|Year : 2022 | Volume
| Issue : 2 | Page : 174-179
|Evaluation of efficacy of subgingival administration of 1% chlorhexidine gel as an adjunct to scaling and root planing in the treatment of chronic periodontitis - A clinical and microbiological study
Varsha Goswami1, Ramreddy K Yeltiwar2, Shirish Kujur1, Parul Agrawal2, Sonika Bodhi3, Shruti Bhatnagar2
1 Department of Periodontics, Government Dental College, Raipur, Chhattisgarh, India
2 Department of Periodontology, Rungta College of Dental Sciences and Research, Bhilai, Chhattisgarh, India
3 Department of Periodontics, Rungta College of Dental Sciences and Research, Bhilai, Chhattisgarh, India
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|Date of Submission||23-Sep-2021|
|Date of Decision||04-Jul-2022|
|Date of Acceptance||05-Jul-2022|
|Date of Web Publication||13-Oct-2022|
| Abstract|| |
Aim: The aim of the present study was to evaluate the clinical and microbiological effects of subgingival administration of 1% chlorhexidine gel (Chlorhexamed® 1% gel) in patients with chronic periodontitis. Settings and Design: The study was done in a parallel-arm design with a total of 30 patients with 60 sites suffering from chronic periodontitis. The patients were divided into control and experimental groups. Materials and Methods: The clinical parameters recorded were plaque index, gingival index, modified sulcular bleeding index, probing pocket depth and relative attachment level at baseline, 1 month and 3 month. Microbiological colony-forming units were assessed for Porphyromonas gingivalis, Fusobacterium nucleatum and Tannerella forsythia at baseline, 1 week, 1 month and 3 months. The control group received scaling and root planing (SRP) after baseline evaluation; however, the experimental group received the application of Chlorhexamed® gel within 48 hours after SRP. Then, the values obtained were subjected to statistical analysis. Results: Both groups showed significant improvement from the baseline to 3 months in all clinical and microbiological parameters. The experimental group showed better improvement in all parameters. Conclusion: The use of Chlorhexamed® gel has proven to be an efficacious adjunct with SRP in the treatment of chronic periodontitis.
Keywords: Antimicrobial agents, chlorhexidine, local drug delivery, periodontitis, subgingival gel
|How to cite this article:|
Goswami V, Yeltiwar RK, Kujur S, Agrawal P, Bodhi S, Bhatnagar S. Evaluation of efficacy of subgingival administration of 1% chlorhexidine gel as an adjunct to scaling and root planing in the treatment of chronic periodontitis - A clinical and microbiological study. Indian J Dent Res 2022;33:174-9
|How to cite this URL:|
Goswami V, Yeltiwar RK, Kujur S, Agrawal P, Bodhi S, Bhatnagar S. Evaluation of efficacy of subgingival administration of 1% chlorhexidine gel as an adjunct to scaling and root planing in the treatment of chronic periodontitis - A clinical and microbiological study. Indian J Dent Res [serial online] 2022 [cited 2022 Nov 29];33:174-9. Available from: https://www.ijdr.in/text.asp?2022/33/2/174/358458
| Introduction|| |
Subgingival anatomy is complex, and subgingival microbiology is a step ahead of it. The proper approach to a disease-free subgingival environment is to have a healthy microbiological niche, devoid of pathogens. Mechanical debridement helps in the reduction of subgingival pathogens, but certain microorganisms may escape this. To overcome this, antimicrobial treatment is used. The action of systemic antimicrobial treatment is limited by factors such as biofilm resistance, variable concentration in the pocket and/or gingival crevicular fluid, and adverse reactions to the drugs. The adverse effects can be avoided if we prefer local delivery of antimicrobial agents. Goodson (1989) proposed that the control of subgingival microflora can be regulated more effectively if the antimicrobial drug reaches the maximum concentration in the periodontal pocket in a controlled manner. The rationale is to bypass the systemic route to achieve the utmost benefit at the target site by overcoming the aforementioned shortcomings. This method of antimicrobial therapy administration also allows for achieving a therapeutic effect without depending on the patient and/or resistance from the biofilm.
Chlorhexidine (CHX) gluconate is a dicationic bisbiguanide chemotherapeutic agent having both bacteriostatic and bactericidal activity. The antimicrobial spectrum for CHX includes Gram-positive bacteria, Gram-negative bacteria, fungi, and yeasts. CHX has been a gold standard and can substantially decrease the bacterial load in subgingival plaque when placed locally in the periodontal pocket. It shows a reversible electrostatic binding to dental pellicle glycoproteins along with adsorption on teeth surfaces. Various concentrations and forms of CHX have been used to improve the efficacy of non-surgical periodontal therapy. Chlorhexamed® is 1% bioadhesive, hydrophobic CHX gel, which has shown anti-inflammatory and anti-gingivitis properties. The efficacy of Chlorhexamed® gel has not been much explored; hence, the aim of the present study was to evaluate the clinical and microbiological effects of subgingival administration of 1% CHX gel (Chlorhexamed® 1% gel) in patients with chronic periodontitis.
| Methods|| |
A total of 30 systemically healthy patients with 60 sites (17 male patients and 13 female) suffering from moderate to severe periodontitis were selected from the outpatient Department of Periodontology, Rungta College of Dental Sciences and Research, Kohka- Kurud, Bhilai, Chhattisgarh, for this parallel-arm study design. The study was approved by the institutional ethical committee (reference number: RCDSR/MDS/SYNOPREG/14). Verbal and written informed consent was obtained from all patients.
(1) Patients in the age group of 20–60 years of both genders. (2) Patients having at least 20 natural teeth in their mouth. (3) Radiographic evidence of alveolar bone loss. (4) Probing pocket depth ≥5 mm.
(1) Patients who are not systemically healthy. (2) Patients who had taken any form of antibiotic therapy in the past 3–6 months. (3) Patients who had undergone any periodontal therapy in the past 6 months. (4) Patients on immunosuppressive therapy. (5) Patients allergic to CHX. (6) Patients who are pregnant or lactating.
The selected sites were randomly divided into control site and experimental site according to the type of treatment rendered to them in a split-mouth design:
Control site: Received SRP;
Experimental site: Received 1% CHX gel (Chlorhexamed®1% Gel) as an adjunct to SRP.
Full-mouth scaling and root planing (SRP) was performed. The patient was instructed to return for gel administration within 48 hours; the sites were isolated and gel was placed at selected sites using a sterile syringe with a blunt needle. No SRP was done in subsequent visits. Coe-Pak was applied for better retention of the gel.
Clinical parameters assessed were the plaque index (PI), gingival index (GI), modified sulcular bleeding index (Mombelli et al.), probing pocket depth (PPD) and relative attachment level (RAL). A self-cured acrylic resin stent was used to measure RAL. All clinical parameters were recorded before the commencement of the study at the baseline, 1 month and 3 months. The same periodontist recorded all of the parameters at each visit to reduce clinicians' bias [Figure 1].
|Figure 1: Composite figure showing the (a) control site: probing at the baseline. (b) Subgingival plaque collection using paper point. (c) Control site: probing at 3 months of follow-up. (d) Experimental site: probing at the baseline. (e) Experimental site: Administration of Chlorhexamed® gel. (f) Experimental site: probing at 3 months of follow-up|
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Plaque sample collection
Subgingival plaque samples were collected for microbiological sampling. Isolation of selected sites was done using sterile cotton to avoid contamination; then, an endodontic paper point was inserted in the sulcus for 10 seconds. The paper point containing the plaque sample was transferred to trypticase soy broth medium and sealed tightly.
The samples collected were then incubated at 37°C for 24 h; after that, they were centrifuged at 3000 rpm for 5 minutes after performing 1/10,000 dilution of the subgingival sample. The sample was then inoculated in the respective medium using a swab which was rubbed on the surface of the medium in the Petri dish More Details. The analysis was done for Porphyromonas gingivalis, Fusobacterium nucleatum and Tannerella forsythia using enriched blood agar, Brewer's anaerobic agar and Bacteroides bile esculin agar, respectively, as culture media. These were then stored in an anaerobic environment incubator at 37°C for 7 days. Because selective media were used, the respective microorganism was seen to form colonies. They were further assessed using Gram staining and shape of microorganisms. A colony counter was used for microbial colony counting. Samples were collected from sites at the baseline, 1 week, 1 month and 3 months and assessed for colony-forming units (CFUs) [Figure 2].
|Figure 2: Composite figure showing microbiological assessment of Porphyromonas gingivalis, Tannerella forsythia and Fusobacterium nucleatum at a 3-month interval|
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The clinical and microbiological parameters recorded at various follow-ups were subjected to the t-test. Clinical changes were expressed in terms of mean difference from the baseline to the final follow-up period; similarly, microbiological changes were recorded and assessed in terms of reduction in CFU from the baseline to 3 months. Comparison was done within the group of each follow-up using the paired t-test. Intergroup comparisons of the clinical and microbiological parameters were done using the unpaired t-test. A P value < 0.05 was considered statistically significant.
| Results|| |
All clinical and microbiological parameters have shown improvement from the baseline to the final follow-up of 3 months. Paired t-test was applied to the plaque index (PI), ginigval index (GI) and modified sulcular bleeding index.
The PI showed a statistically significant decline of 0.61 ± 0.32 from the baseline to 3 months. The GI was significantly reduced from the baseline to 3 months by 0.68 ± 0.34. The modified sulcular bleeding index showed similar results by presenting a statistically significant difference of 0.87 ± 0.41 from the baseline to 3 months [Table 1]. The paired t-test for intragroup comparison and unpaired t-test for intergroup comparison were applied to the remaining clinical and microbiological parameters.
|Table 1: Mean changes in the PI, GI and modified bleeding index score at different follow-up intervals|
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Pocket probing depth
There was statistically significant reduction in the PPD from the baseline to 3 months. The PPD decreased from 5.5 ± 0.732 mm at the baseline to 4.6 ± 0.93 mm at 3 months in the control site, whereas the experimental site showed a reduction from 5.6 ± 0.82 mm at the baseline to 3.53 ± 0.78 mm at 3 months. There was a mean difference of 0.67 ± 0.84 mm amongst the control and experimental group, which was statistically significant [Table 2].
|Table 2: Mean changes in PPD and RAL score at different follow-up intervals within the group and intergroup comparison|
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Relative attachment level (RAL)
The RAL showed a significant reduction from the baseline to 3 months by 1.23 ± 1.2 mm in the control site; however, the experimental site showed a mean difference of 2.73 ± 1.5 mm. Intergroup comparison of control and experimental site showed results in favour of the latter with a mean difference of 1.36 ± 1.52 mm at the end of 3 months [Table 2].
There was a statistically significant difference when experimental and control group reduction was taken into consideration in favour of the former. The experimental group showed a decline from 11.24 ± 3.25 at the baseline to 8.69 ± 2.07 at 3 month counting, whereas the control group showed a value of 12.05 ± 2.76 at the baseline which reduced to 9.85 ± 1.96 at 3 months. There was a mean difference of 1.15 ± 1.8 in the experimental and control groups at the end of 3 months, which was statistically significant [Table 3].
|Table 3: Mean changes in microbiological parameter score at different follow-up intervals within the group and intergroup comparison|
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In the control group, the baseline value was 26.51 ± 7.54, which reduced to 16.48 ± 4.61 at 3 months; the experimental group showed a reduction of 11.29 ± 6.27 from the baseline to 3 months; both were statistically significant. Intergroup comparison showed results in favour of the experimental group with a mean difference of 1.29 ± 3.45 when compared to the control group [Table 3].
Intergroup comparison showed a statistically significant difference in the experimental and control group results. There was a difference of 1.32 ± 2.73 at 3 months. There was a decrease in microbial colony counting from the baseline to 3 months in both experimental and control groups individually. The experimental group noticed a difference of 3.79 ± 2.46, whereas the control group showed a 3.15 ± 1.9 difference [Table 3].
| Discussion|| |
The use of antimicrobials has always been advocated for the treatment of periodontal disease. CHX is a broad-spectrum antibiotic agent which has been proven effective against a variety of periodontal pathogens and has shown success when used as an adjunct to SRP., The present study was aimed to evaluate the efficacy of 1% CHX gel in the treatment of chronic periodontitis as an adjunctive. The study design included a control group to assess the effect of Chlorhexamed® gel as the literature provides with limited studies of the same in periodontal therapy. The follow-up selected was of 3 months as it is the recall period for clinical evaluation of periodontium after an intervention; also, the local delivery of CHX has shown to be effective for as long as 11 weeks.
The outcome of the study demonstrated an improvement in all parameters. The results were skewed in favour of the experimental group. Jeffcot et al. suggested that targeting of the concerned site using an antimicrobial agent can produce beneficial results; the results are consistent with maintaining the agent over a sufficient period of time. The present study affirmed this observation. The reduction in clinical and microbiological parameters was because of the removal of local factors in the form of SRP. However, the experimental group has demonstrated that the use of a local delivery agent will further increase the progress obtained by SRP. Abraham et al. suggested that the probable reason for the reduction in the probing depth is increase in collagen content and firmness of gingiva, resulting in decreased penetration of the probe, thus resulting in improved overall gingival health and improved PPD and RALs. This alteration reflected in microbiological growth, as reduction was evident, showing decreased colony counts. The local drug delivery agent when placed in a periodontal pocket will produce an effect which is many-fold greater than any systemic administration. The method can effectively reduce recurrence, boost the mechanical therapy and cut back the threat of development of resistant bacterial strains.,
CHX has been a standard when it comes to chemical plaque control. The use of CHX mouth rinse has been widely accepted and practised. The antiplaque and anti-gingivitis action is due to cationic nature of CHX and its substantivity. The alteration in adherence of the dental pellicle to enamel, increase in cell permeability, and cell lysis corresponds to its mechanism of action. The effect achieved is directly proportional to the amount and time of exposure. Hence, the use of irrigation in the gingival crevice has not achieved desired results. The gel formulations of CHX are mucoadhesive; therefore, they stick to the pocket lining and are not easily eliminated by washing off actions of oral fluids. They remain in place for around 10–30 days, producing adequate concentrations for microbial inhibition. They are well tolerated and easily degradable.
The results from the present study correlate with the results of some previous studies. Perinetti et al. (2004) have shown that CHX gel had significantly reduced probing depth and microbial count at the end of the study period, suggesting the effectiveness of the CHX gel as an adjunct to SRP. Vaish et al. (2016) conducted a study on 1.5% CHX gel. They found that the use of the CHX gel and chip, when used as an intra-sulcular antimicrobial agent, significantly reduced the PPD and RAL from the baseline to 3 months. No significant difference was observed in the gel group from the chip group. The improvement in clinical and microbiological parameters in our study was in accordance with both aforementioned studies. Sabru et al. (2014) conducted a parallel-arm study on two CHX gels and found that there was statistically significant improvement in the GI, probing depth, and bleeding on probing in both groups, but the PI deteriorated in both groups over the period of 3 months. They found non-significant differences amongst the two groups.
There are scarce studies on Chlorhexamed® 1% CHX Gel assessing effectiveness of the same on periodontal health; hence, the present study was taken up. We have found promising results, but further investigations are awaited to either confirm or negate the present findings. Limitations of the present study include small sample size; a larger sample size can be used; the use of another experimental material is lacking in the study, so studies with positive control are advised.
| Conclusion|| |
The use of Chlorhexamed® gel in subgingival application has been proven beneficial. It has effectively reduced the clinical signs of gingival inflammation, thereby improving the overall periodontal health when compared to mechanical therapy alone. The pathogenic microbiological flora was decreased, further adding to the well-being of the patients. The study concluded that use of an adjunctive CHX gel was a better option in the treatment of mild-to-moderate chronic periodontitis in cases where surgical therapy is not indicated and/or in cases of recurrence.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Shirish Kujur
Department of Periodontics, Government Dental College, Raipur - 492 001, Chhattisgarh
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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