Structure, governance and delivery of specialist training programs in periodontology and implant dentistry.

AIM: To update the competences and learning outcomes and their evaluation, educational methods and education quality assurance for the training of contemporary specialists in periodontology, including the impact of the 2018 Classification of Periodontal and Peri-implant Diseases and Conditions (2018 Classification hereafter) and the European Federation of Periodontology (EFP) Clinical Practice Guidelines (CPGs). METHODS: Evidence was gathered through scientific databases and by searching for European policies on higher education. In addition, two surveys were designed and sent to program directors and graduates. RESULTS: Program directors reported that curricula were periodically adapted to incorporate advances in diagnosis, classification, treatment guidelines and clinical techniques, including the 2018 Classification and the EFP CPGs. Graduates evaluated their overall training positively, although satisfaction was limited for training in mucogingival and surgical procedures related to dental implants. Traditional educational methods, such as didactic lectures, are still commonly employed, but they are now often associated with more interactive methods such as case-based seminars and problem-based and simulation-based learning. The evaluation of competences/learning outcomes should employ multiple methods of assessment. CONCLUSION: An update of competences and learning outcomes of specialist training in periodontology is proposed, including knowledge and practical application of the 2018 Classification and CPGs. Harmonizing specialist training in periodontology is a critical issue at the European level.

A 20-year split-mouth comparative study of two screw-shaped titanium implant systems.

PURPOSE: To prospectively assess marginal bone loss and implant survival with Astra Tech (Dentsply Sirona, Charlotte, NC, USA) (group A) and Brånemark (Nobel Biocare, Zurich, Switzerland) (group B) implants in a split-mouth study conducted over a 20-year follow-up period. MATERIALS AND METHODS: A total of 95 implants (n = 50, group A and n = 45, group B) were randomly placed in the left or right side of the maxilla or mandible in 18 patients. Clinical and radiographic examinations were performed, and results were reported at 5, 10, 15 and 20 years after insertion of the prosthesis. RESULTS: Ten patients were followed up for 20 years (n = 26 implants, group A and n = 25 implants, group B). No implant loss or prosthetic failures were observed. After 20 years of follow-up, no significant differences in marginal bone loss were found between both implant groups (P = 0.25). The proportion of marginal bone loss ≥ 0.5 mm was not significantly different between implant types (P > 0.05), and no statistically significant relationships were found between marginal bone loss and time (P ≥ 0.05). More specifically, there was no significant difference in marginal bone level between year 20 and baseline in group A (P = 0.70), whereas a difference of 0.5 to 1.0 mm was found in group B (P = 0.15). CONCLUSIONS: After 20 years of follow-up, marginal bone loss around screw-shaped titanium implants was clinically insignificant. Furthermore, no significant differences in survival and marginal bone loss were found between group A and B implants over the follow-up period.

A new method of choice for organoleptic scoring: The negative-pressure technique.

AIM: To examine an organoleptic scoring method (OLS) whereby the sample is collected by negative pressure in a syringe and is subsequently smelled and rated away from the patient. MATERIALS AND METHODS: Data of 476 patients visiting a specialized halitosis clinic in Leuven (Belgium) were reviewed retrospectively. Organoleptic (with the classic and with the negative-pressure method) and instrumental (with the Halimeter® and OralChroma™ ) ratings of breath odour were retrieved from patient files together with the final diagnosis. The correlations between the different methods were examined (Spearman correlation coefficient) as well as the positive (PPV) and negative predictive value (NPV), sensitivity and specificity of all methods. RESULTS: Both methods of OLS correlated similarly with the instrumental measurements (Halimeter® and OralChroma™ ). Analysis of PPV, NPV, sensitivity and specificity of both methods of examination showed that the negative-pressure method performed best. CONCLUSION: The negative-pressure method is a valid method for organoleptic scoring of the breath odour and performs as good as the classic organoleptic method.

Subgingival debridement: end point, methods and how often?

Subgingival debridement is the part of nonsurgical therapy which aims to remove the biofilm without intentionally removing the cementum or subgingival calculus. The objective of this review was to describe the end point of this therapy, the different methods used and how often it should be carried out. The literature shows that several methods are currently available for subgingival debridement, namely hand instrumentation, (ultra)sonic instrumentation, laser, photodynamic therapy and air-polishing. None of these methods seems superior to any other regarding clinical benefits or microbiological differences. However, less treatment discomfort is reported using laser, photodynamic therapy or air-polishing compared with hand- and/or (ultra)sonic instrumentation. Subgingival debridement can be carried out when, during supportive periodontal therapy, pockets of 5 mm or deeper are detected.

Periodontal diseases as a source of halitosis: a review of the evidence and treatment approaches for dentists and dental hygienists.

Bad breath (halitosis) is an important social complaint. In most cases (≥90%), the cause of halitosis can be found within the oral cavity. Under this circumstance, the term oral malodor applies. It affects both healthy and periodontally diseased individuals. Oral malodor is mainly caused by a microbial degradation of both sulfur-containing and nonsulfur-containing amino acids into volatile, bad-smelling gases. Anaerobic gram-negative bacteria, the same species that have been linked to periodontal diseases, are especially involved in this process, explaining why clinicians often associate oral malodor with periodontitis. Some volatile organic compounds render patients more susceptible to periodontitis and this supports the malodor-periodontitis link. This review investigates the interaction between oral malodor and periodontal diseases. Pro and con arguments regarding the mechanisms of halitosis and clinical implications will be presented. In general, however, the impact of tongue coatings has been found to be the dominant factor, besides gingivitis and periodontitis. The last part of this review discusses the treatment of bad breath, with different options.

Treatment of aggressive periodontitis.

Despite etiological differences between aggressive and chronic periodontitis, the treatment concept for aggressive periodontitis is largely similar to that for chronic periodontitis. The goal of treatment is to create a clinical condition that is conducive to retaining as many teeth as possible for as long as possible. When a diagnosis has been made and risk factors have been identified, active treatment is commenced. The initial phase of active treatment consists of mechanical debridement, either alone or supplemented with antimicrobial drugs. Scaling and root planing has been shown to be effective in improving clinical indices, but does not always guarantee long-term stability. Antimicrobials can play a significant role in controlling aggressive periodontitis. Few studies have been published on this subject for localized aggressive periodontitis, but generalized aggressive periodontitis has been subject to more scrutiny. Studies have demonstrated that systemic antibiotics as an adjuvant to scaling and root planing are more effective in controlling disease compared with scaling and root planing alone or with supplemental application of local antibiotics or antiseptics. It has also become apparent that antibiotics ought to be administered with, or just after, mechanical debridement. Several studies have shown that regimens of amoxicillin combined with metronidazole or regimens of clindamycin are the most effective and are preferable to regimens containing doxycycline. Azithromycin has been shown to be a valid alternative to the regimen of amoxicillin plus metronidazole. A limited number of studies have been published on surgical treatment in patients with aggressive periodontitis, but the studies available show that the effect can be comparable with the effect on patients with chronic periodontitis, provided that proper oral hygiene is maintained, a strict maintenance program is followed and modifiable risk factors are controlled. Both access surgery and regenerative techniques have shown good results in patients with aggressive periodontitis. Once good periodontal health has been obtained, patients must be enrolled in a strict maintenance program that is directed toward controlling risk factors for disease recurrence and tooth loss. The most significant risk factors are noncompliance with regular maintenance care, smoking, high gingival bleeding index and poor plaque control. There is no evidence to suggest that daily use of antiseptic agents should be part of the supportive periodontal therapy for aggressive periodontitis.

Usefulness of a new malodour-compound detection portable device in oral malodour diagnosis.

A new device (BB Checker) able to detect malodour compounds has recently been made available. This retrospective analysis aimed at evaluating the usefulness of this device as adjunct tool for the diagnosis of oral malodour. Data from 100 consecutive volunteers with bad breath complaints attending their first consultation at a halitosis clinic were analysed. In addition to the standard protocol (organoleptic ratings from mouth and nose air, and from tongue coating when present; OralChroma and Halimeter measurements from mouth air; and intra-oral examinations), oral, exhaled and nasal air samples were examined with the BB Checker. We could not establish a correlation between the BB Checker values and the organoleptic scores, or the sulfur-compound levels determined by the OralChroma or the Halimeter (R < 0.3, p > 0.05). The overall sensitivity and specificity of the new device did not exceed the 50%. The correlations between the organoleptic scores and the OralChroma and the Halimeter measurements were good and in line with previous reports (R between 0.56 and 0.73). Our results do not favour the use of the BB Checker as adjunct tool in the diagnosis of oral malodour.

Efficacy of different mouthrinse formulations in reducing oral malodour: a randomized clinical trial.

AIMS: The aim of this study was to assess the efficacy of mouthrinses formulations in oral malodour. MATERIAL & METHODS: This single-centre, double-blind, randomized, parallel group clinical trial compared the efficacy of Halita™ and meridol(®) with and without zinc lactate versus negative and positive control. Volunteers with confirmed oral malodour (18/group) rinsed with one mouthrinse during 7 days (15 ml, 2x/day for 1 min.). 15 min. after a first rinse (masking effect), and after 7 days (therapeutic effect) the change in organoleptic scores and level of sulphur compounds was recorded. RESULTS: All rinses showed a masking effect (OLS 1 to 2 values reduced), only the rinses with antimicrobial ingredients showed a therapeutic effect (OLS 1 to 1.5 value less). The addition of zinc resulted in a more pronounced masking effect. Halita™ and meridol(®) with zinc showed the best therapeutic effect. CONCLUSION: Although the masking effect of the rinses can be attributed partially to a dilution and the effect of aromas, the therapeutic effect should be linked to the anti-microbial action of active ingredients and counter action of zinc ions on VSC. A complete resolution of the unpleasant breath by additional mechanical intervention remains to be proven.

Clinical utility of a novel colorimetric chair side test for oral malodour.

AIM: The aim of this study was to evaluate the utility of a simple colorimetric chair side test detecting amines in saliva as an adjunct test in the oral malodour diagnosis. MATERIAL AND METHODS: Non-stimulated saliva samples were collected from 100 volunteers with different degrees of oral malodour. The amount of amines detected by the test was estimated clinically (colorimetric test), confirmed semi quantitatively in the laboratory (standard addition method) and consequently compared with (i) the organoleptic score (OLS); (ii) the volatile sulphur compounds (VSCs) levels (OralChroma(™)) and (iii) the amount of amines detected by means of gas chromatography - mass spectroscopy. RESULTS: The chair side test correlated well (Spearman correlation coefficient: 0.46-0.77), with the OLS, the level of VSCs, and the amines determined by using gas chromatography - mass spectroscopy. The results of the new test for patients with and without oral malodour were significantly different (Mann-Whitney U-test, p < 0.0001). The sensitivity, specificity, and positive and negative predictive value of this chair side test were similar to those of the VSCs evaluations. CONCLUSIONS: These results support the "fit for purpose" of the new chair side test as adjunctive diagnostic tool for oral malodour.

A novel and visual test for oral malodour: first observations.

Until now, the application of biogenic amines as bio-markers of oral malodour has been limited because of the complexity of their detection. This study explores the usability of a simple colorimetric reaction detecting amines in saliva as an adjunct test for the diagnosis of oral malodour. The colour reaction caused by a newly discovered enzyme capable of detecting amines in saliva was characterized in vitro. Two colour scales were developed by transforming the colours of selected dilutions of a mixture of cadaverine and putrescine into a 5- and a 10-point pink-colour scale. Afterwards, this new enzymatic test was used to assess the amount of amines in saliva samples of 50 volunteers with different degrees of oral malodour. The enzymatic reaction was shown to be linear towards the concentration of amines and stable over a time of ≥4 h. Colour scores correlated well with organoleptic scores and the volatile sulfur compounds. More importantly differences between patients with and without oral malodour were significant. Based on these results, we conclude that this new enzymatic test, interpreted by means of a simple colour scale, has the potential to be used as an adjunct chair-side test for oral malodour diagnosis.

Are panoramic images reliable in planning sinus augmentation procedures?

OBJECTIVE: The inherent deformation and two-dimensional nature of panoramic radiographs jeopardise their interpretation and quantitative measurements. This study aims to estimate the degree of underestimation of available mesio-distal bone in the premolar area (comparing panoramic radiographs with multi-slice/cone-beam computer tomography [CT]) to determine the prevalence, width, length and position of the bony canal [artery] in the lateral sinus wall and to explore the prevalence, width and length of another (newly detected) bony canal at the palatal aspect of the upper canine. MATERIAL AND METHODS: The distance between the distal side of the canine/first premolar and the mesial side of the first molar or the anterior wall of the maxillary sinus was measured on panoramic radiographs and corresponding multi-slice/cone-beam CT images (65 patients). Measurements were made at apical, mid-radicular and crestal regions, parallel to the occlusal plane. The presence and dimensions of the two above-mentioned intra-osseous canals were verified on multi-slice CT scans (144 patients) using reformatted cross-sectional images and/or axial slices. RESULTS: For all 65 patients, panoramic radiographs underscored the mesio-distal distance of available bone in the upper premolar region (mean 2.9 mm, range 0.1-7.5 mm). An intra-osseous canal in the lateral maxillary sinus wall was clearly visible in 49.5% of the cases (mean diameter 1.4 mm). In the canine region, a bony canal was obvious in 32.9% of the cases, with a mean diameter of 1.23 mm. For both canals, there was no correlation between diameter and patient's age. CONCLUSIONS: Based on the present data, cone-beam CT imaging can be recommended for visualising anatomical structures during planning of sinus augmentation procedures.

Characteristics of 2000 patients who visited a halitosis clinic.

AIMS: The aim of this paper was to analyse the aetiology and characteristics of 2000 patients who visited a multidisciplinary bad breath clinic in Leuven, Belgium and to correlate organoleptic ratings with portable device measurements. MATERIALS AND METHODS: The characteristics and aetiology of breath malodour of two thousand consecutive patients who visited a halitosis consultation were explored by means of a standard questionnaire and a clinical examination, including organoleptic scores provided by a trained and calibrated judge, and a portable bad breath detector (Halimeter). RESULTS: Most patients came without referral and had complaints for several years (mean: 7 years, SD: 8 years). For 76% of the patients, an oral cause was found [tongue coating (43%), gingivitis/periodontitis (11%) or a combination of the two (18%)]. Pseudo-halitosis/halitophobia was diagnosed in 16% of the cases; and ear, nose and throat/extra-oral causes were found in 4% of the patients. Most patients had an organoleptic score <3 and a Halimeter value <240 p.p.b. CONCLUSIONS: Even though it was observed that halitosis has a predominantly oral origin, a multidisciplinary approach remains necessary to identify ear, nose and throat or extra-oral pathologies and/or pseudo-halitosis/halitophobia.

The impact of periodontal therapy and the adjunctive effect of antiseptics on breath odor-related outcome variables: a double-blind randomized study.

BACKGROUND: Bad breath is often caused by periodontitis and/or tongue coating. This study followed the impact of initial periodontal therapy on several halitosis-related outcome variables over a 6-month period. Organoleptic ratings are often uncomfortable for the patient and have several disadvantages. They are, for instance, influenced by external parameters (e.g., food intake and cosmetics) and need to be calibrated among researchers worldwide. A second aim was to evaluate the reliability of saliva incubation as an in vitro indirect test for breath recording. METHODS: In this double-blind, randomized, medium-term, parallel study 45 moderate periodontitis patients without obvious tongue coating were enrolled. Besides a one-stage, full-mouth disinfection and oral hygiene improvement (including daily tongue scraping), patients were instructed to rinse daily for 6 months with one of the following products (randomly allocated): chlorhexidine (CHX) 0.2% + alcohol, CHX 0.05% + cetyl pyridinium chloride (CPC) 0.05% without alcohol (a new formulation), or a placebo solution. At baseline and 3 and 6 months, a series of parameters were recorded including: concentration of volatile sulfide compounds (VSC), tongue coating, and an estimation of the microbial load (at anterior and posterior parts of the tongue, saliva, dental plaque). The intraoral VSC ratings were compared to in vitro VSC recordings and organoleptic evaluations of the headspace air from 1 and 2 hours incubated saliva (0.5 ml, 37 degrees C, anaerobic chamber). RESULTS: Even though the initial VSC values were not high (+/-90 ppb with only 18 patients revealing more than 100 ppb), significant (P <0.05) reductions could be achieved in the CHX and CHX + CPC group, and to a lower extent in the placebo group (P = 0.10). Tongue scraping resulted in a significant reduction (P < or =0.05) of the tongue coating up to month 6 in the placebo and CHX + CPC group, but not in the CHX group (confusion due to staining). The CHX and CHX + CPC group showed, in comparison to baseline, significant (P <0.001) reductions in the number of anaerobic species in the supragingival plaque, in the saliva, and on the anterior part of the tongue. For the posterior part of the tongue the microbial changes remained < or =0.3 log values (P >0.05). For the placebo group, the microbial changes never reached a level of significance (< or =0.3 log values). A strong correlation was found between the intraoral VSC ratings and the 1-hour (r = 0.48, P <0.0001; r = 0.54, P = 0.0003 for baseline data only) and 2-hour (r = 0.43, P <0.0001) VSC production of incubated saliva. The latter also correlated very strongly (r = 0.71) with the number of anaerobic species in the saliva. The VSC values and organoleptic ratings of the incubated saliva also correlated strongly with each other (r = 0.64 for 1-hour and 0.73 for 2-hour incubation). CONCLUSIONS: The results of this study indicate that in patients with moderate periodontitis, initial periodontal therapy including tongue scraping did not have a significant effect on the microbial load of the tongue and had only a weak impact on the VSC level, except when combined with a mouthrinse. Saliva incubation can be used as an indirect way to score breath odor. It offers simplicity, objectivity, and is less invasive.

A 0.05% cetyl pyridinium chloride/0.05% chlorhexidine mouth rinse during maintenance phase after initial periodontal therapy.

BACKGROUND: Chlorhexidine (CHX) mouth rinse/spray can still be considered the gold standard in the chemical prevention of plaque formation and development of gingivitis. The product unfortunately has some side effects, such as extrinsic tooth staining, poor taste, taste disturbance, sensitivity changes in tongue, pain and irritation because of the alcohol content. These side effects led to the search of new formulations. METHODS: In this double-blind, randomized, long-term, parallel study, 48 moderate periodontitis patients rinsed for 6 months (starting immediately after a "one-stage, full-mouth" disinfection) with one of the following products: CHX 0.2%+alcohol (Corsodyl), CHX 0.05%+ cetyl pyridinium chloride (CPC) 0.05% and no alcohol (Perio-Aid Maintenance, a new formulation), or the placebo of the latter. After 1, 3 and 6 months a series of clinical and microbiological parameters were recorded for the supra- and subgingival area as well as for saliva. RESULTS: Although there was a significant treatment impact (mechanical debridement) in all groups, both CHX solutions further decreased both plaque and gingivitis indices (p<0.001 and p<0.05, respectively), when compared with placebo. This was also reflected by additional reductions in the number of CFU/ml of aerobic and especially anaerobic species and by a suppression of Streptococcus mutans (versus an overgrowth for the placebo), in all niches. Differences between both CHX solutions were never encountered. The subjective ratings were slightly in favour of the new CHX-CPC formulation when compared with the other CHX-alcohol formulation, especially for taste of the product (p<0.05), but less impressive for the staining of teeth and tongue. CONCLUSIONS: The results of this study demonstrated the potential of a new CHX 0.05%+CPC 0.05% non-alcoholic formulation as an effective antiplaque agent for long-term use with reduced subjective side effects.