Clinical Study of Iodine as a Chemotherapeutic Agent for the Control of Dental Plaque and Gingivitis in Man
MATERIALS A N D M E T H O D S
Twenty freshmen and 16 sophomore male dental students, between the ages of 20 and 26 years partici pated in the study. A l l subjects chosen for the study fulfilled the following criteria: 1. The presence of a minimum of 24 teeth in an intact dental arch. 2. The gingiva was clinically healthy or with mild gingivitis and generalized pocket depth not exceeding 3 mm. 3. A low D . M . F . index, no open contacts and no overhanging margins or restorations. 4. Good physical health and no known allergy to iodine. 5. N o present history of either antibiotics or topical oral medication. Two to three weeks prior to the start of the 21-day experimental period, the subjects were instructed in oral hygiene procedures. The plaque on the subjects' teeth was stained with P O H disclosing wafers.* They are then instructed in the Bass technique of sulcular brushing, and dental flossing. Following the oral hygiene instruc tion, the teeth were scaled and polished. Once a day in the evening, prior to retiring, the subjects brushed with a Butler gum 411 toothbrush† and flossed with P O H dental floss.‡ For the first week following the oral hygiene instruction, the subjects utilized P O H disclosing tablets after brushing and flossing. This enabled them to observe and improve upon their oral hygiene methods. These oral hygiene procedures enabled the subjects to decrease their plaque and gingival scores to a minimum, prior to the start of the experimental period. The subjects were then divided into two experimental groups. Group I consisted of 20 freshmen students who were going to use iodine solution as a mouthwash (Mouthwash Treatment Group), and Group II consisted of 16 sophomores on whom iodine solution was applied topically by the investigator (Topical Application Treat ment Group).
by BARRY A . KLIGERMAN, D.M.D., M.S. NABIL F . BlSSADA*, B.D.S., M.S.D. SINCE DENTAL PLAQUE is implicated as a causative factor
in the development of gingivitis, its control would be of importance in the prevention of periodontal disease and the maintenance of the supporting structures of the teeth in proper function. A t present, the populace attempts the removal of dental plaque with mechanical oral hygiene procedures. These procedures basically include toothbrushing and dental flossing. However, as evidenced by the prevalence of gingivitis and periodontitis, these mechanical methods of oral hygiene are not fully effec tive for the general population. It appears that the population is either not motivated enough in the use of proper oral hygiene techniques or possibly that brushing and flossing are not capable of removing all dental plaque. Other methods for the control of dental bacterial plaque are thus required for the prevention of periodontal disease. Various chemotherapeutic agents, such as antibi otics, enzymes, and antiseptics, were investi gated in the past for this purpose. Iodine, even though it was shown to be a potent antiseptic agent against most oral microflora, was not thoroughly studied for its plaque-preventing ability. A number of experiments have shown iodine to be an effective antiseptic on the oral mucous membranes, and the tooth surfaces. Iodine has also been shown to reduce the number of viable organisms in saliva, in the gingival crevice, and in the dental bacterial plaque. However, no study was performed to assess the effectiveness of iodine on plaque formation and its concomitant effect on the gingival health. It is therefore the purpose of the present investi gation to study the effect of the local use of iodine solution, as a mouthwash and as topically applied to the tooth surfaces, on the degree of dental plaque formation and on gingival status in the presence and absence of mechanical oral hygiene. 1-11
12-20
41
21-80
31-38
35-39
34
A. Group I—Iodine Mouthwash
40
21
Treatment Study
The 20 participants in Group I were assigned ran domly and in equal number to one of the following four subgroups: Subgroup A. Brushing and flossing were restricted to the right side of the mouth, and the subjects were required to rinse with an iodine solution. Subgroup B. Brushing and flossing were restricted to the left side of the mouth, and the subjects were required to rinse with the iodine solution. Subgroup C. Brushing and flossing were restricted to the right side of the mouth, and the subjects were
Part of a thesis submitted by the senior author to the Graduate School of Case Western Reserve University in partial fulfillment of the requirements for a Master Science Degree. This investigation was supported by N I H Public Health General Research Grant R R 05335-13. * Department of Periodontology School of Dentistry, Case Western Reserve University Cleveland, Ohio.
* P O H disclosing wafers, O r a l Health Products, Inc., Tulsa, Oklahoma. t Butler gum 411 toothbrush, John Butler C o . , Chicago, Illinois. X P O H nylon unwaxed dental floss, O r a l Health Products, Inc., Tulsa, Oklahoma.
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required to rinse with distilled water. Subgroup D. Brushing and flossing were restricted to the left side of the mouth, and the subjects were required to rinse with the distilled water. Dividing the group in such a manner provided the opportunity to compare four different modalities of treatment: 1. The effects of iodine mouthrinse in conjunction with mechanical oral hygiene procedures, i.e. brushing and flossing. 2. The effects of a placebo mouthrinse in conjunction with mechanical oral hygiene procedures. 3. The effects of iodine mouthrinse in the abstinence of mechanical oral hygiene procedures. 4. The effects of a placebo mouthrinse in the absti nence of mechanical oral hygiene procedures. A t the start of the experimental period, each subject's plaque index and gingival index were recorded. A scaling and tooth polishing were then provided. Subgroups A and B were given a week's supply of a 0.02% aqueous iodine solution. The iodine solution was prepared by dissolving 0.02 gm of iodine in 100 cc of distilled water. Fresh iodine solution was prepared and provided weekly. Subgroups C and D were provided with a week's supply of a placebo solution of distilled water. Each subject was provided with a 120 ml brown bottle containing the assigned mouthrinse. In addition, they were given a graduated polyethylene beaker, into which they poured 7.5 ml of the required solution. The subjects rinsed with the appropriate solution twice daily. First, in the morning after breakfast, they rinsed with tap water for ten seconds, then expectorated. They then com menced pouring 7.5 ml of their assigned solution into a graduated beaker. They rinsed in a gentle, swirling motion, allowing the solution to pass over facial and lingual surfaces of the teeth. Two minutes were allowed to elapse prior to completely expectorating the solution. They repeated the same rinsing procedure piror to retiring in the evening. These procedures were em ployed for the duration of the 21-day experimental period. Subjects participating in this study were instruc ted not to use any toothpaste while brushing the as signed side, nor any other mouthwash during the 21 days of the experiment. Prior to scoring the plaque in dex, the patient rinsed vigorously with tap water to re move oral debris and material alba. Plaque scores (Silness and Löe) and gingival score (Löe and Silness) were recorded by one investigator ( B . A . K . ) at 0, 7, 14 and 21 days. Reproducibility of scoring was established prior to the start of the experi mental period. Buccal, lingual, mesial and distal surfaces of all teeth in each quadrant were scored, with the exception of the third molars and central incisors. Scores for all third molars were omitted because of variations in access to brushing, variations in the height of the clinical crown, and their absence in a high percentage of subjects. Scores for the central incisors were omitted because of 42
42
479
the mechanical difficulty of brushing one central incisor and not the other. The four different modalities of treatment were statis tically analysed for significant differences in plaque accumulation and gingivitis for the three weeks of the experimental period. The statistical analysis was per formed by an analysis of variance and Student's "t" tests on A-gingival and plaque scores. A-scores were computed by subtracting the score at time 0 from the score of weeks 1, 2 and 3. Statistical analysis by Student's "t" tests was performed within each time interval. B. Group II—Topical
Iodine Treatment Study
Sixteen male sophomore dental students in Group II were randomly and equally assigned to one of the following four subgroups: Subgroup A. Brushing and flossing were restricted to the right side of the mouth. Topical iodine was applied to the teeth of the maxillary right quadrant and the mandibular left quadrant. Distilled water was applied to the remaining two quadrants. Subgroup B. Brushing and flossing were restricted to the right side of the mouth. Topical iodine was applied to the mandibular right quadrant and the maxillary left quadrant. Distilled water was applied to the remaining two quadrants. Subgroup C. Brushing and flossing were restricted to the left side of the mouth. Topical iodine was applied to the maxillary right quadrant and the mandibular left quadrant. Distilled water was applied to the remaining two quadrants. Subgroup D. Brushing and flossing were restricted to the left side of the mouth. Topical iodine was applied to the maxillary left and mandibular right quadrants. Distilled water was applied to the remaining quadrants. Dividing Group II in this designated manner estab lished a randomized block design and allowed for the investigation and comparison of the following four modalities of treatment: 1. The effects of topical iodine application in conjunc tion with mechanical oral hygiene procedures, i.e. brush ing and flossing. 2. The effects of topical placebo application in con junction with mechanical oral hygiene procedures. 3. The effects of topical iodine application without mechanical oral hygiene procedures. 4. The effects of topical placebo solution without mechanical oral hygiene procedures. A t the start of the experimental period, each subject's plaque index and gingival index were recorded. The teeth were then scaled and polished. Topical applications of iodine and placebo solutions were applied daily between twelve and one o'clock. The topical iodine solution was prepared by dissolving 2 gm of I and 2.4 gm of N a l in 100 m l of distilled water. Topical solutions were applied with a camel hair brush in a field free of excessive saliva and isolated with cotton rolls. The solutions were applied 2
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to all buccal, lingual and accessible embrasure areas of the tooth surface. The order of topical application was the maxillary right quadrant, mandibular right quadrant, maxillary left quadrant and the mandibular left quad rant. The buccal surfaces of a quadrant were completed first, followed by application to the lingual surfaces of each quadrant. Application commenced with the most posterior tooth in the quadrant, moving anteriorly to include the central incisor. The time required for applica tion of each solution was approximately one minute. Two minutes were allowed to elapse after the application of the test solutions. The subjects then rinsed with tap water and thoroughly expectorated. The subjects refrained from utilizing toothpaste, mouthwashes and disclosing solutions. Prior to recording plaque scores, the subjects rinsed vigorously with tap water to remove any food debris or material alba. Plaque and gingival scores were recorded by one investigator ( B . A . K . ) at 0, 7, 14 and 21 day intervals of the 21-day experimental period. Buccal, lingual, mesial and distal surfaces of all teeth were scored, with the exception of the third molars and central incisors. The four different modalities of treatment were evalu ated statistically for a significant difference in plaque accumulation and gingivitis for the three weeks of the experimental period. Statistical evaluation of the data was performed by an analysis of variance and Student's "t" tests on the -gingival and plaque scores. Statistical analysis by Student's "t" tests was performed within each time interval. 42
2. Gingival Score. Mean, standard deviation and median gingival scores of subjects using iodine mouth wash are presented in Table II. The pattern of changes in the mean plaque scores during the experimental period was demonstrated by a histogram in Figure 2. A t the start of the experiment, the mean gingival scores of the mouthwash treatment group were 0.31, W M ; 0.33, I M ; 0.34, B; and 0.33, 1 M B . Thereafter, quadrants without mechanical oral hygiene procedures ( W M and I M ) showed a slight increase in gingival scores at each weekly interval. Quadrants in which mechanical oral hygiene (B and 1MB) was applied maintained a relatively constant gingival score. Quadrants treated by mechanical oral hygiene with or without iodine mouthwash showed a statistically significantly (P < 0.01) lower change in gingival scores when compared to quadrants treated without brushing and flossing ( W M and I M ) during the three weeks. The mean gingival scores did not show significant changes between quadrants treated by either iodine or placebo mouthwashes (P > 0.05), except in the third week. In the third week, the change in gingival scores showed a slight but significant decrease in quad rants treated by the iodine mouthwash (P < 0.05) (see Table I V and Table V ) . B. Topical Application Treatment Group 1. Plaque Score. Mean, standard deviation and me dian plaque scores of the subjects using topical applica-
RESULTS
A. Mouthwash Treatment Group 1 Plaque Score. Mean, standard deviation and me dian plaque scores are presented in Table I. The pattern of changes in the mean plaque score during the experi mental period was demonstrated by a histogram in Figure 1. It was noted that there was an increase in the plaque score from zero, at the start of the experiment, to varying values according to the modality of treatment applied. By the end of the first week, the mean plaque scores in quadrants treated by distilled water mouthwash ( W M ) , iodine mouthwash only ( I M ) , brushing and flossing only (B), and iodine mouthwash with brushing and flossing (1MB) were changed to 1.55, 1.58, 0.35 and 0.36 respectively (see Table I). There were slight changes in plaque scores thereafter, at the end of the second and third weeks, in each quadrant. Quadrants treated by mechanical oral hygiene with or without iodine mouth wash, however, showed statistically significantly (P < 0.01) lower plaque scores when compared to quadrants without brushing and flossing treatment during the three weeks. O n the other hand, the mean plaque scores did not show significant changes between quadrants treated by either iodine or placebo mouthwashes (P > 0.05) (see Table III and Table V ) .
FIGURE 1. Shows the mean plaque score and standard devia tion of the four different modalities of treatment. The data were derived from twenty students participating in the mouthwash group.
Iodine for Dental Plaque and
Volume 46 Number 8
TABLE I. Mean, Standard Deviation and Median Plaque Scores of Mouthwash and Topical Application Groups Mouthwash Group Treatments
Week 1
Week 2
Week 3
Topical Application Group Treatments
WM
ITB
1.55 ±0.18
0.07 ±0.05
B
IT
WT
1MB
B
IM
Mean Standard devia tion Median
0.36 ±0.25
0.35 ±0.21
1.58 ±0.20
0.33
0.34
1.63
1.56
0.06
0.31
0.48
1.50
Mean Standard devia tion Median
0.32 ±0.15
0.31 ±0.19
1.75 ±0.20
1.78 ±0.15
0.08 ±0.07
0.35 ±0.19
0.38 ±0.26
1.79 ±0.26
0.33
0.30
1.79
1.75
0.08
0.38
0.40
1.75
Mean Standard devia tion Median
0.28 ±0.15
0.30 ±0.17
1.83 ±0.09
1.84 ±0.15
0.10 ±0.10
0.35 ±0.20
0.51 ±0.21
1.86 ±0.22
0.26
0.36
1.82
1.84
0.08
0.33
0.46
1.82
0.41 ±0.30
0.52 ±0.20
1.46 ±0.38
1 M B : Iodine mouthwash with brushing and flossing; B: Brushing and flossing only; I M : Iodine mouthwash only; W M : Distilled water mouthwash only; I T B : Topical application of iodine with brushing and flossing; B: Brushing and flossing only; IT: Topical application of iodine only; W T : Topical applica tion of distilled water only. TABLE II. Mean, Standard Deviation and Median Gingival Scores of Mouthwash and Topical Application Groups Mouthwash Group Treatments
WeekO
Week 1
Week 2
Week 3
Topical Application Group Treatments
1MB
B
IM
WM
ITB
B
IT
WT
Mean Standard diviation Median
0.33 ±0.14
0.34 ±0.21
0.33 ±0.16
0.31 ±0.19
0.39 ±0.19
0.37 ±0.20
0.41 ±0.21
0.40 ±0.15
0.30
0.28
0.36
0.30
0.40
0.32
0.38
0.35
Mean Standard devia tion Median
0.40 ±0.13
0.38 ±0.15
0.64 ±0.15
0.57 ±0.15
0.27 ±0.08
0.35 ±0.19
0.41 ±0.14
0.60 ±0.28
0.34
0.39
0.63
0.55
0.27
0.30
0.43
0.57
Mean Standard devia tion Median
0.43 ±0.13
0.40 ±0.14
0.85 ±0.15
0.86 ±0.15
0.25 ±0.12
0.25 ±0.13
0.45 ±0.17
0.88 ±0.25
0.44
0.39
0.88
0.85
0.24
0.24
0.40
0.83
Mean Standard devia tion Median
0.47 ±0.17
0.41 ±0.15
1.02 ±0.13
1.16 ±0.16
0.29 ±0.13
0.31 ±0.16
0.44 ±0.20
1.05 ±0.29
0.46
0.46
1.06
1.11
0.27
0.25
0.40
0.99
1 M B : Iodine mouthwash with brushing and flossing; B: Brushing and flossing only; I M : Iodine mouthwash only; W M : Distilled water mouthwash only; ITB: Topical application of iodine with brushing and flossing; B: Brushing and flossing only; IT: Topical application of iodine only; W T : Topical application of distilled water only.
Gingivitis
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from
zero, at the start of the experiment, to varying
values according to the modality of treatment applied. By the end of the first week, the mean plaque scores in quadrants treated by topical application of distilled water
FIGURE 2. Shows the mean gingival score and standard devia tion of the four different modalities of treatment. The data were derived from 20 students participating in the mouthwash group.
tion of iodine were presented in Table I. The pattern of
FIGURE 3. Shows the mean plaque score and standard devia tion of the four different modalities of treatment. The data were derived from 16 students participating in the topical application group.
changes i n the mean plaque score during the experimen tal period is demonstrated by a histogram in Figure 3. It was noted that there was an increase in the plaque score
TABLE III. Results of Statistical Analysis of Plaque Scores from Mouthwash and Topical Application Groups Plaque Score Topical group
Mouthwash group "t" test score Week 1
Week 2
Week 3
"t" test
"t" test
score
score
1MB < B 1MB < I M 1MB < W M
0.05 11.92* 12.34*
B < IM B < W
13.50* 13.80*
1MB < B 1MB < I M 1MB < W M
0.15 17.89* 21.07*
B < IM B < W
16.45* 19.00*
1MB < B 0.33 1MB < I M 27.85* 1 M B < W M 22.36*
B < IM B < W
24.78* 20.43*
" t " test score
B < IM B < IM B < IM
* Level of significance at 0.01 or greater, t Level of significance at 0.05.
WM WM WM
score
0.40
ITB ITB ITB
0.05) at the first and second weeks of the experimental period. A t the end of the third week, brushing and flossing only was found more effective than
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topical application of iodine solution only in the control of plaque (P
0.05). It was therefore concluded that iodine mouthwash, 0.02%, is generally not an effective
chemotherapeutic
agent in the control of plaque and gingivitis, whereas topical application of iodine solution (2% I N a l ) is effective accumulation
2
and 2.4%
in decreasing the degree of plaque
and in controlling the development of
gingivitis. Since the topical use of chemical agent iodine did not offer a better control for plaque formation and gingival health than mechanical oral hygiene procedures, brushing and flossing are preferred for the daily plaque control program. REFERENCES
1. Mitchell, D. F., and Holmes, L. H.: Topical antibiotic control of dentogingival plaque. J Periodontol 36: 202, 1965. 2. Löe, H . , Theilande, S., Jensen, B., and Schiott, R.: Experimental gingivitis in man. III. The influence of antibiotics on gingival plaque development. J Periodont Res 2:282, 1967. 3. Mitchell, D. F., Holmes, L . A . , Martin, P. W., and Sakurai, E.: Topical antibiotic maintenance of oral health. J Oral Ther Pharmacol, 4: 83, 1967. 4. Jensen, S. B., Löe, H., Schiott, C. R., and Theilade, E.: Experimental gingivitis in man. IV. Vancomycin induced changes in bacterial plaque composition as related to develop ment of gingival inflammation. J Periodont Res 3: 284, 1968. 5. McFall, W. T., Shoulars, H . W., and Carneval, R. A.: Effect of vancomycin on inhibition of bacterial plaque. J Dent Res 47: 1195, 1968. 6. Lobene, R. R . , Brion, M . , and Socransky, S. S.: Effects of erythromycin on dental plaque and plaque-forming microor ganisms of man. J Periodontol 40: 287, 1969. 7. Stallard, R. E., Volpe, A . R., Orban, J. E., and King, W. J.: The effect of an antimicrobial mouth rinse on dental plaque, calculus and gingivitis. J Periodontol 40: 683, 1969. 8. Hunt, D. E . , Sandham, H . J., and Caldwell, R. C : In vitro antibiotic sensitivity of oral microorganisms to actinobolin. / Dent Res 49: 137, 1970. 9. Löesche, W. J., Green, E., Kenney, E. B., and Nafe, D.: Effect of topical kanamycin sulfate on plaque accumulation. J Am Dent Assoc 83: 1063, 1971. 10. Armstrong, P. J. and Hunt, D. E.: In vitro evaluation of actinobolin as an antibiotic for the treatment of periodontal disease. Appl Microbiol 23: 88, 1972. 11. Kaslick, R . S., Tuckman, M . A . , and Chasens, A . I.: Effect of topical vancomycin on plaque and chronic gingival inflammation. J Periodontol 44: 366, 1973. 12. Jensen, A . L . : Use of dehydrated pancrease in oral hygiene. J Am Dent Assoc 59: 923, 1959. 13. Harrisson, J. W. E., Salisbury, G. B., Abbott, D. D., and Packman, E . W.: Effect of enzyme toothpastes upon oral hygiene. J Periodontol 34: 334, 1963. 14. Packman, E . W., Abbott, D. D., Salisbury, G . B., and Harrisson, J . W. E.: Effect of enzyme chewing gums upon oral hygiene. J Periodontol 34: 255, 1963. 15. Molle, W. H . : Efficacy of an enzyme toothpaste in the
retardation of dental plaque. J South Calif Dent Assoc 35: 391, 1967. 16. Shaver, K. J., and Schiff, T.: Oral clinical functionality of enzyme A P used as a mouthwash. J Periodontol 41: 333, 1970. 17. Caldwell, R. C , Sandham, H . J., Mann, S. V., Jr., Finn, S. B., and Formicola, A . J.: The effect of dextranase mouth wash on dental plaque in young adults and children. J Am Dent Assoc 82: 124, 1971. 18. Lobene, R. R.: A clinical study of the effect of dextra nase on human dental plaque. J Am Dent Assoc 82:132, 1971. 19. Allen, D. L., and Courtney, R. M . : A clinical study of plaque reduction by viokase. J Periodontol 43: 170, 1972. 20. Formicola, A. J., Grupe, H . E . , Bradley, E . L . , Jr., Weatherford, T. W., Ill, and Hunt, D. E.: A clinical evaluation of a proteolytic enzyme mouthwash on plaque and gingivitis in children. NY State Dent J 38: 334, 1972. 21. Stalfors, A.: Disinfection of dental plaque in man. Odontol Tiosk 70: 183, 1962. 22. Davies, R. M . , Jensen, S. B., Schiott, C , and Löe, H . : The effect of topical application of chlorhexidine on the bacterial colonization of the teeth and gingiva. J Periodont Res 5: 96, 1970. 23. Schiott, C , and Löe, H.: The effect of mouthrinses and topical application of chlorhexidine on the development of dental plaque and gingivitis in man. J Periodont Res 5: 79, 1970. 24. Barnes, G . P., Carter, H . G., Gross, A . , Blaskar, S. N . , Schildt, N . N . , and Bush, A . G.: Dental plaque reduction with an antibacterial mouth rinse. Part I. Oral Surg 34: 553, 1972. 25. Lobene, R. R., Soparkar, P. M . , Hein, J. W., and Quigley, G . A.: A study of the effects of antiseptic agents and a pulsating irrigating device on plaque and gingivitis. J Periodon tol 43: 564, 1972. 26. Peterson, J. K., and Casad, R. J.: Effects of an antibacterial mouthrinse on gingivitis and dental plaque. I.A.D.R. Abstract No. 824, 1972. 27. Spolsky, V. W., Bhatia, H., and Levin, D.: The effect of an antimicrobial mouthwash on dental plaque in young adults. I.A.D.R. Abstract No. 825, 1972. 28. Carter, H . G., Barnes, G. P., Blaskar, S. N . , Schildt, N . , and Brunelle, J. A.: Dental plaque reduction with an antibacte rial mouthrinse. Part IV. I.A.D.R. Abstract No. 663, 1973. 29. Lobene, R. R., and Soparkar, P. M . : The effect of an alexidine mouthwash on human plaque and gingivitis. J Am Dent Assoc 87: 848, 1973. 30. Zinner, D. D., and Duany, L . F.: Longitudinal effects of an antibacterial mouthwash on gingivitis and dental plaque. I.A.D.R. Abstract No. 364, 1974. 31. Rodriques, F.: Mercuroehrome and iodine disinfectants of mucous membrane in the mouth. JAMA, 91: 708, 1928. 32. Miller, H . A., and Appelton, J. T.: The preoperative sterilization of the oral mucosa, especially preparatory to injections of local anesthetics. Dent Cosmos 73: 74, 1931. 33. Cawson, R., and Curson, I.: The effectiveness of some antiseptics on the oral mucous membrane. Br Dent J 106: 208, 1959. 34. Zinner, D., Jablon, J., and Saslow, M . : Bactericidal properties of povidone-iodine and its effectiveness as an oral antiseptic. Oral Surg 14: 1377, 1961. 35. Bervell, S.: The bacteriology of physiological gingival pocket. Acta Odontol Scand 22: 167, 1964. 36. Blake, G . , and Forman, G.: Preoperative antiseptic preparation of the oral mucous membrane. Br Dent J 113: 295, 1967. 37. Brenman, H . J., and Randall, E.: Reduction of bactere mia by povidone-iodine. I.A.D.R. Abstract No. 211, 1972. 38. Randall, E., and Brenman, H . F.: Antimicrobial action
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of povidone-iodine mouthwash before and during dental pro phylaxis. I.A.D.R Abstract No. 212, 1972. 39. Deed, K. M . , Marshall, F. J., and Rosen, S.: The antiseptic properties of povidone-iodine and tincture of metaphen used topically on the tooth surface. J Br Endod Soc 6: 2, 1972. 40. Scopp, D., and Orvieto, L.: Gingival degerming by povidone-iodine irrigation: Bacteremia reduction in extraction procedures. / Am Dent Assoc 83: 1294, 1972. 41. Bass, C. C : An effective method of personal oral hygiene. Part II. J. La State Med Soc 106: 100, 1954. 42. Löe, H . : The gingival index, the plaque index, the retention index systems. J Periodontol 38: 610, 1967. 43. Lindhe, J., Heyden, G., Svanberg, C , Löe, H . , and Schiott, C. R.: Effects of local application of chlorhexidine on the oral mucosa in the hamster. J Periodont Res 5: 177, 1970. 44. Flotra, L., Gjermo, P., Rolla, G., and Waehaug, J.: Side effects of chlorhexidine mouthwash. ScandJ Dent Res 79: 119, 1971. 45. Helgeland, K., Heyden, G . , and Rolla, G.: Effect of chlorhexidine on animal cells in vitro. Scand J Dent Res 79: 209, 1971. 46. Neiders, M . F., and Weiss, L.: The effects of chlorhexi dine on cell detachment in vitro. Arch Oral Biol 17:961, 1972. 47. Flotra, L.: Different modes of chlorhexidine application and related local side effects. J Periodont Res Suppl. 12: 41, 1973. 48. Hamp, S. E . , Lindhe, J., and Löe, H.: Long-term effect of chlorhexidine on developing gingivitis in the beagle dog. J Periodont Res 8: 63, 1973.
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49. Mobacken, H . , and Wengstron, C : Interference with healing of rat skin incisions treated with chlorhexidine. Acta Derm Venereol 54: 29, 1974. 50. Prombo, M . , and Tilden, E.: Evaluation of disinfectants by tests in vivo. J. Dent Res 29: 108, 1950. 51. Johansen, J. R., Flotra, L . , and Gjermo, P.: A clinical evaluation of the effect of Ascoxal-T on plaque formation and gingivitis. Acta Odontol Scand 28: 661, 1969. 52. Carlson, H . C , and Porter, C. K.: Inhibitory effect of a synthetic antibiotic mouthwash (CR-711) on dental plaque and gingivitis in young adults. J Periodontol 44: 225, 1973. 53. Kutscher, A.: Lack of effectiveness of a dilute iodine solution in the treatment of gingivitis, periocoronitis and recurrent aphthous stomatitis. J Am Dent Assoc 49:63, 1954. 54. Berliner, A.: A clinical investigation of the effects of aqueous iodine solutions. J Dent Res 34: 402, 1955. 55. Löe, H . , Theilade, E . , and Jensen, S. B.: Experimental gingivitis in man. J Periodontol 36: 177, 1965. 56. Erickson, J. D.: Statistical tests for the OHI-S and PI: A commentary. J Dent Res 52: 36, 1973. 57. Glass, R. L., Alman, J. E., Fleisch, S., and D'Agostino, R. B.: The appropriateness of analysis of variance to the statistical analysis of dental clinical trials. Arch Oral Biol 17: 633, 1972. 58. Cochran, W. G., and Cox, G. M . : Experimental designs. 2nd Ed. New York, Wiley, 1957. 59. Johnston, L. E . , Jr., and DeMarco, T. J.: The clinical effectiveness of a new prophylaxis device. J Periodontol 45: 222, 1974.
Announcements THE AMERICAN ACADEMY OF IMPLANT RESEARCH GRANT
DENTISTRY
AWARD
The purpose of these grants is to support clinical and laboratory research in the field of dental implantology. Grants A total of $3,000 will be available for grant awards. The maximum of $1,000 will be made available for any one project. Awards will be made at the Annual Meeting for a period of one year. Purpose The grant awards are to be used for clinical and/or laboratory research related to dental implantology. Funds may be used for: preparation of histological slides, photographic documentation, direct purchase of laboratory animals, microscope time as with Scanning Electron Microscopes. Funds are not to be used for: salaries, travel, permanent equipment or publication costs.
A A I D will have the right to reprint the article in the official publication of A A I D . b. Credit must be given to A A I D for support of the project in all publications and presentations. 2. A n y laboratory project must adhere to the standard of the "Guide for Laboratory A n i m a l Facilities and Care," as promulgated by the committee on the Guide for Laboratory A n i m a l Resources, National Academy of Sciences, National Research Council. 3. A n y clinical project must adhere to the guidelines of the A D A council on Dntal Research, "Ethical guidelines for clinical investiga tions: ethical policy of the American Dental Association regarding the use of human subjects in clinical research." 4. A n application for a grant award may be obtained by writing to M r . John Winiewicz, Executive Director, American Academy of Implant Dentistry, 469 Washington Street, Abington, Mass. 02351. The deadline for receipt of completed applications is August 1, 1975. CALL FOR PAPERS
Eligibility Those who are active, supporting or life members of the American Academy of Implant Dentistry are eligible. Students, residents or interns of American Dental Association approved universities or hospi tal training programs. Dental Laboratory technicians who are accred ited and in good standing with components of organized dentistry. Those members of the biomedical community who are members in good standing of their parent organizations. Application Those applying for a grant award will be considered provided: 1. They furnish a letter of agreement with the application which states: a. That the findings of the project be submitted for publication and
1976 Annual Conference of the Society for Biomaterials in conjunction with the Eighth International Biomaterials Symposium To be held in Philadelphia, Pa. A p r i l 10-13, 1976. Papers are invited in all aspects of implant materials including tissue-materials interfaces, tissue properties and mechanics, restorative materials, and related basic sciences. Abstracts of approximately 400 words typed within space 19.5 cm in width and 13.5 cm in height including title and authors should be sent to D r . S. R . Pollack, Program Chairman, L . R . S . M . Bldg., University of Pennsylvania, Philadelphia, P a . 19174, U . S . A . by October 1, 1975.
MATERIALS A N D M E T H O D S
Twenty freshmen and 16 sophomore male dental students, between the ages of 20 and 26 years partici pated in the study. A l l subjects chosen for the study fulfilled the following criteria: 1. The presence of a minimum of 24 teeth in an intact dental arch. 2. The gingiva was clinically healthy or with mild gingivitis and generalized pocket depth not exceeding 3 mm. 3. A low D . M . F . index, no open contacts and no overhanging margins or restorations. 4. Good physical health and no known allergy to iodine. 5. N o present history of either antibiotics or topical oral medication. Two to three weeks prior to the start of the 21-day experimental period, the subjects were instructed in oral hygiene procedures. The plaque on the subjects' teeth was stained with P O H disclosing wafers.* They are then instructed in the Bass technique of sulcular brushing, and dental flossing. Following the oral hygiene instruc tion, the teeth were scaled and polished. Once a day in the evening, prior to retiring, the subjects brushed with a Butler gum 411 toothbrush† and flossed with P O H dental floss.‡ For the first week following the oral hygiene instruction, the subjects utilized P O H disclosing tablets after brushing and flossing. This enabled them to observe and improve upon their oral hygiene methods. These oral hygiene procedures enabled the subjects to decrease their plaque and gingival scores to a minimum, prior to the start of the experimental period. The subjects were then divided into two experimental groups. Group I consisted of 20 freshmen students who were going to use iodine solution as a mouthwash (Mouthwash Treatment Group), and Group II consisted of 16 sophomores on whom iodine solution was applied topically by the investigator (Topical Application Treat ment Group).
by BARRY A . KLIGERMAN, D.M.D., M.S. NABIL F . BlSSADA*, B.D.S., M.S.D. SINCE DENTAL PLAQUE is implicated as a causative factor
in the development of gingivitis, its control would be of importance in the prevention of periodontal disease and the maintenance of the supporting structures of the teeth in proper function. A t present, the populace attempts the removal of dental plaque with mechanical oral hygiene procedures. These procedures basically include toothbrushing and dental flossing. However, as evidenced by the prevalence of gingivitis and periodontitis, these mechanical methods of oral hygiene are not fully effec tive for the general population. It appears that the population is either not motivated enough in the use of proper oral hygiene techniques or possibly that brushing and flossing are not capable of removing all dental plaque. Other methods for the control of dental bacterial plaque are thus required for the prevention of periodontal disease. Various chemotherapeutic agents, such as antibi otics, enzymes, and antiseptics, were investi gated in the past for this purpose. Iodine, even though it was shown to be a potent antiseptic agent against most oral microflora, was not thoroughly studied for its plaque-preventing ability. A number of experiments have shown iodine to be an effective antiseptic on the oral mucous membranes, and the tooth surfaces. Iodine has also been shown to reduce the number of viable organisms in saliva, in the gingival crevice, and in the dental bacterial plaque. However, no study was performed to assess the effectiveness of iodine on plaque formation and its concomitant effect on the gingival health. It is therefore the purpose of the present investi gation to study the effect of the local use of iodine solution, as a mouthwash and as topically applied to the tooth surfaces, on the degree of dental plaque formation and on gingival status in the presence and absence of mechanical oral hygiene. 1-11
12-20
41
21-80
31-38
35-39
34
A. Group I—Iodine Mouthwash
40
21
Treatment Study
The 20 participants in Group I were assigned ran domly and in equal number to one of the following four subgroups: Subgroup A. Brushing and flossing were restricted to the right side of the mouth, and the subjects were required to rinse with an iodine solution. Subgroup B. Brushing and flossing were restricted to the left side of the mouth, and the subjects were required to rinse with the iodine solution. Subgroup C. Brushing and flossing were restricted to the right side of the mouth, and the subjects were
Part of a thesis submitted by the senior author to the Graduate School of Case Western Reserve University in partial fulfillment of the requirements for a Master Science Degree. This investigation was supported by N I H Public Health General Research Grant R R 05335-13. * Department of Periodontology School of Dentistry, Case Western Reserve University Cleveland, Ohio.
* P O H disclosing wafers, O r a l Health Products, Inc., Tulsa, Oklahoma. t Butler gum 411 toothbrush, John Butler C o . , Chicago, Illinois. X P O H nylon unwaxed dental floss, O r a l Health Products, Inc., Tulsa, Oklahoma.
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required to rinse with distilled water. Subgroup D. Brushing and flossing were restricted to the left side of the mouth, and the subjects were required to rinse with the distilled water. Dividing the group in such a manner provided the opportunity to compare four different modalities of treatment: 1. The effects of iodine mouthrinse in conjunction with mechanical oral hygiene procedures, i.e. brushing and flossing. 2. The effects of a placebo mouthrinse in conjunction with mechanical oral hygiene procedures. 3. The effects of iodine mouthrinse in the abstinence of mechanical oral hygiene procedures. 4. The effects of a placebo mouthrinse in the absti nence of mechanical oral hygiene procedures. A t the start of the experimental period, each subject's plaque index and gingival index were recorded. A scaling and tooth polishing were then provided. Subgroups A and B were given a week's supply of a 0.02% aqueous iodine solution. The iodine solution was prepared by dissolving 0.02 gm of iodine in 100 cc of distilled water. Fresh iodine solution was prepared and provided weekly. Subgroups C and D were provided with a week's supply of a placebo solution of distilled water. Each subject was provided with a 120 ml brown bottle containing the assigned mouthrinse. In addition, they were given a graduated polyethylene beaker, into which they poured 7.5 ml of the required solution. The subjects rinsed with the appropriate solution twice daily. First, in the morning after breakfast, they rinsed with tap water for ten seconds, then expectorated. They then com menced pouring 7.5 ml of their assigned solution into a graduated beaker. They rinsed in a gentle, swirling motion, allowing the solution to pass over facial and lingual surfaces of the teeth. Two minutes were allowed to elapse prior to completely expectorating the solution. They repeated the same rinsing procedure piror to retiring in the evening. These procedures were em ployed for the duration of the 21-day experimental period. Subjects participating in this study were instruc ted not to use any toothpaste while brushing the as signed side, nor any other mouthwash during the 21 days of the experiment. Prior to scoring the plaque in dex, the patient rinsed vigorously with tap water to re move oral debris and material alba. Plaque scores (Silness and Löe) and gingival score (Löe and Silness) were recorded by one investigator ( B . A . K . ) at 0, 7, 14 and 21 days. Reproducibility of scoring was established prior to the start of the experi mental period. Buccal, lingual, mesial and distal surfaces of all teeth in each quadrant were scored, with the exception of the third molars and central incisors. Scores for all third molars were omitted because of variations in access to brushing, variations in the height of the clinical crown, and their absence in a high percentage of subjects. Scores for the central incisors were omitted because of 42
42
479
the mechanical difficulty of brushing one central incisor and not the other. The four different modalities of treatment were statis tically analysed for significant differences in plaque accumulation and gingivitis for the three weeks of the experimental period. The statistical analysis was per formed by an analysis of variance and Student's "t" tests on A-gingival and plaque scores. A-scores were computed by subtracting the score at time 0 from the score of weeks 1, 2 and 3. Statistical analysis by Student's "t" tests was performed within each time interval. B. Group II—Topical
Iodine Treatment Study
Sixteen male sophomore dental students in Group II were randomly and equally assigned to one of the following four subgroups: Subgroup A. Brushing and flossing were restricted to the right side of the mouth. Topical iodine was applied to the teeth of the maxillary right quadrant and the mandibular left quadrant. Distilled water was applied to the remaining two quadrants. Subgroup B. Brushing and flossing were restricted to the right side of the mouth. Topical iodine was applied to the mandibular right quadrant and the maxillary left quadrant. Distilled water was applied to the remaining two quadrants. Subgroup C. Brushing and flossing were restricted to the left side of the mouth. Topical iodine was applied to the maxillary right quadrant and the mandibular left quadrant. Distilled water was applied to the remaining two quadrants. Subgroup D. Brushing and flossing were restricted to the left side of the mouth. Topical iodine was applied to the maxillary left and mandibular right quadrants. Distilled water was applied to the remaining quadrants. Dividing Group II in this designated manner estab lished a randomized block design and allowed for the investigation and comparison of the following four modalities of treatment: 1. The effects of topical iodine application in conjunc tion with mechanical oral hygiene procedures, i.e. brush ing and flossing. 2. The effects of topical placebo application in con junction with mechanical oral hygiene procedures. 3. The effects of topical iodine application without mechanical oral hygiene procedures. 4. The effects of topical placebo solution without mechanical oral hygiene procedures. A t the start of the experimental period, each subject's plaque index and gingival index were recorded. The teeth were then scaled and polished. Topical applications of iodine and placebo solutions were applied daily between twelve and one o'clock. The topical iodine solution was prepared by dissolving 2 gm of I and 2.4 gm of N a l in 100 m l of distilled water. Topical solutions were applied with a camel hair brush in a field free of excessive saliva and isolated with cotton rolls. The solutions were applied 2
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to all buccal, lingual and accessible embrasure areas of the tooth surface. The order of topical application was the maxillary right quadrant, mandibular right quadrant, maxillary left quadrant and the mandibular left quad rant. The buccal surfaces of a quadrant were completed first, followed by application to the lingual surfaces of each quadrant. Application commenced with the most posterior tooth in the quadrant, moving anteriorly to include the central incisor. The time required for applica tion of each solution was approximately one minute. Two minutes were allowed to elapse after the application of the test solutions. The subjects then rinsed with tap water and thoroughly expectorated. The subjects refrained from utilizing toothpaste, mouthwashes and disclosing solutions. Prior to recording plaque scores, the subjects rinsed vigorously with tap water to remove any food debris or material alba. Plaque and gingival scores were recorded by one investigator ( B . A . K . ) at 0, 7, 14 and 21 day intervals of the 21-day experimental period. Buccal, lingual, mesial and distal surfaces of all teeth were scored, with the exception of the third molars and central incisors. The four different modalities of treatment were evalu ated statistically for a significant difference in plaque accumulation and gingivitis for the three weeks of the experimental period. Statistical evaluation of the data was performed by an analysis of variance and Student's "t" tests on the -gingival and plaque scores. Statistical analysis by Student's "t" tests was performed within each time interval. 42
2. Gingival Score. Mean, standard deviation and median gingival scores of subjects using iodine mouth wash are presented in Table II. The pattern of changes in the mean plaque scores during the experimental period was demonstrated by a histogram in Figure 2. A t the start of the experiment, the mean gingival scores of the mouthwash treatment group were 0.31, W M ; 0.33, I M ; 0.34, B; and 0.33, 1 M B . Thereafter, quadrants without mechanical oral hygiene procedures ( W M and I M ) showed a slight increase in gingival scores at each weekly interval. Quadrants in which mechanical oral hygiene (B and 1MB) was applied maintained a relatively constant gingival score. Quadrants treated by mechanical oral hygiene with or without iodine mouthwash showed a statistically significantly (P < 0.01) lower change in gingival scores when compared to quadrants treated without brushing and flossing ( W M and I M ) during the three weeks. The mean gingival scores did not show significant changes between quadrants treated by either iodine or placebo mouthwashes (P > 0.05), except in the third week. In the third week, the change in gingival scores showed a slight but significant decrease in quad rants treated by the iodine mouthwash (P < 0.05) (see Table I V and Table V ) . B. Topical Application Treatment Group 1. Plaque Score. Mean, standard deviation and me dian plaque scores of the subjects using topical applica-
RESULTS
A. Mouthwash Treatment Group 1 Plaque Score. Mean, standard deviation and me dian plaque scores are presented in Table I. The pattern of changes in the mean plaque score during the experi mental period was demonstrated by a histogram in Figure 1. It was noted that there was an increase in the plaque score from zero, at the start of the experiment, to varying values according to the modality of treatment applied. By the end of the first week, the mean plaque scores in quadrants treated by distilled water mouthwash ( W M ) , iodine mouthwash only ( I M ) , brushing and flossing only (B), and iodine mouthwash with brushing and flossing (1MB) were changed to 1.55, 1.58, 0.35 and 0.36 respectively (see Table I). There were slight changes in plaque scores thereafter, at the end of the second and third weeks, in each quadrant. Quadrants treated by mechanical oral hygiene with or without iodine mouth wash, however, showed statistically significantly (P < 0.01) lower plaque scores when compared to quadrants without brushing and flossing treatment during the three weeks. O n the other hand, the mean plaque scores did not show significant changes between quadrants treated by either iodine or placebo mouthwashes (P > 0.05) (see Table III and Table V ) .
FIGURE 1. Shows the mean plaque score and standard devia tion of the four different modalities of treatment. The data were derived from twenty students participating in the mouthwash group.
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Volume 46 Number 8
TABLE I. Mean, Standard Deviation and Median Plaque Scores of Mouthwash and Topical Application Groups Mouthwash Group Treatments
Week 1
Week 2
Week 3
Topical Application Group Treatments
WM
ITB
1.55 ±0.18
0.07 ±0.05
B
IT
WT
1MB
B
IM
Mean Standard devia tion Median
0.36 ±0.25
0.35 ±0.21
1.58 ±0.20
0.33
0.34
1.63
1.56
0.06
0.31
0.48
1.50
Mean Standard devia tion Median
0.32 ±0.15
0.31 ±0.19
1.75 ±0.20
1.78 ±0.15
0.08 ±0.07
0.35 ±0.19
0.38 ±0.26
1.79 ±0.26
0.33
0.30
1.79
1.75
0.08
0.38
0.40
1.75
Mean Standard devia tion Median
0.28 ±0.15
0.30 ±0.17
1.83 ±0.09
1.84 ±0.15
0.10 ±0.10
0.35 ±0.20
0.51 ±0.21
1.86 ±0.22
0.26
0.36
1.82
1.84
0.08
0.33
0.46
1.82
0.41 ±0.30
0.52 ±0.20
1.46 ±0.38
1 M B : Iodine mouthwash with brushing and flossing; B: Brushing and flossing only; I M : Iodine mouthwash only; W M : Distilled water mouthwash only; I T B : Topical application of iodine with brushing and flossing; B: Brushing and flossing only; IT: Topical application of iodine only; W T : Topical applica tion of distilled water only. TABLE II. Mean, Standard Deviation and Median Gingival Scores of Mouthwash and Topical Application Groups Mouthwash Group Treatments
WeekO
Week 1
Week 2
Week 3
Topical Application Group Treatments
1MB
B
IM
WM
ITB
B
IT
WT
Mean Standard diviation Median
0.33 ±0.14
0.34 ±0.21
0.33 ±0.16
0.31 ±0.19
0.39 ±0.19
0.37 ±0.20
0.41 ±0.21
0.40 ±0.15
0.30
0.28
0.36
0.30
0.40
0.32
0.38
0.35
Mean Standard devia tion Median
0.40 ±0.13
0.38 ±0.15
0.64 ±0.15
0.57 ±0.15
0.27 ±0.08
0.35 ±0.19
0.41 ±0.14
0.60 ±0.28
0.34
0.39
0.63
0.55
0.27
0.30
0.43
0.57
Mean Standard devia tion Median
0.43 ±0.13
0.40 ±0.14
0.85 ±0.15
0.86 ±0.15
0.25 ±0.12
0.25 ±0.13
0.45 ±0.17
0.88 ±0.25
0.44
0.39
0.88
0.85
0.24
0.24
0.40
0.83
Mean Standard devia tion Median
0.47 ±0.17
0.41 ±0.15
1.02 ±0.13
1.16 ±0.16
0.29 ±0.13
0.31 ±0.16
0.44 ±0.20
1.05 ±0.29
0.46
0.46
1.06
1.11
0.27
0.25
0.40
0.99
1 M B : Iodine mouthwash with brushing and flossing; B: Brushing and flossing only; I M : Iodine mouthwash only; W M : Distilled water mouthwash only; ITB: Topical application of iodine with brushing and flossing; B: Brushing and flossing only; IT: Topical application of iodine only; W T : Topical application of distilled water only.
Gingivitis
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from
zero, at the start of the experiment, to varying
values according to the modality of treatment applied. By the end of the first week, the mean plaque scores in quadrants treated by topical application of distilled water
FIGURE 2. Shows the mean gingival score and standard devia tion of the four different modalities of treatment. The data were derived from 20 students participating in the mouthwash group.
tion of iodine were presented in Table I. The pattern of
FIGURE 3. Shows the mean plaque score and standard devia tion of the four different modalities of treatment. The data were derived from 16 students participating in the topical application group.
changes i n the mean plaque score during the experimen tal period is demonstrated by a histogram in Figure 3. It was noted that there was an increase in the plaque score
TABLE III. Results of Statistical Analysis of Plaque Scores from Mouthwash and Topical Application Groups Plaque Score Topical group
Mouthwash group "t" test score Week 1
Week 2
Week 3
"t" test
"t" test
score
score
1MB < B 1MB < I M 1MB < W M
0.05 11.92* 12.34*
B < IM B < W
13.50* 13.80*
1MB < B 1MB < I M 1MB < W M
0.15 17.89* 21.07*
B < IM B < W
16.45* 19.00*
1MB < B 0.33 1MB < I M 27.85* 1 M B < W M 22.36*
B < IM B < W
24.78* 20.43*
" t " test score
B < IM B < IM B < IM
* Level of significance at 0.01 or greater, t Level of significance at 0.05.
WM WM WM
score
0.40
ITB ITB ITB
0.05) at the first and second weeks of the experimental period. A t the end of the third week, brushing and flossing only was found more effective than
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topical application of iodine solution only in the control of plaque (P
0.05). It was therefore concluded that iodine mouthwash, 0.02%, is generally not an effective
chemotherapeutic
agent in the control of plaque and gingivitis, whereas topical application of iodine solution (2% I N a l ) is effective accumulation
2
and 2.4%
in decreasing the degree of plaque
and in controlling the development of
gingivitis. Since the topical use of chemical agent iodine did not offer a better control for plaque formation and gingival health than mechanical oral hygiene procedures, brushing and flossing are preferred for the daily plaque control program. REFERENCES
1. Mitchell, D. F., and Holmes, L. H.: Topical antibiotic control of dentogingival plaque. J Periodontol 36: 202, 1965. 2. Löe, H . , Theilande, S., Jensen, B., and Schiott, R.: Experimental gingivitis in man. III. The influence of antibiotics on gingival plaque development. J Periodont Res 2:282, 1967. 3. Mitchell, D. F., Holmes, L . A . , Martin, P. W., and Sakurai, E.: Topical antibiotic maintenance of oral health. J Oral Ther Pharmacol, 4: 83, 1967. 4. Jensen, S. B., Löe, H., Schiott, C. R., and Theilade, E.: Experimental gingivitis in man. IV. Vancomycin induced changes in bacterial plaque composition as related to develop ment of gingival inflammation. J Periodont Res 3: 284, 1968. 5. McFall, W. T., Shoulars, H . W., and Carneval, R. A.: Effect of vancomycin on inhibition of bacterial plaque. J Dent Res 47: 1195, 1968. 6. Lobene, R. R . , Brion, M . , and Socransky, S. S.: Effects of erythromycin on dental plaque and plaque-forming microor ganisms of man. J Periodontol 40: 287, 1969. 7. Stallard, R. E., Volpe, A . R., Orban, J. E., and King, W. J.: The effect of an antimicrobial mouth rinse on dental plaque, calculus and gingivitis. J Periodontol 40: 683, 1969. 8. Hunt, D. E . , Sandham, H . J., and Caldwell, R. C : In vitro antibiotic sensitivity of oral microorganisms to actinobolin. / Dent Res 49: 137, 1970. 9. Löesche, W. J., Green, E., Kenney, E. B., and Nafe, D.: Effect of topical kanamycin sulfate on plaque accumulation. J Am Dent Assoc 83: 1063, 1971. 10. Armstrong, P. J. and Hunt, D. E.: In vitro evaluation of actinobolin as an antibiotic for the treatment of periodontal disease. Appl Microbiol 23: 88, 1972. 11. Kaslick, R . S., Tuckman, M . A . , and Chasens, A . I.: Effect of topical vancomycin on plaque and chronic gingival inflammation. J Periodontol 44: 366, 1973. 12. Jensen, A . L . : Use of dehydrated pancrease in oral hygiene. J Am Dent Assoc 59: 923, 1959. 13. Harrisson, J. W. E., Salisbury, G. B., Abbott, D. D., and Packman, E . W.: Effect of enzyme toothpastes upon oral hygiene. J Periodontol 34: 334, 1963. 14. Packman, E . W., Abbott, D. D., Salisbury, G . B., and Harrisson, J . W. E.: Effect of enzyme chewing gums upon oral hygiene. J Periodontol 34: 255, 1963. 15. Molle, W. H . : Efficacy of an enzyme toothpaste in the
retardation of dental plaque. J South Calif Dent Assoc 35: 391, 1967. 16. Shaver, K. J., and Schiff, T.: Oral clinical functionality of enzyme A P used as a mouthwash. J Periodontol 41: 333, 1970. 17. Caldwell, R. C , Sandham, H . J., Mann, S. V., Jr., Finn, S. B., and Formicola, A . J.: The effect of dextranase mouth wash on dental plaque in young adults and children. J Am Dent Assoc 82: 124, 1971. 18. Lobene, R. R.: A clinical study of the effect of dextra nase on human dental plaque. J Am Dent Assoc 82:132, 1971. 19. Allen, D. L., and Courtney, R. M . : A clinical study of plaque reduction by viokase. J Periodontol 43: 170, 1972. 20. Formicola, A. J., Grupe, H . E . , Bradley, E . L . , Jr., Weatherford, T. W., Ill, and Hunt, D. E.: A clinical evaluation of a proteolytic enzyme mouthwash on plaque and gingivitis in children. NY State Dent J 38: 334, 1972. 21. Stalfors, A.: Disinfection of dental plaque in man. Odontol Tiosk 70: 183, 1962. 22. Davies, R. M . , Jensen, S. B., Schiott, C , and Löe, H . : The effect of topical application of chlorhexidine on the bacterial colonization of the teeth and gingiva. J Periodont Res 5: 96, 1970. 23. Schiott, C , and Löe, H.: The effect of mouthrinses and topical application of chlorhexidine on the development of dental plaque and gingivitis in man. J Periodont Res 5: 79, 1970. 24. Barnes, G . P., Carter, H . G., Gross, A . , Blaskar, S. N . , Schildt, N . N . , and Bush, A . G.: Dental plaque reduction with an antibacterial mouth rinse. Part I. Oral Surg 34: 553, 1972. 25. Lobene, R. R., Soparkar, P. M . , Hein, J. W., and Quigley, G . A.: A study of the effects of antiseptic agents and a pulsating irrigating device on plaque and gingivitis. J Periodon tol 43: 564, 1972. 26. Peterson, J. K., and Casad, R. J.: Effects of an antibacterial mouthrinse on gingivitis and dental plaque. I.A.D.R. Abstract No. 824, 1972. 27. Spolsky, V. W., Bhatia, H., and Levin, D.: The effect of an antimicrobial mouthwash on dental plaque in young adults. I.A.D.R. Abstract No. 825, 1972. 28. Carter, H . G., Barnes, G. P., Blaskar, S. N . , Schildt, N . , and Brunelle, J. A.: Dental plaque reduction with an antibacte rial mouthrinse. Part IV. I.A.D.R. Abstract No. 663, 1973. 29. Lobene, R. R., and Soparkar, P. M . : The effect of an alexidine mouthwash on human plaque and gingivitis. J Am Dent Assoc 87: 848, 1973. 30. Zinner, D. D., and Duany, L . F.: Longitudinal effects of an antibacterial mouthwash on gingivitis and dental plaque. I.A.D.R. Abstract No. 364, 1974. 31. Rodriques, F.: Mercuroehrome and iodine disinfectants of mucous membrane in the mouth. JAMA, 91: 708, 1928. 32. Miller, H . A., and Appelton, J. T.: The preoperative sterilization of the oral mucosa, especially preparatory to injections of local anesthetics. Dent Cosmos 73: 74, 1931. 33. Cawson, R., and Curson, I.: The effectiveness of some antiseptics on the oral mucous membrane. Br Dent J 106: 208, 1959. 34. Zinner, D., Jablon, J., and Saslow, M . : Bactericidal properties of povidone-iodine and its effectiveness as an oral antiseptic. Oral Surg 14: 1377, 1961. 35. Bervell, S.: The bacteriology of physiological gingival pocket. Acta Odontol Scand 22: 167, 1964. 36. Blake, G . , and Forman, G.: Preoperative antiseptic preparation of the oral mucous membrane. Br Dent J 113: 295, 1967. 37. Brenman, H . J., and Randall, E.: Reduction of bactere mia by povidone-iodine. I.A.D.R. Abstract No. 211, 1972. 38. Randall, E., and Brenman, H . F.: Antimicrobial action
Iodine for Dental Plaque and Gingivitis
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of povidone-iodine mouthwash before and during dental pro phylaxis. I.A.D.R Abstract No. 212, 1972. 39. Deed, K. M . , Marshall, F. J., and Rosen, S.: The antiseptic properties of povidone-iodine and tincture of metaphen used topically on the tooth surface. J Br Endod Soc 6: 2, 1972. 40. Scopp, D., and Orvieto, L.: Gingival degerming by povidone-iodine irrigation: Bacteremia reduction in extraction procedures. / Am Dent Assoc 83: 1294, 1972. 41. Bass, C. C : An effective method of personal oral hygiene. Part II. J. La State Med Soc 106: 100, 1954. 42. Löe, H . : The gingival index, the plaque index, the retention index systems. J Periodontol 38: 610, 1967. 43. Lindhe, J., Heyden, G., Svanberg, C , Löe, H . , and Schiott, C. R.: Effects of local application of chlorhexidine on the oral mucosa in the hamster. J Periodont Res 5: 177, 1970. 44. Flotra, L., Gjermo, P., Rolla, G., and Waehaug, J.: Side effects of chlorhexidine mouthwash. ScandJ Dent Res 79: 119, 1971. 45. Helgeland, K., Heyden, G . , and Rolla, G.: Effect of chlorhexidine on animal cells in vitro. Scand J Dent Res 79: 209, 1971. 46. Neiders, M . F., and Weiss, L.: The effects of chlorhexi dine on cell detachment in vitro. Arch Oral Biol 17:961, 1972. 47. Flotra, L.: Different modes of chlorhexidine application and related local side effects. J Periodont Res Suppl. 12: 41, 1973. 48. Hamp, S. E . , Lindhe, J., and Löe, H.: Long-term effect of chlorhexidine on developing gingivitis in the beagle dog. J Periodont Res 8: 63, 1973.
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49. Mobacken, H . , and Wengstron, C : Interference with healing of rat skin incisions treated with chlorhexidine. Acta Derm Venereol 54: 29, 1974. 50. Prombo, M . , and Tilden, E.: Evaluation of disinfectants by tests in vivo. J. Dent Res 29: 108, 1950. 51. Johansen, J. R., Flotra, L . , and Gjermo, P.: A clinical evaluation of the effect of Ascoxal-T on plaque formation and gingivitis. Acta Odontol Scand 28: 661, 1969. 52. Carlson, H . C , and Porter, C. K.: Inhibitory effect of a synthetic antibiotic mouthwash (CR-711) on dental plaque and gingivitis in young adults. J Periodontol 44: 225, 1973. 53. Kutscher, A.: Lack of effectiveness of a dilute iodine solution in the treatment of gingivitis, periocoronitis and recurrent aphthous stomatitis. J Am Dent Assoc 49:63, 1954. 54. Berliner, A.: A clinical investigation of the effects of aqueous iodine solutions. J Dent Res 34: 402, 1955. 55. Löe, H . , Theilade, E . , and Jensen, S. B.: Experimental gingivitis in man. J Periodontol 36: 177, 1965. 56. Erickson, J. D.: Statistical tests for the OHI-S and PI: A commentary. J Dent Res 52: 36, 1973. 57. Glass, R. L., Alman, J. E., Fleisch, S., and D'Agostino, R. B.: The appropriateness of analysis of variance to the statistical analysis of dental clinical trials. Arch Oral Biol 17: 633, 1972. 58. Cochran, W. G., and Cox, G. M . : Experimental designs. 2nd Ed. New York, Wiley, 1957. 59. Johnston, L. E . , Jr., and DeMarco, T. J.: The clinical effectiveness of a new prophylaxis device. J Periodontol 45: 222, 1974.
Announcements THE AMERICAN ACADEMY OF IMPLANT RESEARCH GRANT
DENTISTRY
AWARD
The purpose of these grants is to support clinical and laboratory research in the field of dental implantology. Grants A total of $3,000 will be available for grant awards. The maximum of $1,000 will be made available for any one project. Awards will be made at the Annual Meeting for a period of one year. Purpose The grant awards are to be used for clinical and/or laboratory research related to dental implantology. Funds may be used for: preparation of histological slides, photographic documentation, direct purchase of laboratory animals, microscope time as with Scanning Electron Microscopes. Funds are not to be used for: salaries, travel, permanent equipment or publication costs.
A A I D will have the right to reprint the article in the official publication of A A I D . b. Credit must be given to A A I D for support of the project in all publications and presentations. 2. A n y laboratory project must adhere to the standard of the "Guide for Laboratory A n i m a l Facilities and Care," as promulgated by the committee on the Guide for Laboratory A n i m a l Resources, National Academy of Sciences, National Research Council. 3. A n y clinical project must adhere to the guidelines of the A D A council on Dntal Research, "Ethical guidelines for clinical investiga tions: ethical policy of the American Dental Association regarding the use of human subjects in clinical research." 4. A n application for a grant award may be obtained by writing to M r . John Winiewicz, Executive Director, American Academy of Implant Dentistry, 469 Washington Street, Abington, Mass. 02351. The deadline for receipt of completed applications is August 1, 1975. CALL FOR PAPERS
Eligibility Those who are active, supporting or life members of the American Academy of Implant Dentistry are eligible. Students, residents or interns of American Dental Association approved universities or hospi tal training programs. Dental Laboratory technicians who are accred ited and in good standing with components of organized dentistry. Those members of the biomedical community who are members in good standing of their parent organizations. Application Those applying for a grant award will be considered provided: 1. They furnish a letter of agreement with the application which states: a. That the findings of the project be submitted for publication and
1976 Annual Conference of the Society for Biomaterials in conjunction with the Eighth International Biomaterials Symposium To be held in Philadelphia, Pa. A p r i l 10-13, 1976. Papers are invited in all aspects of implant materials including tissue-materials interfaces, tissue properties and mechanics, restorative materials, and related basic sciences. Abstracts of approximately 400 words typed within space 19.5 cm in width and 13.5 cm in height including title and authors should be sent to D r . S. R . Pollack, Program Chairman, L . R . S . M . Bldg., University of Pennsylvania, Philadelphia, P a . 19174, U . S . A . by October 1, 1975.
