Effect of 0.12% chlorhexidine on bacterial recolonization following periodontal surgery

Early periodontal wound healing after chlorhexidine rinsing: a randomized clinical trial

OBJECTIVES

This single-center randomized, parallel design, clinical trial with a 2-week follow-up involved patients affected by periodontitis undergoing periodontal surgery. The aim was to evaluate periodontal surgical wound healing with the use of chlorhexidine-based mouth rinses versus an untreated control group.

MATERIALS AND METHODS

Periodontal surgery was performed following a standardized protocol. Patients were randomly prescribed i) chlorhexidine (CHX) + anti-discoloration system (ADS) + hyaluronic acid (HA), ii) CHX + ADS or iii) no treatment (control group). Plaque score, gingival inflammation, and Early Healing Index (EHI), assessing the degree of wound closure and the presence of fibrin and necrosis, were evaluated at 3, 7 and 14 days after surgery.

RESULTS

In total, 33 patients were enrolled. Patients were comparable at baseline for all measured clinical parameters. At 3-days wound healing was significantly improved in all patients treated with CHX + ADS-based mouth rinses with a lower EHI score at the interdental papillae compared with control group (p < 0.01). CHX + ADS + HA group presented improved healing across all time points in terms of EHI, plaque containment, and gingival inflammation when compared to control group (p < 0.01).

CONCLUSIONS

The usage of CHX-ADS following periodontal surgery improved early wound healing, reduced plaque accumulation and gingival inflammation. During the early post-operative period the adjunct of HA further improved soft tissue closure.

CLINICAL RELEVANCE

This study aims at evaluating the response of gingival tissues to mouth rinsing with chlorhexidine and anti-discoloration system (CHX + ADS) or CHX + ADS + hyaluronic acid (CHX + ADS + HA) versus no rinse in terms of healing of the periodontal surgical wound. CHX + ADS mouth rinses enhanced early soft tissue closure after periodontal surgery and contributed to the reduction in plaque accumulation and gingival inflammation. The adjunct of HA may be beneficial especially in the early post-operative period. CHX + ADS administration following periodontal surgery may improve soft tissue healing in the first two post-operative weeks.

Hypochlorous Acid as a Potential Postsurgical Antimicrobial Agent in Periodontitis: A Randomized, Controlled, Non-Inferiority Trial

BACKGROUND

Hypochlorous acid (HOCl) is an antimicrobial agent with high affinity to Gram-negative bacteria of the subgingival biofilm. It could have an equivalent or no inferiority effect to chlorhexidine (CHX) to avoid recolonization of these microorganisms after the post-surgical period.

OBJECTIVE

The objective is to compare the reduction of plaque index (PI), gingival index (GI), pocket depth (PD), gain of clinical attachment level (CAL), and bacterial recolonization of periodontopathic microorganisms in subgingival biofilm at 7, 21, and 90 days after Open Flap Debridement (OFD) under two antimicrobial protocols: (A) HOCl 0.05% followed by HOCl 0.025% and (B) CHX 0.2%/CHX 0.12% used per 21 days without regular oral hygiene during the post-surgical period.

MATERIAL AND METHODS

A no-inferiority randomized controlled trial was carried out. Thirty-two patients were randomly divided to receive each antiplaque protocol after OFD in patients with periodontitis. Clinical indexes and bacterial recolonization were assessed using qPCR for up to 90 days. Data were analyzed using repeated measures ANOVA, mixed effects models adjusted for treatment, time, and the Chi-squared/Fisher test. A no-inferiority analysis was also performed using the Hodges-Lehmann hypothesis test for non-inferiority.

RESULTS

HOCl was not inferior to CHX in reducing PI. Both groups showed a comparable reduction of recolonization for Porphyromonas gingivalis, Tannerella forsythia, and Eubacterium nodatum. However, the HOCl protocol was non-inferior to the CHX protocol for Treponema denticola and Aggregatibacter actinomicetemcomitans.

CONCLUSIONS

HOCl improved periodontal healing. HOCl showed an impact in reducing the recolonization of periodontopathic bacteria in the postoperative period.

Influence of periodontal surgery on the subgingival microbiome-A systematic review and meta-analysis

OBJECTIVE

The objective of this systematic review and meta-analysis was to evaluate the effect of periodontal surgery on the subgingival microbiome.

BACKGROUND

Periodontitis is a chronic inflammation of the tooth supporting tissues caused by the dysbiosis of the subgingival biofilm. It is managed through different non-surgical and surgical treatment modalities. Recent EFP S3 guidelines recommended performing periodontal surgery as part of Step 3 periodontitis treatment after Step 1 and Step 2 periodontal therapy, with the aim to achieve pocket closure of persisting sites. Changes in the sub-gingival microbiome may explain the treatment outcomes observed at different time points. Various microbiological detection techniques for disease-associated pathogens have been evolved over time and have been described in the literature. However, the impact of different types of periodontal surgery on the subgingival microbiome remains unclear.

METHODS

A systematic literature search was conducted in Medline, Embase, LILACS and Cochrane Library supplemented by manual search (23DEC2019, updated 21APR2022).

RESULTS

From an initial search of 3046 studies, 28 were included according to our specific inclusion criteria. Seven microbiological detection techniques were used to analyse disease-associated species in subgingival plaque samples: optical microscope, culture, polymerase chain reaction (PCR), checkerboard, enzymatic reactions, immunofluorescence and 16S gene sequencing. The included studies exhibited differences in various aspects of their methodologies such as subgingival plaque sample collection or treatment modalities. Clinical data showed a significant decrease in probing pocket depths (PPD) and clinical attachment loss (CAL) after periodontal surgery. Microbiological findings were overall heterogeneous. Meta-analysis was performed on a sub-cohort of studies all using checkerboard as a microbiological detection technique. Random effect models for Treponema denticola (T. denticola), Porphyromonas gingivalis (P. gingivalis) and Tannerella forsythia (T. forsythia) did not show a significant effect on mean counts 3 months after periodontal surgery. Notably, Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans) showed a significant increase 3 months after periodontal surgery. 16S gene sequencing was used in one included study and reported a decrease in disease-associated species with an increase in health-associated species after periodontal surgery at 3 and 6 months.

CONCLUSION

This systematic review has shown that the effect of periodontal surgery on the changes in subgingival microbiome is heterogeneous and may not always be associated with a decrease in disease-associated species. The variability could be attributed to the microbiological techniques employed for the analysis. Therefore, there is a need for well-designed and adequately powered studies to understand how periodontal surgery influences the subgingival microbiome and how the individual's microbiome affects treatment outcomes after periodontal surgery.

Examination of the effects of kefir on healing factors in a mice burn model infected with E.coli, S.aureus and P.aeruginosa using qRT-PCR

Burn areas are susceptible to bacterial growth and infections, particularly in cases with lengthy periods of hospital stay. Burn wound healing, which involves various molecular and cellular mechanisms, continues to be a significant problem. Growth factors and cytokines play an active and vital role in wound healing. In the present study, the effects of kefir on wound healing in a 2nd-degree mouse burn model infected with e.coli, s.aureus and p.aeruginosa were investigated in vitro. In order to clarify the effects of kefir in the wound healing process, the macroscopic changes in kefir-applied scar tissue as well as wound depth and width were examined and IL-1α, IL-1β, IL-6, IL-8, IL-10 and TNF-α, VEGF, TGF-β protein levels were determined using the qRT-PCR method. The findings of the present study show that kefir has a positive impact on the factors playing a role in wound healing and accelerates the healing process.

Effect of Chlorhexidine Digluconate in Early Wound Healing of Human Gingival Tissues. A Histological, Immunohistochemical and Biomolecular Analysis

Chlorhexidine digluconate (CHX) is considered the gold standard for oral cavity antiseptic treatment. Nevertheless, several in vitro studies have reported detrimental effects in oral tissue repair. The aim of the present study was to evaluate the in vivo effect of post-surgical CHX mouth rinse on gingival tissue (G) 24 h after injury. G biopsies were obtained in three patients 24 h after surgery with the indication of post-surgical 0.12% CHX use and were compared with those obtained from the same patients without any antiseptic use. Changes in collagen production, cell proliferation, and apoptosis were examined by histological and Ki-67/P53 immunohistochemical analysis. Fibrotic markers (COL1A1, αSMA), proapoptotic protein (BAX) expression, and wound healing-related gene modulation (RAC1, SERPINE1, TIMP1) were analyzed by quantitative real-time PCR analysis. CHX was able to reduce cellular proliferation and increase collagen deposition, proapoptotic molecule and fibrotic marker expression, and myofibroblast differentiation, reduce expression of RAC1 and trigger expression of SERPINE1 and TIMP1, showing “scar wound healing response” pattern. This study assessed for the first time the in vivo effects of CHX on gingival tissue. The demonstration of a CHX-induced fibrotic transformation, leading to scar repair, supports the need for new post-surgical clinical protocols based on a strategic and personalized use of CHX.

Influence of Tooth-Brushing on Early Healing after Access Flap Surgery: A Randomized Controlled Preliminary Study

In the present study, the clinical outcomes obtained using three different protocols of post-operative plaque control for the 4 weeks after surgery were compared. Thirty healthy subjects, presenting at least one periodontal pocket requiring resective surgery, were selected and randomly distributed to three different groups corresponding to respective post-surgical protocols: (A) toothbrushes + chlorhexidine + anti-discoloration system (ADS + CHX); (B) toothbrushes + chlorhexidine (CHX); (C) only toothbrushes. The full-mouth plaque score (FMPS), full-mouth bleeding score (FMBS), probing pocket depth (PPD), recession depth (REC), clinical attachment level (CAL), and bleeding on probing (BoP) were measured in six aspects per tooth (mesio-buccal (MB), buccal (B), disto-buccal (DB), disto-lingual (DL), lingual (L), and mesio-lingual (ML)) at baseline, 3 months, and 6 months after surgery. FMPS and FMBS did not significantly change (p > 0.05), whereas PPD and CAL significantly decreased, and REC significantly increased in all groups during the study (p < 0.05). Clinical results were satisfactory in all cases, with no significant differences between groups 3 months after surgery. Six months after surgery, only PPD-MB was significantly different in the three groups (p < 0.05). Nevertheless, this value was not clinically relevant because the value of PPD-B (about 2 mm) in group C was physiologic. The mechanical plaque control was proven to be fundamental and sufficient in all the six aspects per tooth to guarantee an excellent clinical outcome without the need of chemical plaque control.

The Effect of Pre-TURP Bladder Irrigation with 0.2% Chlorhexidine in Patients with Foley Catheter Regarding Postoperative Bacteremia Decrease

Background: Transurethral resection of the prostate (TURP) has been widely used for patients suffering from bladder colonization with bacteria, increasing the probability of bacteremia and sepsis despite consuming prophylaxis antibiotics. Objectives: The study aimed to evaluate the effect of pre- TURP bladder irrigation with 0.2% chlorhexidine in reducing postoperative bacteremia. Methods: This clinical trial study was conducted on 60 benign prostatic hyperplasia (BPH) patients who were candidates for TURP in the urology department of Al-Zahra Hospital. All patients suffered from urinary catheters, and they were allocated into two groups (n = 30). Antibiotic prophylaxis was prescribed for all the patients. In the case group, the bladder was rinsed by chlorhexidine 0.2% before TURP; however, and the bladder in the control group was rinsed by distilled water. Postoperative bacteremia were evaluated using procalcitonin (PCT) measurement and BACTEC automated blood culture six hours after surgery. Results: Positive BACTEC blood culture was observed in three (10%) and no (0%) patients in the control and case groups, respectively (P = 0.071). Moreover, 6.6 % and 46.6 % of the patients in the control group had low and high PCT levels, respectively. Furthermore, 40 % and 6.66 % of the patients in the case group had low and high PCT levels, respectively. There was a significant difference between the two groups in terms of the PCT level (P < 0.01). Conclusions: The frequency of patients with a high PCT level was higher in the control group than in the case group, suggesting that chlorhexidine in the catheterized patients undergoing TURP reduced the number of bacteria in the bladder.

Effect of different concentrations of commercially available mouthwashes on wound healing following periodontal surgery: a randomized controlled clinical trial

OBJECTIVES

The purpose of this study was to evaluate the effect of chlorhexidine and essential oils containing mouth rinses on oral wound healing after periodontal flap surgery.

MATERIALS AND METHODS

Eighty subjects participated in the study and were randomly assigned to use water, 0.12% chlorhexidine (CHX), essential oils (EO), 5% CHX, and 10% EO. Subjects were examined at 1, 2, and 3 weeks postoperatively. Plaque index (PI) and the modified gingival index (GI) were recorded, while wound epithelialization was measured to evaluate the healing process. Numerical data were analyzed with parametric test for multiple comparisons (ANOVA) with Bonferroni correction. Categorical data were analyzed using Chi-square test/fisher exact test.

RESULTS

All groups demonstrated a gradual GI reduction from first to third visit. Patients in the CHX group presented statistically significant lower PI scores than patients in the water group at the all-time points of the study. Wound epithelialization analysis demonstrated that 100% of the sites in the CHX group were healing by secondary intention at visit 1. This finding was statistically significant.

CONCLUSION

Full strength concentrations of CHX and EO did not show any detrimental effects on healing after traditional periodontal surgery at the end of the observation period.

CLINICAL RELEVANCE

The use of chlorhexidine and EO containing mouthwashes does not appear to delay wound healing. Diluting these commercial mouthwashes may present an approach that could possibly reduce the adverse effects (such as tooth staining) associated with their use, while maintaining their antibacterial properties.

Effectiveness of Different Commercial Chlorhexidine-Based Mouthwashes After Periodontal and Implant Surgery: A Systematic Review

OBJECTIVES

The aim of the present study was to review the effectiveness, side effects, and patient acceptance of different concentrations and formulation of chlorhexidine-based mouthwashes used after periodontal and implant surgery.

MATERIALS AND METHODS

The PRISMA guideline was adopted in the search strategy using electronic databases PubMed and MEDLINE to identify randomized and case-control prospective studies on humans written in English language and published up to September 2017.

RESULTS

A total of 10 articles were selected for a total of 344 patients. Because of the significant heterogeneity of the outcome measures, meta-analysis was not performed, and the data were summarized in a table. A positive relationship between the use of chlorhexidine and reduction of plaque was found, demonstrating the effectiveness of the substance in terms of antisepsis and decrease of inflammation after periodontal and implant surgery.

CONCLUSION

Chlorhexidine is recognized as the primary agent for plaque control and the gold standard in preventing infection, although the presence of largely known side effects would affect patient compliance. Future research should be directed at finding chlorhexidine formulation with negligible adverse effects, without compromising or even increasing its effectiveness as the antiseptics and antiplaque agent.

Efficacy of chlorhexidine rinses after periodontal or implant surgery: a systematic review

BACKGROUND

Biofilm management and infection control are essential after periodontal and implant surgery. In this context, chlorhexidine (CHX) mouth-rinses are frequently recommended post-surgically. Despite its common use and many studies in this field, a systematic evaluation of the benefits after periodontal or implant surgery is-surprisingly-still missing.

OBJECTIVES

To evaluate the benefits of chlorhexidine rinsing after periodontal or implant surgery in terms of plaque and inflammation reduction potential. Furthermore, to screen whether the concentration changes or additives in CHX solutions reduce side effects associated with its use.

MATERIALS AND METHODS

A systematic literature search was performed for clinical trials, which compared CHX rinsing after periodontal or implant surgery with rinsing using placebo, non-staining formulations, or solutions with reduced concentrations of the active compound. Four databases (Medline, PubMed, Embase, Cochrane) were searched up to June 2018. Two reviewers independently identified and screened the literature.

RESULTS

From 691 titles identified, only eleven publications met the inclusion criteria and were finally included. Mainly early publications assessed the benefits of CHX over placebo rinsing, whereas more recent publications focused more on the evaluation of new formulations with regard to effectiveness and side effects. The use of CHX after surgery showed in general significant reduction in plaque (means of 29-86% after 1 week) and bleeding (up to 73%) as compared to placebo. No consensus, however, was found regarding the most beneficial CHX formulation avoiding side effects.

CONCLUSION

Chlorhexidine rinsing helps to reduce biofilm formation and gingival inflammation after surgery. However, no additional reduction of periodontal probing depth over any given placebo or control solution could be found irrespective of whether CHX was used or not. The use of additives such as antidiscoloration systems (ADS) or herbal extracts may reduce side effects while retaining efficacy.

CLINICAL RELEVANCE

Within the limitations of this review, it can be concluded that CHX may represent a valuable chemo-preventive tool immediately after surgery, during the time period in which oral hygiene capacity is compromised. To reduce the side effects of CHX and maintain comparable clinical effects, rinsing with less concentrated formulations (e.g., 0.12%) showed the most promising results so far.

Clinical efficacy of a chlorhexidine-based mouthrinse containing hyaluronic acid and an antidiscoloration system in patients undergoing flap surgery: A triple-blind, parallel-arm, randomized controlled trial

OBJECTIVES

To evaluate the postsurgery gingival healing as well as plaque, gingival inflammation and staining levels following the use of a 0.2% chlorhexidine (CHX) solution with or without antidiscoloration system (ADS) and 0.2% hyaluronic acid (HA).

METHODS

Patients undergoing flap surgery at sites with an intact or reduced but healthy periodontium participated in a parallel-arm RCT. After surgery, patients used the assigned mouthrinse (CHX + HA + ADS or CHX) for 21 days. At days 7 and 21, the healing process was evaluated at experimental teeth using a composite index, namely the Gingival Healing Index (GHI). GHI score was obtained as the sum of the scores related to the severity of wound dehiscence (score 1-3) and the profile of the buccal and oral aspects of the papilla (score 1-3). Therefore, GHI ranged from 2 (worst quality of healing) to 6 (optimal quality of healing). Plaque Index (PlI), Gingival Index (GI), angulated bleeding score (AngBS), and tooth and tongue staining were also assessed.

RESULTS

In both groups, GHI assumed values of 5 or 6 at both days 7 and 21 in ≥50% of patients, and low median values of PlI, GI, AngBS and staining were observed during the 21-day period. Except for a significantly lower GI in CHX group at day 7, no other significant intergroup differences were found.

CONCLUSIONS

Postsurgery plaque control based on either CHX or CHX + HA + ADS mouthrinses results in optimal plaque control and quality of early gingival healing along with limited tooth and tongue staining.

Effect of essential oil and chlorhexidine mouthwashes on gingival fibroblast survival and migration

BACKGROUND

Chemical plaque control is the most commonly recommended means of oral hygiene after periodontal surgery. Commercially available mouthwashes contain a variety of active ingredients that have bactericidal properties but may potentially be toxic to the host cells. The goal of this in vitro study is to investigate the effect of commercially available mouthwashes on the survival and migratory capacity of human fibroblasts.

METHODS

Human gingival and periodontal ligament (PDL) fibroblasts were treated with commercially available mouthwashes that contained either chlorhexidine (CHX) or essential oils (EO) as the active ingredient. Each mouthwash was tested over a range of concentrations for its ability to affect fibroblast survival and migration, as well as long-term effects on cell viability.

RESULTS

Undiluted mouthwashes induced near-complete cell death 24 hours after only a 60-second treatment. Dilutions of 15% to 20% for both CHX and EO mouthwashes resulted in 50% cell death. When diluted to 10% to 15%, EO did not reduce cell migration, whereas similar dilutions of CHX resulted in reduced cell migration. Concentrations of 10% of both EO and CHX mouthwashes retained most of their antibacterial capacity. Treatment with EO did not result in gingival fibroblast death, whereas 5% CHX resulted in near-complete gingival fibroblast death 7 days after exposure.

CONCLUSIONS

The results of this in vitro study indicate that diluted EO displayed no detectable detrimental effects on human gingival and PDL fibroblasts, whereas diluted CHX reduced both cell migration and long-term survival. Both solutions retained their antimicrobial activity in lower concentrations.

Chlorhexidine with an anti discoloration system after periodontal flap surgery: a cross-over, randomized, triple-blind clinical trial

The use of chlorhexidine (CHX) has been recommended for a number of clinical applications including plaque control in the post-operative period. However, the use of CHX is burdened by some side effects that could affect the compliance of the patient. The aim of this clinical trial was to evaluate the side effects, the staining in particular, the patient acceptance, and the efficacy of a 0.2% CHX mouthwash containing an anti discoloration system (ADS) compared with a 0.2% CHX alone, after periodontal flap surgery.

MATERIAL AND METHODS

This single-centre, cross-over, triple-blind randomized clinical trial was carried out on 48 consecutive patients. After periodontal flap surgery, the patients were prescribed to rinse two times per day for 1 min for 1 week with 10 ml of test or control CHX, contained in anonymous bottles coded K or M and assigned randomly. No brushing and interdental cleaning of the surgical area was allowed. At week 1, after suture removal, patients received full-mouth prophylaxis and were given a second anonymous bottle, reversing the products, with the same instructions as at baseline. Patients resumed tooth-brushing but not interdental cleaning. At the end of week 2, prophylaxis was repeated, mouth rinsing was discontinued and patients resumed normal oral hygiene. At weeks 1 and 2, the following variables were recorded: presence of pigmentation, gingival parameters at the surgically treated sites (gingival inflammation, tissue inflammation around the sutures, gingival swelling and presence of granulation tissue), patient perception and acceptance of the 2 mouthwashes.

RESULTS

Forty-seven patients completed the study. The difference between treatments related to gingival variables was not statistically significant. The test CHX caused consistently less pigmentations than the control CHX in all the evaluated areas of the dental surfaces (odds ratio (OR)=0.083 p<0.0001 in the incisal area, OR=0.036 p<0.0001 in the approximal area and OR=0.065 p<0.0001 in the gingival area). The CHX ADS was found to be more tolerated by patients than the control mouthwash and to cause less food alteration, less alterations to the perception of salt and to be less irritant for the oral tissues.

CONCLUSIONS

(1) CHX ADS caused less pigmentation, was burdened by less side effects and was more agreeable than the control CHX; (2) CHX ADS was as effective as CHX without ADS in reducing gingival signs of inflammation in the post-surgical early healing phase; (3) the use of CHX ADS could be of value in treatment protocols in which the patient compliance with a CHX mouthwash prescription is relevant.

Effect of Autogenous Cortical Bone Particulate in Conjunction With Enamel Matrix Derivative in the Treatment of Periodontal Intraosseous Defects

BACKGROUND

The aim of the present study was to assess the additional clinical benefit of autogenous cortical bone particulate (ACBP) when added to enamel matrix derivative (EMD), compared to EMD alone, in the treatment of deep periodontal intraosseous defects.

METHODS

A total of 28 intraosseous lesions in 27 patients with advanced periodontitis were included in this controlled clinical trial and randomly assigned to the EMD group (14 defects) or to the EMD + ACBP group (14 defects). Immediately before surgery (baseline) and after 6 and 12 months, probing depth (PD), clinical attachment level (CAL), and gingival recession (REC) were recorded. Radiographic depth of the defect (DEPTH) was also measured at baseline and 12 months post-surgery.

RESULTS

At 6 and 12 months, PD and CAL significantly improved from baseline in both groups (P <0.000). No significant differences in terms of CAL gain and PD reduction were detected between groups. However, defect distribution according to CAL gain was significantly different between groups (P <0.05). DEPTH significantly decreased from baseline to 12 months in both groups (P <0.000); between-group differences were not significant. At 12 months, a significantly greater REC increase in the EMD group (1.1 +/- 0.7 mm) compared to the EMD + ACBP group (0.3 +/- 0.8 mm) was observed (P <0.05).

CONCLUSIONS

Both EMD and EMD + ACBP treatments led to a significant improvement in clinical and radiographic parameters at follow-up with respect to presurgery condition. The combined approach resulted in reduced post-surgery recession and increased proportion of defects with substantial CAL gain (> or = 6 mm).

Non-surgical treatment of peri-implant pathology

INTRODUCTION

Peri-implant pathologies consist of an inflammatory process affecting the soft and hard tissues surrounding the implants. Chlorhexidine is considered the gold standard antiseptic, with a large variety of choice in administration. In this study, a protocol for the irrigation of peri-implant pockets with a chlorhexidine gel, using a plastic needle for the delivery of the product into the peri-implant pockets is described.

STUDY PARTICIPANTS AND METHODS

Nine patients with at least one implant presenting peri-implant pathology (inflamed soft tissue associated with bone loss around the implant) were enrolled in this prospective clinical study, and followed-up for 1 year, where clinical parameters such as modified plaque index, modified bleeding index, probing pocket depths, attachment levels were assessed at baseline, 1 month, and 1 year after implementation of the treatment protocol.

RESULTS

Treatment success was achieved in eight of the nine patients (and in 11 of the 13 implants) according to the success criteria adopted by the authors of this study.

DISCUSSION

Infection control lies at the heart of peri-implant treatment. The control of three factors such as optimal diagnosis, removal of the aetiological factor of the disease (proper removal of debris and decontamination of the peri-implant sulcus/pocket) and a good patient's oral hygiene self-care represents the key to success, resulting in good treatment outcomes when managing peri-implant pathologies. The protocol used (irrigation of peri-implant pockets with chlorhexidine gel delivered by a plastic needle) is considered to be of utility.

Effectiveness of a calcium hydroxide and chlorhexidine digluconate mixture as disinfectant during retreatment of failed endodontic cases

OBJECTIVE

The purpose of this in vivo investigation is to compare the effect of a slurry of Ca(OH)2 mixed in aqueous 2% chlorhexidine (CHX) versus aqueous Ca(OH)2 slurry alone on the disinfection of the pulp space of failed root-filled teeth during endodontic retreatment.

STUDY DESIGN

Forty single-rooted previously root-filled teeth with associated periradicular lesions were included. The teeth were nonsurgically retreated and medicated over 3 treatment visits with 7-10-day intervals with either Ca(OH)2 in water or Ca(OH)2 in 2% aqueous CHX. Root canal cultures were collected in fluid thioglycollate, and bacterial growth was assessed by turbidity daily for 1 week, then weekly for an additional 3 weeks. The presence of enterococci in the root canals at the initial treatment session was determined.

RESULTS

Of the total sample population, 12 of 40 (30%) were positive for bacteria before root filling. The control medication disinfected 12 of 20 (60%) teeth including 2 of 4 teeth originally diagnosed with enterococci. The experimental medication resulted in disinfected 16 of 20 (80%) teeth at the beginning of the third appointment. None of the teeth originally containing enterococci showed remaining growth. This difference between the overall positive cultures was not statistically significant (P > .05).

CONCLUSIONS

Canal dressing with a mixture of 2% CHX and Ca(OH)2 slurry is as efficacious as aqueous Ca(OH)2 on the disinfection of failed root-filled teeth.

Clinical Evaluation of Demineralized Freeze-Dried Bone Allograft and Enamel Matrix Derivative Versus Enamel Matrix Derivative Alone for the Treatment of Periodontal Osseous Defects in Humans

BACKGROUND

A recent study suggests that the addition of enamel matrix derivative to demineralized freeze-dried bone allograft may enhance osseoinduction. The purpose of this study was to evaluate the use of demineralized freeze-dried bone allograft (DFDBA) in combination with enamel matrix derivative (EMD + DFDBA) compared to enamel matrix derivative (EMD) alone in the treatment of human intrabony periodontal defects.

METHODS

Forty patients with a total of 67 sites (intrabony defect > or = 3 mm deep) were selected to participate in this single-masked, parallel design, randomized, controlled clinical trial. Each subject received either EMD alone (34 sites) or in combination with DFDBA (33 sites). Soft tissue measurements included probing depth (PD), clinical attachment level (CAL), and recession. Hard tissue measurements included defect depth, alveolar crestal resorption, and defect morphology. Following 6 months of healing, all soft tissue measurements were repeated. Forty-nine sites (EMD + DFDBA = 26 sites, EMD alone = 23 sites) were surgically reentered. Statistical analyses were performed using unpaired and paired Student t tests.

RESULTS

Analyses showed a significant improvement in soft tissue parameters for both treatment groups (P < 0.001) as compared to preoperative measurements. There were no statistical differences between treatment groups. The probing depth reduction (PDR) for the EMD + DFDBA was 3.6 +/- 0.2 mm, while the EMD alone had a PDR of 4.0 +/- 0.3 mm. The CAL gain for the EMD + DFDBA group was 3.0 +/- 0.3 mm and 3.2 +/- 0.3 mm for the EMD alone group. The mean value for bone fill in the EMD + DFDBA group was 3.7 +/- 0.2 mm (74.9%), while the EMD alone group demonstrated a mean bone fill of 2.6 +/- 0.4 mm (55.3%). While there were no significant differences between the two treatments with regards to soft tissue measurements, the combination of EMD + DFDBA therapy yielded statistically significant improvements in bone fill, crestal resorption, and percentage of sites gaining greater than 50% and 90% bone fill when compared to EMD alone (P < 0.001).

CONCLUSION

The results of this study indicate that there may be an enhancement of hard tissue parameters when enamel matrix derivative is added to demineralized freeze-dried bone allograft.

Chlorhexidine spray versus mouthwash in the control of dental plaque after implant surgery

BACKGROUND/PURPOSE

This randomized clinical trial was aimed at comparing two different means of delivering chlorhexidine digluconate (CHX) for plaque control during the 2 weeks following implant surgery.

MATERIALS AND METHODS

Twenty patients selected for implant therapy were randomly divided into two groups: 10 subjects used 15 ml of 0.12% CHX mouthrinse (control group) and 10 used 0.2% CHX spray (test group). Professional oral hygiene was carried out immediately before surgery. During the 14 days following surgery mechanical oral hygiene was performed only at the teeth not surgically involved. Plaque index (PI), stain index (SI), modified gingival index and taste alteration were assessed on the 7th and 14th day after surgery. The clinical parameters were evaluated at four tooth surfaces by a single examiner. Teeth proximal to surgical site and teeth not involved were statistically compared.

RESULTS

In both groups, the PI increased similarly, with respect to the baseline, at days 7 and 14. There was no significant difference between the two groups at either time point. On the contrary, in the control group, the SI increased significantly when compared with baseline over the 14 days both at teeth nearest to surgical sites and at not-involved sites. In the test group pigmentation was consistent only at teeth proximal to the surgical site. When considering not-involved sites, tooth staining was significantly lower in the test with respect to the control group.

CONCLUSIONS

The present study indicates that the efficacy of CHX spray in the post-surgical control of dental plaque is similar to that of CHX mouthwash. Tooth staining, however, is significantly lower in the spray group at sites not surgically involved. These effects might be related to the route of CHX delivery, as well as the total dose administered that was significantly lower in the spray group with respect to the rinse group.

A clinical comparison of a bovine-derived xenograft used alone and in combination with enamel matrix derivative for the treatment of periodontal osseous defects in humans

BACKGROUND

Enamel matrix protein derivative (EMD) and particulate anorganic cancellous bovine-derived bone xenograft (BDX) have both shown favorable clinical results in reducing intrabony periodontal defects as compared to open flap debridement alone. These materials have shown results comparable to those obtained with guided tissue regeneration. The primary aim of the present study was to evaluate the effectiveness of EMD combined with BDX as compared to BDX alone, with a secondary aim to compare the treatment outcomes of the 2 modalities.

METHODS

Seventeen patients with paired intrabony defects and probing depths measuring > or = 5 mm who were being treated for chronic periodontitis were selected for this controlled, blinded, split-mouth study. Following non-surgical periodontal therapy, sites were randomly selected to receive either a combination of EMD and BDX (test group) or BDX alone (positive control group). Baseline and 6-month surgical reentry measurements were taken by a calibrated examiner blinded to the treatment. A paired Student t test was utilized to evaluate differences between baseline and post-treatment and between the treatment groups.

RESULTS

Favorable clinical outcomes for both hard and soft tissue measurements were achieved for both treatment groups when compared to baseline (P < 0.001). There was no statistically significant difference for any of the measured clinical parameters. Probing depth reduction for the test group and control group was 4.2 +/- 1.1 mm and 3.9 +/- 1.3 mm, respectively (P > 0.8). Mean gain in clinical attachment levels for the test and control groups was 3.8 +/- 0.9 mm and 3.7 +/- 1.5 mm, respectively (P > 0.6). Hard tissue measurements obtained at surgical reentry were used to calculate the bone fill (BF) and percent bone fill (%BF). The BF was 3.2 +/- 1.4 mm and 3.0 +/- 1.2 mm (P > 0.6), and the %BF was 63.3 +/- 16.3% and 67.0 +/- 19.0% (P > 0.4) for the EMD + BDX and BDX groups, respectively.

CONCLUSIONS

In summary, both the particulate anorganic cancellous bovine-derived bone xenograft used alone and in combination with enamel matrix derivative are effective for the treatment of human intrabony periodontal lesions.

Clinical evaluation of wound healing following multiple exposures to enamel matrix protein derivative in the treatment of intrabony periodontal defects

BACKGROUND

Multiple exposures to enamel matrix protein derivative (EMD) during periodontal therapy have been shown to be safe for the patient. The purpose of this study was to clinically determine if an altered course of wound healing would occur after multiple exposures to EMD in the treatment of intrabony defects. A secondary aim was to assess the efficacy of EMD in probing depth reduction and clinical attachment level gain.

METHODS

Thirty-two systemically healthy patients (18 females, 14 males, 33 to 69 years old) who were being treated for moderate to advanced periodontal disease were selected for the study. Surgical procedures involving 2 sites were separated by at least 8 weeks, and wound healing comparisons were made between the first and second procedure. Patients were given a diary card the day of surgery, which consisted of questions concerning the presence and severity of headaches, root hypersensitivity, tooth pain, swelling, and itching. Patients were also examined at postoperative visits to clinically assess wound healing and discuss responses to the questionnaire. Soft tissue measurements were taken the day of surgery and 6 months postoperatively to ascertain probing depth reduction (PD) and gains in clinical attachment levels (CAL).

RESULTS

The results revealed no clinically detectable reaction that could not be attributed to normal postoperative sequelae. There were no differences in reported symptoms between patient gender, first and second procedures, or intrabony and non-intrabony defects. Smokers were found to have a statistically significantly higher incidence of severe symptoms in root hypersensitivity, tooth pain, and swelling compared to non-smokers (n = 21). The mean probing depth reduction was 3.8 +/- 1.5 mm (2 to 9 mm), while the mean clinical attachment level gain was 2.8 +/- 1.7 mm (0 to 8 mm).

CONCLUSIONS

The findings of this study demonstrate that EMD is a clinically safe product to use in the treatment of periodontal defects and that multiple uses do not have a negative impact on periodontal wound healing. In addition, a statistically significant gain in clinical attachment and reduction in probing depth were demonstrated.

Design and implementation of clinical trials of antimicrobial drugs and devices used in periodontal disease treatment

The design and implementation of clinical trials (CTs) carried out to evaluate antimicrobial and anti-infective drugs and devices are one of the most difficult challenges in contemporary periodontal research and product development. The overwhelming amount of evidence which has established a microbial etiology for periodontitis is the basis for developing and testing antimicrobial treatments. Well-designed antimicrobial CTs start with a carefully crafted hypothesis and a protocol which explicitly integrates the requirements of the patient, the clinician, the sponsor, and regulatory authorities. Surrogate variables for effectiveness must be clinically relevant, scientifically sound, and statistically valid. Currently, clinical attachment level measurements and alveolar bone assessments are accepted as proof of effectiveness. Indication and claim support of the antimicrobial product guide the design and implementation of the CT. Adverse microbiologic consequences, such as lack of antimicrobial susceptibility, wrong spectrum, incorrect dosage, non-compliance, and drug interference, must be monitored. Successful CTs balance a large group of variables used to screen, randomize, and assign subjects to experimental and control groups to ensure that prognostic and risk factors are properly accounted for.

The effect of hexetidine spray on dental plaque following periodontal surgery

The aim of the present study was to determine the effects of a 0.2% hexetidine spray, used as a supplement to regular oral hygiene measures, on dental plaque and gingival condition following periodontal surgery. This study was carried out on 38 patients who required 2 episodes of periodontal surgery. Examinations regarding dental plaque were performed at 0, 7, 14, 21 and 28 days, while the condition of the gingiva were examined at 0 and 28 days. Dental plaque was assessed by the Turesky modification of Quigley-Hein index; the gingival condition was evaluated using the gingival index of Löe-Silness and the papilla bleeding index. In a double-blind cross-over study of 28 days duration, significant reduction in plaque accumulation and an improvement in wound healing were demonstrated for the test spray compared to the placebo.

Bacterial penetration in vitro through GTAM membrane with and without topical chlorhexidine application. A light and scanning electron microscopic study

Premature exposure of membrane in the oral cavity is considered the most common complication as well as a reason for failure or incomplete success of guided tissue regeneration, as the exposed membrane undergoes plaque accumulation. A method to control, or at least to reduce the bacterial invasion of the membrane allowing a delay in the membrane removal, could be of clinical interest. The purpose of the present study was to evaluate the possibility of treating, with topical chlorhexidine application, the bacterial colonization of exposed membranes. A special device was developed in order to evaluate, under an experimental environment, the bacterial colonization. This device was made from a removable acrylic denture base to which 5 gold cups were attached. The cups consisted of an internal compartment, isolated from the oral cavity by a GTAM membrane, and an external compartment exposed to the oral environment. 3 healthy subjects had this device fitted, bilaterally, in the molar-premolar region of the upper jaw. The cups of one side of each subject had 0.2% chlorhexidine gluconate gel applied 2x a day for 1 min, whereas those of the other side served as controls. 12 cups were removed after 2 weeks and the remainder removed after 1 month. The non-treated control specimens were characterized by greater amounts of plaque accumulation. In all the test sites, plaque deposits increased in thickness and quantity during the 4 weeks of the experiment. Complete invasion of the membrane and initial colonization of its internal surface were observed only in 4-week specimens. A relatively simple flora consisting mainly of cocci and short rods, was found in bacterial deposits forming under the influence of chlorhexidine, whereas in non-treated specimens, it was possible to observe a more mature and complex plaque, composed mostly of filamentous bacteria. In conclusion, topical application of chlorhexidine gel is an effective method of reducing plaque and calculus formation on the surface of GTAM membranes exposed to the oral cavity for up to 4 weeks. This study has, however, failed to demonstrate the capacity of chlorhexidine to prevent or to retard bacterial penetration through the thickness of the inner portion of the membranes.

The influence of supragingival plaque control on clinical and microbial outcomes following the use of antibiotics for the treatment of periodontitis

Although supragingival plaque control is essential to successful periodontal therapy, the role of plaque control following systemic antibiotic use in periodontal disease has not been well defined. This study evaluated, following antibiotic use, which clinical and microbial parameters appeared to be influenced primarily by the antibiotics, independent of plaque control, and which outcomes appeared to be dependent on plaque control. Two hundred thirty-six patients (236) with moderate to severe periodontitis were clinically evaluated and microbial samples were taken by their private-practice periodontists. All patients were treated with scaling and root planing and a variety of systemic antibiotics, which were selected based on the microbial and clinical profile of the patient. Three months after therapy, patients were reevaluated and grouped by post-treatment plaque control, as either having very good oral hygiene (LoPl: N = 143; < or = 10% plaque-covered surfaces) or poor oral hygiene (HiPl: N = 93; > or = 25% plaque-covered surfaces). The two groups had different plaque and bleeding scores initially, but similar numbers of pockets probing > 5 mm and similar microbial patterns. Although the LoPl group had a significantly greater reduction in plaque than the HiPl group, bleeding scores and probing depths changed comparably in both groups after antibiotic therapy. Plaque control influenced outcomes significantly, but in a complex manner. The LoPl group exhibited a significantly greater reduction in certain bacteria, for example P. gingivalis. Interactions between plaque control and specific microbial parameters significantly affected clinical outcomes, although neither alone was sufficient to predict outcomes following antibiotic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Association of clinical risk factors with treatment outcomes

A patient's decision to accept treatment recommended by his dental health care provider will be strongly influenced by the quality of the information he is given. Estimates of prognosis and treatment predictability must be based on the evidence available from the literature and the practitioners' own experience. Thorough, accurate, and relevant clinical and adjunctive diagnostic data will be a major influence in the development of the patient's individualized treatment strategy. Some clinical findings such as severity of disease for age, deepening pockets accompanied by loss of clinical attachment, frequent bleeding on probing, and bone loss can be considered as risk and prognosis factors. "Hard" data implicating specific clinical or diagnostic findings as risk factors or markers are difficult to find because there are few randomized longitudinal trials available. A new approach which attempts to focus on reducing the risk of undesirable outcomes while improving the probability of successful outcomes following treatment has been referred to as the Treatment Predictability Model. A key feature of this approach is the focus on individual patient circumstances and preferences through the use of decision analysis techniques. A large scale, long-term project utilizing a practice-based research network (PBRN) provided some descriptive information about factors that could distinguish between responders and nonresponder patients undergoing treatment for advanced periodontitis. Bacterial colonization, level of post-treatment plaque control, and smoking were major predictive variables in this group of periodontitis patients. The predictive treatment approach may be one way to develop evidence that will improve the predictability of outcomes for individual patients.

Gingival enhancement in fixed prosthodontics. Part II: Microbiologic findings

This study assessed the changes of the subgingival/marginal microflora during fixed prosthodontic procedures and evaluated the effect of adjunctive rinsing with 0.12% chlorhexidine on the subgingival/marginal microflora during fixed prosthodontic treatment. Thirty patients scheduled for fixed prosthodontics were randomly assigned to either rinsing with 15 ml of tap water b.i.d. (control) or rinsing with 15 ml of 0.12% chlorhexidine gluconate b.i.d. (experimental). Subgingival and marginal plaque was analyzed at baseline, before crown preparation (2 weeks), before crown cementation (5 weeks), and 2 weeks after cementation (7 weeks). The fixed prosthodontic procedures alone altered the subgingival and marginal microbiota toward a more health-associated flora. Adjunctive rinsing twice daily with 0.12% chlorhexidine had a significantly greater effect in reducing putative periodontal pathogens compared with the control regimen. This medication was a useful adjunct to regular oral hygiene during fixed prosthodontic procedures by permitting the establishment and maintenance of a microflora compatible with periodontal health.

Gingival enhancement in fixed prosthodontics. Part I: Clinical findings

This study assessed the efficacy of a 0.12% chlorhexidine gluconate (CHX) rinse on the enhancement and maintenance of gingival health in patients receiving fixed prosthodontic treatment. Thirty patient participants in this examiner blind study were randomly assigned into two groups, one control and another group using CHX 15 ml b.i.d. in addition to normal oral hygiene. The medication was used for 2 weeks prior to crown preparation, 3 weeks during provisional crown placement, and 2 weeks after definitive crown cementation. Plaque and gingivitis indices were measured initially and at the three aforementioned points during the 7-week period. The plaque index for the control group decreased by 0.26 units; CHX decreased by 0.63 units at 7 weeks. The gingival index of the control group decreased by 0.37 units; CHX decreased by 0.87 units. Adjunctive use of chlorhexidine with fixed prosthodontic procedures significantly reduced plaque levels and significantly improved gingival health compared with the control patients. Fixed prosthodontic procedures alone decreased plaque levels and increased gingival health.

Report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

The growth in the dental literature continues to escalate, as evidenced by the publication of at least 326 new books in 1988 and 1989 and more than 20 new journals in 1989. There still appears to be undue emphasis on quantity instead of quality of research. This proliferation in the literature poses ever increasing difficulties to this Committee in filtering out the articles that are of particular interest to the members of the Academy and identifying those that are most likely to have a major impact on dental practice and service. The subjects covered include periodontics, caries and preventive dentistry, craniomandibular disorders, occlusion, pulp biology, ceramics, and restorative dental materials.