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

All rights rfu

Copyrighi Munk.sgatirii IV98

mm

Clinical penodontoiogy

The use of 0.2% chlorhexidine in the absence of a structured mechanical regimen of oral hygiene following the non-surgical treatment of periodontitis
Christie P. Claffey N. Renvert S: The use of0.2"<' chlorhexidine in the absence of a structured niechcinicdl regimen oJ oral hygiene Jol/oning the non-surgical treatment of periodontitis. J Clin Periodontol 1998: 25: 15-23. Munksgaard, 1998. Abstract. The aim of the present study was to evaluate a O.^'-^i chlorhexidine mouthrinse following the non-surgical treatment of advanced human periodontitis in the absence of a structured mechanical oral hygiene regimen. 10 patients and a total of 1483 sites were used. Recordings for plaque, bleeding, pocket depth and attachment levels were made at baseline and at 3, 6, 9. and 12 months. Debridement was performed under local anaesthesia. No instruction or reinforcement in mechanical ocal hygiene procedures was given at any time. However, at each visit the patients were instructed in the 2x daily use of 0.2'/^) chlorhexidine mouthwash. The plaque indices, scored as "/i of sites with removable deposits, showed negligible improvement from baseline scores of SO'YolOO'Mi for all categories of initial probing depth. Mean bleeding score was reduced lo 10-20'yi> irrespective of initial probing pocket depth, site location or tooth surface location. Sites ^ 7 mm at baseline demonstrated a reduction in mean probing pocket depth of 3.9 mm and a gain in mean probing attachment level of 2.5 mm. Moderately deep sites (4-6.5 mm) demonstrated a reduction in mean probing pockel depth of 2 mm and a gain in mean probing attachment level of 0.8 mm. Shallow sites (3.5 mm) demonstrated a reduction in mean probing pocket depth of 0.5 mm and a loss in mean probing attachment level of 0.2 mm. Sitespecific attachment level analysis demonstrated Ihat over 80'/.. of losing sites were shallow with low bleeding frequency, indicating that the loss of attachment may have occurred for reasons other than inflammatory periodontal disease. The results indicate that chlorhexidine can be used as an adjunct to inadequate mechanical oral hygiene over an observation period of 1 year.

Philip Christie\ Noel Claffey^ and Stefan Renvert^

'School of Dental Science, Trinity College, Dublin, Ireland, ^School of Dental Hygiene, Kristianslad College of Health Sciences. Kristianstad, Sweden

Key words; periodontitis; chlorhexidine; non-surgical therapy Accepted for publication 21 April 1997

There is a wealth of evidence supporting the non-surgical treatment of adult periodontitis. The 2 essential components of successt""ul non-surgical therapy are adequate subgingival dehridement and effective plaque control (Egelberg 1995). Although effective mechanical

plaque control is an achievable goal for most patients, many individuals, including those with mental and physical disablement, cannot maintain a suitable standard of self administered mechanical plaque control in order to prevent disease recurrence following treatment.

It has been demonstrated that the effects of debridement without adequate plaque control results in ineffective therapy within a period of months (Magnusson et al. 1984). Furthermore, the failure to control supragingival plaque following surgical therapy may

16

Chri.slie ei al. and at night. At the 3-month visit and thereafter, compliance was eonfirmed by questioning and by noting the presence of slain on the teeth and the patients were reinstructed. Sealing and root-planing was performed under local anaesthesia over a 2-4 week period. The debridemenl was performed using a combination of subsonic and hand instruments and was earried out until the operator was confident that the roots were adequately debrided. The debrided areas were irrigated immediately after with 0.2% ehlorhexidine gluconate. Gross occlusal anomalies were eliminated as part of the therapeutic regimen.
Clinical measurements

result in ;i rapid i":itc of loss of clinical attachment (Lindhe & Nymiiii 1985). Accordingly, there is an obvious need for adjunctive aids to inadequate mechanical oral in a significant proportion of patient.s needing treatment for periodontitis. Chlorhexidine diglueonate has been shown to be safe and effective as an anti-plaque and anti-gingivitis agent in both short and long term studies (Loe & Schiott 1970. Lindhe et al. 1970. Davies et al, 1970. Loe el at. 1972. 1976, Lang et al. 1982. Westfelt et al. 1983. Grossman et al, 1986. Kornman 1986). The aim of this study was to evaluate, using clinical parameters over an observation period of 1 year, healing following subgingival debridement in patients who did not reeeive meehanieal oral hygiene instruction but who rinsed 2X daily with d.2'A\ chlorhexidine diglueonate. Material and Methods
Patients

lars. 8 sites were measured: mesiobuccal. mid-mesiobueeal root, bueeal furcation, mid-distobuccal root, distobueeal. distopalatal fureation. midpalalal root and niesiopalatal furealion. For mandibular molars ten sites were measured: mesiobueeal, mid-mesiobuceat root., bueeal furealion. niid-dislobuccal root, distobueeeal. disiolingual. mid-distolingual root, lingual fureation. mid-mesiolingual root and mesiolingual. Each of the above sites was measured for the 4 elinical parameters: presence or absence of plaque, presence or absence o\' bleeding on probing, probing depth and probing attachment level. In all, 1.483 sites were studied.
Plaque score

Recordings were made at 6 sites tor non-molar teeih: mesiobuccal. midbuccal. distobueeal. distolingual. midlingual and mesiolingual. For maxillary mo-

Plaque was recorded as present or absent after staining with Bismuth brown

100

10 patients between the ages of 25-60 years were used in ihis study. The patients were seleeted from those atlending the Dublin Dental Hospital for the treatment of advanced periodontitis. None of ihe patients had received treatment for periodontitis in ihe previous 5 years and all were free of any systemic disease. All patients had a minimum of 14 teeth, at least two of which were molars and demonstrated al least 10 sites with probing depths ^ 7 mm. All available teeth were used except for 3rd molars.

90 f 80
7 0 6 0 50 40 3 0 2 0 10 0 -

->7mm 4-G.5mm -<3.rJinm

12

Months

Experimentai design

The study used a longitudinal, sequential observational approach. Baseline measurements of the elinieal parameters were reeorded. This was followed by crown and root debridemenl and twice daily 1 min rinsing with an aqueous solution of 0.2''<i chlorhexidine gluconate over a twelve month period with measurements taken every 3 months.
Therapy Furcation Proximal Lingual Buccal

The patients were not given any instruction in meehanieal oral hygiene proeedures. They were provided with ehlorhexidine glueonate 0.2"'^i aqueous solution and instrueted in its use. i.e. 1 full minute (timed) rinse in the morning

Fig. /, Mean plaque score ["'i) by site location (buccai. lingual, pro,\iiTiiil and furcation) and by L-iUcgoiy of initial probing depth (^,1,5 mm. 4-6-5 mm and 27 mm).

Clorhexidine yinse in non-siirgica! periodonUi! ihenipv

17

was directed epically towards the perceived location of the apex of the tooth. Midbuccal and midlingual sites were measured by placing the probe at these locations and directing it longitudinally along the root surface. For furcation sites the probe was guided to the deepest point by the furcal groove. Alt recordings were done by the same examiner throughout.
Analysis of data

Months

100 J

90 .-

Mean of patient bleeding scores, plaque scores, probing depths and change in probing attachment levels were calculated for all patients subgrouped by initial probing depths (^3.5 mm. 4.0-6,5 mm and ^7.0 mm), by site location inio proximal, furcation, buccal and lingual sites, and by site location into non-molar, molar flal (those molar sites other than those located at the furcation) and molar furcation sites. With respect to the site specific analysis, linear regression analysis was used lo detect probing attachment level change. Measurements at sequential time intervals over the period of study were subjected to linear regression analysis. The threshold for change required to designate a site as having lost attachment was chosen as ^1,5 mm with a;f<0.05. 12 Results Although no instruction in hygiene was given to any of the patients, a limited improvement in mean plaque scores occurred for all categories of initial probing depth and location studied (Fig. 1). Changes in mean bleeding score occurred for all 3 categories of initial probing depth over the twelve months (Fig. 2). The deepest sites had the highest mean bleeding score at baseline of over 90"/li. The mean bleeding scores for sites ^ 7 mm was reduced by 72%, for sites initially 4-6,5 mm deep by 71% and for sites ^ 3 mm by 47%. When these reductions are analysed with respect to their baseline values, the percentage improvement* in mean bleeding score was similar for all three categories of initial probing depth. When mean bleeding scores were analysed by site location, the same trends were observed for all site locations. Mean bleeding * The % improvement is given by the reduction in mean bleeding score as a percentage of the baseline score.

Furcation Proximal ingual Buccal

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

Stain. Stained plaque at the gingival margin that could easily be removed with the tip of a periodontal probe however small, was recorded. The plaque score was then taken as the number of sites displaying plaque as a percentage of the total number of sites measured.
Bleeding on probing

Probing depths and probing attachment ievel

Bleeding was recorded as present or absent during the measurement of probing depth and probing attachment level. The bleeding score was then taken as the number of sites bleeding on probing as a percentage of the total number of sites measured.

These measurements were made with an electronic, pressure sensitive probe (Electronic Periodontal Probe, model 200, Vine Valley research. Middlesex, NY., USA) with a probing force of 0,5 N, The probe was graduated in Imm increments and had tip diameter of 0,4 mm. The measurements were made to the nearest 0.5 mm. A vacuum adapted, I mm thick, soft acrylic onlay was used to provide reference points for the probing attachment level measurements. For proximal surfaces, the placement of the probe was guided by the interdental indentations of the onlay, and the probe

18

Christie et al. while furcation sites displayed a reduction of 1.1 mm. The improvement in mean probing attachment levels over the twelve months of this study amounted 2.5 mm for initially deep sites (3^7 mm), 0,8 mm for initially moderately deep sites (4-6.5 mm), whereas initially shallow sites demonstrated a loss of attachment of 0.2 mm (Fig. 4). When probing attachment level data is analysed by location of sites, the furcation and proximal sites demonstrated the largest gain in probing attachment level (0.5 mm) at the twelve month examination (Fig. 4). The dimensional changes (0-12 months) for different category of sites are presented in Figs, 5 10. In non-molar sites analysed by initial probing depth only sites ^2.5 mm demonstrated mean probing attachment level loss. Alt other categories of initial probing depth from 3-3.5 mm through to 5^10 mm demonstrated a gain of mean probing attachment level. The trend was for most gain of mean probing attachment in the deeper sites. Also, mean amount of recession tended to be greater in the initially deeper sites (Fig. 5). The same trend was true in molar flat surfaces (all moiar surfaces except furcation sites) and furcation sites (Figs. 6, 7). However, only fifteen deep furcation sites were available for the three categories of 7-7,5 mm, 8-8.5 mm and 9-9.5 mm. Nevertheless, only sites of the shallowest category, i.e., ^2.5 mm. demonstrated loss of mean probing attachment. For proximal, buccal and lingual sites (Figs. 8-10) the trends were the same as for previous categories of sites, with a tendency for the greatest changes to occur for sites with the greatest initial mean probing depth. The gains in mean probing attachment level tended to be less in groups of initial probing depth for buccal sites than for all other categories of sites. Linear regression analysis over time was used to assign probing attachment loss to sites. The threshold for change required to designate a site as having lost attachment using linear regression analysis was chosen as s i . 5 mm (p<0.(i5). There were a total of 57 sites detected as losing attachment. This represented approximately 4% of the total number of sites. In this instance, one patient accounted for about 50"/) of those 57 sites. By location, 27 of the 57 sites were proximal, 26 were buccal or lingual and 5 were furcation sites, 8 out often ofthe patients had no losing sites in either the moderately deep or deep categories. 45 ofthe 57 losing sites, (79'/.) were of the shallow initial probing depth category Only 2 patients were deemed to have losing sites by this method in the moderately deep and deep categories and almost half of the losing sites by linear regression analysis were located in one and the same individual. Table I shows the mean bleeding frequencies (average number of examinations at which the bleeding score was positive over the 5 examinations) for the 57 sites with attachment loss grouped by initial probing depth and by surface location. 45 out of 57 of the losing sites were shallow by initial probing depth and had a low bleeding frequency. 9 losing sites were moderately deep by initial

scores were reduced to 10-20"/) irrespective of site location. However, proximal and t^urcation sites maintained slightly higher mean bleeding scores than lingual and buccal sites over the period of observation. The changes in mean probing depth over ihe twelve month period are presented in Fig, 3. Probing depths were reduced by 3.9 mm for deep sites (^7 mm), 1.9 mm for moderately deep sites (4-6.5 mm) and 0.5 mm for shallow sites (^3.5 mm). Analysis of the sites broken down by site location revealed that the mean probing depths for furcation sites and proximal sites were somewhat greater than for buccal and lingual sites at baseline (Fig. 3). Proximal sites displayed the greatest reduction in mean probing depth of 1,5 mm.

9 x

-O-

-O-

6 Months

12

Fig. S. Mean probing depths (mm) by site location (buccal. lingual, proximiil furcation) and by initial probing depth category (s3,5 mm. 4-6.5 mm and ^ 7 mm).

Clorhexidine rin.se in non-surgical periodontal therapy

19

-0.0-

F urea tion Proximal Lingual Buccal

12

Months

Fig. 4. Change in meiin prnhing attachmeni levels (mm) by initial probing depth category by site location (buccal. lingual, proximal and furcation) and by initial probing depth category (s3,5 mm. 4-6.5 mm and s^l mm).

' Gingival recession

7 S B i

Residual probing depth

4 3 2

2,6

nflB
3-3,5 4-4,5 5-5.5 6-6,5

Initial probing depth

'Gain or loss of probing attachment level

8-6.5 9-9.5
>10 mm

7-7,5

Initial Probing Depth

Fig. 5. Mean dimensional changes (0 12 months) for non-molar sites by initial probing depth categories. Interpretation for Figs, 5-10: The total length of the bar represents the mean probing pocket depth for each group of initial probing pocket depth at baseline. The dark shaded area at the top of the bar represents the mean itmount of recession which occurred for each group of initial probing pocket depth. The medium shaded area represents the gain in mean probing attachment level while the light shaded area represents residua! mean probing pocket depth for each group of initial probing pocket depth, A loss of mean probing attachment level is represented by ihe medium shaded area below the .v-axis. There are 6 to 9 groups of initial probing pocket depth from ^2,5 mm through to s^ll) mm depending on the category.

the gingival conditions reported after conventional non-surgical periodontal therapy (for review, see Egelberg (1995) could be obtained by substituting twice daily rinses with chlorhcxidine for the high levels of mechanical oral hygiene. Nordland el al. (1987) noted the importance of continuous reinforcement of the oral hygiene regimen in terms of maintaining the improvements in gingival condition following subgingival mechanical debridement. It appears that the success of therapy is dependent on achieving very low plaque scores (in the order of 2O'l4^25"/>). The efficacy of ehlorhexidene in the prevention of gingivitis is established (Addy et al. 1994), In situations of no oral hygiene chlorhexidine digluconate has been shown to inhibit Ihe quantity of plaque and the degree of gingivitis by as tnuch as 'iV'/o as compared to placebo solutions (Siegrist et al, 1986. Moran et al, 1988). Chlorhexidine significantly improves the effect of normal mechanical oral hygiene proeedures (Flotra et al, 1972. Addy & Hunter 1987). Although chlorhexidine has been shown to have an inhibitory effect on oral microorganisms (Lang & Brecx 1986, Siegrist et al. 1986) plaque does still form (Breex et al. 1990). The rather minor changes in mean plaque score found in this study cannot explain the improvements in gingival bleeding, reductions in probing depth and gain of probing attachment levels found in this study. However, the baeterial component of the plaque formed using ctorlicxidine rinses has been reported to be in different states of lysis and the plaque vitality scores was found to be l5-3O'/o less as compared to controls (Brecx et al. 1990). Thus, chlorhexidine may have both quantitative and qualitative effects on deposits formed in its presenee. Accordingly, a possible explanation of the favourable clinical results obtained in this study is that, although plaque index remained high during the experimental period, the vitality and eomposition of the reeorded plaque may not have been disease inductive. It should be remembered tbat the method of plaque scoring used in this study was not capable of qualitative or quantitative discrimination, but merely reflected the presence or absenee of a stained, removable deposit. Mean bleeding score was reduced to 1O'^^2O'^,, regardless of the baseline score. The final bleeding score was similar for all three categories of initial

probing depth and had a slighlly higher bleeding frequency. No deep furcation site was deemed to have lost attachment by this method of analysis.

Discussion The aim of the present study was to investigate whether the improvements in

20

Chrislic et al. more enhanced panoral antimicrobial effect of chlorhexidine than possible with mechanical hygiene methods. Van der Velden (1980) demonstrated that more than yS"A> of sites displayed bleeding on probing after periodontal therapy using a probing force of 0,5 N, The same probing force used in clinically healthy sites results in a bleeding score of about 20% (Lang et al. 1991. Karayiannis et al. 1992). In this study only 1 l%i of all sites displayed bleeding on probing after initial therapy using the a probing force of 0.5N. This infers that the bleeding seen in this study after therapy may have been traumatic rather than inflammatory in nature. The concept of a graded bleeding score might have been useful in order to distinguish the relative amounts of traumatic and inflammatory bleeding in this study (Renverl et al. 1992), Initially shallow sites demonstrated a reduction in probing depth of approximately 0,5 mm. This i,s in contrast to previous studies using mechanical plaque control measures were shallow sites remained virtually unchanged throughout the studies (Badersten el al. 1987, Loos et al. 1987, Claffey et al, 1988, 1990). The higher amount of inflammation, as represented by higher mean bleeding scores at baseline in this study, may to some extent explain this improved reduction in probing depth. A greater amount of the initial probing depth measurement in this study might have been due to oedematous soft tissue swelling or pseudo-pockeling. The fundamental pattern for less improvement and poorer healing response in molar furcation sites after initial treatment is not evident in this study. Analysis of mean data by tooth surface location indicates that molar furcation sites show a healing response which is twice that of non-molar sites in terms of probing attachment level gain. This is in contrast with the results by Nordland et al, (1987) where the 24-nionth probing depth for molar furcation sites was similar to its baseline recording. The favorable results in the furcation areas may relate to the greater initial probing depth for furcation sites as compared to non-molar sites. It is however, important to point out the small number of molar furcation sites available in the present study (only 15 furcation sites were available in the deep category). The improvement in probing attachment level in this study are higher than quoted for previous studies (for review, sec Egelberg (1995)) Caution is warranted in the interpretation of these seemingly enhaiiced probing attachment level improvements over previous studies since no control group of sites is available in this study. The lack of control group is a limitation worthy of consideration. However, an untreated control group (placebo rinsing) was not considered ethical in view of severity of the periodontitis in these patients.

probing depth regardless of site location. These reductions arc comparable to the results reported by Badersten ei al. (1985a, 1985b. 1987) on single rooted teeth. In studies involving molar teeth the bleeding scores following nonsurgical treatment has been reported to be higher (AifA.) than in this study (20%) fNordiand et al. 1987, Loos ct al. 1989. Claffey et al. 1990). The more profound decrease in mean bleeding score seen in this study may reflect a

Gingival recession Residual probing depth

Initial
piTDbin

depth

Gain or loss of probing attachment level

S2,5 3-3,5 fl-4,5 5-5.5 6-6 5 7-7 5

a-8,5

9-9,5

>10mni

Initial Probing Deptli

Fig. 6, Mean dimensional changes (0-12 nionthsj for molar flal surfaces by initial probing depth categories.

-|-Gingival . recession Residual probing depth

Initial probing depth

nfl
2,5 3-3,5 4-4.5 5-5.5 6-6,5 7-7,5 8-8,5 Initial Probing Depth 9-9,5
>10 mm 10 9 ,

Gain or loss of probing

attachment level

Fig. 7. Mean dimensional changes (0-12 months} for furcation sites by inilial probing J e p l h categories.

Gingival

. recession Residual probing depth Gain or I oes of probing attnchment levd Initial proHng depth

s
7

s
5 4 3 2 1 0 -I

4-4,5

5-5,5 6-6 5 7 7 Initial Probng Depth

e-B.5

9-9,5

Fig. H. Mean dimensional changes (d 12 months) for proximal sites by initial probing depth categories.

Clorhexidine rinse in non-surgical periodonial therapy

Giiigwal recefflion Re sidual probing depth Gainor lossof probing attadunentlevel

21

Initial pro ting depth

clear that pocket depth rather than surface location is the common denominator in relation to this probing attachment loss. The reason for loss of attachment in shallow sites might be due to (a) trauma from mechanical hygiene, (b) trauma from instrumentation and (c) some type of remodelling process of the tissues as a consequenee of the treatment (Claffey & Egelberg 1994). 80% of the sites deemed to have lost attachment by regression analysis in this study were shallow apparently healthy sites with a low bleeding frequency. Furthermore, only the shallowest sites (in the ^2.5 mm category) were deemed to have lost attachment on average and the average loss for sites ^3.5 mm was 0.2 mm. In previous studies, mean loss of attachment in shallow sites was reported to be as high as 0.6 mm (Egelberg & Claffey 1994) These discrepancies may be related to differences in mechanical hygiene measures between this and previous studies. The residual probing depths and bleeding frequencies found for sites of all categories of initial depth with probing attachment loss suggests that only 2 of the 29 sites may have lost due to ongoing inflammatory disease. Deep molar furcation sites would be expected to display a high frequency of probing attachment loss (Nordland et al, 1987. Loos et al. 1989. Claffey et al. 1990), However, no deep molar furcation sites were identifled as losing probing attachment in the present study. In this regard, one should bear in mind that only a small number of deep fureation sites were available in this study and the period of study was less than for the other studies cited. The unexpected equality in the mean healing response of the molar furcation sites and those of other locations in the present study is worthy of note. Again, a limitation in this respect is that only a small number of molar furcation sites ill a small number of patients was available for study, disallowing flrm conclusions. Previously, the poorer response of the furcation sites has been attributed to difficulties in debridement associated with anatomical and morphological features of these sites (Egelberg & Claffey 1994). The clinical circumstances of the present study cannot be assumed to be markedly different from those of other studies and it is likely that the same difficulties with furcation debridement were encountered.

Initial Proting Depth Fig. 9. Mean tiimensional changes (0-12 months) for lingual sites by initial probing depth categories.

Gingival recession

Residual probing depth

Initia! probing depth

Gain or loss ol " " probing -*- attachment level Initial ProUng DepUi Fig. 10. Mean dimensional changes (0 12 months) lor buccal siles by initial probing depth categories.

Moreover. Magnusson et al. (1984) demonstrated the lack of response to non-surgical therapy in the absence of adequate plaque control, A control with a structured mechanical plaque control regimen was considered. However, there is a wealth of information available on nonsurgical therapy with good mechanical plaque control including previous data from Claffey et al, (1988, 1990). These studies could to some degree be used as comparisons to this report. Various studies on the effects of initial treatment have consistently demonstrated that the highest proportion of sites with probing attachment loss was found for sites with initial probing depth

of ^3.5 mm (Badersten et al. 1984a.b, 1987. Loos et al. 1987. Claffey et al. 1988. Egelberg & Claffey 1994), The shallower the initial pocket depth, the greater the likelihood of loss of probing attachment at a particular site (Badersten et al. 1987) The clinical characteristics of (hese shallow sites would suggest that the probing attachment loss occurs for reasons other than ongoing periodontal disease. Although displaying attachment loss, these sites display no increase in probing depth froin baseline and a low bleeding frequency (Claffey 1991). The present study also shows the same pattern of attachment toss for initially shallow sites. When sites are broken down by location and by initial probing depth it is

I. Bleeding frequency (number of examinations al wiiich ihe siles bled on probing) and distribution o( the 57 sites (3,8% of total) with attachment loss (determined using linear regression) from 0-12 months by initial probing depth (IPD) category and by surface location Bleeding frequency IPD category ^3,5 mm ( = Buccal and lingual /V=517
22 2

Proximal ;V=K53 19

Furcation ,V=M3

4,0-6,0 (/;=9)

2,2/5

22

Christie et al. rodiintitis ohnc geordnete Anleitung fur mechanLwhe Mundhygiene Gegenstand dieser Studie war. die Wirkung einer Mundspiilllussigkeit mit 0.2'S^iigem Chlorhexidin nach iiichi-chirurgischer Behandiung forlgeschrittencr Parodontitis auszuwcrlen, ohne cJaB niiin cine struklurierte Vorschrifl fiir mechanise lie Mundhygiene 7.\xgiinglich machle, Filr diese SUidie wurden 10 Palienieii und insgesamt 1483 Slellen hcrangezogen, Befundungen fur Plaque. Girigivablutuiig. Taschentiefc und Attachmenlhohe wurden eingangs und nach 3. 9 und 12 Vcrsuchsmonaien registriert. Harte und weiche Bcliige cntfernif man iinler Lokalanaeslhesie. Anleitungen fur mechanischc MundhygienemaBnahmcn oder filr ihre Verbesserung teilte man nicht mit, Allerdings wurden die Patienten bei jeder Einbestcllung dartiber unterrichteU wie die zweimal lagliche Mundsplilung mit der 2'/Jiigen Cblorhexidinlosung vorzunehmen sei. Die als prozentuales Vorkommen von Stellen mit entfernbaren Beliigen bewerlclcn Plaqueindize^, lieBen bei 80"''r.-100"/; aller Behandlungsklassen der ursprtingiich sondierten Tascheniiefen nur unbedeuleiidende Verbesserung der eingangs registrierten Scores erkennen, Ungeachlet der initial sondierten Taschentiefe, der Lokalisation der Stelle oder der Oberfliiche. worde eine Reduktion der mittieren Bliilungs-Score zwischen IO-2O"/(i konstatiert. Bei Stellen mit eingangs sondierter. Taschenliefe von ^ 7 mm. stellte man eine mittlere Reduktion von 3,9 mm fc'^t und einen miitleren Gewinn sondierter Atlachmenthohe von 2,5 mm, Bei miiRig liefen Slellen (4 6.5 mm) lag eine Verringerung der sondierten Taschentiefe von im MiUel 2 mm vor. und ein sondierler Niveaugewinn des Attachments von durchscbnittlicb 0.8 mm, Bei flachen Stellen (^3,5 mm) kam es zur Reduktion der sondierten Taschenliefe von Im Mittel 0,5mm und zum Verlust des sondierten miitleren Attachmentniveaus von 0,2 mm, Eine sleilenspezifischc Analyse des Attachmentniveaus macble deullich. daO Uber 80"'ii der Verluststellen flach waren, mil gerlnger Vorkommenshiiufigkeit von Gingivablutungen, Das spricht dafUr. daB der .AttaclimeiUverlust aus anderen Griinden als durch eine entziindliche Parod onta Ik rank heit entstanden sein kann. Uber eine Beobachtungszeil von I .luhr zeigen die Ergebnisse. daB Chlorhexidin bei unzureichender mechanischcr Mundhygiene als Adjuvans angebrachl ist. ment. de la profondeur de poche et des niveaux d'attache onl ete realises lors de l'examen initial et apres 3, 6, 9 et 12 mois. Le surfagage a ete effectue sous anesthesie locale. Aucune instruction ni renforcement de I'hygiene buccale meeanique n'a ete donne a aucun moment, Cependant les patients ont ete instructs a I'utilisation biquotidienne d'un bain de bouche a la chlorhexidine 0,2%, Les indices de plaque enregistrcs cn tant que pourcentage de sites avec des depots pouvant s'enlever ont montre une amehoralion negligeable depuis les scores initiaux de 80 a 100'^. pour toutes les categories de profondeur de poche initiale, Le score moyen de saignement a ete reduit de iO a 20"/. quelle qu'etait la profondeur de poche initiale, la localisation du site ou la localisation de la surface dentaire. Les sites avec 3^7 mm de profondeur lors de I'examcn initial ont subi une reduction dans la profotideur moyennc de !a poche parodontale de 3.9 mm et un gain du nivcau d'attache moyen de 2,5 mm, Les sites de profondeur moyenne (4 a 6.5 mm) ont subi une reduction moyenne dc la profondeur de poche au sondage de 2 mm et un gain du niveau d'attache moyen de (1,8 mm, Les sites de faible profondeur {^3.5 mm) ont accuse une reduction moyenne de profondeur de poche de 0,5 mm et une perte du niveau d'attache de 0,2 mm, L'anatyse du niveau d'attacbe par sile specifique a demontre que plus de 80% des sites avec perie etaient peu prolonds avec une frequence de saignement faible. indiquant que la perle d'attache peut s'etre produite pour des raisons autres que la maladie parodontalc inllammatoire, Les resultats indiqucnt que ia chlorhexidine peul etre utilisee en tant qu'aide lorsqu'une hygiene buccale meeanique inadequate est pratiquec durant une periode d' une annee.

One interpretation of the enhanced results for furcation areas of the present study would be that the difficulty in debriding furcation areas is not as critical a factor as is the control of supragingival plaque. It is possible that chlorhexidine had an effect on those areas relatively innaccessible to mechanical plaque removal, such as the the concave entrances lo mesial and distal fucations on maxillary molars. Further studies are needed to assess whether chemical supragingival plaque control can overcome the widely reported diffieulties in treating furcation involvement. While it is theoretically undesirable to exert long-term changes on the oral micro-environment, a number of longterm studies have reported no untoward effects (Loe et ai. 1976. Schiott et al, 1976, Briner & Wunder 1977). No reduced bacterial sensitivity to chlorhexidine was found in a four year animal study (Briner & Wunder 1977). In the present study, no adverse effects, other than the well documented side effects of bad taste and staining, were experienced by the subjects. The results of this study indicate that chlorhexidine digiuconatc as an 0.2'^i solution used as a mouthrinse for 1 min, 2X daily, is effective as an alternative to structured mechanical oral hygiene in non-surgical treatment of chronic advanced human periodontilis over an observation period of one year. Studies of dental disease prevalence indicate that handicapped groups have a higher prevalence of periodontal disease and significantly poorer levels of oral hygiene than able-bodied counterparts (Morton 1977, Noah 1982). It appears on the basis of the results of the present study that treatment for handicapped people of advanced periodontal disease can be expected to be successful provided that compliance with the mouthwash ean be assured either at home or in an institution.

References Addy. M., Moran J, & Wade W (1994) Chemical plaque control in the prevention of 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 of a 0,2"',i chlorhexidine gluconate mouthrinse on plaque, looth staining and candidii in aphtbous ulcer patients a doublebiind placebo-controlled cross over study. Journal f)f Ciinicai Periodvntohgv 14, 267273. Badersten. A., Nilveus. R. & Egelberg. J. (1984a) Effect of non surgical periodontal therapy (II). Severely advanced periodontitis. Journal of Clinical Periodontology 11.63-76, Badersten. A., Nilveus. R, & Egelberg. J. (1984b) Effect of non surgical periodontal therapy (III), Single versus repeated instrumentalion. Journal of Clinical Periodontology 11, 114-124. Biidcrsicn. A,. Nilveus, R. & Egelberg, J. (1985a) Effect of non surgical periodontal therapy (VII). Bleeding, suppuration and

Acknowledgments The authors would like to express their thanks to Agnes Hagan for help with manuscript preparation, to Geraldine Clark for help in the clinic and to Jim Larragy for help with the data analysis. Resume L utilisation de la chlorhe.xidine 0.2% san.\ regime structure li'hygiene buccale meeanique aprex traitement non-chirurgica! dc la parodontite Le but de celte elude a etc d'cvaluer un bain de bouche a la chlorhexidme 0.2"';i apres le trailement non-chirurgieal de la parodoniite hnmaine avancee en absence d'un regime d'hygiene bnccale meeanique structure. Dix palients et 1 483 siles onl ete suivis. Les enregistrements de la plaque dentaire, du saigne-

Zusammenfassung Dw Anwcndung \vn 2"''i-igem Chlorhexidin nach nichi-chirurgischer Behandlung der Pa-

Clorhexidine rinse in non-siirgieal periodontal therapy

probing deplh in sites with probing attaehnient loss, Juuniui of Clinical Pcrioikmlology 12. 432-440. Badersten, A,, Nilveus, R. & Egelberg. J, (iy85b) Effeet of non surgical periodontal therapy (IV), Operator variability. Journal of Clinical Pel iotkmlology 12, 190-200, Badersten. A., Nilveus, R, & Egeiberg. J. (1987) Effect of non surgical periodonta! therapy (VII). Probing atlachment changes related to clinical characleristics. Journal of Clinicul Periodontology 14, 425432. Breex. M.. Neiuschil, L., Reiehert. B. & Schreil. G, (1990) Efficacy of Listerine. Meridol and ehlorhexidine moulhrinses on plaque, gingivitis and plaque bacteria vitality. Journal of Clinical Periodonlology 17. 292-297. Briner. W. W. & Wunder, J. A, (1977) Sensiliviiy of dog plaque microorganisms to chlorhexidine during longitudinal studies. Journal of Periotloiual Research 12. 135 139. Claffey. N & Egelberg, J. (1994) Clinical characierisiics of periodontal siles wilh probing altachmenl loss following initial periodonial treatment, Jouruut of Clinical Perioclonlologv 21. 670-679. Claffey, N. (1991) Decision making in periodontal iherapy, Tbe reevaluation. Journal oJ Clinical Perlockmlohgy 18, .184-3S9, Claffey, N,, Loos, B,. Games. B,, Martin, M,. Heins, P, & Egelberg. J, (1988) The relative effects of therapy and periodontal disease on loss of probing atiachmenl after root debridement. Journal of Ciinicai Periodonrologv IS. I(i3-169, Claffey, N,, Nylund, K,, Kiger. R,, Garrett, S. & Egelberg. J. (1990) Diagnostic predictability of scores of plaque, bleeding, .suppuration and probing depth for probing aitaehment loss: 3,5 years of observation following initial periodonial therapy, Jaiirmil of Clinical Periochnlology 17, 108-114, Davies. R, M,, Jensen. S. B., Schiott. C, R, & Loe, H, (1970) The effeet of lopieal application ol' ehlorhexidine on ihe bacterial colonisation of the teeth and gingiva. Journal of Periodonial Research 5. 96-101. Egelberg. J. (1995) Periodontics, the seienlific way. 2n(j edition, Malmo: OdontoScience, Egelberg, J, & Claffey. N, (1994) Periodonties re-evaluation. The scientific way. Ist edition. Copenhagen: Munksgaard. Fletra, L.. Gjermo. P. Rolla. G. & Waerhaug. J. (1972) A 4-month study on ihe effects of chlorhexidine mouihwashes on 50 soldiers. Scandinavian Journal of Denial Research m. 10-17, Grossman. E., Reiter, G.. Sturzenberger. O. P.. de la Rosa. M,, Dickinson. T. D.. Eerrettl. G, A,. Ludlam. G. E. & Mcckel. A. H, (1986) Six-month study of the effecls of a chlorhexidine mouthrinse on gingivitis in adults. Journal of Periodonial Research 21, (suppl, no, 21). 33-43. Karayiannis. A,, Lang, N,P,, Joss, A. & Nyman. S, (1992) Bleeding on probing as il relates to probing pressure and gingival heallh in patients wilh a reduced but heallhy periodontium: a clinical study. Journal ofClinicai Periodomology 19, 471475. Kornman, K. S, (1986) The role of supragingival plaque in the prevention and treatment of periodontal diseases. A review of current eoneepts. Journal of Periodontal Researcli 21 (suppl. 16), 5-22. Lang, N. P & Brecx, M. C (1986) Chlorhexidine digluconate an agent for chemical plaque control and prevention of gingival inflammation. Journal of Periodontal Research 21 (suppl, 16), 74 89, Lang, N, P, Uou. P. Graf. H,, Geering. A, H.. Saser U, P, Sturxenberg, O, P & Meckel, A, H, (1982) Effects of supervised chlorhexidine mouthrinses in children, A longitudinal clinical Irial, Journal of Periodonial Research 17. 101-111. Lang. N, P, Nyman. S,, Senn, C. & Joss, A. (1991) Bleeding on probing as it relates to probing pressure and gingival heallh. Journal of Clinical Pt'riodonlologx 18, 257261, Lindhe. J, & Nyman, S. (!986) Scaling and granulation tissue removal in periodontal therapy. Journal of Clinical Periodonlotogv 12, 374-388, Lindhe. J., Hamp. S, E.. Loe, H. & Schiott, C R, (1970) Influenee of lopieal applieation of chlorhexidine on chronic gingivitis and gingival wound healing in the dog. Scandinavian Journal of Denial Research IS. 47 \ 478, Loe. H, & Schiott, C. R, (1970) The effect of mouthrinses and topical applieation of chlorhexidine on the development of denta! plaque and gingivitis in man. Journal of Periodonial Research 5, 79-83, Loe. H.. Sehiott, C, R,, Glavind, L, & Karring, T, (1976) Two years of oral use of chlorhexidine in man (I). General design and clinieal effects. Journal of Periodonial Re.warch 11. L35-144. Loe. H,, Frithjof. R,. von der Eehr, F, R, & Schiott, C. R. (1972) Inhibition of e.xperimental caries by plaque prevention. The efTect of chlorhexidine mouthrinses, Scandinavian Journal of Denial Research 80, 1 9, Loos, B,, Kiger. R, & Fgelberg, J. (1987) An evaluation of basic periodontal therapy using sonie and ultrasonic sealers. Journal of Clinical Periodontology 14, 29 33.

23

Loos, B.. Nylund, K.. Claffey. N, & Egelberg, J. (1989) Ciinicai effects of root debridement in molar and non-molar teeth. A 2-year follow up. Journal of Clinical Periodonlology 16, 498-604. Magnus,son, L. Lindhe, J., Yoneyama, T, & Liljenberg. B, (1984) Reeolonization of a subgingival miurobiota following scaling in deep poekets. Journal of Ciinicai Periodonlology II, 193-207, Moran. J., Addy, M. & Newcombe. R, (1988) A clinical trial to assess the effieaey of sanguinarine-zine mouthrinse (Veadent) compared wilh chlorhexidine moulhrinse (Corsodyi), Journal ofClinicai Periodonlology 15,612-616. Morton, M. E, (1977) Dental disease in a group of adult mentally handieapped patients. Puhlic Health 91. 23-32. Noah, M. O, (1982) Caries experience and stale of oral cleanliness of fiveyear and fifteen-year-old handieapped children in the Bradford area. Journal of ihc Inlernalional As.socialion Dcnlislry for Children 12, 1723, Nordland. P, Garrett. S,. Kiger. R,. Vanooleghem, R,, Hutchens, L, H. & Egelberg J, (1987) The effect of plaque control and root debridement in molar teeth. Journal of Clinical Periodonlology 14, 231-236, Renvert, S,, Wikstrom. M,. Helmersson, M., Dahlen, G. & Claffey, N, (1992) Comparative study of subgingival microbiological sampling techniques. Journal of Periodoniolo^r6X 797-801, Schiott. C R,, Loe, H. & Briner, W, W. (1976). Two year oral use of chlorhexidine in man (IV). EtTecl on various medical parameters. Journal of Periodonnil Re.search 11, 158 164, Siegrist, B, E,, Gusberti, F, A,. Breex. M, C . Weber, H. p & Lang, N. P (1986) Efficacy of supervised rinsing wilh chlorhexidine digluconate in comparison to phenolic and plant alkaloid compounds. Journal of Periodonlai Research (suppl, 16), 60-73, Van der Velden. U (1980) Influence of periodonta! heallh on probing depth and bleeding tendency. Journal of Clinical Periodonhilogyl. 129-139, Westfelt, E.. Nyman, S., Lindhe, J, & Socransky S. S. (1983). Use of chlorhexidine as a plaque control measure following surgieal treatment of periodontai disease. Journal of Clinical Periodonlology 10, 22-36. Address: Noel Claffey School of Denial Science Trinity College Dublin 2 Ireland