ORIGINAL Jentsch ARTICLE et al
Periodontal Dressing as an Adjunct after Scaling and Root Planing – A Useful Preventive Tool? Holger F. R. Jentscha/Gerhild U. Knöflerb/Regina E. Purschwitzb/Sigrun Eickc Purpose: To determine the preventive effect of a periodontal dressing containing colophony, zinc oxide and magnesium oxide applied after scaling and root planing on clinical variables, subgingival bacteria and local immune response in patients with chronic periodontitis. Materials and Methods: In this randomised prospective clinical study, 28 volunteers with generalised moderate chronic periodontitis were treated with full-mouth scaling in a split-mouth design. In the test quadrants, the periodontal dressing was applied during the first three days. At baseline and after 6 and 12 weeks, probing pocket depth (PD), attachment level (AL) and bleeding on probing (BOP) were recorded, and subgingival plaque samples were taken for laboratory analysis. Results: In both groups, PD, AL and BOP were significantly reduced (p = 0.001). BOP was significantly lower in the control than the test group after 6 weeks (p = 0.046). Significantly reduced bacterial counts of Porphyromonas gingivalis were found in the control group after 12 weeks (p = 0.013). No differences were found for the microbiological results between the groups. After 12 weeks, interleukin (IL)-8 and matrix metalloproteinase (MMP)-8 were significantly higher in the test group (p = 0.023 and p = 0.003, respectively). Conclusion: The adjunctive application of a periodontal dressing had no additional preventive effect on clinical data 12 weeks after scaling and root planing. Key words: bacteria, chronic periodontitis, cytokines, periodontal dressing, root planing Oral Health Prev Dent 2016;14:101-109 doi: 10.3290/j.ohpd.a35612
M
edical dressings are used to prevent wound infection,5 stimulate wound healing,27 prevent accumulation of exsudates and decrease the superficial inflammation.43 Such dressings are also applied to reduce pain,7 induce granulation, reduce healing time and lower the stress level of patients with chronic wounds.22,36 It has been also stated that dressings can stabilise the wound area and a
Professor, Centre for Periodontology, Department of Cariology, Endodontology and Periodontology, University Hospital of Leipzig, Leipzig, Germany. Idea, hypothesis, wrote manuscript.
b
Dentist, Centre for Periodontology, Department of Cariology, Endodontology and Periodontology, University Hospital of Leipzig, Leipzig, Germany. Performed experiments.
c
Associate Professor, Department of Periodontology, Laboratory of Oral Microbiology, School of Dental Medicine, University of Bern, Bern, Switzerland. Idea, hypothesis, performed experiments, wrote manuscript.
Correspondence: Prof. Holger F. R. Jentsch, University Hospital of Leipzig, Centre for Periodontology, Department of Cariology, Endodontology and Periodontology, Liebigstr. 12, D-04103 Leipzig, Germany. Tel: +49-341-972-1208. Fax: +49-341-972-1259. Email:
[email protected]
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Submitted for publication: 06.01.15; accepted for publication: 17.02.15
promote haemostasis.8,19 Polished surfaces protect from early plaque and calculus formation.43 Periodontitis is a disease affecting the supporting tissues of the teeth.25 Dressings were commonly used in periodontitis treatment for many years. It is suggested that periodontal dressings protect the area of wound healing from saliva (which is fibrinolytically active12), food impaction and trauma after scaling and root planing (SRP) or periodontal surgery.29 Dressings can stabilise the fragile attachment between the soft tissues and the root surface, especially in the earlier phases of wound healing.37,38-40 Several in vitro studies have been undertaken on modified compositions of periodontal dressings. Srakaew et al34 suggested sodium-phosphorylated chitosan as a biocompatible ingredient after direct contact testing with human gingival fibroblast cells. Hammad et al14 did not find any negative influence of chlorhexidine, hyaluronan or allantoin as components of dressings on the healing of epithelial and
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connective tissue wounds in rats. In contrast, the study by Saito et al31 showed an intensive inflammatory reaction when using a dressing with zinc oxide, magnesium oxide and colophony after 28 days in a rat model. In an in vitro-study, a periodontal dressing containing zinc oxide, zinc sulphate and calcium sulphate was highly cytotoxic against gingival fibroblasts, whereas other dressings based on carboxymethylcellulose and polyvinyl acetate induced only a slight inhibitory effect on cell proliferation.28 Today, dressings are generally no longer used, although there is no evidence of an inferior clinical outcome after SRP with application of a dressing material. Only very few studies examined the relationship of periodontal dressings with the clinical outcome of treatment. Sigusch et al33 found higher reductions in probing depths and greater attachment gains after 6 and 24 months when a periodontal dressing was applied after SRP for 7 to 8 days. The comparison between areas treated by SRP with and without dressing included patients with generalised aggressive periodontitis. Recently, this result was confirmed by Genovesi et al,11 who applied a dressing in patients with chronic periodontitis for seven days. However, no data on the microbiota and host-derived markers were provided in either study. The application of a dressing resulted in fewer instances of reported pain after full-mouth SRP.17 These studies suggest a better outcome using a dressing and encourage further clinical studies. The aim of the present randomised, clinical-controlled study using a split-mouth design was to determine the additional preventive effect of periodontal dressing on the outcome of scaling and root planing assessed by clinical, microbiological data and host-derived markers in patients with moderate chronic periodontitis. A eugenol-free dressing containing colophony, zinc oxide and magnesium oxide, i.e. no special anti-inflammatory or antimicrobial ingredients, was applied for three days to test sites. The null hypothesis was that there is no difference between SRP treatment with and without the dressing. The study evaluates clinical, microbiological data and inflammation markers up to 12 weeks after SRP.
MATERIALS AND METHODS Subjects and study design This was a prospective randomised clinical trial. The study was approved by the Ethics Committee
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of the Medical Faculty of the University of Leipzig (348/2007); all participants signed an informed consent form. Twenty-eight male and female patients (mean age: 50.6 ± 10.5 years) with generalised, moderate chronic periodontitis were recruited from the Centre of Periodontology at the University Hospital of Leipzig. They had to fulfill the following inclusion criteria: (i) over 30 years of age; (ii) untreated moderate chronic periodontitis, except the two sessions of prophylaxis and instruction before the planned SRP;2 (iii) > 20 teeth; (iv) at least one site with probing depth ≥ 5 mm; and (v) no removable prostheses. Patients were excluded if they had received antibiotics or anti-inflammatory drugs during the four months prior to baseline examination or if they were pregnant or nursing. The interproximal plaque index (API) had to be below 30% after two initial prophylaxis and instruction sessions.23 The volunteers performed the oral hygiene measures as instructed without further interference by the clinical investigators during the study period. Third molars were not included in the study. For group allocation (test group = quadrant of the maxilla with dressing; control group = quadrant of the maxillla without dressing), a randomisation table was applied. Under local anaesthesia with articaine hydrochloride/epinephrine hydrochloride (Ultracain D-S, Sanofi-Aventis; Frankfurt/Main, Germany), the patients received full-mouth scaling and root planing alternately with hand instruments (Hu-Friedy; Chicago, IL, USA) and ultrasonic devices in one session. During SRP, subgingival irrigation (10 ml per quadrant) with 0.9% sodium chloride solution was performed. The SRP took about 5 min per tooth. The endpoint of the SRP was achieved when the operator felt a smooth root surface. After SRP in the test area on premolars and molars, a periodontal dressing (Voco pac, VOCO; Cuxhaven, Germany) containing colophony, zinc oxide and magnesium oxide was applied for three days. During the manual dressing application, retention in the supragingival interproximal area of the premolars and molars was used. The dressing was firmly placed with slight pressure on all surfaces of the gingival half of the clinical crown and the attached gingiva. The mucogingival margin was carefully avoided. Occlusion of the wound area and occlusal freedom were carefully controlled. The volunteers were instructed to rinse their mouth with 10 ml of 0.12% chlorhexidine digluconate (Chlorhexamed Forte 0.2%, GlaxoSmithKline; Bühl, Germany) twice daily for ten days after SRP and performed normal oral
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SRP with / without dressing for 3d
Baseline
1 week
6 weeks
12 weeks
PD, AL, BOP, GI collection of subgingival plaque/GCF
GI collection of GCF
PD, AL, BOP, GI collection of subgingival plaque/GCF
PD, AL, BOP, GI collection of subgingival plaque/GCF
Fig 1 Flow chart of the study protocol.
hygiene using a toothbrush and interdental brushes, except in the dressing area. Before SRP (baseline) and after 6 and 12 weeks, the clinical variables probing depth (PD), attachment level (AL) and bleeding on probing (BOP) were determined at six points per tooth with a manual periodontal probe (PCP-UNC 15, Hu-Friedy). The gingival index24 (GI) was also recorded. The examiner was blinded to the study and calibrated. First, before recording clinical parameters, samples of gingival crevicular fluid (GCF) were taken from the entrance to the deepest site of the tested area at baseline and after 1, 6 and 12 weeks using paper strips (Periopaper, Oraflow; Smithtown, NY, USA). Immediately following GCF sampling, at baseline and after twelve weeks, subgingival biofilm was sampled for 30 s by inserting an endodontic paper point (ISO 60, Roeko; Langenau, Germany) into the same periodontal pocket until resistance was felt. All samples were taken under relative dryness and after the removal of all supragingival plaque and debris.41 After removing the paper strips and points, they were transferred to tubes, placed on ice and stored at -20°C as soon as possible until analysis. Sampling of plaque and GCF as well as the assessment of the clinical data were performed by a different investigator, who was blinded to the application of dressings. The study design is presented as a flow chart in Fig 1. All volunteers finished the study between 2009 and 2010.
Analysis of selected bacterial species and host-derived markers For microbiological analysis, extraction of periodontal pathogen DNA was performed using the Chelex method.42 Real-time polymerase chain reaction (PCR) was carried out using a real-time PCR analyzer (7500 Real Time PCR System, Life Technolo-
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gies; Carlsbad, CA, USA). Real time PCR using GoTaq qPCR Master Mix (Promega; Madison, WI, USA) was performed according to the manufacturer’s recommendation with a reaction volume of 25 μl containing 2.5 μl of template DNA. The primers for Porphyromonas gingivalis, Tannerella forsythia and Treponema denticola were designed as described by Ashimoto et al,3 those for Aggregatibacter actinomycetemcomitans as described by Tran and Rudney.35 Negative and positive controls were included in each batch of specimens. The positive control consisted of 2.5 μl genomic DNA in concentrations ranging from 102 to 107 bacteria of the reference strains (A. actinomycetemcomitans ATCC 33384, P. gingivalis ATCC 33277, T. forsythia ATCC 43037 and T. denticola ATCC 35405). Furthermore, the specificity of the amplification was always assayed using melting curves. For quantification, the results from unknown plaque specimens were projected on the counted pure culture standard curves of the target bacteria. For adjusting the methods (sensitivity), the reference species were used in a concentration of 10 – 10,000,000 bacteria per sample. Before analysis, samples were eluted at 4°C overnight into 750 μl of phosphate-buffered saline containing proteinase inhibitors (Sigma-Aldrich; St. Louis, MO, USA). Afterwards, the eluate was centrifuged at 3000 g for 10 min. From the supernatants, the levels of IL-1β, IL-8 and MMP-8 were determined using commercially available enzyme-linked immunosorbent assay (ELISA) kits (R&D Systems Europe; Abingdon, UK) according to the manufacturer’s instruction. The detection levels of the kits were 2 pg/site for IL-1β and IL-8 and 25 pg/site for MMP-8.
Data analysis The clinical and laboratory data were statistically analysed using PASW18.0 (SPSS; Chicago, IL,
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Table 1 Clinical results at baseline, 1 week (only GI), 6 weeks and 12 weeks after treatment Test mean ± SD n = 28
Control mean ± SD n = 28
Test vs control Wilcoxon-test (p)
Mean age (years)
50.61 ± 10.58
n.a.
Range (years)
30–68
n.a.
Male (n) / Female (n)
5 / 23
n.a.
PD (mm) Baseline 6 weeks 12 weeks
3.3 ± 0.6 2.9 ± 0.3 2.8 ± 0.4
3.3 ± 0.6 2.8 ± 0.3 2.8 ± 0.4
0.656 0.529 0.839
PD ≥ 5 mm (n) Baseline 6 weeks 12 weeks
3.7 ± 2.2 1.9 ± 1.5 1.6 ± 1.5
4.0 ± 2.3 1.8 ± 1.0 2.0 ± 1.6
0.490 0.381 0.752
AL (mm) Baseline 6 weeks 12 weeks
3.6 ± 0.9 3.0 ± 0.9 3.1 ± 1.0
3.6 ± 0.7 3.0 ± 0.8 3.0 ± 0.7
0.400 1.000 0.876
AL ≥ 5 mm (n) Baseline 6 weeks 12 weeks
4.4 ± 4.0 2.3 ± 3.9 2.5 ± 3.8
4.4 ± 3.7 1.8 ± 2.9 2.5 ± 3.0
0.769 0.299 0.938
BOP (%) Baseline 6 weeks 12 weeks
29 ± 17 7±8 18 ± 13
35 ± 18 10 ± 15 11 ± 12
0.057 0.083 0.615
GI Baseline 1 week 6 weeks 12 weeks
0.3 ± 0.3 0.5 ± 0.2 0.1 ± 0.1 0.1 ± 0.2
0.3 ± 0.3 0.2 ± 0.3 0.1 ± 0.2 0.1 ± 0.2
0.455 0.011 0.101 0.318
n.a. – not applicable, n = number of teeth per test site. PD: probing pocket depth; AL: attachment level; BOP: bleeding on probing; GI: gingival index.
USA). Two quadrants (each in the region of the first premolar to the second molar in the maxilla) were the units of analysis in all statistical tests. Differences in PD were set as the primary outcome variable and used to estimate the sample size. A mean difference of 1 mm (± 1 mm) in the observed PD between two groups or two examination dates would require 16 patients per group to detect a significant difference (p ≤ 0.05) with an 80% test power. The collected PCR data were analysed for total counts of selected species. The non-parametric Friedman and Wilcoxon tests were used for intraand intergroup testing, respectively. A level of α ≤ 0.05 was considered significant.
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RESULTS Clinical data The clinical results of the 28 included patients at baseline are given in Table 1. The mean PD was 3.3 ± 0.6 mm in the test and control groups. The mean AL was 3.6 ± 0.9 mm in the test and 3.6 ± 0.7 mm in the control group. The corresponding BOP values were 29 ± 17% and 35 ± 18%. There were no significant differences between the groups at baseline. No adverse effects of dressings were observed during the study. PD, AL and BOP were significantly improved after 6 and 12 weeks in both groups (p = 0.001). The number of sites with PD or AL > 5 mm was significantly reduced in both groups after 6 and 12 weeks (p = 0.001). No significant differences were seen
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Table 2 Changes (Δ) of clinical data after six (t6) and twelve weeks (t12) in comparison with baseline (t0) including p-values (Wilcoxon test) and comparison of differences between test and control groups (Wilcoxon test; each group 1 quadrant / patient) Variable
Test (n = 28), mean ± SD
p
Control (n = 28), mean ± SD
p
Test vs control p
ΔPD t6 -t0 (mm)
-0.33 ± 0.50
