CHLORHEXIDINE AS AN ADJUVANT IN ULTRASOUND SCALING

Vol. 6, No. 3, July - September 14 CHLORHEXIDINE AS AN ADJUVANT IN ULTRASOUND SCALING Cristian Marin*, Vlad Popescu, Radu Costea Carol Davila" University of Medicine and Pharmacy - Bucharest, Romania, Faculty of Dentistry, Department of Pedodontics *Corresponding author: Cristian Marin, DMD, PhD student Carol Davila" University of Medicine and Pharmacy - Bucharest, Romania; e-mail: admin@med-clinic.net ABSTRACT In this study the authors have studied the results of using Chlorhexidine during preventive strategies. It evaluates the clinical results after conventional methods of professional cleaning by ultrasonic scaling, brushing, sanding (air flow) using Chlorhexidine (CHX). The study was conducted on a total of 328 Subjects equally divided in one reference group and one study group. The purpose is to establish a risk assessment strategy and apply preventive measures to each individual according to the diagnosis illness preponderance. The result is a better wellness status after the use of Chlorhexidine during the ultrasound scaling procedures. Keywords: scaling, chlorhexidine, prevention, periodontal, risk INTRODUCTION Dental and periodontal disorders in all forms, affects statistically about 9% from the contemporary population [1, 14]. The most common human oral diseases have a complex etiology that includes several microbial agents( like Streptococcus mutans, lactobacylus, Actynomyces Actinomicetemcomitans and Porfiromonas Gingivalis), time and environmental variables [1]. Oral microorganisms functions in the body as a unique ecosystem compared with a macroorganism due to saprophytic flora and ideal conditions for microbial growth (temperature, humidity, food intake frequency) [2,15]. Pathology of infectious diseases is represented by acid attack after demineralisation performed on the surface of the teeth by oral biofilm accumulation on the surface in time. The oral biofilm is acting like a macroorganism so it is very important to properly clean the dental plaque and maintain the oral health status in order to keep the oral wellness, the desiderate of the modern approach of modern dentistry [3,15]. Epidemiological studies [2], [3] have shown a strong relationship between the degree of deposition of plaque and chronic gingivitis, while clinical trials have provided evidence that dental plaque is the main etiological factor in gingival inflammation [3]. Subgingival plaque, derived from supragingival plaque, is also directly associated with lesions typical of advanced periodontal disease. Persistence present of the dental plaque subsequently is inevitably caused of gingival and periodontal lesions [4]. These periodontal diseases is produced mainly when the subgingival plaque accumulated grow microbial pathological microorganisms that linger inside the grooves beneficing on the poor hygiene. In time that 11

Vol. 6, No. 3, July - September 14 lead to the creation of environment conducive to the development of a trench with damaged periodontal microflora conducting to irreversible periodontitis [14]. Therefore, it s necessary to use antiseptic solutions and sometimes antibiotics to reduce the number of bacteria in sub gingival ditches and maintain periodontal tissues in good shape in order to prevent the disease. Among the antimicrobial agents one of the most effective is Chlorhexidine due to its unique slow release time and applications used by infiltration with gel concentration of 1% inside the grooves. In the dental office prevention of periodontal disease due to accumulation of plaque is made through ultrasonic scaling, removes dental plaque accumulated under or over the gums. As auxiliary methods there are professional brushing, sanding (air-flow) and fluoride applications which remineralize the enamel and prevent also dentin hypersensitivity [7]. Therefore, this study highlights the benefits of CHX added in this cleaning process by application in the form of gel concentration of 1% Chlorhexidine directly inside the periodontal space in subjects with severe periodontal disease. The ultimate goal is achieving a good hygiene of the oral cavity by the techniques mentioned above: scaling ultrasound, professional cleaning, sanding and fluoridation and improving the wellness state by adding Chlorhexidine inside the periodontal space. MATERIAL AND METHODS A total of 328 subjects were included in the study divided in two study groups: a reference group and a study group. Reference group included 164 subjects, of which 83 subjects with gingival disorders (26 men and 4 women), aged between 15 and 29 years (mean age years) in men and between 16 and 3 years in women (average age 24 years); while the remaining 81 subjects (45 men and 52 women) - aged between 32 and 7 years (mean age 45 years) for women and between 31 and 63 years for men, composed of moderate to severe already installed chronic marginal periodontal disease. Regarding the study group selected from a total of 164 subjects, 81 with gingivitis (37 men and 41 women) aged between 12 and 24 years for women and 14-35 for men; and in subjects with periodontitis amounted to a sample of 83 men aged 34. Subjects were between 3 and 72 years, while for women, 52 in number, age range was between 29 and 72 years. To all the subjects in the study was applied a risk assessment program to establish the risk factors. In the first meeting has been initiate preventive measures who were consisting of education regarding the proper cleaning off the teeth, risk factors evaluation and professional cleaning ultrasonic scaling. Subsequently, depending on the case were added professional cleaning, sanding and local fluoridation. On the study group adjacent has been added local application off Chlorhexidine gel 1% in subgingival intrasulcular and interdental maintained with sterile compresses ditches for 1-3 minutes. Calibration of the medical team has been performed before starting the study according to professional protocols. Ultrasound Scaling was performed at the level of plaque deposition tough on the surface of teeth and subgingival and supragingival grooves. The ultrasonic scaling aimed remove all deposits of plaque from all tooth surfaces, approximate spaces and in spaces supragingival and subgingival trenches mostly through mechanical vibration with a frequency of 25 and 46 Hz. Irrigation was performed at ultrasound machine with distilled water, without adding antiseptic in any of the study groups or reference during ultrasonic scaling. It has been used the SATELEC NEWTRON PRO cleaning system 111

Vol. 6, No. 3, July - September 14 using CHX rinse as cooling on the study group and water on the reference group. Professional cleaning with a brush has been done using the side piece dental unit, using professional clean - Kerr pasta or Detartrine - Septodont, which achieve the removal of soft plaque from all tooth surfaces, and the subgingival sulcus as long as the physiological limit. Blasting has been done with the device "EMS Air Flow Handy 2" turbine mounted on dental unit using original EMS powder containing sodium bicarbonate to remove debris and stains. Fluoride applications reduce the risk of plaque retention. That remineralization of enamel was made by sprinkling some balls soaked with initial fluoride gel aminofluorfosfat or by disposable fluoride gel application trays. The buccal and lingual surfaces distemper all (palatal, lingual respectively) tooth dentin sensitivity in history, leaving balls soaked in fluoride tooth contact surfaces for 5 minutes. Subjects were advised to avoid ingesting food and liquids for 3 minutes after removing fluorine to allow time action of fluoride. Only to the study group at the end of professional cleaning sessions has been performed local applications with Chlorhexidine gel concentrate 1% in the grooves subgingival and interdental spaces. Patients were asked, as in the case of fluoride applications do not consume food or fluids for 3 minutes to allow for Fluoride, Chlorhexidine respectively to accumulate in the tissues. In all 328 subjects has been performed professional cleaning. From the group of 164 subjects from the reference group (LR): - L1: subjects - Professional ultrasonic scaling associated with fluoridation - L2: 137 subjects - ultrasonic scaling, cleanings, fluoride professional - L3 7 subjects - ultrasonic scaler, professional cleaning, sanding, fluoridation. Of the 164 subjects in the study group (GS): - G1: subjects - ultrasonic scaling, professional cleaning, professional fluoride applications chlorhexidine gel form in concentrations of 1% - G2: 5 subjects - ultrasonic scaling, professional cleaning applications chlorhexidine gel form in concentrations of 1% - G3: 15 subjects ultrasonic scaling, professional cleaning, sanding and then applications chlorhexidine gel form in concentrations of 1% - G4 19 subjects - ultrasonic scaling, cleanings, fluoride professional air flow - blasting and application of chlorhexidine gel as the concentration of 1%. Table 1. LR Distribution of subjects by gender % 137 % 7 % 164 Women 1 1% 86% 3 3% 93 56% Men 1 7.1% 57 % 4 5% 71 4% Table 2. Distribution of LR subjects by impaired gingival periodontal % 137 % 7 % 164 Gingivitys 9 1% 72 86% 2 2% 83 5% Periodontitys 11 13% 65 % 5 6% 81 49% % % 112

Vol. 6, No. 3, July - September 14 9 7 6 5 4 3 1 9 1 72 65 Figure 1. Distribution of subjects on gingival periodontal diseases in the reference group 2 83 81 Gingivitys 5 Periodontitys 1 6 4 1 1 57 Figure 2. Distribution of subjects by gender in the reference group 3 93 Women 4 Men 71 Table 3. Distribution of subjects in the study group by gender G1 G2 G3 G4 GS % 5 % 15 % 19 % 164 % Women 47 51% 22 23% 12 13% 11 11% 92 56% Men 33 45.8% 28 38.8% 3 4.1% 8 11.1% 72 44% Table 4. Distribution of subjects in the study group by affecting gingival periodontal G1 G2 G3 G4 GS % 5 % 15 % 19 % 164 % Gingivitys 48 59% 17 21% 3 3% 13 16% 81 49% Parodontititys 32 13% 33 % 12 6% 6 49% 83 5% 1 8183 1 92 72 6 4 48 32 33 17 12 3 13 6 G1 G2 G3 G4 GR Gingivitys Periodontitys Figure 3. Distribution of subjects on gingival periodontal diseases in the study group 6 4 47 33 28 22 12 11 8 3 G1 G2 G3 G4 GR Women Men Figure 4. Distribution of subjects by gender in the study group 113

Vol. 6, No. 3, July - September 14 All the data were collected in a spreadsheet with Microsoft Excel 7 from Microsoft and statistically analysed with statistic tests T-test with the professional program SPSS 16. produced by IBM. The variables of interest were compared according to statistic protocols with the statistic relevance p lower than 5% ( p<=.5). RESULTS In the reference group resulted cleaning professional cleaning deposit entirely hard (tartar) and soft (non-adherent film of plaque on the tooth surfaces, removing stains from tooth surfaces and prevents the buildup of plaque and teeth remineralization by the action of fluoride. Subjects only with gingivitis was bacterial cause temporary reported improvement in the appearance of clinical dental periodontal tissue, while in the case of periodontitis periodontal tissue healing is long lasting, without visible signs of softening recolonisation microflora gingival grooves. In the study group, the hygiene training to completely remove both dental plaque by ultrasonic scaling, professional cleaning and sanding, and local prevent applications lodged by fluoride, which also had the role of remineralization and prevent teeth dentin sensitivity after scaling. As a difference from the reference group, concentrate 1% Chlorhexidine gel applications in subgingival and interdental spaces, grooves and ditches were designed to prevent recolonisation by subgingival microflora. Comparing the two groups, to all subjects in the study group were observed clinically diminish symptoms regarding periodontal gum disease, gum inflammation disappearance, bleeding gums, and reduce tartar deposition in a much shorter time compared to the group of reference. Periodic control after 6 months revealed 1 in the reference group who developed a layer of scum intervention by requiring consistent scaling. In 5 of these cases scaling has been followed by brushing and fluoride application in the study group in two cases has been needed scaling. Also in terms of deposits of soft deposits that was found in the 164 cases studied in both groups a number significantly lower - only 15 cases who were regularly found to control plaque deposits staining method, compared to a total of 5 who had plaque in the reference group. It follows that the application of CHX after scaling reduces the dental plaque adhesion up to three times. 1 Chi-squared = 4.24, p =.395* 1 Chi-squared = 22.18, p <.1* 16 14 1 154 162 16 14 1 114 149 1 1 6 6 4 1 Reference group Study group 2 4 5 Reference group 15 Study group 114

Vol. 6, No. 3, July - September 14 DISCUSSIONS Study, which includes a total of 328 subjects was conducted in the clinically "Med Clinic" for six years. In the first three years of the study (6-9) had no use of Chlorhexidine as a feature in any of STIs forms in dental treatment, while from 1 to present using Chlorhexidine gel in 1% concentrate grooves and subgingival interdental spaces after professional cleaning. There is however controversies related to gel applications in terms of improving clinical parameters. [6] [1] In the studied articles we find that the use of CHX in the preventive methods is a helpful way to improve the bacterial control of the dental plaque. The risk assessment tools used to help identify and correct the etiology of periodontal disease is a very important therapeutic step in order to have best clinical results. CONCLUSIONS The vast majority of fail to maintain optimum control plaque by brushing performed individually at home due to wrong brushing techniques. Applying a direct antimicrobial inside the pockets or grooves is the optimal solution in controlling and maintaining normal parameters of the periodontium. Therefore due to the properties of Chlorhexidine, professional cleaning with ultrasonic scaler in combination with professional cleaning, sanding and fluoride give better results in the study group compared with the reference group without Chlorhexidine. Applications of Chlorhexidine gel form in Concentrations of 1% following therapeutic ultrasound scaling implement could become a mandatory step in maintaining optimum hygiene subjects periodontitis. REFERENCES 1 Dumitrescu A. L. Antibiotics and antiseptocs in periodontal therapy 11 2 Dănilă I, Evghenikos A, Petersen P E, Sălăvăstru C, Stan A. Oral health teachers behavior change a major factor of progress. The Journal of Preventive Medicine 5; 13 (1-2): 18-115. 3 Cohen E S. Atlas of Cosmetic and reconstructive periodontal surgery, 3rd edition, 7 4 Faveri M, Gursky LC, Feres M, Shibli JA et al. Scaling and root planning and chlorhexidine mouthrinses in the treatment of chronic periodontitis: a randomized, placebo-controlled clinical trial. J Clin Periodontol 6; 33(11): 819-28; 5 F. R Dametto, C C Randi Ferraz, Figueiredo de Almeida Gomes, A Augusto Zaia, F B Teixeira, c and F Jose de Souza-Filho. In vitro assessment of the immediate and prolonged antimicrobial action of chlorhexidine gel as an endodontic irrigant against Enterococcus faecalis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 5; 99:768-72 6 Kamagata A, Kone D, Coulibaly NT et al. Subgingival irrigation combined with scaling and root planing. Results of a study with chlorhexidine and sodium hypochlorite. Odontostomatol Trol 5; 28 (19): 28-32 7 Lindhe Jan, Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and implant dentistry, 4th edition 3 : 255, 412 8 Mohammed M, Abdel Nasser M El Refai, Usama M Gouda and Hassam Abdel Atty. Evaluation of topical application of CHLO-SITE (chlorhexidine gel) in management of chronic periodontitis. 8; 11(1): 35-4 9 Michael G. Newman, Henry H. Takei, Fermin A. Carranza. Carranza s Clinical Periodontology, 9th edition, 2 1 Oosterwaal PJM, Mikx FHM van t Hof and Renggli HH. Short term bactericidal activity of chlorhexidine gel, stannous fluoride gel and amine fluoride gel tested in periodontal pokets. J Clin Periodontal 1991;18:97-1 11 Pietruska M, Paniczko A, Waszkiel D, Pietruski J, Benraczy A. Efficacy of local treatment with chlorhexidine gluconate drugs on the clinical status of periodontium in chronic periodontitis. 115

Vol. 6, No. 3, July - September 14 Advances in Medical Science 6; 51(suppl.1). 12 http://www.chlorhexidinefacts.com/history-of-chlorhexidine.html 13 http://www.chlorhexidinefacts.com/mechanism-of-action.html 14 Tangade P., Matul A. The effect of sugar free and sugar chewing gums on plaque deposition. Dental research Journal 12; 9(3). 15 Arunimma Pr., Koshi E., Rajesch S. Risk assessment for periodontal disease. Journal of Indian Society of periodontology 12; 16(3): 324-328. 116