Wednesday, May 23, 2018

Periodontal Disease Linked to 70% Higher Risk of Alzheimer’s Disease

Posted:  Feb. 28, 2017

A large longitudinal study has found a strong correlation between periodontal disease and risk of Alzheimer’s Disease.  This study compared 9,291 patients with periodontitis and 18, 672 control patients without gum disease over 16 years.  The results were published in Alzheimer’s Research and Therapy

The study found that chronic periodontal disease gives people 70% increased risk of developing Alzheimer’s. In addition to increasing the risk of dementia, the same study reported increased risk of depression and high cholesterol in people with chronic gum disease.  This study established a link but not a causal relationship.  Further studies are needed to establish a link that the treatment of chronic gum disease will lower the risk of Alzheimer’s.  “It could be that people with impaired cognitive function are less likely to take care of themselves, and so are more likely to develop gum disease”, states Mark Ide, periodontist at King’s College of London.

Chen, et al. Alzheimer’s Research and Therapy. 2017
July 2016, 


New Limits For Opioid Prescriptions

in Ohio

Posted:  January 31, 2018

New guidelines for opiod prescriptions were approved by Ohio Governor John Kasich, in an attempt to reduce the number of opiates getting into the hands of addicts.  Highlights of Ohio’s new opiate prescribing guidelines and limits for acute pain include:
•    No more than seven days of opiates can be prescribed for adults.  (Patients have 14 days to fill their prescription.)
•    No more than five days of opiates can be prescribed for minors.
•   Health care providers can prescribe opiates in excess of the day supply limits only if they provide a specific reason in the patient’s medical record.  Unless such a reason is given, a health care provider is prohibited from prescribing opiates that
exceed Ohio’s limits.
•    Except for certain conditions specified in the rules, the total morphine equivalent dose (MED) of a prescription for acute pain cannot exceed an average of 30 MED per day.
•    The new limits do not apply to opioids prescribed for cancer, palliative care, end-of-life/hospice care or medication-assisted treatment for addiction.


FDA Advises To Restrict

Fluoroquinolone Antibiotic Use

Posted Jan. 17, 2018

In July 2016, the FDA issued safety information about the systemic use of antibacterial drug. fluoroquinolone.  Current fluoroquinolone drugs include:

    *  Avelox
    *  Cipro
    *  Levaquin
    *  Moxifloxacin
    *  Ofloxacin

An FDA safety review has shown that fluoroquinolones when taken systemically are associated with side effects of nerve damage that can be disabling and potentially permanent, involving tendons, muscles, and joints.  The FDA is advising that these potential side effects outweigh the benefits for patients with infections including sinusitis, bronchitis, and urinary tract infections.  Therefore, fluoroquinolones should be reserved for patients with these conditions that do not have other treatment options.  Signs and symptoms of side effects include “pins and needle” tingling sensation, tendon, muscle, and joint pain, confusion, and hallucination.  If side effects are reported by patients, health providers need to immediately stop the fluoroquinolone treatment and prescribe another antibiotic. 

Connective Tissue Graft

Posted Dec. 27, 2017

The May issue of NoPlak News identified several different gingival grafting techniques.  This issue is about Connective Tissue Graft (CTG), a type of soft tissue graft that is indicated to correct gingival recession and cover exposed root surfaces.  The graft is obtained from the palate, but the tissue is removed from under epithelium, rather than the surface (free gingival graft).  Therefore, CTG is often referred to as a subepithelial graft.  In this method there is a minimal open wound on the palate which, therefore, is more comfortable and quicker-healing for the patient.

A connective tissue graft lacks the epithelium and therefore has increased healing properties and is especially useful in covering the exposed roots of teeth.  CTG is usually the first choice for covering the exposed roots of teeth.


Chewing Gum Detects Peri-implantitis

Posted Dec. 27, 2017

A chewing gum has been developed by a team of European researchers that will detect early stages of peri-implantitis to help prevent advanced bone loss.  The gum will taste bitter in less than 5 minutes if a patient has inflammation around one or more dental implants.  In patients with healthy implants, the flavor of the gum does not change. 

The study reported in Nature Communications (August 15, 2017) used the saliva of 14 healthy patients and 19 patients with peri-implantitis.  Within 5 minutes, the saliva from patients with peri-implantitis deteriorated the gum.  The gum has been developed to specifically react with the protein-degrading enzymes present in the saliva of inflamed implants, followed by a release of a bitter tasting substance.  Although this gum is not on the market, this will be a quick, easy, and affordable method to detect peri-implantitis outside the dental office. Further trials are being completed at this time.

This research  can lead to other quick and affordable diagnostic methods to detect various forms of inflammation,  bacterial and viral infections.  Patients can then see their doctors/dentists to confirm the diagnosis and proceed with necessary treatment.

The Bale Doneen Method

Posted Dec. 27, 2017

Bradley Bale, MD and Amy Doneen, DNP, ARNP are co-founders of the Bale/Doneen Method , which is a comprehensive program for attaining and maintaining arterial health, thus preventing heart attacks and strokes.  Their research shows the causal connection between periodontal disease (PD) and cardiovascular disease (CVD).  The Bale/Doneen Method (BDM) has been shown to halt, stabilize, and achieve regression of atherosclerotic vascular disease.  In their recent study at John Hopkins University*, the soft, inflamed, rupture-prone, lipid-rich plaque was resolved in the 100% of 324 patients undergoing the BDM over a 5-year period.  BDM’s mission and goals are to reduce the number of heart attacks and strokes via educational opportunities available to medical and dental providers by emphasizing the oral-systemic connection.  Some of the key components to the BDM include education, identifying disease, eliminating inflammation, incorporating genetic information, identifying risk factors, and assessing response.

Periodontal Disease and Cardiovascular Disease:  

Association or Causal?

Posted:  August 11, 2017

Many epidemiological studies report the relationship between periodontal disease (PD) and cardiovascular disease (CVD).  The majority of Americans age 30 and older are affected by PD. CVD is the number one cause of morbidity and mortality in the United States.  PD is increasingly regarded as a risk factor for CVD.  The mechanism by which periodontal disease affects coronary heart disease has not been established, though there are numerous theories, ranging from the actions of periodontal pathogens in the coronary arteries or endothelium leading to systematic inflammation, with subsequent detrimental effects on cardiovascular health. The current position of the American Heart Association and the American Dental Association is that while periodontal disease and heart health have an association, additional research is needed to establish whether one causes the other.

Most recently, the work of Drs. Bradley Bale and Amy Doneen in the Postgraduate Medical Journal * claim that PD resulting from high risk periodontal pathogens should be considered causal of CVD.  Their studies show that the inflammatory response of this periodontal infection which causes destruction of the periodontium (bone and attachment) and eventual tooth loss, promotes the systemic effect that leads to CVD.  Bale-Doneen claim that treatment and management of PD will result in a favorable effect on the prevention of CVD.  They have developed the Bale-Doneen Method (BDM), which is a comprehensive protocol to establish and maintain arterial health, thus preventing heart attacks and strokes in our patients with PD (see next article)

*  Bale BF, et al.,Postgrad Med J 2017; 93:215-220

Chao Pinhole® Surgical Technique

Posted July 12, 2017

May's Noplak News newsletter discussed the conditions and etiologies of gingival recession. There are multiple methods to treat gingival recession.  Traditional gum recession treatments involve the use of donor tissue or soft tissue grafts from the patient’s palate in order to increase the attached gingiva, eliminate mucogingival pull, and attain root coverage.
An alternative method of achieving the treatment of gingival recession is the Chao Pinhole® Surgical Technique (PST), which was invented and patented by Dr. John Chao.  He has developed a scalpel-free, suture-free procedure which involves creating a small hole in the existing gum tissue.  Through this pinhole, specially designed instruments are used to gently loosen the existing gingival tissue to expand and reposition the tissue coronally to cover the exposed root surface.  Studies are underway to compare results using traditional grafting techniques.
Some of the benefits of the Chao Pinhole® Surgical Technique are:
  • No incisions and sutures
  • Donor tissue not needed from the patient’s palate
  • Multiple teeth in the arch can be treated by this technique
  • Increase in attached gingiva and root coverage can be achieved
The link which follows shows an animated, abbreviated version of the Chao Pinhole® Surgical Technique:

The Chao Pinhole® Surgical Technique is an alternative procedure to correct gingival recession without the use of palatal or other donor tissues, and no incisions or sutures.


Dental Therapist Position Proposed

Posted May 31, 2017  


Legislation to create a dental therapist position in Ohio has been introduced in the Ohio Senate. The Ohio Dental Association strongly opposes Senate Bill 98, which is sponsored by Sen. Peggy Lehner (R-Kettering) and Sen. Cecil Thomas (D-Cincinnati). This radical proposal would allow a person with only three years of post-high school training to perform irreversible surgical dental procedures including the extraction of teeth, cutting tooth structure and gums, and the administration of local anesthetic injections.

The Ohio Dental Association opposes this proposal because it presents an unnecessary risk to the health of our most vulnerable dental patients and is a diversion of scarce resources that are better utilized supporting programs proven to improve access to quality dental care.  

Gingival Grafts – Indications, 

Benefits, and Treatment

Posted May 25, 2017    

Gingival grafts are performed to correct mucogingival conditions such as recession, minimal or lack of attached gingiva, and pocket depths beyond the mucogingival junction. The goal of gingival grafting is to restore the gingival form and function, along with root coverage and gingival augmentation. Several indications for gingival grafts are:

1.    Cover and protect the root from plaque, calculus, and root caries

2.    Minimize tooth hypersensitivity

3.    Improve esthetics

4.    Increase zone of attached/keratinized gingiva

The success of gingival graft depends on these factors:

1.     Periodontal  health – inflammation needs to be controlled prior to grafting

2.     Dimension of the defect (root exposure) – narrow defect s have greater success

3.     Height of interdental bone – grafts will only take to the level of the adjacent papilla

4.    Occlusion – occlusal trauma on the tooth being grafted must be eliminated 

5.    Muscle pull – anything causing the graft to move will affect healing

The following are different gingival grafting techniques:

1.    Free Gingival Graft

2.    Lateral Positioned Flap

3.    Coronally Repositioned or Advanced Flap

4.    Subepithelial Connective Tissue Graft

5.    Acellular Dermal Matrix

6.    Guided Tissue Regeneration

7.    Vestiibular  Incision Subperiosoteal  Tunnel Access (VISTA)     

8.    Pinhole Surgical Technique (PST)

Each of these grafts will be featured in future blog articles.

Occlusal Therapy Associated With Periodontal Disease

Posted May 17, 2017

Our article from last month indicated that occlusal discrepancies are a significant risk factor for the progression of periodontal disease.  Other studies also showed that the treatment of occlusal discrepancies can slow the progression of periodontal disease. These studies concluded that the occlusion should be closely evaluated in all patients with periodontal disease and occlusal therapy should be a key component of periodontal treatment.  Definitive form of occlusal treatment include:

1.    Occlusal adjustment to reshape contours of teeth
2.    Orthodontic treatment
3.    Bite appliances and splints
4.    Multiple full coverage restorations

The purpose of changing the occlusion in advanced periodontal cases is to relieve the damage from occlusal contact.  Studies show that centric prematurities, nonworking contacts, and protrusive contacts on posterior teeth are greater risk factors for deepening of probing pocket depths than risk factors of smoking and poor oral hygiene.  The occlusal adjustment will permanently remove the occlusal discrepancies and pressure off the teeth.  Proper training is necessary for occlusal adjustment since there is potential for harm to the teeth. 

Bite appliances and splints are frequently used during periodontal treatment to manage and control the occlusal forces until the periodontal treatment is complete and overall prognosis of the involved teeth is established.

Orthodontic treatment and multiple full coverage restorations are usually performed following active periodontal treatment when all infection and inflammation are eliminated and stability in the periodontium is established. 

Studies show that centric prematurities, nonworking contacts, and protrusive contacts on posterior teeth are greater risk factors for deepening of pocket depths than risk factors of smoking and poor oral hygiene. 

Dentinal Hypersensitivity - Part II

Posted April 7, 2016

A recent NoPlak News newsletter (Jan., 2017) discussed the various etiologies of dentinal hypersensitivity (DH).  The hydrodynamic theory is the current accepted mechanism of action for sensitivity.  We will discuss the treatment strategies and products for DH in this issue.  A combination of at-home and in-office treatment may need to be instituted to obtain the best results for reducing dentinal hypersensitivity.

The treatment of DH, whether at home or in-office, will focus on 2 goals:

  1. Occluding the dentinal tubules
    Impeding the stimulation of pulpal nerve receptors


At-Home Treatment options include:

  1. Potassium salts (potassium nitrate, chloride, or citrate) - potassium ions move along the dentinal tubules and block the nerve action, thus dulling the pain

  2. Fluoride (sodium fluoride, stannous fluoride. Sodium monofluorophosphate) – occludes the dentinal tubules, thus reducing sensitivity.

  3. Calcium phosphate (tricalcium phosphate (TCP), casein phosphopeptide-amorphous calcium phosphate (CPP-ACP)) enhances remineralizations, thus minimizing whitening-induced DH

In-Office Treatment options include:

  1. Fluoride varnish

  2. Potassium oxalate

  3. Resin modified glass ionomer

  4. Protein precipitants

  5. Chlorohexidine varnish

  6. Oxalates

  7. Light cured desensitizer

Invasive Treatment options include:  

  1. Bonding agents

  2. Soft tissue grafting

  3. Nd:YAG laser

Treatment decisions are based on severity and etiology of DH. Combinations of at-home and in-office treatment may need to be instituted to obtain the best results.

The Role of Occlusion in Periodontal Disease

Posted March 22, 2017

The relationship of occlusal trauma causing the progression of periodontal disease has a controversial history.  Initially it was believed that heavy occlusal contacts were responsible for periodontal disease.  Another group stated that deeper pockets and bone loss occurred when occlusal trauma was in the presence of gingival inflammation (co-destructive force).  Finally, a group argued that all periodontal bone loss was caused solely by subgingival bacteria.  In fact, the 1996 World Workshop in Periodontics concluded that there was no proof that occlusal trauma played a role in the progression of periodontal disease.  

Occlusal examination, evaluation, and treatment should be an important part of the treatment of periodontal disease.

Recent research and retrospective evaluation of the available data reveals the following:

  1. In patients diagnosed with periodontal disease but not having any treatment, the rate of deepening pockets were greater with occlusal discrepancies compared to teeth without occlusal trauma.
  2. In patients that received root planning and occlusal adjustment, significant reduction of the rate of deepening pockets was seen compared to the group with root planning with no occlusal adjustment.
  3. Studies show teeth with centric prematurity or nonworking contacts have greater pocket depths than similar teeth lacking these contacts.
The 1996 Workshop noted that ethical research to determine the definitive role of occlusion in periodontal disease progression was impossible since a group in the study diagnosed with periodontal disease and occlusal trauma would be withheld from treatment during the clinical trial.  Current data reveals that occlusal trauma and certain occlusal contacts does play a role in the progression of periodontal disease, and the treatment to remove the occlusal prematurity has a beneficial effect.

Future blogs will discuss the various modes of treatment to correct or reduce occlusal discrepancies.


Update on Silver Diamine Fluoride

Posted January 17, 2017

One of our previous blog articles (April, 2016) introduced silver diamine fluoride 38% (Advantage Arrest by Elevate Oral Care) as a product approved by the US Food and Drug Administration (FDA) in 2016 as treatment for dentinal hypersensitivity. The FDA has since approved its use for arresting dental caries in children and adults. The approval was granted following the FDA’s review of 10 worldwide clinical trials which indicated clinical evidence that the drug may show substantial improvement over other available treatment.

Dentinal Hypersensitivity – Etiology

Posted January 11, 2017

Dentinal hypersensitivity is one of the most common patient complaints in a dental office. Dentinal hypersensitivity is defined as “short, sharp pain arising from exposed dentin in response to stimuli, which are usually thermal, evaporative, tactile, and osmotic or chemical” (according to Holland, et al.).  Usually, the pain is localized and of short duration, which differs from pulpal pain, which is typically dull, aching, and longer lasting.

It can affect 57% of patients, with prevalence being higher in women, with canines and bicuspids of both arches most commonly involved.  

The hydrodynamic theory is often agreed upon as the cause and mechanism of dentinal hypersensitivity. The open dentinal tubules of the exposed dentin results a dentinal fluid shift in response to stimuli such as air blasts, hot, cold. touch, and chemical stimuli. The dentinal fluid movement activates the odontoblasts and its nerve complex as sensor cells in the pulp, thus generating the pain. Therefore if the tubules are blocked, dentinal tubule fluid flow would decrease, thus reducing or eliminating sensitivity.

The following conditions can lead to exposed dentinal tubules that result in hypersensitivity:

1. Periodontal disease (loss of attachment on bone loss) and treatment (causing recession)
2. Gingival recession (exposure of dentin)
3. Caries (in dentin)
4. Erosion (chemical/acidic dissolution)
5. Abrasion (mechanical force from foreign source)
6. Attrition (occlusal /parafunctional)
7. Abfraction (occlusal stress)
8. Cracked and fractured  teeth
9. Scaling and root planning (cementum removed)
10. Restorative procedure
11. Extreme toothbrushing
12. Teeth whitening

Xylitol and Caries

Posted November 11, 2016

Xylitol is a non-fermentable sugar alcohol used as a sweetener.  Unlike other natural or synthetic sweeteners, xylitol is actively beneficial in dentistry by reducing caries and is known to induce remineralization of demineralized enamel. Xylitol is categorized by the US FDA as a food additive and is allowed to be labeled with the claim that they do not promote dental cavities. Xylitol is most frequently found in chewing gum, lozenges, and nasal spray.

Xylitol products have been promoted for patients with xerostomia due it its non-cariogenic and remineralization properties.

 Benefits of Xylitol include:

*  Low calories (safe for diabetics and hyperglycemics)

*  Few or no side effects

*  No aftertaste

*  Interferes with bacterial growth and reproduction

*  No know toxicity in humans

Studies from the 1970s found that, compared with chewing sucrose-sweetened gum, xylitol resulted in nearly two fewer cavities or missing teeth. In the 33-month Xylitol for Adult Caries Trial, participants were given xylitol lozenges or a sucrose-sweetened placebo, and the result revealed a significant reduction (40%) in the incidence of root caries in the group that had xylitol.  A study from Japan shows that “fluoride and xylitol together have synergistic inhibitory effects on the acid production of Streptococcus mutans and suggests that xylitol has the potential to enhance inhibitory effects of low concentrations of fluoride”.*

Xylitol products have been promoted for patients with xerostomia due it its non-cariogenic and remineralization properties. In addition,  the perception of sweetness found in xylitol causes the secretion of saliva which raises the pH and acts as a buffer against the acidic production of microorganisms in dental plaque.

Xerostomia and Caries

Posted November 11, 2016

Xerostomia or dry mouth is a common side effect of many medications (over the counter, prescription, and dietary supplements) that lowers salivary flow, which affects oral health of patients, particularly increasing caries risk.

“Studies show that 20%-30% of the patients that take one daily drug report xerostomia”

In 2011, the American Dental Association requested that the Food and Drug Administration consider requiring medications that are commonly associated with dry mouth side effects to carry warning-label information about the oral complications associated with reduced salivary flow and increased risk of dental caries.  The letter specifically stated, “Without the cleansing effects of saliva, chronic (medication induced) dry mouth can lead to tooth decay.”  Here are some highlights:

  1. It is important to obtain information on all medications taken by the patient, including over-the-counter medications, prescription medications, and dietary supplements, since many affect salivary flow

  2. Common prescription medications causing xerostomia include analgesics,antidepressants, antihypertensives, acid reflux medications, seizure disorder medications, and antianxiety medications

  3. Common over-the-counter medications causing dry mouth include analgesics, allergy medications, antihistamines, and decongestant/cold medicines

  4. Dry mouth has also been reported by patients taking vitamins/dietary supplements

  5. Studies show that 20%-30% of the patients that take one drug daily report xerostomia. Recent research clearly shows that the prevalence of dry mouth increases with the number of drugs taken daily. This increases to greater than 60% when 6 or more different drugs are taken daily.Studies show that 20%-30% of the patients that take one drug daily report xerostomia. Recent research clearly shows that the prevalence of dry mouth increases with the number of drugs taken daily. This increases to greater than 60% when 6 or more different drugs are taken daily.


However, for most patients, their daily medications may not be able to be modified.  Especially among the elderly, patients are generally taking multiple drugs to combat life-threatening diseases. Effective treatment for oral dryness is currently lacking, however much research is being conducted.  Products include saliva replacements, pH neutralization products, xylitol containing dental products, and increased fluoride exposure.

Categories of Medications Associates with Xerostomia:


Dental Extractions and Opioids

Posted October 10, 2016

Opioid abuse is currently at an epidemic proportion in the US.  According to the Centers for Disease Control and Prevention (CDC), the death rate from opioid overdose has more than doubled in the US in the last 15 years.  A recent study in the Journal of American Medical Association reports dentists may be prescribing an excessive amount of opioids following tooth extractions.  Brian Bateman, MD and co-author stated, "This common dental procedure may represent an important area of excessive opioid prescribing in the United States.  As the nation implements programs to reduce excessive prescribing of opioid medications, it will be important to include dental care in these approaches."  The study noted that this abuse can start with a prescription for a pain medication.  Research shows that dentists commonly prescribe opioids following extractions, despite studies that show a combination of non-steroidal medications and acetaminophen may provide as effective relief for post-extraction pain.

According to this study, the median number of opioids prescribed to adults following extraction was 24 5-mg tablets of hydrocodone or 16 5-mg tablets of Oxycodone .  The authors went on to state, "Although a limited supply of opioids may be required for some patients following tooth extraction, these data suggest that disproportionately large amounts of opioids are frequently prescribed given the expected intensity and duration of post-extraction pain, particularly as non-opioid analgesics may be more effective in this setting."

The Centers for Disease Control and Prevention (CDC) has issued new guidelines for prescribing opioid medications for chronic pain.  They include:

  • Nonopioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care.
  • When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose.
  • Providers should always exercise caution when prescribing opioids and monitor all patients closely.

*JAMA March 16, 2016

Non-Opioid Management of Dental Pain

Posted October 10, 2016

Dental professionals must be keenly aware of the potential hazards when prescribing opioid analgesics for patients and the possible risk of adverse physical effects as well as the potential abuse of these drugs.  Evidence from third molar extraction postoperative pain studies* reveals that non-opioid analgesic combinations such as non-steroidal anti-inflammatory drugs (NSAIDS) and acetaminophen appear to provide analgesia equivalent to those of opioid combination medications. Suggested combination dosage: Ibuprophen 400-800 mg + Acetaminophen 500-1000 mg, every 6 hours

Non-opioid analgesics differ from opioid agents in several ways:

  • Non-opioids do not produce physical or tolerance dependence.
  • NSAIDS are anti-inflammatory agents.
  • Non-opioids inhibit prostaglandin synthesis at the site of injury in the peripheral nervous system; Opioids act on receptors in the central nervous system.
  • Non-opioids have a ceiling effect in pain control (a maximum dose beyond which analgesic effect does not increase).
  • Non-opioids are not classified under Controlled Substances.
Non-opioid combination analgesic is recommended to reduce postoperative pain without causing adverse effects commonly induced by opioid medications.  However, adverse effects for both NSAIDS and acetaminophen need to be identified and closely monitored.

* Moore PA, Hersh EV J Am Dent Assoc. 2013;144:898-908


Periodontal Disease May Be Linked to Lung Cancer

Posted October 3, 2016

The American Cancer Society ranks lung cancer as the leading cause of cancer death in men and women.  A recent report in the Journal of Periodontology* finds that individuals with periodontal disease may have a 1.24-fold increased risk of developing lung disease.  The researchers reviewed five studies involving over 320,000 subjects.  They identified a specific oral bacteria which may be involved in the development of cancer cells.  One study showed substantial lowering of lung cancer risk following successful treatment of periodontal disease.  Further research is necessary to strengthen this link and/or to create a cause-and-effect relationship.

*Journal of Periodontology Abstract (Posted online June 13, 2016)

Frequency of Dental Implant Maintenance

Posted September 27, 2016

At the current time, there is no consensus about the frequency of dental implant maintenance. Two important parameters that will help decide the frequency are:

  1. The health of patient’s overall dentition
  2. The health of the peri-implant tissue

The following guidelines will assist in deciding the frequency of implant maintenance:

  • Patients with no signs of inflammation around both implants and natural teeth – twice a year
  • Patients with generalized gingivitis, but healthy peri-implant tissue – twice a year
  • Patients with compromised or incorrect prosthetic design – three to four times a year
  • Patients with periodontal disease (past or present), but healthy peri-implant tissue – three to four times a year
  • Implants with peri-implantitis require appropriate treatment for resolving the inflammation, potential infection and subsequent bone loss.
Peri-implantits presents with multiple etiological factors, therefore different treatment modalities are involved (to be discussed in future newsletter articles).



Open Contacts of Dental Implant Restorations

Posted: August 13, 2016

An open contact often develops between a restored dental implant and an adjacent natural tooth when initially there was an interproximal contact. An open contact can result in trapping of food which can lead to periodontal problems and caries.  According to a review of studies by Greenstein, et al *, the following observations and comments were noted:

•    The incidence of a developing an interproximal gap was 34% to 66%.
•    The opening of interproximal space can occur as early as 3 months
      post-restorative treatment.
•    The interproximal gap was usually on the mesial aspect of the implant
•    The development of an open contact is due to the physiological mesial
     drifting of natural teeth, while the implant remains stationary, functioning like
     an ankylosed tooth.

The authors suggested the following regarding this phenomenon:

•    A thorough evaluation of the patient’s occlusion and arch alignment
     is necessary.
•    Patients need to be informed of the possibility of developing interproximal
     gaps after implants are restored.
•    If open contact develops with no food impactions, no treatment will be
     needed other than monitoring.
•    Replacements or repairs of implant crowns and/or restoring adjacent teeth
     may be necessary to close the open contact. This is another reason in favor
     of retrievable implant crowns (screw-retained).
•    Peri-implant maintenance protocol (3-6 months) is recommended to monitor
     contacts surrounding implants, possible related caries and periodontal
     problems, and overall occlusion.


More Evidence Links Alzheimer's Disease to Periodontitis

Posted: August 13, 2016

Researchers have recently found a link between periodontal disease and greater rates of cognitive decline in people with early stages of Alzheimer’s disease. While periodontitis may be more common in those with Alzheimer’s Disease since they may be less able to maintain oral hygiene as the disease progresses, researchers have found higher levels of antibodies to periodontal bacteria associated with an increase in levels of inflammatory molecules which has also been linked to greater rates of decline in Alzheimer’s Disease. The latest study measured inflammatory markers via blood samples from Alzheimer patients with periodontal disease, and found a 6-fold increase in the rate of cognitive decline. The researchers concluded that periodontitis is associated with an increase in cognitive decline in Alzheimer’s disease. This information builds on previous studies that have shown that chronic inflammatory conditions have a detrimental effect on disease progression in people with Alzheimer’s disease. It suggests that effective periodontal treatment, which reduces the levels of these inflammatory molecules, could possibly lead to slower rates of cognitive decline.

The study, “Periodontitis and Cognitive Decline in Alzheimer’s Disease,” was published by PLOS ONE.


Burning Mouth Syndrome

Posted: July 12, 2016

Patients who have the chronic pain condition known as “burning mouth syndrome” (BMS) endure an unremitting burning sensation in the mouth, usually without any visible abnormalities or unusual laboratory findings. Approximately some 2.5% to 5.1% of people in the general population and 14% of postmenopausal women have BMS.

A recent study of 195 participants examined the therapeutic efficacy of benzodiazepine clonazepam (frequently prescribed for insomnia and seizures) in the treatment of BMS.  Both short term (10 weeks or less) and long term (longer than 10 weeks) duration were studied, as well as two forms of administration: systemic, which means the patients swallowed the tablet, and topical, which means the participants sucked on the tablet near the pain sites, retaining saliva without swallowing for three minutes before expectorating.

The results of this study of 195 participants show that clonazepam is effective for symptom remission in patients with BMS both in short-term and long-term application and with topical and systemic administration.  The investigators commented that clonazepam are known GABAA receptor agonists that bind to both peripheral and central receptor sites, resulting in pain inhibition.


Pregnancy and Gingivitis

Posted: July 12, 2016

Pregnancy gingivitis is the most common form of periodontal disease in pregnant women. Various studies report a range of 40-80% of the pregnant women develops gingivitis.  Current information indicates that gingival inflammation increases progressively throughout pregnancy and returns to baseline levels postpartum.  Therefore, frequently the condition is considered harmless with the concept to continue with routine care despite increased inflammation.  A study presented recently at the International Association for Dental Research (IADR) by Dr. Michael Reddy, Dean of the School of Dentistry at the University of Alabama at Birmingham (UAB) found the following:

•    Younger women, in general, had higher measured gingivitis.
•    With increased age, periodontal diseases tend to escalate in severity.
•    The level of inflammation in pregnancy gingivitis does not seem to increase for the first and second trimester.

Dr. Reddy concluded by stating, “pregnancy gingivitis may not be a harmless oral finding, and intervention may be important for the patient's oral health and for the well-being of the fetus.”

Suggested intervention includes increasing the frequency of re-care/recall appointments, advanced daily oral hygiene, and in many cases, periodontal treatment.



New ADA Code for Scaling

Posted: June 12, 2016

A new ADA code has been developed and approved for scaling for patients with gingival disease.  Code  D4346 is "scaling in the generalized presence of moderate or severe gingival inflammation and no attachment loss— full mouth, after oral evaluation," Current code D1110 (Prophylaxis) is used as a preventive procedure that applies to patients with healthy periodontium. Codes D4341 and D4342 are therapeutic codes indicated for patients who need scaling and root planning due to periodontal pockets, bone loss, and attachment loss. However, there had been no code available for therapeutic treatment of patients with gingivitis. The new code is under the periodontics category and will bridge the gap for patients with gingival disease and no attachment loss.


Americans Could Prevent Roughly Half of All Cancer Deaths by Taking Four Actions


Posted: June 12, 2016

A recent finding published in the Journal JAMA Oncology reveals how fostering healthy lifestyles could prevent a disease that claims over 600,000 Americans lives annually and another 1.6 million with a new diagnosis. Approximately half of cancer deaths in the United States could be prevented or arrested if Americans did the following:

•    Quit Smoking
•    Reducing drinking alcohol
•    Maintain a healthful weight
•    Exercise at least 150 minutes each week

For men, these healthy lifestyle measures could reduce all cancer deaths by 67% and avert 63% of new cancer diagnoses each year. For women, the same measures could lower cancer deaths by 59% and prevent new cancers by 41%. 

This report presents an opposing view from a research study from last year that stated that approximately 80% of all cancers might be attributable to factors beyond the control of the individuals, frequently referred to as the “bad luck” hypothesis. This recent study reveals that “bad behavior” may be more of a factor as a cause of cancer than “bad luck”.


Dental Calculus May Hold Clues About Ancient Life

Posted: May 11, 2016

Archaeologists have successfully sequenced DNA from fossilized dental calculus on 700-year-old teeth.  Christina Warinner and colleagues describe in the American Journal of Physical Anthropology how they found 25 times more DNA in calculus than ancient teeth or bone, in hopes that information can be obtained about the ancient world of native North Americans.  Most archaeological DNA research involves using chips of teeth or bone, pulverizing it, and then extracting DNA from the resulting powder.  With calculus, the calcium phosphate in the saliva solidifies with the plaque and deposits in layers, thus trapping bacteria, food, human DNA, and proteins in the calculus similar to bugs in amber.  Calculus was removed from six Oneota Native American skeletons buried about 700 years ago at a site called Norris Farms in central Illinois.  Warinner discovered enough human DNA from the samples of calculus to sequence the entire mitochondrial genome of each of the six individuals.  That took just 20 milligrams of calculus, which would be about the size of a grain of rice.  The results from the calculus matched a previous study of the genomes done on the chips of bone and teeth of three of the individuals.  Warinner states “This is the richest source of ancient DNA that's ever been described…. I was doing a happy dance.”  This information from mitochondrial DNA can reveal clues about genetic diversity in North American prehistory, such as how populations migrated over time.


Antidepressants Associated with Increased Dental Implant Failures

Posted: April 24, 2016

Antidepressants are the second most prescribed medication in the U.S.  Researchers from the University of Buffalo School of Dental Medicine have shown that antidepressants may have a negative effect on dental implants. Their retrospective study analyzed 74 patients who were 18 and older and received dental implants at the UB dental clinic between January 2014 and August 2014. The odds of implant failure among antidepressant drug users were about four times higher compared with controls.  Each year of antidepressant use was associated with a twofold increase in the odds of implant failure.

Selective serotonin reuptake inhibitor (SSRI), the most widely used drugs for the treatment of depression have been linked to:

  • Reducing bone metabolism
  • Developing xerostomia
  • Increased bruxism

Although no guidelines have been developed, close monitoring of these patients, both medically and dentally will be necessary.  Researchers state, "For patients who have been on antidepressants a long time, we're not telling them to quit their medication. We just want them to be aware -- the dentist, patient, and physician….it’s a risk factor.” More studies will be needed to study this association.

(Journal of Dental Research, November 2014, Vol. 93:11, pp. 1054-1061)


Caries Arrest in Adults Using Silver Diamine Fluoride

Posted: April 7, 2016

The incidence of tooth decay in adults in the U.S. today is higher than children.  The rise of decay rate in adults is associated with increased longevity, decreased tooth loss, and increase in root caries (with periodontal attachment loss).   Silver diamine fluoride has recently been cleared for use by the U.S.  Food and Drug Administration in 2015 (Advantage Arrest, Elevate Oral Care, LLC)  for treating dentinal hypersensitivity in adults.  Silver diamine fluoride has been used on carious lesions for more than 80 years in Japan, Australia, and other countries. Silver diamine fluoride is a colorless topical medication with a pH of 10, 5-6% fluoride, and 25-29% silver. The ammonia stabilizes the high concentration in solution, the fluoride promotes remineralization, and the silver acts as an antimicrobial. 

Numerous studies have shown the following:
•    When applied every 6 months, 90% of the caries is
•    Demonstrated better caries prevention than other
     noninvasive materials
•    Promotes remineralization and  resistance to
     demineralization of both enamel and dentin
•    Antimicrobial activity remains well after application

Indications for topical treatment with silver diamine fluoride include:
•    Treating sensitive root surfaces (studies show better  
      than fluoride varnish)
•    Caries control of patient with extensive and
     uncontrolled decay rate
•    Patients with high caries rate  (e.g., cancer patient
     with xerostomia)
•    Difficult to treat or access- limiting caries lesions
     (e.g., furcations, subgingival margins)
•    Non cooperative adults due to cognitive disabilities
     (e.g., autism, dementia)
•    Patients with limited access to dental care
•    Caries vulnerable tooth surfaces (e.g., overdenture
     abutments, periodontally exposed roots, partially
     exposed third molars)

The application involves simply drying the tooth surface, then applying the liquid to the lesion, with no special instructions for post-application care.  Dentists and auxiliaries that apply this solution must be aware of the precautions for handling silver diamine fluoride.

Is Excess Cement Around Dental Implants Radiographically Visible?

Posted:  March 23, 2016

Cementation of dental implant prostheses is a universal practice. Excess cement in the gingival sulcus has been reported to cause peri-implantitis, which could lead to implant failure.  One possible way to identify excess cement is with the use of radiographs if the cement has sufficient radiopacity.

A recent study by Wahdwani, C.*, et al, compared the radiographic density of different cements used for implants.  In this study, eight different cements were compared: TempBond Original, TempBond NE, Fleck’s, Dycal, RelyX Unicem , RelyX Luting, Improv, and Premier Implant Cement.  Specimen disks were radiographed and the radiopacity was determined using the grey level values of the test materials as compared to a standard aluminum step wedge.

The results showed the highest level of radiopacity were recorded for the zinc cements ( TempBond and Zinc Phosphate).  A lower level of radiopacity was recorded for Dycal, which also contains zinc. The popular implant cements (Rely X, Rely XL, Improv, Premier Implant Cement )  had the lowest radiopacity values and could not be detected radiographically.

The authors concluded that many types of cement commonly used for the cementation of implant-supported prostheses have poor radiopacity and may not be detectable following radiographic examination.
Comments by Dr. Sakamoto:  This study reveals the lack of radioopacity in some of the more popular dental implant cements.  Today’s two dimensional radiographs (periapicals and bitewings) are also limited in not showing excess cement on the buccal and lingual aspects of implants.  Understanding the different radiodensities of cements will help in selecting the appropriate cement.  This article points to one of many controversial issues regarding the cementation of dental implant prostheses.  Future newsletter issues will discuss cementation techniques, abutment design, and screw-retained options to avoid excess cement-induced peri-implantitis.
* (J Prosthet Dent 2010;103:295-302)


Nonsurgical Periodontal Disease Treatment

Posted: March 7, 2016

For patients who present in the early stages of periodontal disease, nonsurgical periodontal therapy is often the first line of defense against further disease progression. Nonsurgical treatment options, include manual and ultrasonic scaling and root planing (SRP), antimicrobials, and a variety of other adjuncts.  

The ADA guidelines indicate that SRP remains the gold standard for nonsurgical therapy and should be considered as the initial treatment for chronic periodontitis.  The guidelines also point out that SRP performed with manual instrumentation results in similar clinical outcomes as SRP using ultrasonic scaling units, but does not always lead to complete removal of subgingival calculus and biofilm. However, the ADA guidelines found that that none of the adjunctive therapies, including systemic antimicrobials, systemic host modulators, and locally delivered antimicrobials resulted in a greater gain in clinical attachment loss over SRP alone.  

For more advanced stages of periodontal diseases, management of chronic periodontitis requires treatment that is much more comprehensive than just nonsurgical treatment.  Depending on the case, the overall treatment plan should include individualized oral hygiene education; in-depth medical, social, and psychiatric assessment; occlusal evaluation; post-SRP reevaluation; potential surgical therapy; and ongoing maintenance.  In many cases, nonsurgical therapy is just the beginning


Laser Assisted Peri-Implantitis Procedure (LAPIP)

Posted: February 16, 2016

Peri-implantitis is reported to be at a rate of 5-16% of all implants being placed today.  This inflammatory and infective process leads to loss of supporting bone loss surrounding a functioning implant. 

Laser Assisted Peri-Implantitis Procedure (LAPIP) is a modification of the LANAP protocol to treat the peri-implantitis condition.  The LAPIP protocol has been demonstrated through clinical results to effectively eliminate inflammatory processes to halt the bone loss process and, at times, show regeneration of supporting bone.

The Periolase MVP-7 from Millennium Dental seeks and eliminates the dark pigmented gram negative anaerobic organisms that are responsible for the bone loss.


February is American Heart Month!

The Association Between Periodontal and Cardiovascular Diseases

Posted: February 1, 2016

The association between periodontal disease and one or more forms of cardiovascular disease have been known since epidemiological studies demonstrated an association between periodontal disease and functional or morphological markers of coronary heart disease.  Higher levels of tooth loss were associated with the highest risk of stroke, cardiovascular death or all-cause death, but the pathway by which tooth loss led to these outcomes remains unclear.  The mechanism by which periodontal disease affects coronary heart disease has not been established,

The American Dental Association (ADA) reported in October 2105 that while studies present evidence that tooth loss and adverse cardiovascular health are associated with each other, it does not demonstrate that tooth loss causes poor cardiovascular health, nor that periodontal treatment improves cardiovascular health.

The current position of both the ADA and the American Heart Association “is that while periodontal disease and heart health have an association, additional research is needed to establish whether one causes the other.”


Posted: January 25, 2016

QUESTION:  Do we need to use prophylactic antibiotics prior to dental procedures in patients with prosthetic joints?

ANSWER:  NO.  Prophylactic antibiotics are NOT recommended prior to dental procedures to prevent prosthetic joint infections (PJI) in patients with prosthetic joint implants.  According to the ADA, there is no evidence associating dental procedures with PJI or that antibiotics prevent PJI.  Click here to read the complete abstract.

Do Periodontally Susceptible Patients Have Higher Incidence of Implant Complications?

Posted: January 7, 2016

Yes! Tooth loss caused by periodontal disease is often the reason for dental implants replacement. A recent study* summarized 27 longitudinal publications to investigate the effects of implant outcomes in partially edentulous patients comparing treated periodontal patients and periodontally healthy patients.

RESULTS: In periodontally healthy patients, implant success and survival were higher. In patients with history of treated periodontal disease, bone loss and incidence of peri-implantitis were increased.

CONCLUSION: The authors of this study found that history of severe or advanced forms of periodontal disease is associated with higher rates of implant complications (lower success and survival rates) when compared to periodontally healthy patients. 

My comments: This study shows that the risks associated with periodontal disease may be a concern for implant therapy. It should emphasize more rigorous supportive therapies for high risk patients with implants.  In our practice, similar successful outcomes for implants are achieved with periodontally-susceptible patients as well as periodontally healthy patients with the proper maintenance support. 

My recommendations: Communicate with your high-risk patients the importance of early detection of periodontal disease and prevention. Although dental implant therapy is highly successful, our primary goal for patients is to retain their natural teeth via proper prevention, treatment, and maintenance.

-*Sousa V., et al Clinical Oral Implants Research Sept 2015

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