the number of teeth needing periodontal surgery or extraction was 0.06 teeth per patient after 1.1 year, 0.22 after 2.3 years, 0.51 after 3.6 years and 0.86 after 5.1 years. CONCLUSIONS: A noninvasive treatment regimen for an anaerobic infection in teeth seriously compromised by periodontal disease resulted in a reduced need for surgery or tooth extraction for at least five years after completion of the initial treatment.

DNA Probe and Enzyme Analysis in Periodontal Diagnostics.

Recent research in periodontology has indicated that a finite number of bacterial species are associated with periodontal disease. This has generated the hypothesis that periodontal disease is essentially an infection due to one or more of the putative periodontopathogens; i.e., the specific plaque hypothesis (SPH). This microbial specificity paradigm has already changed the way researchers and some clinicians view periodontal disease. The clinician must heed several cautions signs, however, if he is to use the SPH to provide treatment options that could enhance the delivery of care. There are several diagnostic technologies that can be used to detect and semi-quantitate those bacterial species that have been identified as periodontopathogens. This paper discusses diagnostic tests based upon the detection in plaque of DNA segments or enzyme activity(ies) that are unique for one or more of the suspected periodontopathogens. J Periodontol 1992; 63:1102- 1109.