Clinical effects on chronic periodontitis of a simplified system of oral hygiene including subgingival pulsated jet irrigation with chlorhexidine

Oral Irrigation Devices: A Scoping Review

OBJECTIVES

Self-performed oral hygiene is essential for preventing dental caries, periodontal, and peri-implant diseases. Oral irrigators are adjunctive oral home care aids that may benefit oral health. However, the effects of oral irrigation on oral health, its role in oral home care, and its mechanism of action are not fully understood. A comprehensive search of the literature revealed no existing broad scoping reviews on oral irrigators. Therefore, this study aimed to provide a comprehensive systematic review of the literature on oral irrigation devices and identify evidence gaps.

METHODS

The Joanna Briggs Institute and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines were utilized to prepare the review. Four databases and eight gray literature sources were searched for English publications across any geographical location or setting.

RESULTS

Two hundred and seventy-five sources were included, predominantly from scientific journals and academic settings. Most studies originated from North America. Research primarily involved adults, with limited studies in children and adolescents. Oral irrigation was safe and well-accepted when used appropriately. It reduced periodontal inflammation, potentially by modulating the oral microbiota, but further research needs to clarify its mechanism of action. Promising results were reported in populations with dental implants and special needs. Patient acceptance appeared high, but standardized patient-reported outcome measures were rarely used. Anti-inflammatory benefits occurred consistently across populations and irrigant solutions. Plaque reduction findings were mixed, potentially reflecting differences in study designs and devices.

CONCLUSIONS

Oral irrigators reduce periodontal inflammation, but their impact on plaque removal remains unclear. Well-designed, sufficiently powered trials of appropriate duration need to assess the clinical, microbiological, and inflammatory responses of the periodontium to oral irrigation, particularly those with periodontitis, dental implants, and special needs. Patient-reported outcome measures, costs, caries prevention, and environmental impact of oral irrigation need to be compared to other oral hygiene aids.

Comparative evaluation of two subgingival irrigating solutions in the management of periodontal disease: A clinicomicrobial study

Context

Local administration of antimicrobial agents offer a "site-specific" approach to the periodontal therapy and it has several benefits.

Aim

The present study was aimed to assess the clinical and microbial changes by subgingival irrigation using different subgingival irrigants in periodontitis patients and also to assess the mechanical effect of different local irrigation devices; if any.

Settings and Design

Split-mouth design was employed on ten individuals.

Materials and Methods

The study sample consisted of 10 individuals in whom full-mouth scaling and root planing was performed and subgingival irrigation therapy was instituted for an experimental period of 30 days. The clinical as well as microbiological parameters were evaluated.

Statistical Analysis Used

To calculate baseline data with day thirty data, paired t-test was used. Intergroup comparison was carried out using one-way ANOVA. Multiple comparisons among groups were carried out using post hoc Tamhane's T2 test.

Results

Among the different subgingival irrigants used, 0.2% chlorhexidine gluconate is most effective followed by ozonated water, whereas saline was found to be ineffective when compared to the other two subgingival irrigants. Subgingival irrigation using pulsated device may not have any additive effect in alteration of the subgingival microflora.

Conclusion

Within the limits and scope of the study, it can be safely concluded that 0.2% chlorhexidine may be used as an adjunct to mechanical therapy for achieving a significant reduction in inflammatory periodontal changes and also reduction in periodontopathogenic microflora.

Effectiveness of Subgingival Irrigation as an Adjunct to Scaling and Root Planing in the Treatment of Chronic Periodontitis: A Systematic Review

AIM

Subgingival applications of various chemotherapeutic agents have been used as an adjunct to nonsurgical periodontal treatment and preventive periodontal therapy. Their use in regular clinical practice, however, is less, perhaps due to concerns about clinical success or probably due to a lack of knowledge of their effectiveness or cost. The aim of this systematic review is to obtain overall quantitative estimate of effectiveness of subgingival irrigation (SI) in the treatment of chronic periodontitis.

MATERIALS AND METHODS

A literature search of electronic database was performed for articles published through December 31, 2014, followed by manual search of dental journals. Randomized controlled trails (RCTs) assessing the effect of SI as an adjunct to scaling and root planing (SRP) in the treatment of chronic periodontitis evaluated by changes in the clinical and microbiological outcomes were included.

RESULTS

This literature search yielded only two randomized, placebo-controlled studies that evaluated the efficacy of SI as an adjunct to SRP in patients with chronic periodontitis. The studies were methodologically not perfect (in terms of mediocre quality) with a risk of bias to come to any final conclusions to be reached. These studies didn't clearly mention about randomization, allocation concealment, blinding, dosage and formulation of irrigants, severity of periodontal disease, patient-centered outcomes and results data.

CONCLUSION

Due to insufficient evidence supporting the efficacy of SI as an adjunct to SRP in treating chronic periodontitis, more rigorous scientific research is required to assess the efficacy of SI as an adjunct to SRP in the treatment of periodontal diseases.

Treatment modalities and evaluation models for periodontitis

Periodontitis is the most common localized dental inflammatory disease related with several pathological conditions like inflammation of gums (gingivitis), degeneration of periodontal ligament, dental cementum and alveolar bone loss. In this perspective, the various preventive and treatment modalities, including oral hygiene, gingival irrigations, mechanical instrumentation, full mouth disinfection, host modulation and antimicrobial therapy, which are used either as adjunctive treatments or as stand-alone therapies in the non-surgical management of periodontal infections, have been discussed. Intra-pocket, sustained release systems have emerged as a novel paradigm for the future research. In this article, special consideration is given to different locally delivered anti-microbial and anti inflammatory medications which are either commercially available or are currently under consideration for Food and Drug Administration (FDA) approval. The various in vitro dissolution models and microbiological strain investigated to impersonate the infected and inflamed periodontal cavity and to predict the in vivo performance of treatment modalities have also been thrashed out. Animal models that have been employed to explore the pathology at the different stages of periodontitis and to evaluate its treatment modalities are enlightened in this proposed review.

Position Paper: The Role of Supra- and Subgingival Irrigation in the Treatment of Periodontal Diseases

This position paper addresses the role of supra- and subgingival irrigation in the treatment of periodontal diseases. It was prepared by the Committee on Research, Science and Therapy of the American Academy of Periodontology. The document is divided into two portions, consisting of supragingival irrigation and subgingival irrigation. In their respective segments, these treatment techniques are assessed as monotherapies and as adjuncts to conventional treatment. The conclusions drawn in this paper represent the position of the American Academy of Periodontology regarding irrigation therapy in the treatment of periodontal diseases.

Impact of local adjuncts to scaling and root planing in periodontal disease therapy: a systematic review

BACKGROUND

Chronic periodontitis affects many adults in the United States, some severely enough to threaten tooth loss. Of particular clinical importance is whether scaling and root planing (SRP) accompanied by a local adjunctive therapeutic agent improves outcomes over time compared to SRP alone. The adjunctive therapeutic agents investigated include: tetracycline, minocycline, metronidazole, a group of other antibiotics, chlorhexidine, and a group of antimicrobials. Primary outcomes considered are reductions in probing depth (PD) and gains in clinical attachment level (CAL).

METHODS

RTI-UNC Evidence-Based Practice Center staff searched MEDLINE (1966 through December 2002) and EMBASE (through February 2002) to identify clinical trials published in English that 1) involved adults with chronic periodontitis but no serious comorbidities; 2) tested one or more chemical antimicrobial agents as an adjunct to SRP alone or with a placebo; 3) had a concurrent control group that received the same SRP as the treatment group; 4) reported outcomes for specified, fixed time periods; and 5) if multiple antimicrobials were tested, reported outcomes for each agent separately. We performed qualitative analyses and meta-analyses of PD and CAL effect sizes when the necessary data were available from at least three studies at 6-month follow-up.

RESULTS

Among the locally administered adjunctive antimicrobials, the most positive results occurred for tetracycline, minocycline, metronidazole, and chlorhexidine. Adjunctive local therapy generally reduced PD levels. Differences between treatment and SRP-only groups in the baseline-to-follow-up period typically favored treatment groups but usually only modestly (e.g., from about 0.1 mm to nearly 0.5 mm) even when the differences were statistically significant. Effects for CAL gains were smaller and statistical significance less common. The marginal improvements in PD and CAL were a fraction of the improvement from SRP alone.

CONCLUSIONS

Whether such improvements, even if statistically significant, are clinically meaningful remains a question. A substantial agenda of future research to address this and other issues (e.g., costs, patient-oriented outcomes) is suggested.

Can we successfully maintain risk patients?

The most fundamental premise in the current view of periodontal disease is that not all individuals are at equal risk for disease and disease progression. Studies reveal that about 5-20% of the population is at risk for severe disease progression. The purpose of this paper is to define at-risk patients, review risk factors and indicators of disease progression, and outline an evidence-based strategy that includes both self-care and professional care for maintaining periodontal health. Risk factors/risk indicators considered include history of previous disease, increased pocket depth and loss of clinical attachment, frequency of dental care, specific bacterial pathogens, and systemic/environmental host factors such as smoking, diabetes mellitus, genetics, and stress. Because host factors may have more influence on disease progression than periodontal pathogens, personal and professional maintenance care must include the role of the host in periodontal disease progression. By examining the evidence surrounding these complex issues, dentists and dental hygienists are able to determine the extent to which evidence supports available approaches to maintain periodontal health and control disease progression.

Does professional preventive care benefit from additional subgingival irrigation?

The effect of an oral irrigator (Water Pik, Intersante) with a subgingival tip (Pik Pocket Subgingival Tip, Intersante) in the reduction of gingivitis was investigated in a single-blind three-group study involving 45 volunteers (age 46.2+/-10.2). All volunteers (inclusion criteria: gingivitis or a superficial periodontitis) were examined and underwent professional tooth cleaning at the first appointment. They were then randomly distributed in three groups: one group used the irrigator with the subgingival tip once daily with just tap water, in addition to their regular oral hygiene; another group also used an herbal-based mouth rinse (Parodontax, GlaxoSmithkline) in the water of the irrigator; a third group did not use an irrigator or any irrigant and therefore served as control. All groups received professional oral care education at each appointment. The investigation period was 3 months. At baseline and after 4, 8, and 12 weeks, the plaque index (PI, scores 0-5), gingival index (GI, scores 0-3), bleeding index (BI scores 0-5), and sulcus fluid flow rate (SFFR, Periotron 6000) at the Ramfjord teeth were scored. At baseline and after 3 months, the probing depth (millimeters) was measured at six surfaces of all teeth. A significant reduction in BI, PI, GI, probing depth, and SFFR was observed within 3 months. With all volunteers, however, there was no statistically significant difference ( p>/=0.05, Wilcoxon-test, SAS 6.04) between the three groups at any time. The additional use of the Water Pik irrigator with the Pik Pocket subgingival irrigation device with or without an herbal mouth rinse showed no clinical benefit over professional education in oral hygiene alone.

Local anti-infective therapy: pharmacological agents. A systematic review

BACKGROUND

It is well recognized that periodontal diseases are bacterial in nature. An essential component of therapy is to eliminate or control these pathogens. This has been traditionally accomplished through mechanical means (scaling and root planing [SRP]), which is time-consuming, difficult, and sometimes ineffective. Over the past 20 years, locally delivered, anti-infective pharmacological agents, most recently employing sustained-release vehicles, have been introduced to achieve this goal.

RATIONALE

This systematic review evaluates literature-based evidence in an effort to determine the efficacy of currently available anti-infective agents, with and without concurrent SRP, in controlling chronic periodontitis.

FOCUSED QUESTION

In patients with chronic periodontitis, what is the effect of local controlled-release anti-infective drug therapy with or without SRP compared to SRP alone on changes in clinical, patient-centered, and adverse outcomes?

SEARCH PROTOCOL

MEDLINE, the Cochrane Central Trials Register, and Web of Science were searched. Hand searches were performed of the Journal of Clinical Periodontology, Journal of Periodontology, and Journal of Periodontal Research. Searches were performed for articles published through April 2002. In addition, investigators contacted editors of the above-mentioned journals and companies sponsoring research on these agents for related unpublished data and studies in progress.

SELECTION CRITERIA

INCLUSION CRITERIA

Studies included randomized controlled clinical trials (RCT), and case-controlled and cohort studies at least 3 months long. Therapeutic interventions had to include 1) SRP alone; 2) local anti-infective drug therapy and SRP; or 3) local anti-infective drug therapy alone. Included studies had to report patient-based mean values and measures of variation for probing depth (PD) and/or clinical attachment levels (CAL) for both test and control groups.

EXCLUSION CRITERIA

Studies were excluded if they: 1) included data from a previously published article; 2) included daily rinsing with chlorhexidine (CHX); or 3) had unclear descriptions of randomization procedures, examiner masking, or concomitant therapies.

DATA COLLECTION AND ANALYSIS

For the meta-analysis, PD and CAL were expressed as summary mean effects with 95% confidence intervals (CI) for the effect, and analyzed using a standardized difference between SRP alone and experimental agent groups. The results were assessed with both fixed-effects and random-effects models. Studies were ranked according to the York system.

MAIN RESULTS

1. Thirty-two studies were included (28 RCT, 2 cohort, and 2 case-control), incorporating a total patient population of 3,705 subjects. 2. Essentially all studies reported substantial reductions in gingival inflammation and bleeding indices, which were similar in both control and experimental groups. 3. A meta-analysis completed on 19 studies that included SRP and local sustained-release agents compared with SRP alone indicated significant adjunctive PD reduction or CAL gain for minocycline (MINO) gel, microencapsulated MINO, CHX chip and doxycycline (DOXY) gel during SRP compared to SRP alone. 4. Use of antimicrobial irrigants or anti-infective sustained-release systems as an adjunct to SRP does not result in significant patient-centered adverse events.

REVIEWERS' CONCLUSIONS

1. In some populations, anti-infective agents in a sustained-release vehicle alone can reduce PD and bleeding on probing (BOP) equivalent to that achieved by SRP alone. 2. No evidence was found for an adjunctive effect on reduction of PD and BOP of therapist-delivered CHX irrigation during SRP compared to SRP alone. 3. Additional RCTs are needed which evaluate the effectiveness of these therapies in all forms of periodontitis. 4. The study protocol for future RCTs should include appropriate statistical analyses and complete data sets to facilitate future evidence-based reviews. 5. Alternative surrogate parameters to PD and CAL need to be identified and validated such as microbial, inflammatory, or tissue-destructive markers that could be used in conjunction with clinical parameters to help determine the patient's response to emerging technologies that target the infectious and/or inflammatory aspects of periodontitis. 6. Future Phase IV clinical trials should be designed that evaluate local anti-infective therapies in conjunction with SRP in a manner consistent with current standards of care and evaluate cost-effectiveness. 7. The use of local anti-infective agents in at-risk patient populations and for the treatment of at-risk disease sites needs to be validated in randomized controlled clinical trials. 8. Several local anti-infective agents combined with SRP appear to provide additional benefits in PD reduction and CAL gain compared to SRP alone. The decision to use local anti-infective adjunctive therapy remains a matter of individual clinical judgment, the phase of treatment, and the patient's status and preferences.

Nonsurgical periodontal therapy in 2000: a literature review

BACKGROUND

This article addresses the advantages and limitations of nonsurgical periodontal therapies to treat patients with mild-to-moderate chronic periodontitis.

TYPES OF STUDIES REVIEWED

Controlled clinical trials were selected that assessed the efficacy of the following treatment methods: mechanical instrumentation, ultrasonic débridement, supragingival irrigation, subgingival irrigation, local drug delivery, administration of systemic antibiotics and host-response modulation. Evidently, data with regard to alterations of probing depth, clinical attachment levels and inflammatory status were evaluated.

RESULTS

Comparison of the data from test and control groups revealed the following results. Manual and ultrasonic débridement can be used to treat most patients with mild-to-moderate chronic periodontitis. Patients who do not practice optimal plaque control can enhance their personal hygiene procedures by using supragingival irrigation. Subgingival irrigation usually does not provide any benefit beyond that achieved with root planing. Systemic and locally delivered antimicrobial agents appear to be most beneficial among patients who do not respond to conventional treatment. Host modulation may enhance root planing modestly.

CLINICAL IMPLICATIONS

The data indicate that most patients with mild-to-moderate periodontitis can be treated with nonsurgical therapies. However, clinicians need to be aware of the limitations of each technique with regard to the magnitude of improvement that it can induce at specific sites.

0.1%/0.2% commercial chlorhexidine solutions as subgingival irrigants in chronic periodontitis

This study compared 2 proprietary chlorhexidine (CH) products, Corsodyl (CO-0.2% CH, then ICI, U.K.) and Eludril (EL-0.1% CH, Pierre Fabre, France) as subgingival irrigants adjunctive to Simplified Oral Hygiene. 19 subjects, 8M, 11F, aged 30-57 years, mean 44 years, took part. Probing pocket depth (PPD) ranged from 5-10 mm, mean 6.5 mm (CO and EL), with 60 CO and 65 EL sites. After oral hygiene instruction, without stress on interdental cleaning, patients received on visit supra- and subgingival debridement, and instruction in subgingival irrigation using the Max-I-Probe system (Smith & Nephew MPL, USA). For baseline, days 28 (end of irrigation), 56 and 84, data were respectively: GI (medians): 1.7, 1.2, 1.2, 1.0 (CO), 1.9, 1.5, 1.3, 1.0 EL); BOP (medians): 1.2, 0.4, 0.7, 0.4 (CO), 1.5, 0.6, 0.6, 0.25 (EL); PPD (mm) (means): 6.3, 4.8, 4.2, 4.5 (CO), 6.8, 5.2, 5.3, 4.7 (EL); PAL (mm) (means-change relative to day 0): 0.6, 0.5, 0.8 (CO), 0.8, 0.8, 1.5 (EL). By Wilcoxon for non-parametric and t-tests for parametric data, both groups showed significant improvement for all variables at all times relative to baseline, with only one significant difference between the groups, in favour of EL, for PAL at day 84 (p < 0.05). This pilot study indicates that both simplified oral hygiene regimes are effective in periodontitis, but that there was no difference between the 2 commercial irrigants as adjunctives.

The effect of irrigation with chlorhexidine or saline on plaque vitality

24 adult patients suffering from Adult periodontitis were assigned to 4 groups: the 1st rinsed for 1 min with 0.2% chlorhexidine gluconate (CHX); the 2nd group were irrigated for 15 s with 0.2% CHX in a pulsed oral irrigator; the 3rd group rinsed for 1 min with saline and the 4th group were irrigated for 15 s with saline. Plaque vitality was measured after the 4 experimental procedures, using the method described by Netuschil et al. and scored using the method described by Rundegren et al. The results showed that a single rinse or irrigation with 0.2% CHX solution decreased the % of viable micro-organisms, but the vitality of the bacteria remained unchanged in saline groups. Statistical analysis indicated that irrigation with CHX was more effective at reducing plaque vitality than rinsing with CHX.

A review of chlorhexidine and its use in special populations

The purpose of this paper is to review the mechanism of the action, safety, and side-effects of chlorhexidine, and to provide guidelines for its use in special populations. Chlorhexidine has been used orally since 1959, primarily for the control of dental plaque. Chlorhexidine is a safe material, with low toxicity potential when used correctly. The most conspicuous side-effects are the development of yellow-brown stains on the teeth, tongue, and at the margins of anterior restorations, and an alteration in taste sensation. The use of chlorhexidine is indicated in developmentally disabled, medically compromised patients, and in dependent elderly populations, since these groups are often physically unable to remove plaque by mechanical means. Clinicians should not prescribe chlorhexidine indiscriminately for all patients, however, until analyzing its efficacy, safety, and side-effects.

The role of subgingival irrigations in the treatment of periodontitis

While the efficacy of oral irrigations with antimicrobial agents on the clinical and microbial parameters of gingivitis is well established, the study of the efficacy of intrapocket irrigants on periodontitis has yielded conflicting and inconclusive results regarding both clinical and microbiological parameters. The overall goal of this review paper is to summarize the available information on the efficacy of intrapocket irrigation in the treatment of patients with periodontitis. The following topics are addressed: 1) the penetrability of the irrigant; 2) pocket irrigation without scaling and root planing; 3) professional pocket irrigation following scaling and root planing; 4) irrigations between recalls; and 5) safety of intrapocket irrigation. Single irrigation of periodontal pockets for short periods of time before or after scaling and root planing has limited effects on periodontal healing. However, continuous irrigation of the periodontal lesion with agents such as povidone iodine during thorough scaling and root planing, such as that carried out under local anesthesia, has promise as an antimicrobial adjunct in periodontal therapy.

Clinical effects of simultaneous ultrasonic scaling and subgingival irrigation with chlorhexidine. Mediating influence of periodontal probing depth

The clinical and microbial effects of a single episode of simultaneous ultrasonic scaling and subgingival irrigation with chlorhexidine (CHX) were studied as a function of clinical probing depth in patients with adult periodontitis. 60 patients were randomly assigned to receive subgingival irrigation under cavitation with either sterile water or 0.12% CHX delivered through the tip of an ultrasonically activated scaler as part of initial periodontal therapy in a double-blind study design. 3 periodontal sites were randomly selected for examination from each patient on the basis of clinical probing depth, with 1 site being selected within each of the following ranges: 1-3 mm, 4-6 mm, and 7-9 mm. Pretreatment and post-treatment (days 14 and 28) clinical assessments included a plaque index (PI), gingival index (GI), and clinical probing depth (CPD). Subgingival specimens also were collected from 1-3 mm and 4-6 mm sites on a random subset of patients (15 per group). Plaque counts of spirochetes and motile organisms were made by darkfield microscopy. Significant reductions in PI, GI, and CPD were observed among all sites within both treatment groups at 14 and 28 days post-treatment. CHX irrigation resulted in a significantly greater reduction in CPD than did water among sites initially probing 4-6 mm at both 14 and 28 days post-treatment (25% versus 13% and 31% versus 18%, respectively). Spirochete counts were modestly but nonsignificantly reduced at 14 days post-treatment among sites 4-6 mm within both treatment groups. These results suggest that subgingival irrigation with CHX during ultrasonic scaling provides differential clinical benefits that are site-dependent.

Clinical effect of subgingival chlorhexidine irrigation on gingivitis in adolescent orthodontic patients

Twenty-three adolescent orthodontic patients with gingivitis affecting all banded first molars volunteered for the study. Three measures associated with gingivitis (papilla bleeding index, plaque index, and probing depth) were recorded at four sites for all four molars. A single application of subgingival irrigation with 0.12% chlorhexidine digluconate or isotonic saline was performed for 5 seconds at each site. As determined by coin toss, the first molars on the right or left side of the mouth received either chlorhexidine or saline irrigation. The papilla bleeding index, plaque index, and probing depth were recorded before the treatment and subsequently at 2 weeks and then 4 weeks. The gingival bleeding as determined by papilla bleeding index, was virtually eliminated in 4 weeks by a single application of subgingival irrigation with either chlorhexidine or saline. However, there was no significant reduction in pocket depth or plaque index. In addition, no significant difference between the effect of chlorhexidine or saline was found for any of the outcome measures.

Comparison of a subgingivally placed cannula oral irrigator tip with a supragingivally placed standard irrigator tip

This study compared the depth of irrigation of periodontal pockets achieved by a cannula subgingival irrigator tip and a standard oral irrigator tip. They were tested on periodontally involved teeth recommended for extraction from 17 patients. Before extraction, reference grooves were made circumferentially in each study tooth at the level of the gingival margin. In one group of 5 patients (29 teeth), a cannula was inserted halfway into the pocket at the facial, mesiofacial, distofacial, lingual, mesiolingual and distolingual surfaces and the surface irrigated for 5 s at 5 psi with a solution of plaque-staining dye from an oral irrigator. A 2nd group of 7 patients (29 teeth) was tested similarly with a standard irrigating tip at 80 psi. A 3rd (control) group of 5 patients (26 teeth) rinsed with the dye solution. Teeth were then extracted. The distance on each tooth from the reference notch to the apical extent of the stained plaque, and also to the coronal limit of the connective tissue attachment, was measured at 4 sites (mesial, distal, buccal, lingual) under a dissecting microscope to determine the extent of dye penetration. Mean linear penetration for the control group was only 0.1 mm. Irrigation with the cannula tip penetrated farther into both the medium (3.5-6 mm) and the deep (greater than 6 mm) periodontal pockets (p less than 0.01) than did irrigation with the standard tip.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical effects of pulsed oral irrigation with 0.2% chlorhexidine digluconate in patients with adult periodontitis

The aim of this study was to investigate the effects of using 0.2% Chlorhexidine digluconate in an pulsated jet irrigator by patients as part of their daily dental home-care measures. After initial assessment, 16 patients diagnosed as having adult periodontitis received scaling and polishing together with advice on the subgingival use of a pulsated jet oral irrigator with which they were supplied. 8 patients having 293 active sites with probing depths equal to or in excess of 4 mm used 0.2% chlorhexidine digluconate (CHX) in the oral irrigator, 2 x daily for 56 days. The other group of 8 patients with 253 active sites over 4 mm used a placebo as the irrigating solution. A modified dichotomous plaque index (MPI), gingival bleeding index (GBI) and probing pocket depths (PPD) were assessed on days 0, 28 and 56. Within-group comparisons showed that the CHX regime reduced MPI, GBI and PPD significantly but that the placebo group (PG) only achieved a significant reduction in the PPD. Between-group comparisons showed that the use of 0.2% CHX as an irrigant was significantly more effective than the placebo solution at reducing all the clinical parameters studied. The patients found the oral irrigator easy and pleasant to use, although all the CHX group developed staining to a varying extent. This double blind study demonstrated that 0.2% CHX used 2 x daily in an oral irrigator was effective at reducing plaque deposition, periodontal inflammation and probing pocket depths. The effects of using lower concentrations of chlorhexidine digluconate in this regime need to be investigated.

Clinical effectiveness of subgingival irrigation with a pulsated jet irrigator versus syringe

Previous studies have shown clinical and microbiological improvement with subgingival irrigation particularly after scaling and root planing. In this study we monitored the effects of saline irrigation on non-treated periodontal pockets. Ten subjects with severe periodontal disease and symmetrical lesions on multirooted teeth were selected. They had not received periodontal treatment or antibiotics for the previous 6 months. Patients were given simplified oral hygiene instructions. Neither scaling nor root planing was provided during the study. Two teeth were randomly selected per quadrant for subgingival irrigation with saline solution. One side was treated with a syringe and the other side with a pulsated jet irrigator with a modified tip, professionally administered. Clinical parameters (pocket depth, plaque index, gingival index, crevicular fluid, bleeding index, attachment level, and subgingival microflora) were evaluated on days 0, 15, 30, 60, and 90. Both subgingival irrigation products induced changes (reductions) in these indices during the study. Significant differences (P less than 0.001) with the oral irrigator were found for the following parameters: microscopy, pocket depth, crevicular fluid, and plaque index. In this study, professionally administered saline irrigation with a pulsated jet irrigator was more effective than syringe treatment with the same solution. Neither treatment resulted in a detectable gain in probing attachment level. Since gain in attachment level is achievable by other techniques, neither of these subgingival irrigation procedures alone can be considered adequate for periodontal therapy.

Reviewing nonsurgical periodontal therapy

Selection of the appropriate case and clinical competency in treatment modalities results in success in nonsurgical periodontal therapy. The patient with early periodontitis with significant local factors in the form of professionally accessible plaque and calculus is the most receptive to nonsurgical periodontal treatment. The clinician must make decisions centering around the important question, "Can the patient, or moreover, can the therapist delivering the debridement, gain access to the microbial subgingival plaque on a frequent basis below the host defense threshold of the respective patient?" If the answer is "yes," nonsurgical periodontal therapy will be rewarding. If the answer is "no," other modalities such as periodontal surgery must be instituted.

Current concepts of periodontal maintenance

Changing concepts and a more complete understanding of the aetiology of chronic marginal periodontitis allow a more rational approach to the treatment of patients with periodontal diseases. A sequence of treatment steps of increasing complexity is presented for the prevention of recurrence of chronic marginal periodontitis during the maintenance phase of treatment.

Pulsated jet subgingival irrigation with 0.1% chlorhexidine, simplified oral hygiene and chronic periodontitis

This study investigated the efficacy of a 0.1% chlorhexidine preparation as an aid to a basic oral hygiene programme comprising only baseline root and crown debridement, instruction in bass brushing without emphasis on interdental cleaning, and pulsated mono-jet subgingival irrigation. Baseline data for plaque index, papilla bleeding index and probeable pocket depth were similar in both test and control groups. Mean values for all 3 parameters were clearly lower in the chlorhexidine group, both at the end of the period of active treatment and up to 2 months thereafter. These differences were statistically significant for P1I at day 28, PBI at day 56 and PPD at days 56 and 84, but not at day 168. Proportionately more sites generally showed improvement in the chlorhexidine group at all times. It was concluded that 0.1% chlorhexidine significantly enhances the effects of the practical oral hygiene regime described.

"Spontaneous" oral hygiene: a predictor for future preventive behavior?

The aim of this study was to establish whether a patient's "spontaneous" hygiene could be a reliable predictor of his or her tendency to maintain a certain permanent level of hygiene. The sample comprised 147 private periodontal patients whose plaque indices were recorded before (index 1) and after (index 2) a standardized hygiene program was carried out. According to their initial indices the patients were distributed in 10 classes (Class 0: from 0 to 10% using O'Leary's plaque index, class 1: from 11% to 20%, etc.). The two biggest classes were greater than 50% (48.3% of the subjects of the whole sample belonged to classes 5 and 6). A coefficient (IC) = Index 1 - Index 2/Index 1 + Index 2 was conceived to appreciate the different degrees of improvement. There was a marked difference in behavior between patients whose initial plaque index was less than 50% and those whose initial index was greater than 50%. The former improved noticeably, whereas the latter did not. Within the limits of the investigated population the following conclusions can be drawn: 1) initial plaque index and possibilities of improvement are correlated; 2) initial plaque index, recorded prior to any periodontal treatment, may be a reliable predictor of a patient's future compliance.

The in vitro effects of chlorhexidine on subgingival plaque bacteria

The purpose of this study was to determine the susceptibility to chlorhexidine of a range of bacteria which may be isolated from subgingival plaque. In addition, the effect of chlorhexidine on the survival of bacteria in subgingival plaque samples from patients with chronic inflammatory periodontal disease was investigated. The minimum inhibitory concentration (MIC) of chlorhexidine for 52 strains of bacteria ranged from 8 to 500 micrograms/ml. The modal value of the MIC was found to be 62 micrograms/ml, 64% of the strains tested being inhibited at this concentration. A concentration of 250 micrograms/ml of chlorhexidine inhibited the growth of all bacteria in the 25 subgingival plaque samples investigated. The MIC of chlorhexidine for the samples ranged from 31 to 250 micrograms/ml, the modal value being 125 micrograms/ml.

Subcutaneous facial emphysema secondary to use of the Cavi-Jet

A case of subcutaneous facial emphysema secondary to use of the Cavi-Jet air polishing system is reported. Air pressure of the Cavi-Jet may exceed that of other dental instruments such as the air/water syringe or air turbine handpiece. Inadvertent angulation of the nozzle tip into a severe periodontal pocket precipitated this condition, which resolved with no serious sequelae. No treatment other than prophylactic antibiotics was prescribed.

Effects of subgingival irrigation on periodontal status

Periodontal diseases are localized, plaque-related infections. Often, clinical signs of inflammation are not eradicated by supragingival plaque control, dictating that subgingival microbial populations must be reduced. Confirmation that it is possible to deliver medicaments to the base of deep pockets stimulated numerous investigations. This report evaluates the role of site-specific pharmacotherapy to enhance periodontal status.

Modes of application of anti-plaque chemicals

Because interdental and subgingival sites are relatively inaccessible to mouthrinsing, they necessitate alternative methods of application of anti-plaque chemicals. These include routine oral hygiene aids, surfactants to enhance uptake and retention of antimicrobials, gels and periodontal dressings. The principal modes of application that have received attention recently, apart from the systemic route, are syringe and pulsated jet irrigation and slow release compounds. Slow release devices currently receiving attention may be classified as membrane diffusion, solution of drug in polymer and solid drug dispersed in polymer matrix. The most widespread dental instance of a slow release device appears to be the use of varnishes and resins to carry fluoride. Recent attempts at devising improved methods of antimicrobial application include the testing of materials for their biodegradability or for their potential to adhere to mucosal surfaces. It is concluded that the potential exists for antimicrobials applied directly to the site of intended action to contribute significantly to dental health, particularly when employed as components of practical oral hygiene regimes.