Gingival enhancement Anamnestic findings
in fixed prosthodontics.
John A. Sorensen, D.M.D.,* and Michael G. Newman, University of California, School of Dentistry, Los Angeles, Calif.
Part III:
D.D.S.**
This study obtained anamnestic data from a questionnaire given at the conclusion of a 7-week chlorhexidine gingival enhancement study regarding patients’ oral hygiene practices, perception of change in gingival health, and side effects. In the patient population using the 7-week chlorhexidine treatment regimen, most patients noticed an improvement in gingival health, were willing to continue usage after the study, and would recommend the rinse to others. Of the patients who reported side effects, taste alteration was more objectionable than staining. The patients’ observed gingival health benetits were more important than the patients’ perception of the side effects such as staining and taste alteration. (J PROSTHET
D~~~1991;65:600-4.)
T
he efficacy of adjunctive daily rinsing with 0.12% chlorhexidine gluconate to significantly reduce plaque levels and significantly improve gingival health during fixed prosthodontic procedures was demonstrated in Part I.’ Part II of this study confirmed that chlorhexidine rinsing significantly reduced putative periodontal pathogens, retarded bacterial recolonization, and favored development of subgingival and marginal microflora associated with gingival health during fixed prosthodontic treatment.2 The most effective prescription chemotherapeutic agent is useless unless the patient follows the therapeutic regimen. Objectionable side effects of any medication are a frequent reason for patient noncompliance.3~4 This study used a poststudy questionnaire to determine patient compliance, oral hygiene practices during the study period, and chlorhexidine patients’ overall perception of the mouthrinse treatment and to assessside effects.
Chlorhexidine’s
action
and side effects
The antimicrobial efficacy of cblorhexidine gluconate has been well substantiated in Europe.57s Chlorhexidine’s mechanism of action is nonspecific. The positively charged chlorhexidine molecule first binds to negatively charged regions on the bacterial cell wall. With the attachment of the chlorhexidine molecule, bacterial cell wall permeability is altered causing rupture and cell death. This nonspecific mechanism of action makes development of resistant strains difficult and provides a broad spectrum of activity. Six-month trials have demonstrated continued effec-
Presented in part before the Pacific Coast Society of Prosthodontista meeting, Sun River, Ore., and the American Academy of Periodontology meeting, San Diego, Calif. This study was supported by the Procter and Gamble Co., Cincinnati, Ohio.
10/l/25873
tiveness without development of resistant organisms.7*s Chlorhexidine has the property of substantivity, which allows it to attach to teeth, pellicle surfaces, and mucous membranes to provide a continuous extended antiplaque effect for many hourss-12 The ability of 0.2% and 0.12% chlorhexidine to significantly reduce plaque and subsequent gingival inflammation both short and long term has been shown in many studies.5*13-15Clear reductions in plaque scores and gingivitis scores during longitudinal investigations have been documented?? 16-18 The primary side effect of all oral chemical antimicrobial agents is the development of brown pellicle discolorations.1g-21 Cblorhexidine also forms extrinsic tooth discolorations.5* 22*23In a al-day study of patients rinsing with a placebo, Listerine, sanguinarine, and chlorhexidine there was no significant difference in the mean discoloration index or mean MVL stain grading scores.l’ Staining appears to be greatest at the interproximal aspect of the mandibular anterior teeth.23-25 The mechanism for staining is not fully understood.26-28 Researchers have observed a marked variation in discoloration among individuals.27y 28 The yellow-brown stain is superficial and can be removed with a rubber cup and pumice.12 Clinical investigations have correlated discoloration tendency and smoking habits or consumption of certain tannin-containing beverages.ss*3o Other side effects include altered taste sensation, discoloration of the tongue, and mucosal and gingival irritation. The altered taste perception immediately subsides after termination of the medication.31 In Florta et al’s study23 of 50 soldiers rinsing with 0.12 % and 0.2% concentrations of chlorhexidine rinse for 4 months,
they found
that
12% of tooth
surfaces were
discolored, 62% of silicate surfaces were discolored, and 36% of the subjects’ tongues had discoloration. Some desquamations and soreness of oral mucosa were occasionally observed.
APRIL
1901
VOLUME
66
NUMBER
4
GINGIVAL ENHANCEMENT. III: ANAMNESTIC
Table I. Study design 2 Weeks
Baseline
Rinse procedure
CHX/control Assignment to experimental group Oral hygiene instruction
Measurement
1. Clinical 2. Microbiology
6 Weeks
CHX/control Preparation Gingival displacement Impression Provisional restoration 1. Clinical 2. Microbiology
7 Weeks
CHX/control Cementation
CHX/control Questionnaire
1. Clinical 2. Microbiology
1. Clinical 2. Microbiology
Table II. Frequency of brushing/day (% ) Control Frequency
Before
Once Twice 3 or >
Table III.
study
Chlorhexidlne During
0 79 21
study
0 71 29
Before
study
During
22 64 14
study
14 57 29
Frequency of dental flossing (% ) Control
Frequency
Before
Never Sometimes 3-6 Per week Once/day Twice/day 3 or >/day
study
Chlorhexidine During
0 29 0 43 21 7
In another study where the effect on plaque levels and gingival health were evaluated with adjunctive rinsing with Listerine and two concentrations of chlorhexidine, no significant extrinsic tooth discolorations developed during the B-week trial. l8 Approximate 1y 14% of the subjects had mucosal lesions in the chlorhexidine group. In Siegrist et al’s al-day study,17 the placebo, sanguinarine, and chlorhexidine groups all experienced similar side effects. The Listerine group reported a significantly higher incidence of “burning” on the tongue and oral mucosa. In summary, all antimicrobial agents have demonstrated side effects and should therefore be evaluated in terms of the patient’s experience in relation to perceived benefits of the antimicrobial mouthrinse.
MATERIAL
AND METHODS
Patients who required fixed prosthodontic treatment were recruited from the School of Dentistry at the University of California, Los Angeles. To be accepted into the study, patients could not have systemic disease or have
THE JOURNAL OF PROSTHETIC DENTISTRY
study
0 29 0 29 29 13
Before
study
7 36 7 43 7 0
Daring
study
7 7 7 36 36 7
used medication effecting the gingiva, antibiotics, antimicrobials, or fluoride rinses 2 months prior to baseline. Thirty patients were randomly assigned to either the chlorhexidine group or the control group. The chlorhexidine subjects were instructed to brush and floss as they normally would and then rinse with 0.12% chlorhexidine gluconate (Peridex, The Procter and Gamble Co., Cincinnati, Ohio), 15 ml b.i.d. for 30 seconds, and the control group was instructed to brush, floss, and rinse with water for 30 seconds b.i.d. The medication was used for 2 weeks before crown preparation, 3 weeks during provisional crown placement, and 2 weeks after definitive crown cementation. The study period lasted 7 weeks (Table I). At the conclusion of the study, patients were given a 15 question, multiple-answer, and fill-in questionnaire to complete unassisted and in private. The results of the questionnaire were tabulated and mean scores for each treatment group were calculated. When applicable, differences in treatment groups were analyzed with a Wilcoxon two-sample test. A Kruskal-Wallis ANOVA test was used to evaluate significance of intragroup differences.
501
SORENSEN
Table
Months since last prophylaxis (% )
IV.
Frequency (months)
3 6 9 12 18 24 or >
Table
VII.
AND
NEWMAN
Reason for not using rinse as requested* (% )
Frequency
Chlorhexidine
Chlorhexidine
Control
43 14 14 14 7 0
15 31 0 15 23 8
T&e Other
33 67
*Three patients responded.
Table
VIII.
Would subject continue to use rinse after
study? (%) Frequency Table
V.
Chlorhexidine
Opinion of mouthrinse (% )
Frequency
Liked Indifferent Did not like Did not uee
Control
No Yes
Chlorhexidiie
0 0 0 100
57 7 29 7
Table
IX.
17
83
Would subject recommend rinse to others (% )
Frequency
Frequency of use of chlorhexidine rinse during study (% ) Table
VI.
Frequency
Did not use 1 Day or more Once Twice
No
a
Yes
92
Chlorhexidine
8 21 21 50
RESULTS Fourteen of 15 subjects in each group completed the survey, 13 were women and 15 were men. The mean age of the patients was 39 years of age in an age range of 20 to 73 years. Before the study, 22% of the chlorhexidine subjects brushed only once a day whereas all of the control group brushed at least twice a day (Table II). The apparent shifts of increased frequency of brushing were not statistically significant. There was a significant increase in flossing frequency for the chlorhexidine group from never or sometimes to three or more times per week (Table III). The reported period since the last prophylaxis was greater for the chlorhexidine group than the control group (Table IV). Regarding the chlorhexidine patients’ opinion of the mouthrinse, more than half liked the taste, approximately one thiid did not like the taste, and one patient did not use the rinse (Table V). Half of the chlorhexidine subjects followed directions and rinsed twice a day whereas the other half rinsed once a day or less (Table VI). When queried why they did not follow the given instructions, the three respondents had 502
Chlorhexidine
varying reasons for not complying. One person reported that it was because of the disagreeable taste, one said it was because of dental staining, and one said that the rinse irritated her gums (Table VII). Despite the disagreeable properties of the chlorhexidine rinse, 33% of the subjects said that they would continue to use the chlorhexidine after the study (Table VIII) and 92 % said they would recommend the rinse to a friend (Table IX). Apparently the benefits to the subjects’ gingival health were great enough for the subjects to continue using the rinse and recommend it to others. The benefits of chlorhexidine rinsing observed by the patients were less bleeding of the gums, observed by 50% of the subjects (Table X), and 57 % of the subjects observed less swelling and redness of the gums (Table XI). None of the control patients noticed a change in gingival bleeding or redness and swelling over the period of the study (Tables X and XI). When asked about changes in the appearance of the subjects’ teeth during the study, 3% of the chlorhexidine patients and 100 % of control patients noted no difference in the appearance of their teeth (Table XII). For the chlorhexidine patients, 8% noticed slight dental staining, 23% heavy staining, and 23% interproximal staining. Other changes noticed by the chlorhexidine patients included tongue discoloration, transient taste alteration, consistent taste alteration, and gingival soreness (Table XIII). Again, despite these side effects most of the chlorhexidine subjects were willing to continue to rinse after the completion of the study and would recommend it to others.
APRIL
1991
VOLUME
65
NUMBER
4
GINGIVAL
Table
ENHANCEMENT.
X.
III: ANAMNESTIC
Table
Changes in bleeding of gums (% )
Frequency
Control
Lessbleeding No change
0 100
XII.
Changes in appearance of teeth (% )
Frequency
Chlorhexidine
None Slight Heavy Interproximal
50 50
XI.
31 8 23
100 0 0 0
23 16
0
Other Table
Chlorhexidine
Control
Changes in swelling and redness of gums (% )
Frequency
Control
Chlorhexidine Table
Less swelling and redness No change
0
57
loo
43
XIII.
Noticed other changes (%) Frequency
Tongue discoloration Transient taste alteration Consistent taste alteration Gingival soreness
Chlorhexidine
11 67 11 11
DISCUSSION A review of the questionnaire answers revealed that half of the patients followed directions and rinsed twice a day, one patient did not use the rinse, and the others used the rinse once a day or less. Yet Parts I and II of this study still found a significantly greater reduction in plaque index and gingival index, favoring the development of health oriented microorganisms. l* 2 The chlorhexidine rinse is probably strong and effective enough when used only once a day. To evaluate only the effects of chlorhexidine and placebo treatment, no professional scaling, root planning, or prophylaxis was performed at any point in this study. This makes the reduction in plaque and gingival indices with the use of chlorhexidine even more compelling. The resulting answers expressed by the patients also demonstrated improved gingival health from chlorhexidine rinsing. Although Florta et al.23observed staining of 62 % of silicate restorations, the present study did not find any staining of class III anterior composite resins. Silicate restorations are considerably rougher than the composite resins used 18 years later. Florta et al.23used a It-month regimen of chlorhexidine rinsing and observed some tooth surface discoloration, tongue discoloration, and mucosal irritation. The 7-week chlorhexidine regimen of this study saw fewer subjects with mucosal or gingival irritation and tongue discoloration. Approximately 46% of the subjects reported interproximal or heavy dental staining. A 6-week study comparing placebo, Listerine, sanguinarine, and chlorhexidine found no significant staining in any of the groups.32
CONCLUSIONS The results of a questionnaire given to patients using the 7-week chlorhexidine treatment regimen in conjunction with fixed prosthodontics were as follows: 1. Most patients perceived an improvement in their gingival health, such as decreased bleeding, redness, and swelling of their gums. 2. Eighty-three percent would continue to use the rinse
THE JOURNAL
OF PROSTHETIC
DENTISTRY
after the study and 92 % would recommend the mouthrinse to others. 3. Of the reported side effects, taste alteration was a more objectionable side effect than staining. 4. The patients’ perceived gingival health benefits were more important than the patients’ perception of the side effects such as staining and taste alteration. REFERENCES 1. Sorensen JA, Doherty FM, Newman MG, Flemmig TF. Gingival enhancement in fixed prosthodontics. I: Clinical findings. J PROSTHET DENT 1991;65:100-7. 2. Flemmig TF, Sorensen JA, Newman MG, Nachnani S. Gingival enhancement in fixed prosthodontics. II. Microbiologic findings. J PROSTHETDENT 1991;65:365-72. 3. Michaux MW. Side effects, resistance, and dosage deviations in psychiatric out-patients treated with tranquilizers. J Nerv Ment Dis 1961; 133:203-12. 4. Blackwell W. The drug defaulter. Clin Pharmacol Ther 1972;13:841-8. 5. Los H, Schiott CR, Glavind L, Karring T. Two years oral use of chlorhexidine in man. I. General design and clinical effects. J Periodont Res 1976,17:135-44. 6. Florta L, Gjermo P, Rolla G, Waerhaug J. A 4-month study on the effect of chlorhexidine mouth washes on 50 soldiers. Stand J Dent Res 1972;80:10-7. 7. Lang NP, Holtz P, Graf H, et al. Effects of supervised chlorhexidine mouthrinses in children. A longitudinal clinical trial. J Periodont Res 1982;17:101-11. 8. Grossman E, Rieter D, Sturzenberger OP, et al. Six-month study on the effect of a chlorhexidine mouthrinse on gingivitis in adults. J Periodont Res 1986,16(Suppl):33-43. 9. Rolla G, Loe H, Schiott CR. The affinity of chlorhexidine for hydroxyapatite and salivary mucins. J Periodont Res 1970;5:890-5. 10. Rolla G, Lee H, Schiott CR. Retention of chlorhexidine in the human oral cavity. Arch Oral Biol 1971;16:1109-16. 11. Rolla G, Melson B. On the mechanism of the plaque inhibition by chlorhexidine. J Dent Res 1975;54(Special Issue B):57-62. 12. Kornman KS. The role of supragingival plaque in the prevention and treatment of periodontal disease. A review of current concepts. J Periodont Res 1986;21(Suppl):5-22. 13. Wennstrom J, Lindhe J. The effect of mouthrinses on parameters characterizing human periodontal disease. J Clin Periodontol 1986; 13~86~ 93. 14. Segreto VA, Collins EM, Beiswagner BB, et al. A comparison of mouthrinses containing two concentrations of chlorhexidine. J Periodont Res 1986;21(Suppl):23-32.
503
SORENSEN
15. Gusberti FA, Sampathkumar P, &grist BE, Lang NP. Microbiological and clinical effects of chlorhexidine gluconate and hydrogen peroxide mouthrinses on developing plaque and gingivitis. J Periodontol 1988;15:60-7. 16. Lang NP, Brecx MC. Chlorhexidine digluconate-an agent for chemical plaque control and prevention of gingival inflammation. J Periodont R.es 1986;21(Suppl):74-89. 17. Siegrist AE, Gusberti FA, Brecx ML, Weber HP, Lang NP. Efficacy of supervised rinsing with chlorhexidine digluconate in comparison to phenolicandplantelkaloidcompounds. JPeriodontRes1986;21(Suppl): __ -_ 60-m
18. Axelsson P, Lindhe J. Efficacy of mouthrinses in inhibiting dental plaque and gingivitis. J Clin Periodontol 1987;14:205-12. 19. Weatherford TW, Finn SB, Jamison HC. Effects of an alexidine mouthwash on dental plaque and gingivitis in humans over a six-month period. J Am Dent Assoc 1977;94:528-36. 20. Plum E. Plaque inhibition and staining by Hibitane and Vantocil. Helv Odontol Acta 1975;19:61-4. 21. Vogel RI, Austin G. Tetracycline-induced extrinsic discoloration of the dentition. Oral Surg 1977;44:50-3. 22. Svatun B, Gjermo P, Eriksen HM, Rolla GA. A comparison of the plaque-inhibiting effect of stannous fluoride and chlorhexidine. Acta Odontol Scaud 1977;35:247-50. 23. Florta L, Gjermo P, Rolla G, Waerhaug J. Side effects of chlorhexidine mouth washes. Stand J Dent Res 1971;79:119-25. 24. Eriksen HM, Jemtland B, Finckenhagen HJ, Gjermo P. Evaluation of extrinsic tooth discoloration. Acta Odontol Stand 1979;37:371-5.
AND
25. Eriksen HM, Solheim H, Nordbo H. Chemical plaque control and extrinsic tooth discoloration in viva. Acta Odontol Stand 1983;41:87-91. 26. Eriksen HM, Nordbo H, Kantanen H, Ellingsen JE. Chemical plaque control and extrinsic tooth discoloration. A review of possible mechanisms. J Clin Periodontol 1985;12:345-50. 27. Solheim H, Eriksen HM, Nordbo H. Chemical plaque control and extrinsic discoloration of teeth. Acta Odontol Stand 1980;38:303-9. 28. Vogel RI. Intrinsic and extrinsic discoloration of the dentition. A literature review. J Oral Med 1975;30:99-104. 29. Addy M, Prayitino S, Taylor L, Codogan S. An In vitro study of the role of dietary factors in the etiology of tooth staining associated with the use of chlorhexidine. J Periodontal Res 1979;14:403-10. 30. Prayitino S, Taylor L, Codogan S, Addy M. An in vivo study of dietary factors in the etiology of tooth staining associated with the use of chlorhexidine. J Periodont Res 1979;14:411-17. 31. Lang NP, Catalanotto FA, Knopfli RU, Antnak AA. A quality-specific taste impairment following the application of chlorhexidine gluconate mouthrinse. J Periodontol 198&15:43-S. 32. Lang NP, Briner WW. Chemical control of gingivitis in man. J Am Dent Assoc 1984;109:223. Reprint requests to: DR. JOHN A. SORENSEN CHS 33-041 SCHOOL OF DENTWRY thIVFaWITY OF CALIFORNIA LOS ANGELES, CA 90024
Comparison of exothermic release during polymerization four materials used to fabricate interim restorations Carl F. Driscoll, D.M.D.,’ Gerald William M. Ferguson*** Fort Leavenworth,
NEWMAN
of
Woolsey, D.D.S., M.S.,** and
Kan., and Fort Hood, Tex.
Four materials commonly used to make resin crown and fixed partial denture interim restorations (poly)methylmethacrylate, vinyl ethylmethacrylate, visiblelight activated resin, and a Bis-acryl composite resin) were studied to evaluate their heat-producing capabilities. All four materials, despite manufacturers’ claims, created a rise in temperature during polymerization. Poly(methylmethacrylate)‘s temperature increases were signiilcantly higher than those of the other three materials and visible-light activated resin had temperature increases that were significantly lower than those of the other three products. Dentists must be aware of all potential heat-producing sources to minimize thermal injury to the hard and soft tissues of the oral cavity during the fabrication of interim crowns and fixed partialdentures. (J PROSTEIET D~~~1991;65:504-6.)
Fabrication
of a successful crown or fixed partial denture requires the precise execution of many steps, from The opinions or assertions contained herein are the private views of the authors and are not te be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. *Lieutenant Colonel, U.S. Army, DC; Chief of Prosthodontics, Fort Leavenworth, Kan. **Colonel, U.S. Army, DC; Chief of Prosthodontics, Fort Hood, Tex.
***Chief Laboratory Technician, Fort Leavenworth, Kan.
10/l/25264
504
the initial visit for data collection and diagnosis through the postinsertion visits. One of the intermediate steps that is often hastened or neglected is the fabrication of the interim crown or fixed partial denture. The interim restoration is often referred to as the “temporary,” a term that may suggest that this step requires less stringent adherence to prosthodontic principles than other steps of crown or fixed partial denture fabrication. Experienced restorative clinicians realize that lack of attention to any step in the restorative procedure can yield disastrous results. Many authors have discussed the requirements for making interim restorations. l-6 They agree that interim resto-
APRIL
1991
VOLUME
85
NUMBER
4
in fixed prosthodontics.
John A. Sorensen, D.M.D.,* and Michael G. Newman, University of California, School of Dentistry, Los Angeles, Calif.
Part III:
D.D.S.**
This study obtained anamnestic data from a questionnaire given at the conclusion of a 7-week chlorhexidine gingival enhancement study regarding patients’ oral hygiene practices, perception of change in gingival health, and side effects. In the patient population using the 7-week chlorhexidine treatment regimen, most patients noticed an improvement in gingival health, were willing to continue usage after the study, and would recommend the rinse to others. Of the patients who reported side effects, taste alteration was more objectionable than staining. The patients’ observed gingival health benetits were more important than the patients’ perception of the side effects such as staining and taste alteration. (J PROSTHET
D~~~1991;65:600-4.)
T
he efficacy of adjunctive daily rinsing with 0.12% chlorhexidine gluconate to significantly reduce plaque levels and significantly improve gingival health during fixed prosthodontic procedures was demonstrated in Part I.’ Part II of this study confirmed that chlorhexidine rinsing significantly reduced putative periodontal pathogens, retarded bacterial recolonization, and favored development of subgingival and marginal microflora associated with gingival health during fixed prosthodontic treatment.2 The most effective prescription chemotherapeutic agent is useless unless the patient follows the therapeutic regimen. Objectionable side effects of any medication are a frequent reason for patient noncompliance.3~4 This study used a poststudy questionnaire to determine patient compliance, oral hygiene practices during the study period, and chlorhexidine patients’ overall perception of the mouthrinse treatment and to assessside effects.
Chlorhexidine’s
action
and side effects
The antimicrobial efficacy of cblorhexidine gluconate has been well substantiated in Europe.57s Chlorhexidine’s mechanism of action is nonspecific. The positively charged chlorhexidine molecule first binds to negatively charged regions on the bacterial cell wall. With the attachment of the chlorhexidine molecule, bacterial cell wall permeability is altered causing rupture and cell death. This nonspecific mechanism of action makes development of resistant strains difficult and provides a broad spectrum of activity. Six-month trials have demonstrated continued effec-
Presented in part before the Pacific Coast Society of Prosthodontista meeting, Sun River, Ore., and the American Academy of Periodontology meeting, San Diego, Calif. This study was supported by the Procter and Gamble Co., Cincinnati, Ohio.
10/l/25873
tiveness without development of resistant organisms.7*s Chlorhexidine has the property of substantivity, which allows it to attach to teeth, pellicle surfaces, and mucous membranes to provide a continuous extended antiplaque effect for many hourss-12 The ability of 0.2% and 0.12% chlorhexidine to significantly reduce plaque and subsequent gingival inflammation both short and long term has been shown in many studies.5*13-15Clear reductions in plaque scores and gingivitis scores during longitudinal investigations have been documented?? 16-18 The primary side effect of all oral chemical antimicrobial agents is the development of brown pellicle discolorations.1g-21 Cblorhexidine also forms extrinsic tooth discolorations.5* 22*23In a al-day study of patients rinsing with a placebo, Listerine, sanguinarine, and chlorhexidine there was no significant difference in the mean discoloration index or mean MVL stain grading scores.l’ Staining appears to be greatest at the interproximal aspect of the mandibular anterior teeth.23-25 The mechanism for staining is not fully understood.26-28 Researchers have observed a marked variation in discoloration among individuals.27y 28 The yellow-brown stain is superficial and can be removed with a rubber cup and pumice.12 Clinical investigations have correlated discoloration tendency and smoking habits or consumption of certain tannin-containing beverages.ss*3o Other side effects include altered taste sensation, discoloration of the tongue, and mucosal and gingival irritation. The altered taste perception immediately subsides after termination of the medication.31 In Florta et al’s study23 of 50 soldiers rinsing with 0.12 % and 0.2% concentrations of chlorhexidine rinse for 4 months,
they found
that
12% of tooth
surfaces were
discolored, 62% of silicate surfaces were discolored, and 36% of the subjects’ tongues had discoloration. Some desquamations and soreness of oral mucosa were occasionally observed.
APRIL
1901
VOLUME
66
NUMBER
4
GINGIVAL ENHANCEMENT. III: ANAMNESTIC
Table I. Study design 2 Weeks
Baseline
Rinse procedure
CHX/control Assignment to experimental group Oral hygiene instruction
Measurement
1. Clinical 2. Microbiology
6 Weeks
CHX/control Preparation Gingival displacement Impression Provisional restoration 1. Clinical 2. Microbiology
7 Weeks
CHX/control Cementation
CHX/control Questionnaire
1. Clinical 2. Microbiology
1. Clinical 2. Microbiology
Table II. Frequency of brushing/day (% ) Control Frequency
Before
Once Twice 3 or >
Table III.
study
Chlorhexidlne During
0 79 21
study
0 71 29
Before
study
During
22 64 14
study
14 57 29
Frequency of dental flossing (% ) Control
Frequency
Before
Never Sometimes 3-6 Per week Once/day Twice/day 3 or >/day
study
Chlorhexidine During
0 29 0 43 21 7
In another study where the effect on plaque levels and gingival health were evaluated with adjunctive rinsing with Listerine and two concentrations of chlorhexidine, no significant extrinsic tooth discolorations developed during the B-week trial. l8 Approximate 1y 14% of the subjects had mucosal lesions in the chlorhexidine group. In Siegrist et al’s al-day study,17 the placebo, sanguinarine, and chlorhexidine groups all experienced similar side effects. The Listerine group reported a significantly higher incidence of “burning” on the tongue and oral mucosa. In summary, all antimicrobial agents have demonstrated side effects and should therefore be evaluated in terms of the patient’s experience in relation to perceived benefits of the antimicrobial mouthrinse.
MATERIAL
AND METHODS
Patients who required fixed prosthodontic treatment were recruited from the School of Dentistry at the University of California, Los Angeles. To be accepted into the study, patients could not have systemic disease or have
THE JOURNAL OF PROSTHETIC DENTISTRY
study
0 29 0 29 29 13
Before
study
7 36 7 43 7 0
Daring
study
7 7 7 36 36 7
used medication effecting the gingiva, antibiotics, antimicrobials, or fluoride rinses 2 months prior to baseline. Thirty patients were randomly assigned to either the chlorhexidine group or the control group. The chlorhexidine subjects were instructed to brush and floss as they normally would and then rinse with 0.12% chlorhexidine gluconate (Peridex, The Procter and Gamble Co., Cincinnati, Ohio), 15 ml b.i.d. for 30 seconds, and the control group was instructed to brush, floss, and rinse with water for 30 seconds b.i.d. The medication was used for 2 weeks before crown preparation, 3 weeks during provisional crown placement, and 2 weeks after definitive crown cementation. The study period lasted 7 weeks (Table I). At the conclusion of the study, patients were given a 15 question, multiple-answer, and fill-in questionnaire to complete unassisted and in private. The results of the questionnaire were tabulated and mean scores for each treatment group were calculated. When applicable, differences in treatment groups were analyzed with a Wilcoxon two-sample test. A Kruskal-Wallis ANOVA test was used to evaluate significance of intragroup differences.
501
SORENSEN
Table
Months since last prophylaxis (% )
IV.
Frequency (months)
3 6 9 12 18 24 or >
Table
VII.
AND
NEWMAN
Reason for not using rinse as requested* (% )
Frequency
Chlorhexidine
Chlorhexidine
Control
43 14 14 14 7 0
15 31 0 15 23 8
T&e Other
33 67
*Three patients responded.
Table
VIII.
Would subject continue to use rinse after
study? (%) Frequency Table
V.
Chlorhexidine
Opinion of mouthrinse (% )
Frequency
Liked Indifferent Did not like Did not uee
Control
No Yes
Chlorhexidiie
0 0 0 100
57 7 29 7
Table
IX.
17
83
Would subject recommend rinse to others (% )
Frequency
Frequency of use of chlorhexidine rinse during study (% ) Table
VI.
Frequency
Did not use 1 Day or more Once Twice
No
a
Yes
92
Chlorhexidine
8 21 21 50
RESULTS Fourteen of 15 subjects in each group completed the survey, 13 were women and 15 were men. The mean age of the patients was 39 years of age in an age range of 20 to 73 years. Before the study, 22% of the chlorhexidine subjects brushed only once a day whereas all of the control group brushed at least twice a day (Table II). The apparent shifts of increased frequency of brushing were not statistically significant. There was a significant increase in flossing frequency for the chlorhexidine group from never or sometimes to three or more times per week (Table III). The reported period since the last prophylaxis was greater for the chlorhexidine group than the control group (Table IV). Regarding the chlorhexidine patients’ opinion of the mouthrinse, more than half liked the taste, approximately one thiid did not like the taste, and one patient did not use the rinse (Table V). Half of the chlorhexidine subjects followed directions and rinsed twice a day whereas the other half rinsed once a day or less (Table VI). When queried why they did not follow the given instructions, the three respondents had 502
Chlorhexidine
varying reasons for not complying. One person reported that it was because of the disagreeable taste, one said it was because of dental staining, and one said that the rinse irritated her gums (Table VII). Despite the disagreeable properties of the chlorhexidine rinse, 33% of the subjects said that they would continue to use the chlorhexidine after the study (Table VIII) and 92 % said they would recommend the rinse to a friend (Table IX). Apparently the benefits to the subjects’ gingival health were great enough for the subjects to continue using the rinse and recommend it to others. The benefits of chlorhexidine rinsing observed by the patients were less bleeding of the gums, observed by 50% of the subjects (Table X), and 57 % of the subjects observed less swelling and redness of the gums (Table XI). None of the control patients noticed a change in gingival bleeding or redness and swelling over the period of the study (Tables X and XI). When asked about changes in the appearance of the subjects’ teeth during the study, 3% of the chlorhexidine patients and 100 % of control patients noted no difference in the appearance of their teeth (Table XII). For the chlorhexidine patients, 8% noticed slight dental staining, 23% heavy staining, and 23% interproximal staining. Other changes noticed by the chlorhexidine patients included tongue discoloration, transient taste alteration, consistent taste alteration, and gingival soreness (Table XIII). Again, despite these side effects most of the chlorhexidine subjects were willing to continue to rinse after the completion of the study and would recommend it to others.
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GINGIVAL
Table
ENHANCEMENT.
X.
III: ANAMNESTIC
Table
Changes in bleeding of gums (% )
Frequency
Control
Lessbleeding No change
0 100
XII.
Changes in appearance of teeth (% )
Frequency
Chlorhexidine
None Slight Heavy Interproximal
50 50
XI.
31 8 23
100 0 0 0
23 16
0
Other Table
Chlorhexidine
Control
Changes in swelling and redness of gums (% )
Frequency
Control
Chlorhexidine Table
Less swelling and redness No change
0
57
loo
43
XIII.
Noticed other changes (%) Frequency
Tongue discoloration Transient taste alteration Consistent taste alteration Gingival soreness
Chlorhexidine
11 67 11 11
DISCUSSION A review of the questionnaire answers revealed that half of the patients followed directions and rinsed twice a day, one patient did not use the rinse, and the others used the rinse once a day or less. Yet Parts I and II of this study still found a significantly greater reduction in plaque index and gingival index, favoring the development of health oriented microorganisms. l* 2 The chlorhexidine rinse is probably strong and effective enough when used only once a day. To evaluate only the effects of chlorhexidine and placebo treatment, no professional scaling, root planning, or prophylaxis was performed at any point in this study. This makes the reduction in plaque and gingival indices with the use of chlorhexidine even more compelling. The resulting answers expressed by the patients also demonstrated improved gingival health from chlorhexidine rinsing. Although Florta et al.23observed staining of 62 % of silicate restorations, the present study did not find any staining of class III anterior composite resins. Silicate restorations are considerably rougher than the composite resins used 18 years later. Florta et al.23used a It-month regimen of chlorhexidine rinsing and observed some tooth surface discoloration, tongue discoloration, and mucosal irritation. The 7-week chlorhexidine regimen of this study saw fewer subjects with mucosal or gingival irritation and tongue discoloration. Approximately 46% of the subjects reported interproximal or heavy dental staining. A 6-week study comparing placebo, Listerine, sanguinarine, and chlorhexidine found no significant staining in any of the groups.32
CONCLUSIONS The results of a questionnaire given to patients using the 7-week chlorhexidine treatment regimen in conjunction with fixed prosthodontics were as follows: 1. Most patients perceived an improvement in their gingival health, such as decreased bleeding, redness, and swelling of their gums. 2. Eighty-three percent would continue to use the rinse
THE JOURNAL
OF PROSTHETIC
DENTISTRY
after the study and 92 % would recommend the mouthrinse to others. 3. Of the reported side effects, taste alteration was a more objectionable side effect than staining. 4. The patients’ perceived gingival health benefits were more important than the patients’ perception of the side effects such as staining and taste alteration. REFERENCES 1. Sorensen JA, Doherty FM, Newman MG, Flemmig TF. Gingival enhancement in fixed prosthodontics. I: Clinical findings. J PROSTHET DENT 1991;65:100-7. 2. Flemmig TF, Sorensen JA, Newman MG, Nachnani S. Gingival enhancement in fixed prosthodontics. II. Microbiologic findings. J PROSTHETDENT 1991;65:365-72. 3. Michaux MW. Side effects, resistance, and dosage deviations in psychiatric out-patients treated with tranquilizers. J Nerv Ment Dis 1961; 133:203-12. 4. Blackwell W. The drug defaulter. Clin Pharmacol Ther 1972;13:841-8. 5. Los H, Schiott CR, Glavind L, Karring T. Two years oral use of chlorhexidine in man. I. General design and clinical effects. J Periodont Res 1976,17:135-44. 6. Florta L, Gjermo P, Rolla G, Waerhaug J. A 4-month study on the effect of chlorhexidine mouth washes on 50 soldiers. Stand J Dent Res 1972;80:10-7. 7. Lang NP, Holtz P, Graf H, et al. Effects of supervised chlorhexidine mouthrinses in children. A longitudinal clinical trial. J Periodont Res 1982;17:101-11. 8. Grossman E, Rieter D, Sturzenberger OP, et al. Six-month study on the effect of a chlorhexidine mouthrinse on gingivitis in adults. J Periodont Res 1986,16(Suppl):33-43. 9. Rolla G, Loe H, Schiott CR. The affinity of chlorhexidine for hydroxyapatite and salivary mucins. J Periodont Res 1970;5:890-5. 10. Rolla G, Lee H, Schiott CR. Retention of chlorhexidine in the human oral cavity. Arch Oral Biol 1971;16:1109-16. 11. Rolla G, Melson B. On the mechanism of the plaque inhibition by chlorhexidine. J Dent Res 1975;54(Special Issue B):57-62. 12. Kornman KS. The role of supragingival plaque in the prevention and treatment of periodontal disease. A review of current concepts. J Periodont Res 1986;21(Suppl):5-22. 13. Wennstrom J, Lindhe J. The effect of mouthrinses on parameters characterizing human periodontal disease. J Clin Periodontol 1986; 13~86~ 93. 14. Segreto VA, Collins EM, Beiswagner BB, et al. A comparison of mouthrinses containing two concentrations of chlorhexidine. J Periodont Res 1986;21(Suppl):23-32.
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SORENSEN
15. Gusberti FA, Sampathkumar P, &grist BE, Lang NP. Microbiological and clinical effects of chlorhexidine gluconate and hydrogen peroxide mouthrinses on developing plaque and gingivitis. J Periodontol 1988;15:60-7. 16. Lang NP, Brecx MC. Chlorhexidine digluconate-an agent for chemical plaque control and prevention of gingival inflammation. J Periodont R.es 1986;21(Suppl):74-89. 17. Siegrist AE, Gusberti FA, Brecx ML, Weber HP, Lang NP. Efficacy of supervised rinsing with chlorhexidine digluconate in comparison to phenolicandplantelkaloidcompounds. JPeriodontRes1986;21(Suppl): __ -_ 60-m
18. Axelsson P, Lindhe J. Efficacy of mouthrinses in inhibiting dental plaque and gingivitis. J Clin Periodontol 1987;14:205-12. 19. Weatherford TW, Finn SB, Jamison HC. Effects of an alexidine mouthwash on dental plaque and gingivitis in humans over a six-month period. J Am Dent Assoc 1977;94:528-36. 20. Plum E. Plaque inhibition and staining by Hibitane and Vantocil. Helv Odontol Acta 1975;19:61-4. 21. Vogel RI, Austin G. Tetracycline-induced extrinsic discoloration of the dentition. Oral Surg 1977;44:50-3. 22. Svatun B, Gjermo P, Eriksen HM, Rolla GA. A comparison of the plaque-inhibiting effect of stannous fluoride and chlorhexidine. Acta Odontol Scaud 1977;35:247-50. 23. Florta L, Gjermo P, Rolla G, Waerhaug J. Side effects of chlorhexidine mouth washes. Stand J Dent Res 1971;79:119-25. 24. Eriksen HM, Jemtland B, Finckenhagen HJ, Gjermo P. Evaluation of extrinsic tooth discoloration. Acta Odontol Stand 1979;37:371-5.
AND
25. Eriksen HM, Solheim H, Nordbo H. Chemical plaque control and extrinsic tooth discoloration in viva. Acta Odontol Stand 1983;41:87-91. 26. Eriksen HM, Nordbo H, Kantanen H, Ellingsen JE. Chemical plaque control and extrinsic tooth discoloration. A review of possible mechanisms. J Clin Periodontol 1985;12:345-50. 27. Solheim H, Eriksen HM, Nordbo H. Chemical plaque control and extrinsic discoloration of teeth. Acta Odontol Stand 1980;38:303-9. 28. Vogel RI. Intrinsic and extrinsic discoloration of the dentition. A literature review. J Oral Med 1975;30:99-104. 29. Addy M, Prayitino S, Taylor L, Codogan S. An In vitro study of the role of dietary factors in the etiology of tooth staining associated with the use of chlorhexidine. J Periodontal Res 1979;14:403-10. 30. Prayitino S, Taylor L, Codogan S, Addy M. An in vivo study of dietary factors in the etiology of tooth staining associated with the use of chlorhexidine. J Periodont Res 1979;14:411-17. 31. Lang NP, Catalanotto FA, Knopfli RU, Antnak AA. A quality-specific taste impairment following the application of chlorhexidine gluconate mouthrinse. J Periodontol 198&15:43-S. 32. Lang NP, Briner WW. Chemical control of gingivitis in man. J Am Dent Assoc 1984;109:223. Reprint requests to: DR. JOHN A. SORENSEN CHS 33-041 SCHOOL OF DENTWRY thIVFaWITY OF CALIFORNIA LOS ANGELES, CA 90024
Comparison of exothermic release during polymerization four materials used to fabricate interim restorations Carl F. Driscoll, D.M.D.,’ Gerald William M. Ferguson*** Fort Leavenworth,
NEWMAN
of
Woolsey, D.D.S., M.S.,** and
Kan., and Fort Hood, Tex.
Four materials commonly used to make resin crown and fixed partial denture interim restorations (poly)methylmethacrylate, vinyl ethylmethacrylate, visiblelight activated resin, and a Bis-acryl composite resin) were studied to evaluate their heat-producing capabilities. All four materials, despite manufacturers’ claims, created a rise in temperature during polymerization. Poly(methylmethacrylate)‘s temperature increases were signiilcantly higher than those of the other three materials and visible-light activated resin had temperature increases that were significantly lower than those of the other three products. Dentists must be aware of all potential heat-producing sources to minimize thermal injury to the hard and soft tissues of the oral cavity during the fabrication of interim crowns and fixed partialdentures. (J PROSTEIET D~~~1991;65:504-6.)
Fabrication
of a successful crown or fixed partial denture requires the precise execution of many steps, from The opinions or assertions contained herein are the private views of the authors and are not te be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. *Lieutenant Colonel, U.S. Army, DC; Chief of Prosthodontics, Fort Leavenworth, Kan. **Colonel, U.S. Army, DC; Chief of Prosthodontics, Fort Hood, Tex.
***Chief Laboratory Technician, Fort Leavenworth, Kan.
10/l/25264
504
the initial visit for data collection and diagnosis through the postinsertion visits. One of the intermediate steps that is often hastened or neglected is the fabrication of the interim crown or fixed partial denture. The interim restoration is often referred to as the “temporary,” a term that may suggest that this step requires less stringent adherence to prosthodontic principles than other steps of crown or fixed partial denture fabrication. Experienced restorative clinicians realize that lack of attention to any step in the restorative procedure can yield disastrous results. Many authors have discussed the requirements for making interim restorations. l-6 They agree that interim resto-
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1991
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