selected were those who from clinical and radiographic assessment required comparable bilateral internal be velled flap procedures. A total of 15 patients (5 male and 10 female) were selected and consented to the trial. The mean age of the group was 38.2 years with a range of 24 to 57 years. The treatment sides were matched for num ber, type of teeth and pocket depths. The patients were given oral hygiene instruction and scaling and polishing of the teeth. When this treatment had been completed, only those patients who demonstrated a satisfactory re sponse to oral hygiene instruction were retained in the study (Plaque score < 1.0). Clinical measurements were made for each side im mediately prior to surgery. Pocket depths were measured using a Williams round probe, and the sulcus bleeding index was recorded. Periodontal surgery was carried out using the internal bevelled flap procedure described by Glickman, no bone surgery being performed. On completion of the surgery either a proprietary pack (Coepak) was placed over the operation site, or a 0.2% Chlorhexidine gluconate mouthwash was prescribed. The mouthwash was to be used three times a day, 10 ml being rinsed for 1 minute and expectorated. The treat ment employed was selected according to random selec tion tables. These postoperative treatments were pre scribed by an examiner independent of the clinician undertaking the surgery and recording the preoperative and postoperative indices. The patients were given a chart and asked to record the degree of postoperative discomfort at the same time of day for the first 7 post operative days according to an arbitrary numerical scale of 0 = no discomfort, 1 = uncomfortable, 2 = fairly painful and 3 = very painful. After 1 week the postoperative treatment given was discontinued and the sutures were removed before the patient was seen by the original examiner. The plaque index and sulcus bleeding index were again recorded for the side under treatment. At 1 month and 3 months these parameters were recorded, together with pocket depths in millimeters. The internal bevelled flap procedure was carried out on the second of the two sides 1 month after the first operation. At the termination of the trial the patients were questioned about the postoperative care and asked to state their preference for the mouthwash or dressing. Statistical analysis of the results was carried out using students / test for paired data.
A Comparison of a Periodontal Dressing and Chlorhexidine Gluconate Mouthwash After the Internal Bevelled Flap Procedure
15
by P. S. N E W M A N , * B.D.S. M . A D D Y , B.D.S, M . S C , F.D.S., R.C.S.
16
dressing have been formulated since the advent of Ward's cement (1923) but relatively few have any well documented evidence to substantiate their effi cacy. A periodontal dressing is applied primarily to afford protection to the wound surface, provide patient comfort and prevent the formation of exuberant granu lation tissue. ' Although dressings have been used for many years without obvious detriment to the patient, there is still lack of agreement as to whether a periodontal dressing has any long-term benefit to healing following gingival surgery. Thus the rate of healing of gingivectomy wounds assessed by histological methods has been shown to be enhanced by the use of a dressing and a better clinical result has been observed at 28 days postoperation. Con versely, a greater reduction in pocket depths on the side with no dressing has been reported. However, despite these differing conclusions, the maintenance of a clean wound surface would appear to be of importance to uneventful healing of gingivectomy wounds. Therefore it may be that improved postsurgical results would be obtained by a treatment which enhances and maintains wound cleanliness by the prevention of bacterial plaque accumulation postoperatively. With the advent of Chlorhexidine gluconate and its proven effectiveness as an antiplaque agent, much in terest has been shown in its use for postoperative care. " To examine further the possible value of Chlorhexidine gluconate in periodontal surgery, a trial was carried out to compare a 0.2% Chlorhexidine mouthwash with a proprietary periodontal dressing (Coepak)f in the post surgical care of patients undergoing treatment with the internal bevelled flap procedure.
MANY TYPES OF
17
1
2 3
4
5
6
7
8
9
14
RESULTS
A l l 15 patients completed both treatments and review appointments. A total of 60 teeth were treated within each group. No side effects attributed to the dressing were reported. However, slight staining of teeth and tongue with the Chlorhexidine mouthwash was noticed with several of the patients.
MATERIALS AND METHODS
The patients were chosen from those attending the Department for periodontal treatment. Patients initially * Department of Periodontology, Dental School, Welsh National School of Medicine, Cardiff, Wales, United Kingdom, † Coe Laboratories Inc., Chicago, 111 60658, U.S.A.
Plaque
Indices
Before surgery the teeth were polished so that the 576
Volume 49 Number 11
Chlorhexidine
plaque score for both groups was zero. Figure 1 shows the mean and standard deviation of the plaque scores for the group of patients recorded at 1 week on the mouthwash and dressing treated sides. The difference between the amount of plaque accu mulated was significantly less on the side treated with the Chlorhexidine mouthwash (P < 0.02). Pocket
Depths
The mean and standard deviation of the pocket depths preoperatively and at 1 and 3 months after surgery for the group of patients for each treatment received are shown in Table 1. Preoperatively both groups were comparable with no significant difference in the mean pocket depths of the two sides (P > 0.3). Both treatment regimens resulted in a significant reduction in pocket depths (P < 0.001). A comparison of the postoperative pocket depths showed small mean differences in favor of the mouth-
Gluconate Mouthwash
Postsurgery
577
wash (0.20 mm at 1 month and 0.05 mm at 3 months) neither of which was statistically or clinically significant (P > 0.2). Sulcus Bleeding
Index
Following periodontal surgery, at 1 week, there was a significant increase in the sulcus bleeding index on the side receiving the dressing when compared to the mouth wash treated side (P < 0.02) (Table 2). No significant change in the mean sulcus bleeding index for the mouth wash treated side was apparent. At 1 month and 3 months the sulcus bleeding indices for the two sides had fallen to a level significantly below the preoperative scores (P < 0.01). However, there were no longer any significant differences between the two postoperative treatments. Postoperative
Discomfort
and Patient
Preference
From the subjective scores of postoperative discomfort experienced by the patients during the first week, the mean score for each day for the whole group was cal culated. Representing the results graphically (Fig. 2) for the two postoperative treatments, a difference in the amount of discomfort was apparent. Thus, there was less TABLE 2. Mean
Pre- and Postoperative Sulcus Bleeding Mouthwash and Pack Treated Sides
PACK
MOUTHWASH
Preoperatively One week
Indices for
Mean
S. D.
Mean
S.D.
0.71
(0.40)
0.71
(0.35)
0.71
(0.31)
0.99
(0.40)
0.38
(0.19)
0.45
(0.35;
0.34
(0.21)
0.39
(0.21)
Postoperatively One month Postoperatively Three months Postoperatively
FIGURE 1. M e a n plaque for mouthwash and pack TABLE 1. Mean
scores treated
recorded sides
Pre- and Postoperative Millimeters for Mouthwash MOUTHWASH
Preoperatively
1 week
postoperatively
Pocket Depths Measured Treated Sides
in
PACK
Mean
S.D.
Mean
S.D.
2.73
(0.47)
2.84
(0.71)
1.35
(0.47)
1.55
(0.59)
1.35
(0.50)
1.40
(0.41)
One month Postoperatively Three months Postoperatively
FIGURE 2. M e a n discomfort scores during the week for mouthwash and pack treated sides
first
postoperative
578
Newman,
J. Periodontol. November, 1978
Addy
discomfort on the side being treated with the mouthwash during the first 4 days which however was not statistically significant (P < 0.1). Throughout the remainder of the 7 day period, a similar trend in the pain experienced between the two treatments was not apparent. Consid ering the patients' preference, on the basis of discomfort experienced, nine preferred the mouthwash and five preferred the dressing, one showing no preference for either the dressing or the mouthwash. DISCUSSION
This study demonstrated that the use of a 0.2% Chlor hexidine gluconate mouthwash following the internal bevelled flap procedure resulted in significantly less plaque accumulation at the site of the operation when compared to a proprietary periodontal dressing. Fur thermore, the degree of imflammation as assessed by the sulcus bleeding index, was similarly reduced on the mouthwash treated side during the initial healing phase after surgery. However, at the 1 month and 3 month follow-up periods there was no difference between the mouthwash and dressing treated sides. The clinical results, assessed by the measurement of pocket depths, was comparable for both treated sides. The continued reduction in the sulcus bleeding indices to below preoperative levels at 1 and 3 months would be consistent with the reported 90 day healing period for gingival tissue. The amount of plaque recorded under the periodontal dressing at the end of the first postoperative week further demonstrated the inability of periodontal dressings to inhibit the bacterial colonization of the wound area. ' ' Since bacterial colonization of the wound causes retarded healing due to increased inflammatory response and granulation tissue formation this plaque accumulation beneath the dressing may be responsible for the increased sulcus bleeding index seen at 1 week when compared to the mouthwash treated side. Ideally, therefore, the pro tective property of a periodontal dressing should be antibacterial as well as physical. In this respect the incorporation of antibacterial agents in dressings have been shown to reduce postoperative pain and to facilitate the healing process ' which may in part arise from the inhibition of plaque formation by the medicament em ployed. The greater patient preference for the mouthwash based on discomfort experienced contrasts the findings for the simple gingivectomy. The considerable differ ence in patient preference observed between these two trials would appear to be related to the amount of exposed wound surface left by the two operative tech niques. The follow-up assessments made at 1 and 3 months are in agreement with previous work and dem onstrate that neither postoperative treatment had any prolonged effect upon the healing of the surgical wound. The use of a Chlorhexidine gluconate mouthwash would appear to have a definite beneficial effect in maintaining a clean wound surface and therefore be a 4
6 10 18
19
2
10 20
12
13
5
major factor in permitting the uneventful healing follow ing surgery. From this study by direct comparison, it would seem that during the initial healing phase follow ing the internal bevelled flap procedure, a 0.2% Chlor hexidine gluconate mouthwash produces a better result than a periodontal dressing (Coepak). However, without employing control sites with no mouthwash or no dress ing, a direct beneficial effect of Chlorhexidine on the parameters measured cannot be stated. Nevertheless, in those periodontal procedures where no, or minimal, exposed wound surface remains postoperatively, an antiplaque agent such as Chlorhexidine gluconate may be a useful adjunct to therapy, particularly for the mainte nance of oral hygiene during the early postoperative phase. 7
SUMMARY
A group of 15 patients requiring comparable bilateral internal bevelled flap procedures took part in a study to compare the clinical results achieved when a dressing or Chlorhexidine mouthwash was used during the first post operative week. Initial preoperative conditions were comparable. At the end of the first postoperative week, significantly more plaque accumulated and the sulcus bleeding index was significantly higher on the dressing treated side. At 1 month and 3 months postoperatively the sulcus bleeding indices were below preoperative lev els for both treated sides with no significant differences between the sides. A significant and comparable reduc tion in pocket depths occurred following the two post operative treatments. Subjectively recorded pain scores demonstrated that more pain was experienced on the dressing treated side, particularly during the first 4 post operative days. More patients preferred the mouthwash as a postoperative treatment. ACKNOWLEDGMENTS
We are grateful to Dr. T. Khosla, Senior Lecturer in Medical Statistics, Welsh National School of Medicine, for statistical analysis of the results. Our thanks to Professor A. E. Dolby, Department of Periodontology, Dental School, Cardiff, for his advice and encouragement throughout this study. REFERENCES
1. Ward, A. W.: Inharmonious cusp relation as a factor of periodontoclasia. J. A m D e n t Assoc 10: 471, 1923. 2. Baer, P., Summer, C. F., and Miller, G.: Periodontal dressings. D e n t C l i n N A m 13: 181, 1969. 3. O'Neil, T. C. A.: Antibacterial properties of periodontal dressings. J Periodontol 46: 469, 1975. 4. Bernier, J. L., and Kaplan, H.: The repair of gingival tissue after surgical intervention. J A m D e n t Assoc 35: 697, 1947. 5. Greensmith, A. L. and Wade, A. B.: Dressing after reverse bevelflapprocedures. J Clin Periodont 1: 97, 1974. 6. Waerhaug, J., and Löe, H.: Tissue reaction to gingivec tomy pack. O r a l Surg 10: 923, 1957. 7. Löe, H., and Silness, J.: Tissue reactions to a new gingi vectomy pack. O r a l Surg 14: 1305, 1961. 8. Löe, H., Schiott, C. R., Jensen, S. B., Kilian, M., Davies, R. M., and Glavind, K.: The effect of Chlorhexidine mouth rinses on the human oralflora.J Periodont Res 5: 84, 1970.
Volume 49 Number 11
Chlorhexidine
9. Lindhe, J., Hamp. R., Löe, H., and Schiott, C. R.: Influ ence of the topical application of Chlorhexidine on chronic gingivitis and gingival wound healing in the dog. Scand J Dent Res 78: 471, 1970. 10. Asboe-Jorgensen, V., Attstrom, R., Lang, N . P., and Löe, H.: Effect of Chlorhexidine dressing on the healing after periodontal surgery. J Periodontol 45: 13, 1974. 11. Hamp, R , and Lindhe, J.: Effect of Chlorhexidine on gingival wound healing in the dog. J C l i n Periodont 2: 143, 1975. 12. Pluss, E. M., Engelberger, P. R., and Rateitschak, K. H.: Effect of Chlorhexidine on dental plaque formation under a periodontal pack. J C l i n Periodont 3: 136, 1975. 13. Addy, M., and Dolby, A. E.: The use of Chlorhexidine mouthwash compared with a periodontal dressing following the gingivectomy procedure. J C l i n Periodont 3: 59, 1976. 14. Langebaek, J., and Bay, L.: The effect of Chlorhexidine
Gluconate
Mouthwash
Postsurgery
579
mouth rinse on healing after gingivectomy. Scand J Dent Res 84: 224, 1976. 15. Greene, J. C , and Vermillion, J. R.: Oral hygiene index: A method for classifying oral hygiene status. J Am Dent Assoc 61: 172, 1960. 16. Muhlemann, H. R., and Son.: Gingival sulcus bleed ing—a leading sympton in initial gingivitis. Helv Odontol Acta 15: 107, 1971. 17. Glickman, I.: Clinical
Periodontology,
ed 4, pp 711-780.
Philadelphia and London, W. B. Saunders, 1972. 18. Heany, G. G., Melville, T. H , and Oliver, W. M.: The effects of two dressings on the flora of periodontal surgical wounds. O r a l Surg 33: 146, 1972.
19. Burke, J. F.: Effects of inflammation on wound repair. J Dent
Res 50: 296,
1971.
20. Fraleigh, C. M.: Evaluation of topical terramycin in post-gingivectomy pack. J Periodontol 27: 201, 1956.
Announcements SCHOOL OF DENTISTRY M E D I C A L C O L L E G E OF GEORGIA
examine patients who have been maintained in different plaque control programs for several years.
The School of Dentistry, Medical College of Georgia announces the following continuing education course: TITLE: Periodontal Therapy DATES: February 22-23, 1979 LOCATION: School of Dentistry, Medical College of Georgia, Augusta, Georgia FACULTY: DR. SIGURD P. RAMFJORD
For further information contact: Nina Klubal, Administrative As sistant, Department of Periodontology, School of Dentistry, University of Gothenburg, Fack, S-400 33 Gothenburg 33, Sweden.
For further information contact: Division of Continuing Education, Medical College of Georgia, Augusta, Georgia 30901 (Phone: 404/8283967).
UNIVERSITY OF G O T H E N B U R G SCHOOL OF DENTISTRY The University of Gothenburg, School of Dentistry, Gothenburg, Sweden announces the following course: TITLE: DATES: FACULTY:
Clinical periodontology and periodontal prosthesis August 13-16, 1979 JAN LINDHE, L.S.D., O.D., Professor of Periodontology, Dean, School of Dentistry, University of Gothenburg, Sweden. STURE NYMAN, L.S.D., O.D., Professor and Acting Chair man, Department of Periodontology, School of Den tistry, University of Gothenburg, Sweden. This course is designed to give the general practitioner as well as the specialist a comprehensive review of periodontology. Etiology and pathogenesis of periodontal disease will be analyzed in detail and emphasis will be placed on the clinical, radiographical and histopathological character of different types of periodontal lesions. The micro biology of plaque as well as host resistance are topics of central importance. Trauma from occlusion as well as other co-destructive components will be critically analyzed and the biological rationale for splinting will be discussed. The preparation and design of provisional and permanent bridgework will be outlined and detailed information in relation to the presentation of patients maintained for several years in a careful recall program will be given. Diagnosis, treatment planning and rationale for technique selection will be discussed in small groups and patients will then be presented in the clinic. The course will emphasize the maintenance care program and present how such pro grams can be designed. The participants will have the opportunity to
THE UNIVERSITY OF M I C H I G A N W. K . K E L L O G G F O U N D A T I O N INSTITUTE The University of Michigan W. K . Kellogg Foundation Institute announces the following continuing education courses: TITLE: Refresher Course in Periodontics I: DATES: December 4, 5, 6, 1978 FACULTY: SIGURD P. RAMFJORD, L.D.S., Ph.D., Chairman, Depart ment of Periodontics RAUL G. CAFFESSE, GLORIA D. KERRY, FREDERIC N . SMITH (This course is open to dental hygienists) Course objectives: 1. Up to date review of research concerning periodontal biology and etiology of periodontal disease. 2. Evaluation of preventive dentistry programs. 3. Survey of nonsurgical methods for periodontal treatment. 4. Reassess the role of occlusion and restorative dentistry in perio dontics. TITLE: Refresher Course in Periodontics II DATES: March 21, 22, 23, 1979 FACULTY: SIGURD P. RAMFJORD, L.D.S., Ph.D., Professor and Chair man, Department of Periodontics RAUL G. CAFFESSE, GLORIA D. KERRY, FREDERIC N . SMITH Course objectives: 1. An up to date evaluation of all surgical techniques used in periodontics, illustrated by movies. 2. Detailed discussion of causes for success or failure of periodontal surgery. 3. Assessment of reattachment, grafts and bony implants. 4. Report on longitudinal studies evaluating results from various modalities of periodontal surgery. For further information contact: Director of Continuing Education, The University of Michigan, 1000 Kellogg Building, Ann Arbor, Mich. 48109.
A Comparison of a Periodontal Dressing and Chlorhexidine Gluconate Mouthwash After the Internal Bevelled Flap Procedure
15
by P. S. N E W M A N , * B.D.S. M . A D D Y , B.D.S, M . S C , F.D.S., R.C.S.
16
dressing have been formulated since the advent of Ward's cement (1923) but relatively few have any well documented evidence to substantiate their effi cacy. A periodontal dressing is applied primarily to afford protection to the wound surface, provide patient comfort and prevent the formation of exuberant granu lation tissue. ' Although dressings have been used for many years without obvious detriment to the patient, there is still lack of agreement as to whether a periodontal dressing has any long-term benefit to healing following gingival surgery. Thus the rate of healing of gingivectomy wounds assessed by histological methods has been shown to be enhanced by the use of a dressing and a better clinical result has been observed at 28 days postoperation. Con versely, a greater reduction in pocket depths on the side with no dressing has been reported. However, despite these differing conclusions, the maintenance of a clean wound surface would appear to be of importance to uneventful healing of gingivectomy wounds. Therefore it may be that improved postsurgical results would be obtained by a treatment which enhances and maintains wound cleanliness by the prevention of bacterial plaque accumulation postoperatively. With the advent of Chlorhexidine gluconate and its proven effectiveness as an antiplaque agent, much in terest has been shown in its use for postoperative care. " To examine further the possible value of Chlorhexidine gluconate in periodontal surgery, a trial was carried out to compare a 0.2% Chlorhexidine mouthwash with a proprietary periodontal dressing (Coepak)f in the post surgical care of patients undergoing treatment with the internal bevelled flap procedure.
MANY TYPES OF
17
1
2 3
4
5
6
7
8
9
14
RESULTS
A l l 15 patients completed both treatments and review appointments. A total of 60 teeth were treated within each group. No side effects attributed to the dressing were reported. However, slight staining of teeth and tongue with the Chlorhexidine mouthwash was noticed with several of the patients.
MATERIALS AND METHODS
The patients were chosen from those attending the Department for periodontal treatment. Patients initially * Department of Periodontology, Dental School, Welsh National School of Medicine, Cardiff, Wales, United Kingdom, † Coe Laboratories Inc., Chicago, 111 60658, U.S.A.
Plaque
Indices
Before surgery the teeth were polished so that the 576
Volume 49 Number 11
Chlorhexidine
plaque score for both groups was zero. Figure 1 shows the mean and standard deviation of the plaque scores for the group of patients recorded at 1 week on the mouthwash and dressing treated sides. The difference between the amount of plaque accu mulated was significantly less on the side treated with the Chlorhexidine mouthwash (P < 0.02). Pocket
Depths
The mean and standard deviation of the pocket depths preoperatively and at 1 and 3 months after surgery for the group of patients for each treatment received are shown in Table 1. Preoperatively both groups were comparable with no significant difference in the mean pocket depths of the two sides (P > 0.3). Both treatment regimens resulted in a significant reduction in pocket depths (P < 0.001). A comparison of the postoperative pocket depths showed small mean differences in favor of the mouth-
Gluconate Mouthwash
Postsurgery
577
wash (0.20 mm at 1 month and 0.05 mm at 3 months) neither of which was statistically or clinically significant (P > 0.2). Sulcus Bleeding
Index
Following periodontal surgery, at 1 week, there was a significant increase in the sulcus bleeding index on the side receiving the dressing when compared to the mouth wash treated side (P < 0.02) (Table 2). No significant change in the mean sulcus bleeding index for the mouth wash treated side was apparent. At 1 month and 3 months the sulcus bleeding indices for the two sides had fallen to a level significantly below the preoperative scores (P < 0.01). However, there were no longer any significant differences between the two postoperative treatments. Postoperative
Discomfort
and Patient
Preference
From the subjective scores of postoperative discomfort experienced by the patients during the first week, the mean score for each day for the whole group was cal culated. Representing the results graphically (Fig. 2) for the two postoperative treatments, a difference in the amount of discomfort was apparent. Thus, there was less TABLE 2. Mean
Pre- and Postoperative Sulcus Bleeding Mouthwash and Pack Treated Sides
PACK
MOUTHWASH
Preoperatively One week
Indices for
Mean
S. D.
Mean
S.D.
0.71
(0.40)
0.71
(0.35)
0.71
(0.31)
0.99
(0.40)
0.38
(0.19)
0.45
(0.35;
0.34
(0.21)
0.39
(0.21)
Postoperatively One month Postoperatively Three months Postoperatively
FIGURE 1. M e a n plaque for mouthwash and pack TABLE 1. Mean
scores treated
recorded sides
Pre- and Postoperative Millimeters for Mouthwash MOUTHWASH
Preoperatively
1 week
postoperatively
Pocket Depths Measured Treated Sides
in
PACK
Mean
S.D.
Mean
S.D.
2.73
(0.47)
2.84
(0.71)
1.35
(0.47)
1.55
(0.59)
1.35
(0.50)
1.40
(0.41)
One month Postoperatively Three months Postoperatively
FIGURE 2. M e a n discomfort scores during the week for mouthwash and pack treated sides
first
postoperative
578
Newman,
J. Periodontol. November, 1978
Addy
discomfort on the side being treated with the mouthwash during the first 4 days which however was not statistically significant (P < 0.1). Throughout the remainder of the 7 day period, a similar trend in the pain experienced between the two treatments was not apparent. Consid ering the patients' preference, on the basis of discomfort experienced, nine preferred the mouthwash and five preferred the dressing, one showing no preference for either the dressing or the mouthwash. DISCUSSION
This study demonstrated that the use of a 0.2% Chlor hexidine gluconate mouthwash following the internal bevelled flap procedure resulted in significantly less plaque accumulation at the site of the operation when compared to a proprietary periodontal dressing. Fur thermore, the degree of imflammation as assessed by the sulcus bleeding index, was similarly reduced on the mouthwash treated side during the initial healing phase after surgery. However, at the 1 month and 3 month follow-up periods there was no difference between the mouthwash and dressing treated sides. The clinical results, assessed by the measurement of pocket depths, was comparable for both treated sides. The continued reduction in the sulcus bleeding indices to below preoperative levels at 1 and 3 months would be consistent with the reported 90 day healing period for gingival tissue. The amount of plaque recorded under the periodontal dressing at the end of the first postoperative week further demonstrated the inability of periodontal dressings to inhibit the bacterial colonization of the wound area. ' ' Since bacterial colonization of the wound causes retarded healing due to increased inflammatory response and granulation tissue formation this plaque accumulation beneath the dressing may be responsible for the increased sulcus bleeding index seen at 1 week when compared to the mouthwash treated side. Ideally, therefore, the pro tective property of a periodontal dressing should be antibacterial as well as physical. In this respect the incorporation of antibacterial agents in dressings have been shown to reduce postoperative pain and to facilitate the healing process ' which may in part arise from the inhibition of plaque formation by the medicament em ployed. The greater patient preference for the mouthwash based on discomfort experienced contrasts the findings for the simple gingivectomy. The considerable differ ence in patient preference observed between these two trials would appear to be related to the amount of exposed wound surface left by the two operative tech niques. The follow-up assessments made at 1 and 3 months are in agreement with previous work and dem onstrate that neither postoperative treatment had any prolonged effect upon the healing of the surgical wound. The use of a Chlorhexidine gluconate mouthwash would appear to have a definite beneficial effect in maintaining a clean wound surface and therefore be a 4
6 10 18
19
2
10 20
12
13
5
major factor in permitting the uneventful healing follow ing surgery. From this study by direct comparison, it would seem that during the initial healing phase follow ing the internal bevelled flap procedure, a 0.2% Chlor hexidine gluconate mouthwash produces a better result than a periodontal dressing (Coepak). However, without employing control sites with no mouthwash or no dress ing, a direct beneficial effect of Chlorhexidine on the parameters measured cannot be stated. Nevertheless, in those periodontal procedures where no, or minimal, exposed wound surface remains postoperatively, an antiplaque agent such as Chlorhexidine gluconate may be a useful adjunct to therapy, particularly for the mainte nance of oral hygiene during the early postoperative phase. 7
SUMMARY
A group of 15 patients requiring comparable bilateral internal bevelled flap procedures took part in a study to compare the clinical results achieved when a dressing or Chlorhexidine mouthwash was used during the first post operative week. Initial preoperative conditions were comparable. At the end of the first postoperative week, significantly more plaque accumulated and the sulcus bleeding index was significantly higher on the dressing treated side. At 1 month and 3 months postoperatively the sulcus bleeding indices were below preoperative lev els for both treated sides with no significant differences between the sides. A significant and comparable reduc tion in pocket depths occurred following the two post operative treatments. Subjectively recorded pain scores demonstrated that more pain was experienced on the dressing treated side, particularly during the first 4 post operative days. More patients preferred the mouthwash as a postoperative treatment. ACKNOWLEDGMENTS
We are grateful to Dr. T. Khosla, Senior Lecturer in Medical Statistics, Welsh National School of Medicine, for statistical analysis of the results. Our thanks to Professor A. E. Dolby, Department of Periodontology, Dental School, Cardiff, for his advice and encouragement throughout this study. REFERENCES
1. Ward, A. W.: Inharmonious cusp relation as a factor of periodontoclasia. J. A m D e n t Assoc 10: 471, 1923. 2. Baer, P., Summer, C. F., and Miller, G.: Periodontal dressings. D e n t C l i n N A m 13: 181, 1969. 3. O'Neil, T. C. A.: Antibacterial properties of periodontal dressings. J Periodontol 46: 469, 1975. 4. Bernier, J. L., and Kaplan, H.: The repair of gingival tissue after surgical intervention. J A m D e n t Assoc 35: 697, 1947. 5. Greensmith, A. L. and Wade, A. B.: Dressing after reverse bevelflapprocedures. J Clin Periodont 1: 97, 1974. 6. Waerhaug, J., and Löe, H.: Tissue reaction to gingivec tomy pack. O r a l Surg 10: 923, 1957. 7. Löe, H., and Silness, J.: Tissue reactions to a new gingi vectomy pack. O r a l Surg 14: 1305, 1961. 8. Löe, H., Schiott, C. R., Jensen, S. B., Kilian, M., Davies, R. M., and Glavind, K.: The effect of Chlorhexidine mouth rinses on the human oralflora.J Periodont Res 5: 84, 1970.
Volume 49 Number 11
Chlorhexidine
9. Lindhe, J., Hamp. R., Löe, H., and Schiott, C. R.: Influ ence of the topical application of Chlorhexidine on chronic gingivitis and gingival wound healing in the dog. Scand J Dent Res 78: 471, 1970. 10. Asboe-Jorgensen, V., Attstrom, R., Lang, N . P., and Löe, H.: Effect of Chlorhexidine dressing on the healing after periodontal surgery. J Periodontol 45: 13, 1974. 11. Hamp, R , and Lindhe, J.: Effect of Chlorhexidine on gingival wound healing in the dog. J C l i n Periodont 2: 143, 1975. 12. Pluss, E. M., Engelberger, P. R., and Rateitschak, K. H.: Effect of Chlorhexidine on dental plaque formation under a periodontal pack. J C l i n Periodont 3: 136, 1975. 13. Addy, M., and Dolby, A. E.: The use of Chlorhexidine mouthwash compared with a periodontal dressing following the gingivectomy procedure. J C l i n Periodont 3: 59, 1976. 14. Langebaek, J., and Bay, L.: The effect of Chlorhexidine
Gluconate
Mouthwash
Postsurgery
579
mouth rinse on healing after gingivectomy. Scand J Dent Res 84: 224, 1976. 15. Greene, J. C , and Vermillion, J. R.: Oral hygiene index: A method for classifying oral hygiene status. J Am Dent Assoc 61: 172, 1960. 16. Muhlemann, H. R., and Son.: Gingival sulcus bleed ing—a leading sympton in initial gingivitis. Helv Odontol Acta 15: 107, 1971. 17. Glickman, I.: Clinical
Periodontology,
ed 4, pp 711-780.
Philadelphia and London, W. B. Saunders, 1972. 18. Heany, G. G., Melville, T. H , and Oliver, W. M.: The effects of two dressings on the flora of periodontal surgical wounds. O r a l Surg 33: 146, 1972.
19. Burke, J. F.: Effects of inflammation on wound repair. J Dent
Res 50: 296,
1971.
20. Fraleigh, C. M.: Evaluation of topical terramycin in post-gingivectomy pack. J Periodontol 27: 201, 1956.
Announcements SCHOOL OF DENTISTRY M E D I C A L C O L L E G E OF GEORGIA
examine patients who have been maintained in different plaque control programs for several years.
The School of Dentistry, Medical College of Georgia announces the following continuing education course: TITLE: Periodontal Therapy DATES: February 22-23, 1979 LOCATION: School of Dentistry, Medical College of Georgia, Augusta, Georgia FACULTY: DR. SIGURD P. RAMFJORD
For further information contact: Nina Klubal, Administrative As sistant, Department of Periodontology, School of Dentistry, University of Gothenburg, Fack, S-400 33 Gothenburg 33, Sweden.
For further information contact: Division of Continuing Education, Medical College of Georgia, Augusta, Georgia 30901 (Phone: 404/8283967).
UNIVERSITY OF G O T H E N B U R G SCHOOL OF DENTISTRY The University of Gothenburg, School of Dentistry, Gothenburg, Sweden announces the following course: TITLE: DATES: FACULTY:
Clinical periodontology and periodontal prosthesis August 13-16, 1979 JAN LINDHE, L.S.D., O.D., Professor of Periodontology, Dean, School of Dentistry, University of Gothenburg, Sweden. STURE NYMAN, L.S.D., O.D., Professor and Acting Chair man, Department of Periodontology, School of Den tistry, University of Gothenburg, Sweden. This course is designed to give the general practitioner as well as the specialist a comprehensive review of periodontology. Etiology and pathogenesis of periodontal disease will be analyzed in detail and emphasis will be placed on the clinical, radiographical and histopathological character of different types of periodontal lesions. The micro biology of plaque as well as host resistance are topics of central importance. Trauma from occlusion as well as other co-destructive components will be critically analyzed and the biological rationale for splinting will be discussed. The preparation and design of provisional and permanent bridgework will be outlined and detailed information in relation to the presentation of patients maintained for several years in a careful recall program will be given. Diagnosis, treatment planning and rationale for technique selection will be discussed in small groups and patients will then be presented in the clinic. The course will emphasize the maintenance care program and present how such pro grams can be designed. The participants will have the opportunity to
THE UNIVERSITY OF M I C H I G A N W. K . K E L L O G G F O U N D A T I O N INSTITUTE The University of Michigan W. K . Kellogg Foundation Institute announces the following continuing education courses: TITLE: Refresher Course in Periodontics I: DATES: December 4, 5, 6, 1978 FACULTY: SIGURD P. RAMFJORD, L.D.S., Ph.D., Chairman, Depart ment of Periodontics RAUL G. CAFFESSE, GLORIA D. KERRY, FREDERIC N . SMITH (This course is open to dental hygienists) Course objectives: 1. Up to date review of research concerning periodontal biology and etiology of periodontal disease. 2. Evaluation of preventive dentistry programs. 3. Survey of nonsurgical methods for periodontal treatment. 4. Reassess the role of occlusion and restorative dentistry in perio dontics. TITLE: Refresher Course in Periodontics II DATES: March 21, 22, 23, 1979 FACULTY: SIGURD P. RAMFJORD, L.D.S., Ph.D., Professor and Chair man, Department of Periodontics RAUL G. CAFFESSE, GLORIA D. KERRY, FREDERIC N . SMITH Course objectives: 1. An up to date evaluation of all surgical techniques used in periodontics, illustrated by movies. 2. Detailed discussion of causes for success or failure of periodontal surgery. 3. Assessment of reattachment, grafts and bony implants. 4. Report on longitudinal studies evaluating results from various modalities of periodontal surgery. For further information contact: Director of Continuing Education, The University of Michigan, 1000 Kellogg Building, Ann Arbor, Mich. 48109.
