Edwin Winkel

Polymorphisms of the Interleukin-1 Gene Family, Oral Microbial Pathogens, and Smoking in Adult Periodontitis

Interleukin (IL)-1α, IL-1β, and lL-1ra contribute to regulation of the inflammatory response in periodontal tissues. We aimed to investigate the distribution of polymorphisms in the IL-1 gene family among periodontitis patients and controls, taking into account smoking and microbiology as additional variables. Fifty-three non-smoking and 52 smoking patients with severe adult periodontitis and 53 controls were genotyped for bi-allelic IL-1A-889, IL-1B +3954 , and a penta-allelic 86-bp VNTR IL-1RN gene polymorphisms. The presence of Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans was established by culture techniques. We found a higher frequency of allele 2 carriage in IL-1A, IL-1B, and IL-1RN in periodontitis patients who were non-smokers and in whom P. gingivalis and A. actinomycetemcomitans could not be detected (42.1 % vs. 11.3% in controls; P = 0.0068; OR 5.7, 95% CI: 1.6-19.8). Our results provide evidence that polymorphisms in genes of the IL-1 family are associated with severe adult periodontitis in the absence of other risk factors tested in this patient population.

Extra-oral halitosis: an overview

Halitosis can be subdivided into intra-oral and extra-oral halitosis, depending on the place where it originates. Most reports now agree that the most frequent sources of halitosis exist within the oral cavity and include bacterial reservoirs such as the dorsum of the tongue, saliva and periodontal pockets, where anaerobic bacteria degrade sulfur-containing amino acids to produce the foul smelling volatile sulfur compounds (VSCs), especially hydrogen sulfide (H(2)S) and methyl mercaptan (CH(3)SH). Tongue coating is considered to be the most important source of VSCs. Oral malodor can now be treated effectively. Special attention in this overview is given to extra-oral halitosis. Extra-oral halitosis can be subdivided into non-blood-borne halitosis, such as halitosis from the upper respiratory tract including the nose and from the lower respiratory tract, and blood-borne halitosis. The majority of patients with extra-oral halitosis have blood-borne halitosis. Blood-borne halitosis is also frequently caused by odorous VSCs, in particular dimethyl sulfide (CH3SCH3). Extra-oral halitosis, covering about 5-10% of all cases of halitosis, might be a manifestation of a serious disease for which treatment is much more complicated than for intra-oral halitosis. It is therefore of utmost importance to differentiate between intra-oral and extra-oral halitosis. Differences between intra-oral and extra-oral halitosis are discussed extensively. The importance of applying odor characterization of various odorants in halitosis research is also highlighted in this article. The use of the odor index, odor threshold values and simulation of bad breath samples is explained.

Antibiotics in Periodontics: Right or Wrong?

It is well established that periodontal infections are caused by bacterial deposits in supra- and subgingival dental plaque. These infections respond well to measures that aim to reduce the periodontal bacterial load, and clinical improvement occurs when the bacterial challenge is compatible with the host’s immunocompetence. It has also been established that systemic antibiotics can significantly enhance the effects of mechanical periodontal therapy, i.e., scaling and root planing in conjunction with measures that improve the oral hygiene level. 1-3 A minor proportion of the patients with periodontitis does not respond adequately to mechanical treatment, and factors such as smoking, stress, reduced immunocompetence and systemic diseases are held responsible. 3 These patients are prime candidates for adjunctive systemic antimicrobial therapy. A combination of metronidazole and amoxicillin (MA) has shown to be an effective antibiotic regime to combat Aggregatibacter actinomycetemcomitans- (previously Actinobacillus actinomycetemcomitans) and Porphyromonas gingivalis-associated periodontal infections. 4-6 Recently, Cionca et al. 7 reported on the adjunctive use of this antibiotic regimen in conjunction to full-mouth scaling and root planing in patients with moderate to severe chronic periodontitis. Guerreo et al. 6 used a comparable treatment protocol in patients with aggressive periodontitis and showed significantly better improvement of all periodontal parameters in the antibiotic-treated patients compared to placebo-treated subjects 6 months post-treatment. In both clinical trials, the so-called full-mouth disinfection approach was used. This implies scaling and root planing of all affected teeth within 48 hours, subgingival irrigation with chlorhexidine, and chlorhexidine rinsing for 14 days after subgingival treatment. This approach is based on the assumption that untreated periodontal sites may be the source of infection of already treated lesions. This hypothesis of intraoral reinfection has never been proven and cannot be proven based on a clinical protocol. Moreover, it is very unlikely that mechanical periodontal treatment results in complete subgingival elimination of key periodontal path

Halitosis and Helicobacter pylori infection

There is disagreement about a possible relationship between Helicobacter pylori (H. pylori) infection and objective halitosis, as established by volatile sulfur compounds (VSCs) in the breath. Many studies related to H. pylori used self-reported halitosis, a subjective and unreliable method to detect halitosis. In this study a possible relation between H. pylori and halitosis was evaluated, using an objective method (gas chromatography, GC) to detect the VSCs, responsible for the halitosis. The levels of the VSCs hydrogen sulfide (H(2)S), methyl mercaptan (MM) and dimethyl sulfide (DMS) were measured in mouth breath and in stomach air of 11 H. pylori positive patients and of 38 H. pylori negative patients, all with gastric pathology. Halitosis was also established by organoleptic scoring (OLS) of mouth-breath. The levels of H(2)S, MM and DMS in the mouth-breath and stomach air of the H. pylori positive patients did not differ significantly from those of the H. pylori negative patients. OLS of the mouth-breath resulted in 9 patients with halitosis, 1 out of the H. pylori positive group and 8 out of the H. pylori negative group, which is not statistically different. The concentrations of the VSCs in stomach air were in nearly all cases below the thresholds of objectionability of the various VSCs, indicating that halitosis does not originate in the stomach. The patients with gastric pathology were also compared with control patients without gastric pathology and with normal volunteers. No significant differences in VSCs in mouth breath were observed between these groups. Thus, in this study no association between halitosis and H. pylori infection was found. Halitosis, as established by GC and OLS, nearly always originates within the oral cavity and seldom or never within the stomach.

Comparison of different treatment modalities for oral halitosis

Abstract Objectives. To assess the effects on intra-oral halitosis by a mouth rinse containing zinc acetate (0.3%) and chlorhexidine diacetate (0.025%) with and without adjunct tongue scraping. Materials and methods. Twenty-one subjects without a diagnosis of periodontitis were randomized in a cross-over clinical trial. Organoleptic scores (OLS) were assessed to define intra-oral halitosis by total volatile sulfur compound (T-VSC) measurements and by gas chromatography. Results. Twenty-one subjects with a mean age of 45.7 years (SD: ±13.3, range: 21–66). The OLS were significantly lower following active rinse combined with tongue scraping (p < 0.001) at all time points. Immediately after, at 30 min, and at day 14, the T-VSC values were lower in the active rinse sequence than in the negative rinse sequence (p < 0.001, p < 0.001 and p < 0.05, respectively). At 30 min and at day 14, the hydrogen sulfide (H2S) and methyl mercaptan (MM) values were lower in the active rinse sequence compared to the inactive rinse sequence (p < 0.001). The inactive rinse sequence with tongue scraping reduced T-VSC at 30 min (p < 0.001) but not at 14 days. Similar reductions in T-VSC, H2S and MM were found in the active rinse sequence with or without tongue scraping. Conclusion. The use of a tongue scraper did not provide additional benefits to the active mouth rinse, but reduced OLS and tongue coating index.

Volatile sulphur compounds in morning breath of human volunteers

OBJECTIVE morning breath contains elevated concentrations of volatile sulphur components (VSCs). Therefore, morning breath is recognised as a surrogate target for interventions on breath quality. Nevertheless, factors influencing morning breath are poorly understood. Our aim was to evaluate concentrations of VSC at the time of awakening. METHODS a procedure was developed to collect breath samples at home. Intra- and inter-person variations were determined in two small studies based on measurements of hydrogen sulphide, methyl mercaptan and dimethyl sulphide in healthy volunteers. RESULTS highest levels of VSC were found directly after waking up, followed by a significant decline afterward. Considerable day-to-day variation was found, but could not be linked to dietary intake. A significantly higher concentration of H(2)S and CH(3)SH was observed in the group of female subjects compared to males. CONCLUSIONS when morning breath is used as a target for interventions, breath collected at the time of or shortly after waking up is preferred over breath collected later during the morning. Gender plays an important role in VSC levels, and should be taken into account.

Differences in Peri-Implant Microflora Between Fully and Partially Edentulous Patients: A Systematic Review

BACKGROUND The current evidence suggests that the oral microflora differs between individuals who are fully edentulous (FES) and those who are partially edentulous (PES). It is unknown whether this leads to differences in peri-implant microflora when implants are installed. The aim of the study is to compare the submucosal peri-implant microflora between FES and PES. METHODS A systematic review was conducted. The MEDLINE, Embase, and Cochrane databases were searched for publications up to September 1, 2012. To reduce methodologic variations, only studies reporting in the same article about the submucosal peri-implant microflora of FES and PES were selected. RESULTS Eleven publications describing 10 studies were selected. Because of numerous differences among the selected studies, no meta-analysis could be performed. Six of 10 studies showed a significant difference in the composition of the submucosal peri-implant microflora in healthy and peri-implant mucositis conditions between FES and PES, with the latter showing a potentially more pathogenic composition. However, microbiologic results were not unanimous among the studies. CONCLUSIONS In healthy and peri-implant mucositis conditions, PES harbor a potentially more pathogenic peri-implant microflora than FES. The current data are insufficient for a clear conclusion regarding peri-implantitis cases. Overall, because of the lack of a meta-analysis, the variability in microbiologic outcomes and the limited number of studies available, the current evidence seems not to be robust.

In vitro antimicrobial effects of two antihalitosis mouth rinses on oral pathogens and human tongue microbiota

OBJECTIVES The aim of the study was to compare the antimicrobial activity of a mouth rinse containing chlorhexidine and cetylpyridinium chloride (MR1) with a stannous fluoride-based mouth rinse (MR2) in vitro. MATERIALS AND METHODS Samples of the tongues from 10 subjects with and 10 subjects without halitosis were inoculated on blood agar plates. The agar was perforated, and the cylindrical holes were filled either with mouth rinse MR1 or with mouth rinse MR2. After incubation, inhibition zones of the whole tongue microbiota and Fusobacterium nucleatum were measured. In addition, MR1 and MR2 were applied in a short interval killing test (SIKT) on four oral pathogens Porphyromonas gingivalis, Prevotella intermedia, F. nucleatum and Aggregatibacter actinomycetemcomitans. Total viable cell counts were made after two minutes of incubation with increasing concentrations of MR1 and MR2. RESULTS MR1 showed a significantly higher in vitro antimicrobial activity against the whole tongue microbiota and F. nucleatum than MR2 in both groups of subjects. In the SIK test, MR1 showed a significantly greater killing capacity than MR2. The results show that a mouth rinse with low concentrations of chlorhexidine and 0.05% cetylpyridinium chloride appears to be more effective in inhibiting growth of the human tongue microbiota in vitro than a fluoride/stannous fluoride-containing mouth rinse. CONCLUSION This in vitro observation supports the use of chlorhexidine and cetylpyridinium chloride in the treatment of oral halitosis.

Appropriate sample bags and syringes for preserving breath samples in breath odor research: a technical note

It is now generally accepted that the volatile sulfur compounds (VSCs) hydrogen sulfide, methyl mercaptan and dimethyl sulfide are the main contributors to halitosis when of oropharyngeal origin. The VSCs hydrogen sulfide and methyl mercaptan are the major causes of bad breath in oral malodour whereas dimethyl sulfide is generally the major cause of bad breath in extra-oral halitosis. To facilitate research in the field of halitosis, it is highly advantageous to be able to preserve breath samples for longer periods of time before measurement of the VSCs, e.g. for sampling patients at home or when studying a large cohort of patients where an immediate measurement of the VSCs is not possible. After testing numerous sample bags, ultimately the foil balloons, coated inside with the synthetic polymer polyethylene, were the preferred ones. All the VSCs in breath remained quite stable for at least 3 days in these balloons. Besides the sampling bags, the use of an appropriate syringe for sampling mouth air and for injecting samples in e.g. a gas chromatograph is also of great importance. Usually, syringes with a rubber barrel seal are used. However, some rubbers quickly adsorb the VSCs in breath. When preserving breath samples for longer periods, the rubber also releases VSCs, especially methyl mercaptan. It was also found that these syringes release a compound which interferes with dimethyl sulfide, when using gas chromatographic measurements with the OralChroma. We now use all-plastic syringes (B/Braun Injekt), made of polypropylene and polyethylene, in which the VSCs in breath remain quite stable for at least 9 h.

Java project on periodontal diseases: causes of tooth loss in a cohort of untreated individuals

OBJECTIVE To assess the relative contribution of caries and periodontal disease to tooth loss over 24 years in a cohort deprived of regular dental care. MATERIAL & METHODS The study population consisted of 98 subjects from a tea estate on West Java, Indonesia, that had been part of a prospective longitudinal study and provided full datasets of clinical assessments between 1987, 1994 and 2002. In 2011, complete sets of dental radiographs were made which was combined with the survey forms and clinical slides from the previous assessments in order to estimate reasons for tooth loss. RESULTS Thirty-seven subjects lost no teeth, whereas 61 subjects lost 185 teeth. In this group, 45.9% lost ≤2 teeth, 32.8% lost 3 to 4 teeth and 19.7% lost ≥5 teeth. The majority of teeth were lost due to caries. In five subjects, tooth loss could be attributed solely to periodontitis, whereas in four subjects teeth were lost due to both caries and periodontits. Analyses of the predictor variables age, gender, smoking, education, presence of caries and severe periodontitis showed that male gender and caries were significantly associated with tooth loss. CONCLUSION The majority of teeth in this population were lost due to caries.