Periodontics - A Quarterly Newsletter on Dental SpecialtiesJADA Specialty Scan

How patients perceive their smiles

Smiling dental patient

In addition to restored health and function, patients increasingly demand what they perceive as esthetically pleasing results from their oral health professional. The goal of rehabilitative treatment may be better health and improved mastication, yet the outcome also must include visual, esthetic improvement for the patient to consider it acceptable.

There is no surefire way to predict whether a patient will find an outcome appealing. But one way to increase the odds may be to look at a patient as other people do, rather than from the diagnostic view of a dental clinician.

American and Spanish scientists found that most studies of dental discrepancies controlled and limited variables by using smile or intraoral pictures that eliminated the facial structure altogether. The question, they note, is how often is a smile evaluated outside of its facial context? People communicate at a speaking distance, and the smile is perceived as a facial gesture.

Published in the November/December 2013 issue of the International Journal of Periodontics & Restorative Dentistry, this research used a facial photograph of a smiling female. A digitally manipulated symmetric face model was created from the original photo, and different facial and dental structures located along the facial midline were intentionally altered with greater degrees of deviation to create 22 versions. Each image showed progressive alteration made on the dental midline (shift), nose, chin, dental midline (cant) and incisal plane. One hundred randomly selected subjects evaluated the photographs via PowerPoint slides on a 15-inch screen.

The results showed that subjects did not perceive any significant difference in attractiveness for incorporated chin deviations of six millimeters or less compared with the control image. Alterations at the maxillary dental midline (shifting and canting) had the greatest impact on ratings of facial esthetics.

Researchers concluded that visual perception thresholds at which most laypersons first recognize a negative impact are: 2 mm for a dental midline shift; 4 mm for nose deviation; 5 degrees for a dental midline cant; 3 degrees for a frontal view/incisal plane cant. For chin deviations of 6 mm or less, no threshold could be established.

The authors noted that the digitally-made deviations attempt to portray reality, but have limitations because "there is infinite individual variability attached to the human self."

They added, "This study does not aim to establish minimum threshold or recognition levels that can be applied to the general population. Its goal was to establish the levels of recognition for this model created to further investigate where different dental and facial deviations can be combined to try to find their roles in the perception of smile esthetics."


Do quit-smoking programs boost periodontal health?

Person smoking with no smoking sign

The value of smoking cessation programs in dental settings should be evaluated to assess their impact on periodontal health, American and Brazilian researchers said in a study published in the January 2014 issue of the Journal of Periodontology.

The scientists conducted a systemic review to evaluate the effect that quitting smoking has on periodontitis progression and periodontal therapy.

"Although the detrimental effects of tobacco on the periodontal tissues have been reported extensively, little is known about the potential beneficial effect of smoking cessation on periodontal health," researchers said.

To investigate, the scientists searched Medline and EMBASE databases up to December 2012 using relevant search terms. They identified additional studies through a reference list of select publications.

Two types of studies met the review's criteria: prospective studies comparing incidence and/or progression rates of periodontitis between smokers and quitters; and intervention studies evaluating the effect of smoking-cessation programs alone or in combination with periodontal treatment. At least one year of follow-up was required for inclusion. Cross-sectional studies and case series were not included. Of 331studies initially selected as potentially useful, five ultimately were eligible for inclusion—three epidemiologic and two clinical.

Findings showed that progression of clinical attachment loss greater than or equal to 3 millimeters during a six-year period was some three times higher among smokers than quitters. Two studies (with 10 and 20 years of follow-up) observed a decrease in radiographic bone loss approximately equal to 30 percent among quitters when compared with smokers. Among patients receiving non-surgical periodontal treatment, quitters were more likely to have periodontal probing depth reductions than smokers or those who fluctuated between smoking and nonsmoking.

Although the authors believe this to be the first systematic review evaluating the effect of quitting smoking on periodontal health, they noted that indirect evidence from cross-sectional and longitudinal studies supports the assertion that smoking cessation has a positive effect on the periodontal status of former smokers.

They found it “somewhat surprising” that evidence about the effect of quitting smoking on periodontal health is scarce, “given the wealth of studies supporting the negative effect [of smoking], which should propel dental professionals to pursue a better understanding of the possible oral/periodontal benefits of smoking cessation.

"Nevertheless, smoking cessation seems to decrease the risk for incidence and progression of periodontitis, as well as to improve response to periodontal treatment," the authors concluded. They also noted indirect evidence suggesting that a significant reversal of periodontitis risk may be achievable within 10 years after quitting smoking.

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Inflamed gingiva and metastases of cancer

Cancer cells

Chronically inflamed gums may play a role in attracting metastatic cells, according to research published in the January 2014 issue of the Journal of Periodontology. Patients' metastasis occurs in the gingiva significantly more often than in other oral mucosal sites, particularly when teeth are present.

Metastasis of cancer to a distant organ is not a random event but requires a pre-metastatic niche. "The tumor site does not solely dictate its own fate, but the formation of a hospitable microenvironment is essential, not just permissive, for a disseminating tumor cell to spawn secondary tumor growth," the JOP reported, quoting previously accepted research. In other words, a suitable environment must exist for cancer cells to survive.

Scientists from Tel Aviv University and Rabin Medical Center noted that the gingiva is particularly prone to inflammation and is found to be the most common for metastases among the oral mucosal sites. Although the possible role of inflammation in the gingiva had already been raised in the literature, the observation had not been supported statistically.

By conducting a literature review of nearly a century of studies, the scientists analyzed cases of metastatic lesions to the gingiva and compared the results with cases metastasizing in the oral mucosa and the periodontium. In addition, they examined the cause of metastases to the gums, particularly the role of inflammation.

To conduct their investigation, the researchers explored the English-language literature between 1916 and 2011 by searching Medline using PubMed for any publication including combinations of relevant terms. In addition, older material was searched using Index Medicus and the bibliographies cited in the publications

A total of 207 cases of metastatic lesions to the oral mucosa were included in the study. The gingiva was the most common metastatic site (60.4 percent), followed by the tongue and tonsils.

Information concerning the presence of teeth was included in 156 of the 207 cases. When teeth were present, most metastatic lesions were found in the gingiva, whereas in the cases without teeth, the metastases were more frequently distributed in other mucosal sites, mainly the tongue.

Although gingival inflammation was reported in 42 cases, the authors said in discussion that this might be an underestimation, as most reports did not address the gingival condition.

"It has already been shown that the attached gingiva is chronically inflamed even in the absence of overt inflammation," the authors explained in discussion. "Based on the evidence that metastases of various cancer types to distant organs is a site-specific process, one can assume that local factors in the gingival environment, mainly chronic inflammation, favor the attraction of circulation tumor cells."

The scientists called for further studies on the mechanisms between tumor cells and the gingival microenvironment to enable better understanding of the nature of the relationship.


Tooth shape may be linked to gingival characteristics

Three faces with smiles

If tooth shape could be correlated with a patient's gingival and periodontal characteristics, dentists and patients could more realistically discuss outcomes during the treatment planning stage, which is especially important when planning dental implants in the esthetic zone. Also, dental surgeons, restorative dentists, dental laboratory technicians and patients would be able to communicate more effectively about treatment plans.

It was with such benefits in mind that scientists publishing in the October 2013 issue of the Journal of Periodontal Research sought to identify distinctive relationships between different tooth shapes and patients' periodontal properties.

To investigate, the scientists measured periodontal and gingival parameters on one of the central incisors of 50 subjects who had been randomly selected and passed a lengthy list of exclusion criteria.

Criteria included:

Subjects were then separated into three groups based on the shape of their upper front teeth. The types of tooth shapes—triangular, square-tapered and square—had already been defined and quantified in a previous study. Leading that study was a Harvard scientist who also participated in this study to held provide a basis for analyzing the relationship between tooth shape and periodontal phenotypes.

The three groups were then analyzed to determine significant differences as related to the measurements obtained for the patient-specific gingival and periodontal characteristics.

Researchers found that the shape of the maxillary central incisor crowns correlates with the extent of the keratinized mucosa and its bucco-lingual gingival thickness, and with the height of the interproximal maxillary central papilla.

Obstacles overcome, periodontal health restored

By Tanya Dunlap, PhD
Program Development Director
Perio Protect LLC

Practitioners treating patients for periodontal disease often face practical obstacles, including patient anxieties over treatment and concerns about missing work for multiple dental appointments. Yet most patients recognize, perhaps reluctantly, that treatment is crucial if they wish to maintain their oral health. The U.S. Surgeon General has identified periodontal disease as a "silent epidemic." Almost half of the U.S. population—millions of Americans—have the disease, according to the federal Centers for Disease Control and Prevention. Periodontal disease is not only the leading cause of adult tooth loss, but it has also been linked to heart disease, type-2 diabetes and other inflammatory conditions.

Doctors like Craig Buntemeyer of Tulsa, OK, take the disease and the practical concerns surrounding it very seriously. Dr. Buntemeyer recently authored a case study of an anxious patient who had avoided dentists for years. Further complicating this patient's condition was the fact that he was not allotted paid time away from work. He understood his disease was serious, but he wanted to discuss all options before accepting treatment.

Pretreatment mouth

Fig. 1 Pretreatment image

The initial comprehensive exam documented 100 percent bleeding on probing, with 74 percent of pockets measuring 4-7 millimeters. Addressing the patient's concerns about mechanical therapy and time away from work, Dr. Buntemeyer recommended starting treatment with customized prescription tray delivery of medication to begin to treat the infected tissue before mechanical intervention. The patient agreed.

Prescription trays (Perio Tray®, Perio Protect LLC, St. Louis, MO) and a 1.7 percent hydrogen peroxide gel (Perio Gel®, QNT Anderson LLC, Bismarck, ND) were used at home four times per day for 15 minutes each time. This treatment continued for three weeks before the patient returned for full-mouth debridement. The patient continued to use the tray delivery after mechanical therapy.

Mouth four weeks after treatment

Fig. 2 Four weeks after treatment started; one week after full-mouth debridement.

Scaling was scheduled and completed in one office visit to minimize time away from work. At a subsequent recall appointment, bleeding on probing measured 27 percent, and pockets measuring greater than 3mm were reduced to 25 percent. There were still concerns about posterior regions where tissue continued to bleed on probing. The patient then agreed to ongoing periodontal maintenance.

Four months after full-mouth scaling. Fig. 3 Four months after full-mouth scaling.

An important part of successful periodontal maintenance is improving patient homecare. For patients like this one, who enter maintenance with 25 percent of pockets measuring greater than 3 mm, brushing, flossing or rinsing can't reach deep enough below the gum line to combat biofilm regrowth effectively. Prescription trays thus offer a new homecare option. When the trays are used to deliver an oral debriding agent and wound cleanser (active ingredient 1.7 percent hydrogen peroxide), the patient has new tools that also gradually whiten teeth without the sensitivities common to whitening procedures.

This patient emerged from treatment with his periodontal health significantly improved, with minimal time away from work, and with effective tools to maintain his health.

To learn more about prescription tray delivery visit or

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What is Specialty Scan?

This is one in a series of quarterly newsletters updating dentists on selected specialties in dentistry. Information presented is summarized and aggregated from previously published materials, each item attributed to its publication of origin. This issue of JADA Specialty Scan is focused on periodontology, the first in the series on this topic, which is new for 2014. Other Specialty Scan issues will explore prosthodontics, oral and maxillofacial radiology, orthodontics and endodontics. The ADA has engaged the specialty organizations in these areas as well as its own divisions of Science and Legal to assist with these newsletters. We welcome your feedback on this and all Specialty Scan issues.

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