the use of 0,2 % chlorhexidine

7/30/2019 The Use of 0,2 % Chlorhexidine

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/ Ciin Perioihmol I9W: 25: 15-23Printed in Di'iimurk . All rights rfu

Copyrighi Munk.sgatirii IV98mmC l i n i c a l p e n o d o n t o i o g y

The use of 0.2% ch lorhex id ine inthe absence of a s t ructuredmechan ica l reg imen of oralhygiene fol lowing thenon-surg ica l t reatment ofperiodontit isChristie P. Claffey N. Ren vert S: The use of0.2" irrespe ctive of initial pro bin g pocke t de pth , site location o r too thsurface location. Sites ^7 mm at baseline dem onstrated a reduction in meanprobing pocket depth of 3.9 mm and a gain in mean probing attachment level of2.5 mm. Moderately deep sites (4-6.5 mm) demonstrated a reduction in meanprobing pockel depth of 2 mm and a gain in mean probing attachment level of 0.8mm. Shallow sites (3.5 mm) demonstrated a reduction in mean probing pocketdepth of 0.5 mm and a loss in mean probing attachment level of 0.2 mm. Site-specific attachment level analysis demonstrated Ihat over 80'/.. of losing sites wereshallow with low bleeding frequency, indicating that the loss of attachment mayhave occurred for reasons other than inflammatory periodontal disease. The re-sults indicate that chlorhexidine can be used as an adjunct to inadequate mech-anical oral hygiene over an observation period of 1 year.

P h i l i p C h r i s t i e \ N o e l C l a f f e y ^ a n dS t e f a n R e n v e r t ^' S c h o o l o f D e n t a l S c i e n c e , T r i n i t y C o l l e g e ,D u b l i n , I r e l a n d , ^ S c h o o l o f D e n t a l H y g i e n e ,K r is t i a n s l a d C ol le g e of H e a l th S c i e n c e s .K r i s t i a n s t a d , S w e d e n

K e y w o rd s ; p e r i o d on t i ti s ; c h l o rh e x i d i n e ;n o n - s u r g i c a l t h e r a p yA c c e p t e d f o r p u b l i c a t i o n 2 1 A p r i l 1 9 9 7

There is a wealth of evidence support-ing the non-surgical treatment of adultperiodontitis . The 2 essential compon-ents of successt""ul non-surgical therapyare adequate subgingival dehridementand effective plaque control (Egelberg

plaque control is an achievable goal formost patients, many individuals, in-cluding those with mental and physicaldisablement, cannot maintain a suitablestandard of self administered mechan-ical plaque control in order to prevent

It has been demonstrated that the ef-fects of debridement without adequateplaque control results in ineffectivetherapy within a period of months(Magnusson et al . 1984) . Furthermore,the failure to control supragingival


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16 Chri.slie ei al.result in ;i rapid i":itc of loss of clinicalattachment (Lindhe & Nymiiii 1985).Accordingly, there is an obvious needfor adjunctive aids to inadequate mech-anical oral in a significant pro por tionof patient.s needing treatment for peri-odontitis . Chlorhexidine diglueonatehas been shown to be safe and effectiveas an anti-plaque and anti-gingivitisagent in both short and long termstudies (Loe & Schiott 19 70. Lindhe etal . 1970. Davies et al, 1970. Loe el at.1972 . 1976, Lang et al. 1982. Westfelt etal . 19 83 . Grossman et al, 1 98 6 . Korn-man 1986) .

The aim of this study was to evaluate,using clinical parameters over an obser-vation period of 1 year, healing follow-ing subgingival debridement in patientswho did not reeeive meehanieal oral hy-giene instruction but who rinsed 2Xdaily with d.2'A\ chlorhexidine diglueo-nate.

and at night. At the 3-month visit andthereafter, compliance was eonfirmedby questioning and by noting the pres-ence of slain on the teeth and the pa-tients were reinstructed. Sealing androot-planing was performed under localanaesthesia over a 2-4 week period. Thedebridemenl was performed using acombination of subsonic and hand in-struments and was earried out until theoperator was confident that the rootswere adequately debrided. The debridedareas were irrigated immediately afterwith 0.2% ehlorhexidine gluconate.Gross occlusal anomalies were elimin-ated as part of the therapeutic regimen.C l i n i c a l m e a s u r e m e n t sRecordings were made at 6 sites tornon-molar teeih: mesiobuccal . midbuc-cal . distobueeal . distolingual . midlingu-al and mesiolingual . For maxillary mo-

lars. 8 sites were measured: mesiobuccal . mid-mesiobueeal root, bueeafurcation, mid-distobuccal root, distobueeal . distopalatal fureation. midpalalal root and niesiopalatal furealionFor mandibular molars ten sites wermeasured: mesiobueeal, mid-mesiobuceat root., bueeal furealion. niid-dislobuccal root, distobueeeal . disiolingual . mid-distolingual root, lingual fureation. mid-mesiolingual root anmesiolingual. Each of the above sitewas measured for the 4 elinical parameters: presence or absence of plaquepresence or absence o\ ' bleeding oprobing, probing depth and probinattachment level. In all, 1.483 sites werstudied.P l a q u e s c o r ePlaque was recorded as present or absent after staining with Bismuth brow

M a t e r i a l a n d M e t h o d sP a t i e n t s10 patients between the ages of 25-60years were used in ihis study. The pa-tients were seleeted from those atlend-ing the Dublin Dental Hospital for thetreatment of advanced periodontitis .None of ihe patients had received treat-ment for periodontitis in ihe previous 5years and all were free of any systemicdisease. All patients had a minimum of14 teeth, at least two of which were mo-lars and demo nstr ated a l least 1 0 siteswith probing depths ^ 7 m m. All avail-able teeth were used except for 3rd mo-lars .

1 0090 f807 0 6 0 5 0 4 0 3 0 2 0 1 0

0 -0

- > 7m m4-G.5mm-


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Clorhexidine yinse in non-siirgica! periodonU i! ihenipv 1 7

Months

100 J90 . -

Furcat ionProximal

ingualBuccal

1 2Months

Fig. 2. Mean bleeding score (%) by site location (buccal, lingual, proximal ;mti furcmioni andby ini t ial probing depth category (^3.5 mm. 4-6.5 mm and ^1 mm).

Stain. Stained plaque at the gingivalmargin that could easily be removedwith the tip of a periodontal probehowever small, was recorded. Theplaque score was then taken as thenumber of sites displaying plaque as apercentage of the total number of sitesmeasured .

B le e d i n g o n p r o b i n gBleeding was recorded as present or ab-sent during the measurement of probingdepth and probing attachment level .The bleeding score was then taken asthe number of sites bleeding on probingas a percentage of the total number of

P ro b in g d e p t h s a n d p r o b i n g a t t a c h m e n ti e v e lThese measurements were made with anelectronic, pressure sensitive probe(Electronic Periodontal Probe, model200, Vine Valley research. Middlesex,NY., USA) with a probing force of 0,5N, The probe was graduated in Imm in-crements and had tip diameter of 0,4mm. The measurements were made tothe nearest 0.5 mm. A vacuum adapted,I mm thick, soft acrylic onlay was usedto provide reference points for the prob-ing attachment level measurements. Forproximal surfaces, the placement of theprobe was guided by the interdental in-

was directed epically towards the per-ceived location of the apex of the tooth.Midbuccal and midlingual sites weremeasured by placing the probe at theselocations and directing it longitudinallyalong the root surface. For furcationsites the probe was guided to thedeepest point by the furcal groove. Altrecordings were done by the sameexaminer throughout .A n a l y s i s o f d a t aMean of patient bleeding scores, plaquescores, probing depths and change inprobing attachment levels were calcu-lated for all patients subgrouped by in-itial probing depths (^3.5 mm. 4.0-6,5mm and ^7.0 mm), by site location inioproximal, furcation, buccal and lingualsites, and by site location into non-mo-lar, molar flal (those molar sites otherthan those located at the furcation) andmolar furcation sites.

With respect to the site specificanalysis, linear regression analysis wasused lo detect probing attachment levelchange. Measurements at sequentialtime intervals over the period of studywere subjected to linear regressionanalysis . The threshold for change re-quired to designate a site as having lostat tachment was chosen as ^1 ,5 mmwith a; f


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18 Christieet al.scores were reduced to 10-20"/) irrespec-tive of site location. However, proximaland t^urcation sites maintained slightlyhigher mean bleeding scores than lin-gual and buccal sites over the period ofobservation.

The changes in mean probing depthover ihe twelve month period are pre-sented in Fig, 3. Probing depths werereduced by 3.9 mm for deep sites (^7mm), 1.9 mm for moderately deep sites(4-6.5 mm) and 0.5 mm for shallowsites (^3.5 mm). Analysis of the sitesbroken down by site location revealedthat the mean probing depths for fur-cation sites and proximal sites weresomewhat greater than for buccal andlingual sites at baseline (Fig. 3). Proxi-mal sites displayed the greatest reduc-tion in mean probing depth of 1,5 mm.

9 x

while furcation sites displayed a reduc-tion of 1.1 mm.

The improvement in mean probingattachment levels over the twelvemonths of this study amounted 2.5 mmfor initially deep sites (3^7 mm), 0,8 mmfor initially moderately deep sites (4-6.5mm), whereas initially shallow sitesdemonstrated a loss of attachment of0.2 mm (Fig. 4). When probing attach-ment level data is analysed by locationof sites, the furcation and proximal sitesdemonstrated the largest gain in prob-ing attachment level (0.5 mm) at thetwelve month examination (Fig. 4).

The dimensional changes (0-12months) for different category of sitesare presented in Figs, 5 10. In non-mo-lar sites analysed by initial probingdepth only sites ^2.5 mm demonstrated

-O --O-

6Months

12

Fig. S. Mean probing depths (mm) by site location (buccal. lingual, proximiil furcation) and

mean probing attachment level loss. Altother categories of initial probing depthfrom 3-3.5 mm through to 5^10 mmdemonstrated a gain of mean probingattachment level. The trend was formost gain of mean probing attachmentin the deeper sites. Also, mean amountof recession tended to be greater in theinitially deeper sites (Fig. 5). The sametrend was true in molar flat surfaces (allmoiar surfaces except furcation sites)and furcation sites (Figs. 6, 7). How-ever, only fifteen deep furcation siteswere available for the three categoriesof 7-7,5 mm, 8-8.5 mm and 9-9.5 mm.Nevertheless, only sites of the shallow-est category, i.e., ^2.5 mm. demon-strated loss of mean probing attach-ment.

For proximal, buccal and lingual sites(Figs. 8-10) the trends were the same asfor previous categories of sites, with atendency for the greatest changes to oc-cur for sites with the greatest initialmean probing depth. The gains in meanprobing attachment level tended to beless in groups of initial probing depthfor buccal sites than for all other cate-gories of sites.

Linear regression analysis over timewas used to assign probing attachmentloss to sites. The threshold for changerequired to designate a site as havinglost attachment using linear regressionanalysis was chosen as s i . 5 mm(p


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Clorhexidine rin.se in non-surgical periodontal therapy 19

- 0 . 0 - F urea tionProximalLingualBuccal

12Months

Fig. 4. Change in meiin prnhing attachmeni levels (mm) by initial probing depth category bysite location (buccal. lingual, proximal and furcation) and by initial probing depth category(s3,5 mm. 4-6 .5 mm and s^ l mm).

7SB i432 n flB

' GingivalrecessionResidualprobingdepth

'Gain or loss ofprobinga t tachment l eve l

Init ialprobingdepth

2,6 3-3,5 4-4,5 5-5.5 6-6,5 7-7,5 8 -6 .5 9 -9 .5 >10 mmInit ial Probing Depth

Fig. 5. Mean d imensional cha nges (0 12 mon ths) for non-m olar sites by initial probing depthcategories. Interpretation for Figs, 5-10: The total length of the bar represents the meanprobing pocket depth for each group of initial probing pocket depth at baseline. The darkshaded area at the top of the bar represents the mean itmount of recession which occurredfor each group of initial probing pocket depth. The medium shaded area represents the gainin mean probing attachment level while the light shaded area represents residua! mean probingpocket depth for each group of initial probing pocket depth, A loss of mean probing attach-ment level is represented by ihe medium shaded area below the .v-axis. There are 6 to 9 groupsof initial probing pocket depth from ^2,5 mm through to s^ll) mm depending on the category.

probing depth and had a slighlly higherbleeding frequency. No deep furcationsite was deemed to have lost attachmentD i s c u s s i o nThe aim of the present study was to in-

the gingival conditions reported afterconventional non-surgical periodontaltherapy (for review, see Egelberg (1995)could be obtained by substituting twicedaily rinses with chlorhcxidine for thehigh levels of mechanical oral hygiene.Nordland el al . (1987) noted the im-

portance of continuous reinforcementof the oral hygiene regimen in terms ofmaintaining the improvements in gingi-val condition following subgingivalmechanical debridement. It appearsthat the success of therapy is dependenton achieving very low plaque scores (inthe order of 2O'l4^25"/>).The efficacy of ehlorhexidene in theprevention of gingivitis is established(Addy et al . 1994), In situations of nooral hygiene chlorhexidine digluconatehas been shown to inhibit Ihe quantity

of plaque and the degree of gingivitis byas tnuch as 'iV'/o as compared to placebosolutions (Siegrist et al , 1986. Moran etal, 19 88 ). Chlorhexidine significantlyimproves the effect of normal mechan-ical oral hygiene proeedures (Flotra etal , 1972 . Addy & Hunter 1987) . Al-though chlorhexidine has been shownto have an inhibitory effect on oralmicroorganisms (Lang & Brecx 1986,Siegrist et al. 1986) plaque does stillform (Breex et al . 1990). The rather mi-nor changes in mean plaque scorefound in this study cannot explain theimprovements in gingival bleeding, re-ductions in probing depth and gain ofprobing attachment levels found in thisstudy. However, the baeterial compon-ent of the plaque formed using ctorlicx-idine rinses has been reported to be indifferent states of lysis and the plaquevitality scores was found to be l5-3O'/oless as compared to controls (Brecx etal . 1990). Thus, chlorhexidine may haveboth quantitative and qualitative effectson deposits formed in its presenee. Ac-cordingly, a possible explanation of thefavourable clinical results obtained inthis study is that, although plaque indexremained high during the experimentalperiod, the vitality and eomposition ofthe reeorded plaque may not have beendisease inductive. It should be remem-bered tbat the method of plaque scoringused in this study was not capable ofqualitative or quantitative discrimi-nation, but merely reflected the pres-ence or absenee of a stained, removabledeposit .

Mean bleeding score was reduced to1O'^^2O'^,, regardless of the baselinescore. The final bleeding score was simi-


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20 Chrislic et al.probing depth regardless of site loca-tion. These reductions arc comparableto the results reported by Badersten eial . (1985a, 1985b . 1987) on s ingle root-ed teeth. In studies involving molarteeth the bleeding scores following non-surgical treatment has been reported tobe higher (AifA.) than in this study(20%) fNordiand et al . 1987, Loos ct al .1 9 8 9 . Claffey et al . 1 99 0). The m oreprofound decrease in mean bleedingscore seen in this study may reflect a

more enhanced panoral antimicrobialeffect of chlorhexidine than possiblewith mechanical hygiene methods.Van der Velden (1980) demonstratedthat more than yS"A> of sites displayedbleeding on probing after periodontaltherapy using a probing force of 0,5 N,The same probing force used in clin-ically healthy sites results in a bleedingscore of about 20% (Lang et al . 1991.Karayiannis et al . 1992). In this studyonly 1 l%i of all sites displayed bleeding

Gingivalrecession

Residualprobingdepth

Gain or loss ofprobinga t tachment l eve l

Initialp iTD bindepth

S2,5 3-3,5 fl-4,5 5-5.5 6-6 5 7-7 5Init ial Probing Deptli

a-8,5 9-9,5 >1 0mni

Fig. 6, Mean dimen sional changes (0-1 2 nionth sj for molar flal surfaces by initial probin gdepth categories.

nfl- | - G i n g i v a l. recession

ResidualprobingdepthGain or loss ofprobingattachment level

Initialprobingdepth

> 1 0 m m2,5 3-3,5 4-4.5 5-5.5 6-6,5 7-7,5 8-8,5 9-9,5Init ial Probing Depth

Fig. 7. M e a n d i m e n s i o n a l c h a n g e s ( 0 - 1 2 m o n t h s } f o r f u r c a t i o n s i t es by in i l ia l p r o b i n g J e p l hc a t e g o r i e s .

10 ,9s7s543210-I

Gi ng i va l. recessionResidualprobingdepth

Gain or I oes ofprobingattnchment levd

Init ialproHngd e p t h

4-4,5 5-5,5 6-6 5 7 7 Ini t i a l Probng Depth e-B.5 9-9,5Fig. H. Mean dim ensional change s (d 12 months ) for proximal sites by initial probing depth

on probing after initial therapy usingthe a probing force of 0.5N. This infersthat the bleeding seen in this study aftertherapy may have been traumatic ratherthan inflammatory in nature. The concept of a graded bleeding score mighthave been useful in order to distinguishthe relative amounts of traumatic andinflammatory bleeding in this study(Renverl et al . 1992),

Initially shallow sites demonstrated areduction in probing depth of approximately 0,5 mm. This i,s in contrast toprevious studies using mechanicaplaque control measures were shallowsites remained virtually unchangedthroughout the studies (Badersten el al1 9 87 , Loos et al. 1987, Claffey et al1 9 8 8 , 1990). The higher amount of inflammation, as represented by highemean bleeding scores at baseline in thistudy, may to some extent explain thiimproved reduction in probing depth. Agreater amount of the initial probingdepth measurement in this study mighhave been due to oedematous soft tissuswelling or pseudo-pockeling.

The fundamental pattern for less improvement and poorer healing responsin molar furcation sites after initiatreatment is not evident in this studyAnalysis of mean data by tooth surfaclocation indicates that molar furcationsites show a healing response which itwice that of non-molar sites in termof probing attachment level gain. Thiis in contrast with the results by Nordland et al , (1987) where the 24-nionthprobing depth for molar furcation sitewas similar to its baseline recordingThe favorable results in the furcationareas may relate to the greater initiaprobing depth for furcation sites acompared to non-molar sites . It is however, important to point out the smalnumber of molar furcation sites available in the present study (only 15 furcation sites were available in the deecategory).

The improvement in probing attachment level in this study are higher thaquoted for previous studies (for reviewsec Egelberg (1995)) Caution is warranted in the interpretation of thesseemingly enhaiiced probing attachment level improvements over previoustudies since no control group of siteis available in this study. The lack ocontrol group is a l imitation worthy oconsideration. However, an untreatecontrol group (placebo rinsing) was noconsidered ethical in view of severity o


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Clorhexidine rinse in non-surgical periodonial therapy 21GiiigwalrecefflionRe sidualprobingdepthGainor lossofprobinga t t adunen t l eve l

Initialpro tingdepth

Initial Proting DepthFig. 9. Mean tiimensional changes (0-1 2 month s) for lingual sites by initial probing de pthcategories.

Gingivalrecession

Residual Initia!probing probingdepth depth

Gain or loss ol" " probing-*- attachment levelInitial ProUng DepUi

Fig. 10. Mean dimensional changes (0 12 months) lor buccal siles by initial probing depthcategories.

Moreover . Magnusson et al . (1984)demonstrated the lack of response tonon-surgical therapy in the absence ofadequate plaque control, A controlwith a structured mechanical plaquecontrol regimen was considered. How-ever, there is a wealth of informationavailable on nonsurgical therapy withgood mechanical plaque control includ-ing previous data from Claffey et al,( 1 9 8 8 , 1990). These studies could tosome degree be used as comparisons tothis report .Various s tudies on the effects of initialtreatment have consistently demon-strated that the highest proportion ofsites with probing attachment loss wasfound for sites with initial probing depth

of ^3 .5 mm (Baders ten et al . 1984a .b ,1 9 8 7 . Loo s et al. 1 9 8 7. Claffey et al.1 9 8 8 . Egelberg & Claffey 19 94), Theshallower the initial pocket depth, thegreater the likelihood of loss of probingattachment at a particular site (Baderst-en et al. 1987) The clinical characteristicsof (hese shallow sites would suggest thatthe probing attachment loss occurs forreasons other than ongoing periodontaldisease. Although displaying attachm entloss, these sites display no increase inprobing depth froin baseline and a lowbleeding frequency (Claffey 1 9 9 1 ). Thepresent study also shows the same pat-tern of attachment toss for initially shal-low sites. When sites are broken do wn bylocation a nd by initial probing de pth it is

I. Bleeding frequency (number of examinations al wiiich ihe siles bled on probing) anddistribution o( the 57 sites (3,8% of total) with attac hme nt loss (determined using linearregression) from 0 -1 2 mo nths by initial probing depth (IPD ) category and by surface location

IPD categoryBleedingfrequency Buccal andlingual/V=517 Proximal;V=K53

Furcation,V=M3^3 ,5 mm ( =4,0-6,0 (/;=9) 2,2/5

222

196

clear that pocket depth rather than sur-face location is the common denomi-nator in relation to this probing attach-ment loss. The reason for loss of attach-ment in shallow sites might be due to (a)trauma from mechanical hygiene, (b)trauma from instrumentation and (c)some type of remodelling process of thetissues as a consequenee of the treatme nt(Claffey & Egelberg 1994).80 % of the sites deemed to have lostattachment by regression analysis inthis study were shallow apparentlyhealthy sites with a low bleeding fre-quency. Furthermore, only the shallow-est sites (in the ^2.5 mm category) weredeemed to have lost attachment on av-erage and the average loss for sites ^3.5mm was 0.2 mm. In previous studiesmean loss of attachment in shallow siteswas reported to be as high as 0.6 mm

(Egelberg & Claffey 19 94) These discre-pancies may be related to differences inmechanical hygiene measures betweenthis and previous studies. The residuaprobing depths and bleeding frequen-cies found for sites of all categories ofinitial depth with probing attachmenloss suggests that only 2 of the 29 sitesmay have lost due to ongoing inflam-matory disease.Deep molar furcation sites would beexpected to display a high frequency ofprobing attachment loss (Nordland eal , 1987. Loos et al . 1989. Claffey et al .1990), However, no deep molar fur-cation sites were identifled as losingprobing attachment in the presenstudy. In this regard, one should bear inmind that only a small number of deepfureation sites were available in thistudy and the period of study was lessthan for the other studies cited.The unexpected equality in the meanhealing response of the molar furcationsites and those of other locations in thepresent study is worthy of note. Againa limitation in this respect is that onlya small number of molar furcation siteill a small number of patients was available for study, disallowing flrm conclusions. Previously, the poorer response of the furcation sites has beenattributed to difficulties in debridemenassociated with anatomical andmorphological features of these site(Egelberg & Claffey 19 94). The clinicacircumstances of the present study cannot be assumed to be markedly different from those of other studies and i

is likely that the same difficulties withfurcation debridement were encountered.


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22 Christie et al.One interpretation of the enhanced

results for furcation areas of the presentstudy would be that the difficulty in de-briding furcation areas is not as criticala factor as is the control of supragin-gival plaque. It is possible that chlor-hexidine had an effect on those areasrelatively innaccessible to mechanicalplaque removal, such as the the concaveentrances lo mesial and distal fucationson maxillary molars. Further studiesare needed to assess whether chemicalsupragingival plaque control can over-come the widely reported diffieulties intreating furcation involvement.

While it is theoretically undesirableto exert long-term changes on the oralmicro-environment, a number of long-term studies have reported no untowardeffects (Loe et ai. 1976. Schiott et al,1976, Briner & Wunder 1977). No re-duced bacterial sensitivity to chlorhex-idine was found in a four year animalstudy (Briner & Wunder 1977). In thepresent study, no adverse effects, otherthan the well documented side effects ofbad taste and staining, were experi-enced by the subjects.

The results of this study indicate thatchlorhexidine digiuconatc as an 0.2'^isolution used as a mouthrinse for 1min, 2X daily, is effective as an alterna-tive to structured mechanical oral hy-giene in non-surgical treatment ofchronic advanced human periodontilisover an observation period of one year.Studies of dental disease prevalence in-dicate that handicapped groups have ahigher prevalence of periodontal dis-ease and significantly poorer levels oforal hygiene than able-bodied counter-parts (M orton 1977, Noah 1982). It ap-pears on the basis of the results of thepresent study that treatment for handi-capped people of advanced periodontaldisease can be expected to be successfulprovided that compliance with themouthwash ean be assured either athome or in an institution.

AcknowledgmentsThe authors would like to expresstheir thanks to Agnes Hagan for helpwith manuscript preparation, to Ger-aldine Clark for help in the clinic andto Jim Larragy for help with the dataanalysis.

ZusammenfassungDw Anwcndung \vn 2"''i-igem Chlorhexidin

rodiintitis ohnc geordnete Anleitung fur me-chanLwhe MundhygieneGegenstand dieser Studie war. die Wirkungeiner Mundspiilllussigkeit mit 0.2'S^iigemChlorhexidin nach iiichi-chirurgischer Be-handiung forlgeschrittencr Parodontitis aus-zuwcrlen, ohne cJaB niiin cine struklurierteVorschrifl fiir me chanise lie Mu ndh ygie ne 7.\x-giinglich machle, Filr diese SUidie wurden 10Palienieii und insgesamt 1483 Slellen hcran -gezogen, Befundungen fur Plaque. Girigiva-blutuiig. Taschentiefc und Attachmenlhohewurden eingangs und nach 3. 9 und 12 Vcr-suchsmonaien registr iert . Harte und weicheBcliige cntfernif man iinler Lokalanaeslhe-sie. Anleitungen fur mechanischc Mundhy-gienemaBnahmcn oder filr ihre Verbesserungteilte man nicht mit, Allerdings wurden diePatienten bei jeder Einbestcllung dartiber un-terrichteU wie die zweimal lagliche Mund-splilung mit der 2'/Jiigen Cblorhexidinlosungvorzunehmen sei. Die als prozentuales Vor-kommen von Stellen mit entfernbaren Belii-gen bewerlclcn Plaqueindize^, lieBen bei80"''r.-100"/; aller Behandlungsklassen der ur-sprtingiich sondierten Tascheniiefen nur un-bedeuleiidende Verbesserung der eingangs re-gistrierten Scores erkennen, Ungeachlet derinitial sondierten Taschentiefe, der Lokalisa-tion der Stelle oder der Oberfliiche. wordeeine Reduktion der mittieren Bliilungs-Scorezwischen IO-2O"/(i konstatiert. Bei Stellen miteingangs sondierter. Taschenliefe von ^ 7mm. stellte man eine mittlere Reduktion von3,9 mm fc'^t und einen miitleren Gewinn son-dierter Atlachmenthohe von 2,5 mm, BeimiiRig liefen Slellen (4 6.5 mm ) lag eine Ver-ringerung der sondierten Taschentiefe von imMiUel 2 mm vor. und ein sondierler Niveau-gewinn des Attachments von durchscbnit t-licb 0.8 mm, Bei flachen Stellen (^3,5 mm)ka m es zur Reduktion der sondierten Ta-schenliefe von Im Mittel 0,5mm und zumVerlust des sondierten miitleren Attachment-niveaus von 0,2 mm, Eine sleilenspezifischcAnalyse des Attachmentniveaus macbledeullich. daO Uber 80"'ii der Verluststellenflach waren, mil gerlnger Vorkommenshiiu-figkeit von Gingivablutungen, Das sprichtdafUr. daB der .AttaclimeiUverlust aus ande-ren Griinden als durch eine entziindliche Pa-rod onta Ik rank heit entstand en sein kan n.Uber eine Beobachtungszeil von I .luhr zei-gen die Ergebnisse. daB Chlorhexidin bei un-zureichender mechanischcr Mundhygiene alsAdjuvans angebrachl ist.

ResumeL utilisation de la chlorhe.xidine 0.2% san.\ re-gime structure li'hygiene buccale meeaniqueaprex traitement non-chirurgica! dc la paro-dontiteLe but de celte elude a etc d'cvaluer un bainde bouche a la chlorhexidme 0.2"';i apres letrailement non-chirurgieal de la parodonii tehnmaine avancee en absence d'un regimed'hygiene bnccale meeanique structure. Dixpalients et 1 483 siles onl ete suivis. Les en re-

ment . de la profondeur de poche et des ni-veaux d'at tache onl ete realises lors de l'exa-men initial et apres 3, 6, 9 et 12 mois. Lesurfagage a ete effectue sous anesthesie loca-le. Aucune instruction ni renforcement deI'hygiene buccale meeanique n'a ete donne aaucun moment, Cependant les patients ontete instructs a I'utilisation biquotidienne d'unbain de bouche a la chlorhexidine 0,2%, Lesindices de plaque enregistrcs cn tant quepourcentage de sites avec des depots pouvants'enlever ont montre une amehoralion negli-geable depuis les scores initiaux de 8 0 a 100'^pour toutes les categories de profondeur depoche initiale, Le score moyen de saignementa ete reduit de iO a 20"/. quelle qu'etait laprofondeur de poche initiale, la localisationdu site ou la localisation de la surface dentai-re. Les sites avec 3 7 mm de profondeur lorsde I'examcn initial ont subi une reductiondans la profotideur moyennc de !a poche pa-rodontale de 3.9 mm et un gain du nivcaud'attache moyen de 2,5 mm, Les sites de profondeur moyenne (4 a 6.5 mm) ont subi unereduction moyenne dc la profondeur de po-ch e au sondage de 2 mm et un gain du niveaud'attache moyen de (1,8 mm, Les sites de fai-ble profondeur {^3.5 mm) ont accuse une reduction moyenne de profondeur de poche de0,5 mm et une perte du niveau d'at tache de0,2 mm, L'anatyse du niveau d'at tacbe parsile specifique a demontre que plus de 80%des sites avec perie etaient peu prolonds avecune frequence de saignement faible. indi-quant que la perle d'attache peut s'etre pro-duite pour des raisons autres que la maladieparodontalc inl lammatoire, Les resultats in-diqucnt que ia chlorhexidine peul etre utiliseeen tant qu'aide lorsqu'une hygiene buccalemeeanique inadequate est pratiquec durantune periode d' une annee.

ReferencesAddy. M., Moran J, & Wade W ( 1 9 94 )Chemical plaque control in the preventionof gingivitis and periodontitis, Iti: Proceding.s id the 1st European Work.dwp on Periodontology. eds. Lang N, P & Karring T .pp . 244-257, London: Quintessence,Addy, M. & Hunter . L. (!9K7) The efTects ofa 0,2"',i chlorhexidine gluconate mouth-rinse on plaque, looth staining and can-didii in aphtbo us ulcer pat ients a double-biind placebo-controlled cross over study.Journal f)f Ciinicai Periodvntohgv 14, 267 -273.Badersten. A., Nilveus. R. & Egelberg. J.(1984a) Effect of non surgical periodontaltherapy (II). Severely advanced peri-odonti t is . Journal of Clinical Periodonto-logy 1 1 . 6 3 - 7 6 ,Badersten. A., Nilveus. R, & Egelberg. J.(1984b) Effect of non surgical periodontaltherapy (III), Single versus repeated in-strumental ion. Journal of Clinical Period-

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Loos , B.. Nylund, K.. Claffey. N, & Egelberg, J. (1989) Ciinicai effects of root debridement in molar and non-molar teethA 2-year follow up. Journal of ClinicaPeriodonlology 16, 498 -604 .Magnus,son, L. Lindhe, J., Yoneyama, T, &Liljenberg. B, (1984) Reeolonization of subgingival miurobiota following scaling

in deep poekets. Journal of Ciinicai Periodonlology I I , 193-207,Moran. J . , Addy, M. & Newcombe. R, (1988A clinical trial to assess the effieaey of sanguinarine-zine mouthrinse (Veadent) compared wilh chlorhexidine moulhrins(Corsodyi) , Journal ofClinicai Periodonlology 1 5 , 6 1 2 - 6 1 6 .Morton, M. E, (1977) Dental disease in grou p of adult mentally handieapped patients. Puhlic Health 9 1 . 2 3 -3 2 .Noah, M. O, (1982) Caries experience andstale of oral cleanliness of fiveyear and fifteen-year-old handieapped children in thBradford area. Journal of ihc Inlernaliona

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in man (IV). EtTecl on various medicaparameters . Journal of Periodonnil Re.search 1 1, 158 164,Siegrist, B, E,, Gus berti, F, A,. Breex. M, CWeber, H. p & Lang, N. P (1986) Efficacof supervised rinsing wilh chlorhexidindigluconate in comparison to phenolic anplant alkaloid compounds. Journal oPeriodonlai Research (suppl, 16), 60-73,Van der Velden. U (1980) Influence of periodonta! heallh on probing depth anbleeding tendency. Journal of Clinical Perodonhilogyl. 129 - 139 ,Westfelt, E.. Nyman, S., Lindhe, J, & Socransky S. S. (1983). Use of chlorhexidine as plaque control measure following surgieatreatment of periodontai disease. Journaof Clinical Periodonlology 10, 22-36.

Address:Noel ClaffeySchool of Denial ScienceTrinity CollegeDublin 2Ireland


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the use of 0,2 % chlorhexidine

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