Gingival enlargements and localized gingival overgrowths

Gingival enlargements are a common clinical finding and most represent a reactive hyperplasia as a direct result of plaque related inflammatory gingival disease. These generally respond to conservative tissue management and attention to plaque control. However, a small group are distinct from these and whilst they also represent a reactive tissue response, this occurs at the level of the superficial fibres of the periodontal ligament. These epulides grow from under the free gingival margin and not as a result of a primary inflammatory gingival enlargement. This distinct aetiopathogenesis separates this group of lesions both in terms of their specific clinical presentation and behaviour and their propensity for recurrence if managed inadequately.

Subgingival debridement of root surfaces with a micro-brush: macroscopic and ultrastructural assessment

AIM

The aim of this study was to assess the use of a micro-brush to remove plaque deposits from subgingival, periodontally involved root surfaces in vivo.

METHODS

30 periodontally involved teeth requiring extraction for periodontal or prosthetic reasons in 26 adult patients were utilised. For inclusion, teeth had to display at least 30% bone loss radiographically. Following the establishment of local anaesthesia, grooves were cut on the proximal root surface adjacent to the gingival margin at the line angles. For each tooth, 1 proximal root surface was rubbed with the micro-brush for 2 min to the depth of the pocket whilst the other root surface acted as an undebrided control. The teeth were then extracted, rinsed in 0.85% NaCl, stained with 2% erythrosine solution and photographed. The amount of erythrosine staining on each subgingival, periodontally involved root surface was assessed by tracing the areas of stain on a colour photograph and scanning the tracings into a computerised image tracing program.

RESULTS

Results were expressed as the % of the periodontally involved root-surface area that exhibited staining. Stained areas were further examined with the scanning electron microscope (SEM). The undebrided root surfaces each displayed 100% staining. The debrided surfaces (with probing pocket depths of 4-10 mm) displayed mean staining of 16.1% (SD +/-7.1%) of the proximal surface area. SEM assessment showed that undebrided root surfaces were covered with thick deposits of bacteria. On debrided surfaces, stain-free areas were free of plaque whilst areas of faint staining exhibited either no plaque, calculus deposits or scanty, isolated islands of bacteria. Bacteria had been partially removed from the surface of calculus in some areas.

CONCLUSIONS

The findings indicate that subgingival debridement with a micro-brush is effective in removing plaque deposits from periodontally involved root surfaces.

Bacteremia due to periodontal probing: a clinical and microbiological investigation

BACKGROUND

Infective endocarditis can occur in susceptible individuals due to bacteremia of oral origin. The aim of this study was to investigate the occurrence of bacteremia caused by full mouth periodontal probing.

METHODS

Forty patients, 20 with adult periodontitis (10 males, 10 females; mean age 43.0 years) and 20 with chronic gingivitis (11 males, 9 females; mean age 35.5 years) were investigated. Prior to and immediately following periodontal probing, 20 mL of venous blood were obtained from each patient and inoculated into aerobic and anaerobic blood culture bottles and incubated. Negative bottles were monitored continuously for 3 weeks before being discarded. Bottles which signalled positive were subcultured and isolates identified to genus level. Periodontal probing consisted of measuring pockets at 6 points around each tooth and recording the presence or absence of bleeding. A plaque index (PI) was assessed on the 6 Ramfjord teeth.

RESULTS

Probing caused bacteremia of oral origin in 8 (40%) of the periodontitis patients and 2 (10%) of the gingivitis patients. Streptococcus spp. were the most common isolates in both groups. Compared with the gingivitis group the odds ratio (OR) for bacteremia in the periodontitis group was 5.993 (95% CI 1.081 to 33.215). Bleeding on probing (OR 1.025, 95% CI 1.004 to 1.047) and mean probing depth per tooth (OR 1.444, 95% CI 1.055 to 1.977) were significantly associated with bacteremia. No significant correlations were found between bacteremia and age, number of teeth probed, smoking status, PI, or total probing depth.

CONCLUSIONS

Patients with untreated adult periodontitis are at greater risk of bacteremia due to periodontal probing than patients with chronic gingivitis. For individuals at risk of infective endocarditis, radiographic assessment prior to periodontal probing would be advisable to identify those with periodontitis so that appropriate antibiotic prophylaxis can be provided.

Australian dentists' views on toothbrush wear and renewal

The purpose of this study was to survey the views of Australian dentists on toothbrush wear, toothbrush renewal periods and recommendations to patients and to investigate the relationship between dentists' views on patients' toothbrush renewal intervals and dentists' own renewal habits. Questionnaires were mailed to 5,596 Australian general dental practitioners and replies received from 3,406 (61 per cent response rate). The majority of respondents (85.7 per cent) felt patients should renew their toothbrushes more often. However, only 45.3 per cent usually made a recommendation to their patients as to when they should renew their toothbrush and only 41.7 per cent thought patients actually followed such recommendations. Most respondents (56.6 per cent) thought the average adult patient should renew a toothbrush every two-three months. A renewal period of one month or earlier was recommended by 23.8 per cent of dentists; four-five months by 8 per cent; and six months or longer by 11.5 per cent. A highly significant correlation was found between the renewal periods recommended for patients and the intervals selected by the dentists for their personal brushes (p < 0.001; chi-square test). Bending and splaying of bristles was the sign identified by the majority of dentists (70 per cent) as indicating the need for a new brush. The findings suggest dentists' recommendations concerning toothbrush renewal intervals may be based on their own toothbrush renewal habits. It is also concluded that dentists think patients comply poorly with their recommendations on toothbrush renewal.

Effect of localized experimental gingivitis on early supragingival plaque accumulation

Previous investigations have reported increased plaque formation in the presence of gingival inflammation as compared with gingival health. In these investigations, experimental gingivitis has been induced by total abolition of oral hygiene such that increased levels of salivary bacteria could contribute to the increased plaque formation. In the present study, experimental gingivitis was localized to 2 selected teeth whilst maintaining normal oral hygiene measures in the rest of the mouth. The aim of this study was to investigate whether the mass of plaque accumulating in a 3-day period is influenced by the inflammatory status of the adjacent gingival margins. Following scaling, prophylaxis and a period of optimal hygiene to establish gingival health, "plaque-guards" were worn during routine oral hygiene performance to prevent any cleaning on the buccal surfaces of teeth 14 and 15 from days 0 to 3. On day 3, accumulated plaque was removed from a 1.5 mm zone on the buccal surfaces of 14 and 15 adjacent to the gingival margins and weighed immediately. Subjects continued to wear their plaque-guards during oral hygiene until day 14 to induce experimental gingivitis around the experimental teeth. At day 14, all plaque was cleaned from the buccal surfaces of the experimental teeth and the mass of plaque accumulating over the next 3 days weighed on day 17. Comparison of plaque weights showed that the wet-weight of 3 day-old plaque was higher in the presence of experimental gingivitis than in the presence of gingival health (p = 0.02). This observation suggests that the inflammatory status of the marginal gingiva has an important effect on early, supragingival plaque accumulation.

Effect of toothbrush wear on plaque control

The purpose of this study was to investigate the effect of progressive toothbrush wear on plaque control. At baseline (week 0), each of 20 subjects was given a new toothbrush which they used for the 9-week period of the study. At weeks 0, 3 and 6, all plaque was professionally removed. The amount of plaque which accumulated in each of the 3 successive 3-week experimental periods was assessed at weeks 3, 6 and 9. Toothbrush wear was evaluated by measuring the increase in the brushing surface area of toothbrushes at weeks 3, 6 and 9 as compared with week 0. The brushing surface area was measured by computer analysis of tracings of the brushing surface outlines obtained from standardized photographs. Despite progressive toothbrush wear, the amount of plaque which accumulated in each successive 3-week period decreased. The decrease in plaque scores between weeks 3 and 6 and between weeks 3 and 9 were found to be highly significant (p < 0.001). Toothbrush wear varied widely amongst the subjects. When plaque scores were evaluated for the 10 subjects with highest toothbrush wear, and the 10 with lowest wear, no significant differences were found between the 2 subgroups. Under the experimental conditions of this study, progressive toothbrush wear did not lead to a decrease in plaque control. The improvement in plaque scores may have been due to motivational effects resulting from study participation and anticipation of oral examinations. It was concluded that the wear status of a toothbrush may not be critical in ensuring optimal plaque control.

Resolution of cyclosporin A (CsA)-induced gingival enlargement following reduction in CsA dosage

Gingival enlargement due to the immunosuppressive drug, cyclosporin A (CsA), will resolve following discontinuation of drug therapy or extraction of adjacent teeth. This report presents a clinical observation on a patient in whom CsA-induced gingival enlargement failed to resolve with improved plaque control and scaling, but resolved quickly following reduction in the daily dosage of CsA. Despite less than optimal plaque control, the CsA-induced gingival enlargement did not recur on the reduced drug dosage over a 2-year observation period. This finding raises the possibility that reduction of CsA dosage below a certain critical level may lead to resolution of CsA-induced gingival enlargement.

Fractures of the mandible. A 35-year retrospective study

A retrospective survey was carried out of patients presenting with fractures of the mandible over the 35-year period 1951-1985 in Newcastle, Australia. The age, sex and cause of injury were analysed for each of the 1,162 patients. The male:female ratio was 4.4:1. The highest incidence of trauma was in the 20-29-year age group (38.3% of all patients). The number of 20-29-year-olds sustaining mandibular fractures in each 5-year period of study was 2 to 3 times higher than would be expected from the proportion of that age group in the regional population. The major causes of fractures were assault (38.1% of all patients), road traffic accidents (21.5%) and sport (19.0%). The patterns of causes of injury were similar throughout the period of study. Males accounted for most patients in all causes of trauma. In sports, the male:female ratio was 30.6:1, whilst for assaults it was 6.3:1. The number of patients sustaining fractures increased by 364% over the period of study whilst the population involved increased by 47%.

After-hours treatment of anterior dental trauma in Newcastle and western Sydney: a four-year study

This study investigated anterior dental trauma presenting after-hours in Newcastle and western Sydney. During the four-year period 1983-1986, all patients presenting with anterior dental injuries to the Royal Newcastle Hospital (n = 382) or Westmead Hospital (n = 362) on week nights, weekends or public holidays were studied. In both areas, upper central incisors were the teeth injured most frequently. The mean numbers of teeth injured per patient were 1.9 at Newcastle and 2.0 at Westmead. The frequencies of injury types found in Newcastle and Westmead were similar. Luxations and avulsions accounted for 39.5 per cent of injuries at Newcastle and 39.6 per cent at Westmead. In Newcastle, the rate of occurrence of trauma was highest and relatively uniform in the 6-11, 12-17 and 18-23 year age groups. At Westmead, it was highest in the 6-11 year age group, followed closely by the 12-17 year age group. In both centres, the four main causes of trauma were falls, assaults and fights, sports and bicycle accidents. These accounted for 69 per cent of all injuries in Newcastle and for 69.4 per cent at Westmead. This study found a great similarity between Newcastle and western Sydney in relation to the predominant age and sex groups affected, causes of trauma, injury types and numbers and locations of injured teeth per patient. It is suggested that anterior dental trauma presenting after-hours may be more severe, involve more teeth per patient and affect predominantly older age groups than is the situation during normal hours.

Kaposi's sarcoma of the palate in a patient with AIDS: an unusual presentation

Kaposi's sarcoma formerly a rare tumour in the western world, is now found frequently in homosexual patients with the Acquired Immune Deficiency Syndrome. A common site of occurrence is the mouth. The characteristic intra-oral appearance of the lesion is of a flat or raised pigmented lesion. An intra-oral Kaposi's sarcoma which was not pigmented and which presented as a painless, soft swelling on the hard palate is reported. The unusual appearance of the lesion is described and the importance of accurate diagnosis of intra-oral lesions in patients with the Acquired Immune Deficiency Syndrome is emphasized.

Anterior dental trauma treated after-hours in Newcastle, Australia

This study investigated the occurrence, causes and types of anterior dental trauma treated outside normal clinic and practice hours in Newcastle, Australia. During a 2 1/2-yr period, 233 patients presented for treatment of traumatic injuries to anterior teeth on week nights, weekends and public holidays. The highest occurrence of trauma was in the 18 to 23 yr group (24.9%), followed by the 6 to 11 (23.6%) and the 12 to 17 (22.3%) yr groups. Men sustained injuries more frequently than women in all age groups. The male/female ratio was 2.6:1. The four main causes of trauma were falls (26.6%), sports (18.0%), bicycle accidents (14.2%) and assaults or fights (13.3%). The 233 patients sustained 488 injuries to 95 primary and 373 permanent teeth (n = 468). Maxillary central incisors were the most frequently injured teeth. The mean number of teeth injured per patient was 2.01. Luxation (46.9%) was the most common injury in the primary dentition. In the permanent dentition, crown fractures without pulp exposures (25.0%), followed by luxation (23.5%), were the most common injuries. Avulsion represented 11.5% of all injuries. The findings of this study indicate that anterior dental trauma treated after-hours may be more severe, involve more teeth and affect predominantly older age groups than traumatic injuries treated during normal hours.

Lingual haematoma leading to upper airway obstruction

A case is reported in which upper airway obstruction occurred in a patient following suturing of his lacerated tongue under local anaesthesia and the subsequent development of a large lingual haematoma.

Anti-bacterial effect of citric acid treatment of periodontally diseased root surfaces in vitro

This investigation examined whether citric acid may exert an anti-bacterial effect against plaque deposits on root surfaces in vitro. Aerobic and anaerobic blood-agar plate cultures were prepared from plaque samples obtained from the proximal root surfaces of 20 periodontally diseased human teeth following extraction. Ten teeth were exposed to saturated citric acid (pH 1) for 3 min, followed by rinsing in sterile 0.85% saline and plaque samples were then obtained immediately adjacent to those sites sampled initially. Controls consisted of using sterile water instead of citric acid on a further five teeth. The numbers of colonies present on pre- and post-treatment culture plates were counted at 24 h. The results indicated that citric acid application reduced, in all instances, the numbers of colonies grown from post-exposure plaque samples as compared to pre-exposure samples. No colonies were detected in 55% of aerobic and 30% of anaerobic cultures of acid-treated root surface samples. For aerobic cultures, citric acid exposure reduced the number of colonies grown from greater than 10(4) to less than 100 in 95% of the root surfaces sampled, while for anaerobic cultures, reduction from greater than 10(4) to less than 100 was found in 80% of surfaces sampled. The findings indicate that citric acid exerts anti-bacterial activity against microbial plaque deposits present on periodontally diseased root surfaces in vitro.

Histological assessment of periodontally involved cementum

Contamination of periodontally involved cementum by bacterial substances such as lipopolysaccharide (LPS) is considered a major reason for root planing. The purpose of the present study was to investigate the presence and location of lipid and polysaccharide within involved cementum as compared with uninvolved cementum. Frozen sections were prepared from the decalcified roots of 36 periodontally diseased and two control teeth. Serial sections were stained for either lipid (Oil-Red-O) or polysaccharide (Alcian Blue - PAS) and also with haematoxylin & eosin (H & E) or Huberstone's gram stain. Specimens of involved and uninvolved cementum were then examined under the light microscope for assessment of differences. Involved cementum from 12 of the periodontally diseased teeth exhibited strongly PAS-positive stained processes penetrating 3-7 mum into the surface of cementum from overlying plaque. Such processes were not observed in uninvolved cementum, suggesting a possible bacterial origin. Lipid granules were noted in only one involved specimen where they were situated up to 10 mum beneath the cemental surface. Similar granules were observed within plaque deposits but never in uninvolved cementum, again suggesting a possible bacterial origin. H & E and gram-stained specimens revealed the presence of microbial deposits in surface defects and within defects at the cemento-dentinal junction (CDJ), as well as penetration of micro-organisms into cementum in the absence of any surface defects. The results indicate that although lipid and polysaccharide of possible bacterial origin may be present within the 10 mum surface zone of involved cementum, the finding of microbial deposits down to the level of the CDJ suggests that all periodontally involved cementum should be removed during root planing, in order to achieve a root surface free of bacterial contamination.

Bacterial endotoxin: a role in chronic inflammatory periodontal disease?

A review of current information was undertaken examining suggested roles for bacterial endotoxin in periodontal disease. Evidence for the presence of endotoxin in plaque, gingival crevicular fluid and periodontally involved cementum is discussed. The biological effects of endotoxin are numerous, and its abilities to induce tissue inflammation, resorb rat foetal bone, activate the complement pathway, stimulate macrophages and activate immune responses are examined in relation to the suggestion that endotoxin is an important factor in the pathogenesis of periodontal disease.