Perio Reports Vol. 22 No. 9 Perio Reports Provides Easy-To-Read Research Summaries on Topics of Specific Interest to Clinicians

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Perio Reports Vol. 22 No. 9 Perio Reports provides easy-to-read research summaries on topics of specific interest to clinicians. Perio Reports research summaries will be included in each issue to keep you on the cutting edge of dental hygiene science.

Calcium Channel Blockers Bisphosphonates and and Gingival Hyperplasia Osteonecrosis of the Jaws

Bisphosphonate drugs are given intravenously when Gingival hyperplasia is caused by alterations in the treating various cancers and their side effects. It is prescribed connective tissue resulting in overstimulation of fibrob- orally for the treatment of osteoporosis. Bisphosphonates lasts and overgrowth of gingival tissue. Drug-induced preserve bone by inhibiting osteoclast function, inducing hyperplasia occurs within the first three months of taking apoptosis (programmed cell death) for osteoclasts and a drug and begins with enlargement of interdental papilla. inhibiting the differentiation of bone marrow cells into Calcium channel blocker (CCB) drugs inhibit intercellu- osteoclasts. The half-life of intravenous bisphosphonate lar uptake of calcium, which may affect fibroblasts or drugs in bone is approximately 10 years, depending how reduce collagenase production, thus causing gingival long the drug was administered. hyperplasia. CCBs are prescribed for the treatment of car- Bisphosphonate-induced osteonecrosis of the jaws is diovascular diseases. Other drugs prescribed include defined as an area of exposed bone that persists for more than diuretics, beta blockers and renin-angiotensin systems six weeks. Other symptoms may include pain, swelling, infec- affecting drugs (RAS). These drugs have not been found to tion, drainage, bone necrosis, bone fracture, fever and lym- cause gingival hyperplasia. phadenopathy. Osteonecrosis occurs most often in those given Researchers in the Netherlands evaluated medical intravenous bisphosphonate drugs. To a lesser extent, cases and dental charts from a large electronic database of have been reported for those taking oral bisphosphonates such more than 800,000 patients. Subjects were selected as Fosamax. Tooth extraction is the dental procedure most based on CCB prescriptions and also a report of likely to trigger alveolar bone destruction. gingival hyperplasia by the physician and confirmed by Treatment is unclear, but antibiotics are recommended to a dentist. curb potential infection. Due to the long half-life of bisphos- Of the 20,636 subjects taking CCB or RAS drugs, 103 phonate drugs, discontinuing the drug is not likely to speed patients were identified as having definitive gingival hyper- healing of the osteonecrosis, nor is discontinuing the drug plasia. Cases of mild, asymptomatic gingival hyperplasia before a problem exists thought to prevent osteonecrosis. were not identified in the medical charts. Gingival hyper- Prevention is the best approach—being sure the oral cavity is plasia was found to be dose- and time-dependent for healthy prior to beginning bisphosphonate drug therapy. CCBs. Subjects taking the drug for several months and those taking a higher dose were more likely to have a diag- Clinical Implications: At least one month prior to begin- nosis of gingival hyperplasia. Additionally, an association ning bisphosphonate treatment, particularly intra- was found between those taking antiepileptic drugs and venously, patients should be examined by a dentist and gingival hyperplasia. receive any necessary dental work to assure a healthy oral condition. Clinical Implications: Patients taking calcium channel blockers may experience gingival hyperplasia occurring Aldana-Gibaja, R., Traverso-Oviaga, C., Lui-Monteiro, A.: within the first month of drug use. The Link Between Treatment with Bisphosphonates and Osteonecrosis of the Jaws. A Literature Review. J Int Acad Perio Kaur, G., Verhamme, K., Dieleman, J., Vanrolleghem, A., van Soest, E., Stricker, B., Sturkenboom, M.: Association 12: 66-69, 2010. n Between Calcium Channel Blockers and Gingival Hyperplasia. J Clin Perio 37: 625-630, 2010. n

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Denture-induced Stomatitis

Nearly half of all denture wearers experience denture- their dentures with water. Toothbrush with toothpaste was the induced stomatitis (DIS), a redness and swelling where the choice of 24 percent and 15 percent reported soaking their den- denture presses against oral tissues. DIS is seen with both full tures in denture cleaner. Lack of effective denture cleaning is a and partial dentures, primarily in the maxilla and less fre- risk factor for DIS and was found to be significantly linked to quently on the mandible. DIS is DIS in this population. usually asymptomatic, and patients Wearing dentures overnight is may not even be aware of this condi- also a risk factor for DIS and was tion in their mouths. found in this study to be significantly A researcher in the College of linked to the incidence of DIS. Dentistry at King Saud University in Riyadh, Saudia Arabia evalu- Clinical Implications: Dentists ated a total of 71 denture wearers. and hygienists should provide Complete dentures were worn by 48 cleaning instructions to patients subjects and removable partial den- with dentures. Ideally, dentures tures by 23 subjects. DIS was diag- should be rinsed after meals when- nosed in 57 percent of subjects in the maxillary arch and 52 ever possible, and soaked in a non-bleaching denture percent for the mandibular arch. cleaner overnight. Patients should also avoid wearing their Using a questionnaire, patients were asked about denture dentures while sleeping. hygiene habits and denture wearing habits. The three choices for denture cleaning were washing, brushing with paste and soaking Sadig, W.: The Denture Hygiene, Denture Stomatitis and Role of in a denture cleaner. The majority, 61 percent, reported washing the Dental Hygienist. Inter J Dent Hygiene 8: 227-231, 2010. n

Toothbrush with Extended Reach Bristles

Toothbrushes are the primary tool for oral hygiene, Six brushes of each type were tested four times, for a total of 24 despite the fact that disease occurs most often between the tests per brush type. Brushes were tested for 15 seconds with two teeth. Only 10 percent of people regularly clean between their strokes per second. Brushes were positioned at a 90-degree angle to teeth, so toothbrushes are being designed to achieve better the simulated anterior and posterior teeth, since this is the way the interproximal plaque removal. One of these new designs is the majority of people brush, despite being taught to use a 45-degree Aquafresh Between Teeth brush. In addition to the standard, angle. Brushes were tested in both vertical and horizontal motions. rounded end, same-length bristles, there are fine, tapered bris- The AquaFresh extended reach bristles were more effective tle filaments that are four millimeters longer to reach between in removing simulated plaque from interproximal surfaces on the teeth. the laboratory model. Researchers at the GlaxoSmithKline Consumer Health Care Company in Buehl, Germany compared the Aquafresh Clinical Implications: Look for clinical studies in the future Between Teeth brush to the Oral-B CrossAction brush with exploring the potential for innovative manual toothbrush X-angled, dual-length bristles and the Oral-B Indicator designs to remove interproximal plaque. multitufted brush. Laboratory testing followed a method shown to accurately predict clinical outcomes. Laboratory Stiller, S., Bosma, M., Shi, X., Spirgel, C., Yankell, S.: studies are done prior to clinical studies, as they are less Interproximal Access Efficacy of Three Manual Toothbrushes with expensive and can provide useful information to justify Extended, X-Angled or Flat Multitufted Bristles. Int J Dent human clinical trials. Hygiene 8: 244-248, 2010. n continued on page 110

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Interdental Brushes Better than Floss

The toothbrush is successful at removing plaque on facial, lingual and occlusal surfaces, but not very effective on interproximal surfaces. Dental floss, wood sticks, picks, rubber tip stimulators, oral irrigation and interdental brushes are used to reach plaque on interproximal surfaces. Researchers at the Department of Periodontology, Academic Centre for Dentistry Amsterdam in the Netherlands reviewed research evaluating the effectiveness of interdental brushes compared to manual tooth brushing alone, and compared to other interdental aids, including floss and wooden sticks. Of the 234 abstracts and articles found on this RDHs Providing Oral Hygiene topic, nine full text articles were found that for Hospitalized Patients were similar enough to each other to warrant comparison. This elimination process is how systematic reviews are done. Until researchers Aspiration pneumonia is a serious disease of the elderly and those follow similar protocols, using like-indices, hospitalized. Oral bacterial biofilm is responsible for some of these res- only a few studies will qualify for standardized piratory infections. Prevention of these infections can be accomplished comparisons. with proper oral care. Unfortunately, those most in need of good oral Each of these studies were at least four hygiene are left on their own to clean their mouths each day. weeks in length; a few were 12 weeks. A wide Researchers at Saitama Medical University in Saitama, Japan com- variety of interdental brushes were tested from pared professional oral hygiene provided by dental hygienists to brush- several companies. Conclusions found inter- ing and rinsing as instructed by a nurse. The 40 subjects were all dental brushes more effective for plaque inpatients at the Department of Respiratory Medicine in the university removal interproximally than a manual tooth- hospital. All subjects were instructed by a nurse to brush and rinse with brush or dental floss. Interdental brushes also povidone iodine both morning and evening. Half the subjects were ran- reduced pocket probing depths more effectively domly assigned to receive 15 minutes of professional oral hygiene than dental floss. instructions from a dental hygienist with follow-up visits every two to The authors suggest a triangular-shaped inter- three days. Hospital stays for both groups averaged several weeks. dental brush, following the form of commonly Plaque scores for both groups were similar at baseline. Plaque scores used interdental wooden sticks, may provide bet- for the control group remained at 66 percent on day five and the day of ter adaptation in interdental spaces, and thus hospital discharge. Those receiving professional dental hygiene instruc- result in greater tissue healing. They also point tions had a plaque score of 46 percent on day five and 30 percent on the out the importance of selecting products specific day of hospital discharge. According to a short questionnaire, oral to each patient based on patient preference, health attitudes and behaviors improved in the treated group compared ability to use and willingness to comply with to the control group. daily use. Clinical Implications: The most effective oral care for hospitalized Clinical Implications: Interdental brushes are patients is provided by dental hygienists, rather than expecting an appropriate choice for interproximal patients to effectively clean their mouths themselves. plaque removal, when space allows. Sato, T., Abe, T., Ichikawa, M., Fukushima, Y., Nakamoto, N., Koshikiya, Slot, D., Dörfer, C., Van der Weijden, G.: The N., Kobayashi, A., Yoda, T.: A Randomized Controlled Trial Assessing the Efficacy of Interdental Brushes on Plaque and Effectiveness of Professional Oral Care by Dental Hygienists. Int J Dent Parameters of Periodontal Inflammation: A Hygiene 6: 63-67, 2010. n Systematic Review. Int J Dent Hygiene 8: 253- 264, 2010. n

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