Pathogenicity testing of Macaca arctoides subgingival plaque following chlorhexidine treatment

Periodontitis: facts, fallacies and the future

This volume of Periodontology 2000 represents the 25th anniversary of the Journal, and uses the occasion to assess important advancements in periodontology over the past quarter-century as well as the hurdles that remain. Periodontitis is defined by pathologic loss of the periodontal ligament and alveolar bone. The disease involves complex dynamic interactions among active herpesviruses, specific bacterial pathogens and destructive immune responses. Periodontal diagnostics is currently based on clinical rather than etiologic criteria, and provides limited therapeutic guidance. Periodontal causative treatment consists of scaling, antiseptic rinses and occasionally systemic antibiotics, and surgical intervention has been de-emphasized, except perhaps for the most advanced types of periodontitis. Plastic surgical therapy includes soft-tissue grafting to cover exposed root surfaces and bone grafting to provide support for implants. Dental implants are used to replace severely diseased or missing teeth, but implant overuse is of concern. The utility of laser treatment for periodontitis remains unresolved. Host modulation and risk-factor modification therapies may benefit select patient groups. Patient self-care is a critical part of periodontal health care, and twice-weekly oral rinsing with 0.10-0.25% sodium hypochlorite constitutes a valuable adjunct to conventional anti-plaque and anti-gingivitis treatments. A link between periodontal herpesviruses and systemic diseases is a strong biological plausibility. In summary, research during the past 25 years has significantly changed our concepts of periodontitis pathobiology and has produced more-effective and less-costly therapeutic options.

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.

Periodic subgingival antimicrobial irrigation of periodontal pockets (I). Clinical observations

The present investigation was undertaken to study the clinical effect of professionally performed periodic subgingival irrigation per se and as an adjunct to scaling and root planing. 10 patients suffering from moderate-severe periodontal disease participated in the study. Following an initial 3-month period of supervised supragingival plaque control, a total of 102 periodontal sites with probing pocket depth greater than or equal to 6 mm and "bleeding on probing" were selected and subjected to a Baseline examination comprising assessments of oral hygiene and gingival conditions, probing depths and probing attachment levels. The pockets in the various jaw quadrants were randomly assigned to one of the following treatment groups: (1) periodic subgingival irrigation with hydrogen peroxide, (2) periodic subgingival irrigation with chlorhexidine, (3) periodic subgingival irrigation with saline and (4) no subgingival treatment. During the first part of the study (baseline-32 weeks), no mechanical debridement of the subgingival area was performed. The irrigation treatment was carried out by the operator 3 times per week during weeks 1 + 2 and 5 + 6 of the trial. In the 2nd part of the trial (32-52 weeks), the sites were subjected to scaling and root planing combined with professional irrigation during weeks 32-38. The previously non-irrigated control sites were not subjected to adjunctive irrigation when mechanically debrided. During the entire study, the patients were recalled for professional tooth cleaning once every 4 weeks. Re-examinations were carried out at 4, 6, 32, 40 and 52 weeks. The results revealed that repeated professional irrigation of unscaled periodontal pockets with chlorhexidine or hydrogen peroxide resulted in a temporarily reduced frequency of bleeding sites, but not in any clinically significant changes in probing assessments. A similar improvement of bleeding scores was observed in the saline-irrigated control group. Scaling and root planing, in combination with an optimal supragingival plaque control, resulted in a marked resolution of the clinical symptoms of periodontal disease. Adjunctive irrigation with chlorhexidine or hydrogen peroxide did not improve the healing result above and beyond that obtained after mechanical debridement alone or in combination with saline irrigation. Hence, the study failed to demonstrate that professionally performed periodic subgingival irrigation with chlorhexidine or hydrogen peroxide, used alone or in combination with thorough mechanical debridement, has a significant therapeutic effect.

A review of the literature on use of chlorhexidine in dentistry

In addition to its plaque-inhibiting effect, chlorhexidine possesses other properties beneficial for use in dentistry. These effects are outlined, and specific recommendations are given regarding chlorhexidine's use by general practitioners. The side effects of long-term use, such as staining, and the availability of chlorhexidine also are discussed.

The effect of mouthrinses on parameters characterizing human periodontal disease

The objective of the present clinical trial was to assess the efficacy of mouthwashes containing antiseptic agents on established and developing plaque and periodontal disease in adult subjects using a newly described clinical research model. The study was carried out in 21 patients with periodontal disease. At the baseline examination, all tooth surfaces-sites were studied with regard to dental plaque, gingivitis, bleeding on probing to the base of the pocket and probing pocket depths. The patients were subsequently randomly assigned to 1 of 3 groups, each consisting of 7 individuals. Group A rinsed with a 0.01% solution of Sanguinarine, group B rinsed with a 0.2% solution of chlorhexidine and group C rinsed with a placebo solution. No instructions regarding mechanical plaque control measures or information regarding the etiology and pathogenesis of periodontal disease were given to any of the patients during the course of the 6-weeks of trial. The clinical examination was repeated after 2 weeks use of the mouthwash preparations. Following the re-examination, all patients were subjected to scaling and root planing in 2 jaw quadrants chosen at random. After another 2 weeks, the 2nd re-examination was performed and the teeth in the 2 remaining jaw quadrants were thoroughly scaled. The final examination was performed 2 weeks later. During the 4 weeks of rinsing, without adjunctive professional mechanical debridement, the frequency distribution of plaque Index scores 2 + 3 did not change in the group of patients using the placebo solution, but was significantly reduced in both the chlorhexidine and the Sanguinarine groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Gingival bleeding after chlorhexidine rinses with or without mechanical oral hygiene

In a previous paper a slight increase in gingival bleeding tendency was reported after the use of chlorhexidine rinses in dental students with clinically healthy gingivae. For further clarification of this finding the study was repeated using a split mouth approach. 30 dental students brushed the teeth in either the left or the right side of their mouth twice daily during a 7-day period. After each brushing, they rinsed for 1 min with 10 ml of a 0.2% chlorhexidine digluconate solution. Both the Plaque Index (P1I) scores and the bleeding tendency after massage of the gingival margin were low at the initial examination. The low P1I scores at baseline were further reduced on both sides of the jaws. On the side which was only rinsed the P1I scores were higher than on the side of combined mechanical and chemical cleaning. The gingival bleeding tendency was found to decrease on the brushed side and to increase on the side which was only rinsed. An increased bleeding tendency was most often observed in those individuals whose gingivae were the healthiest at baseline. A SEM analysis of the 2 sides of the dentition indicated that bleeding after chlorhexidine rinses may be associated with irritation from debris which, after the 7-day period of no mechanical oral hygiene measures, seemed to obliterate the gingival sulcus.

Stannous fluoride and subgingival chlorhexidine irrigation in the control of plaque and chronic periodontitis

The purpose of this study was to investigate the possible benefits of stannous fluoride dentifrice (SnF2) and once daily chlorhexidine (CH) in the control of chronic periodontitis, following a single course of scaling and root planing. 14 adult patients with pockets 4 mm or deeper received a thorough scaling and root planing, followed by instruction in the irrigation of those pockets with CH. They were given either SnF2-containing or a placebo dentifrice, and a new multituft toothbrush, but no instruction in routine oral hygiene. Plaque Index (PII), Sulcus Bleeding Index (SBI) and pocket depth were recorded prior to scaling on day 0. The same parameters and gingival shrinkage were recorded at weeks 1, 2, 4, 8 and 12. CH irrigation was discontinued at day 28. Both groups showed highly significant improvements in all parameters except gingival shrinkage after 28 days. PII was significantly less at all stages in the SnF2 group. It reached baseline values by day 56 in the placebo and day 84 in the SnF2 group. Periodontitis as assessed by SBI remained reduced significantly below baseline values in both groups at the end of the study. At this time there was no significant difference between the groups as regards SBI. It was concluded that a single course of thorough scaling and root planing followed by once daily subgingival irrigation with CH for 1 month, produced a reduction in periodontitis still apparent 2 months after cessation of irrigation. This regime allows a 3-month interval between oral hygiene visits. SnF2-containing dentifrice had a plaque control effect additional to that produced by the regime but had no effect on periodontitis as assessed by SBI.

Use of chlorhexidine as a plaque control measure following surgical treatment of periodontal disease

Chlorhexidine mouth rinsing was compared with regularly performed professional tooth cleaning as a plaque control measure during healing following periodontal surgery. 14 patients were selected for the study. A Baseline examination included assessment of oral hygiene status, gingival condition, probing depth and attachment level. In each patient, scaling and root planing was carried out in conjunction with the modified Widman flap procedure including recontouring of alveolar bone irregularities in 2 jaw quadrants. The same procedures without osseous surgery were performed in contralateral jaw quadrants. 7 patients rinsed their mouth with a solution of 0.2% chlorhexidine digluconate twice a day, 2 min each time, for the first 6 months after therapy (healing phase). During the same period the remaining 7 patients were recalled every 2 weeks for professional tooth cleaning ad modum Axelsson & Lindhe (1974). Following reexamination after 6 months, all 14 patients were placed on a maintenance care program which included mechanical prophylaxis once every 3 months for 18 months (maintenance phase). Reexaminations were performed 6, 12 and 24 months after completion of initial therapy. The results revealed that professional tooth cleaning was somewhat more effective as a plaque control measure during healing following surgery than chlorhexidine mouth rinsing. At the end of the healing phase (1) there was a higher frequency of sites with pockets deeper than 4 mm in the patients who rinsed with chlorhexidine, (2) less gain of attachment occurred following chlorhexidine rinsing in pockets with an initial probing depth of greater than 4 mm, and (3) attachment loss in initially shallow pockets was somewhat more pronounced in the patients who rinsed with chlorhexidine. The differences in the effect of the 2 methods of plaque control, however, were small and in most respects diminished in the course of the maintenance phase. It was concluded that mouth rinsing with chlorhexidine is a proper alternative to plaque control during healing following periodontal surgery.

Gingival bleeding after chlorhexidine mouthrinses

During a clinical trial for evaluating the antiplaque effect of two flavoured chlorhexidine rinses, the observation was made that bleeding after gentle massage of the gingival margin occurred more often after chemical than after mechanical oral hygiene measures. In order to ascertain the validity of this unexpected observation, the same dental students participated in a repetition of the trial 18 months later. The results of the two trials indicate that gingival bleeding after gentle massage of the margin with the side of a periodontal probe actually occurs more frequently after rinsing twice daily with a 0.2% aqueous chlorhexidine solution for 1 week than after meticulous mechanical oral hygiene measures during an equally long time period. The average frequency of bleeding, in per cent of all examined gingival units, ranged from 1.3% after mechanical cleaning of the teeth to 5.4% after rinsing with chlorhexidine for 1 week. Neither the frequency of bleeding nor the difference between mechanical and chemical plaque control were considered to be of clinical significance. Further microbiological and histological studies are being conducted in an attempt to clarify the reason for the observed bleeding tendency.